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 Table of Contents  
REVIEW ARTICLES
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 55-58

COVID-19 and the prospects for telemedicine in India


1 Department of Pulmonary Medicine, Dr. D Y Patil Hospital, Navi Mumbai, Maharashtra, India
2 Department of General Medicine, Dr. D Y Patil Hospital, Navi Mumbai, Maharashtra, India

Date of Submission22-Oct-2020
Date of Decision17-Apr-2021
Date of Acceptance19-May-2021
Date of Web Publication26-Dec-2021

Correspondence Address:
Ashwini Patankar
Department of General Medicine, Dr. D Y Patil Hospital, Nerul, Navi Mumbai - 400 706, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/dypj.dypj_9_20

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  Abstract 

Restrictions in movements of all nonessential services have been curtailed in India and worldwide owing to the current COVID-19 situation. This potentiates the use of telemedicine to provide healthcare services during the COVID-19 pandemic and lockdown. Telemedicine which was initially primitive and not very well explored is now emerging to be a safe option for healthcare delivery in the interim. Recently, the Ministry of Health and Family Welfare in India has come up with a set of guidelines that eases both the doctors and patients. The clarity in regulations provides a boost to the existing private startups that were operating under a grey area until now and would also attract investors to provide the required push to establish these services in India at a national level. Hence, if accepted as a standard model of healthcare delivery in India, telemedicine will help address the COVID-19 situation as well as provide healthcare access in remote areas. Furthermore, with millions of people already using the “Aarogya Setu” mobile app, it serves as a potential platform to integrate a national telemedicine service.

Keywords: COVID-19, telemedicine, telemedicine in India


How to cite this article:
Modi P, Uppe A, Reddy N, Patankar A, Bagarhatta P, Bhrungi S, Gayathri H, Nair G. COVID-19 and the prospects for telemedicine in India. D Y Patil J Health Sci 2021;9:55-8

How to cite this URL:
Modi P, Uppe A, Reddy N, Patankar A, Bagarhatta P, Bhrungi S, Gayathri H, Nair G. COVID-19 and the prospects for telemedicine in India. D Y Patil J Health Sci [serial online] 2021 [cited 2022 Jul 1];9:55-8. Available from: http://www.dypatiljhs.com/text.asp?2021/9/2/55/333774




  Introduction and Background Top


With persistently rising cases of COVID-19 in the world and in India, lockdowns have been implemented and restrictions in movements of all nonessential services have been curtailed. This worsens the scenario for regular outpatient consultations and emergency healthcare services that happen to be tough to acquire. With respect to India, the situation is far worse in remote areas than urban, further debilitating the already overburdened healthcare system. Hence, telemedicine has been a boon in the current situation in providing delivery of healthcare services where distance is a factor of paramount importance. Telemedicine, which was initially primitive and not very well explored in most countries is now emerging to be a safe option for healthcare delivery in the interim. Although multiple barriers are present, these can be dealt with tactfully and are negligible considering the rapid accessibility and widespread use of the Internet among the Indian population. Thus, there is an urgent need to evaluate the current telemedicine scenario and review the prospects of integrating a national telemedicine service.


  Review Top


Methods

PubMed database and Google Scholar were searched using the key terms “telemedicine,” “COVID-19,” “India” up to May 18, 2020. In addition, existing guidelines by the Ministry of Health and Family Welfare (MoHFW) by the Government of India were reviewed.


  Results Top


A total of 19 articles matched the search criteria and all were included in the review. It included 3 reviews, 1 survey, 10 commentaries, 2 position papers, and 3 letters. Seven of these were on diabetic care with the use of telemedicine in India, 4 were with regards to ophthalmological care, 3 were about general guidelines regarding telemedicine during the lockdown, and 2 were based on the practice of neurology in the lockdown period. Other articles included care of head and neck cancers, trauma, and rehabilitation via telemedicine, and one paper discussed the management of noncommunicable diseases with telemedicine.

Telemedicine in India during the COVID-19 lockdown

India, with a population of more than 1.3 billion has always grappled with a disproportionate doctor-patient ratio, more so in the rural setting.[1] With social distancing being one of the major preventive strategies during the COVID-19 lockdown, limited access to health services has had a huge impact on healthcare outcomes. Hence, the use of telemedicine is substantiated to provide contactless healthcare facilities ranging from emergency consults to regular checkups and specialist consultations.

Telemedicine in India dates back to the 20th century.[2] Despite being established worldwide, the use of telemedicine in India has been ambiguous. Skewed by guidelines, various judgments, and lack of cover by the medical council in the past, it has been underexplored. To steer clear of this enigma, the (MoHFW) in India has come up with a set of guidelines that eases both the doctors and patients.[3] These guidelines provide an in-depth review of definitions, scope of practice, modes of communication, and a complete framework describing the workflows for various scenarios involving interactions between the patient, (registered medical practitioner [RMP]), and a specialist. Consultations are executed in the form of video, audio, and text in real-time or in the form of an asynchronous exchange of information. Seven recommended elements that should be considered before starting any consultation are as follows:

  1. After taking an overall view of the situation the RMP should decide if telemedicine would be appropriate and sufficient in the scenario


  2. A telemedicine consultation should not be anonymous and both the RMP and patient should identify themselves before the consult


  3. An appropriate mode of delivering telemedicine service should be used (e.g. audio, video, text)


  4. Consent is considered as implied when the patient initiates the telemedicine consult. However, explicit consent is required in the form of an E-mail, text, or audio/video message when an RMP initiates the consult


  5. An RMP should ensure every effort is made to gather a sufficient amount of patient information including medical and personal history. The RMP can initiate a video consultation or examination by another RMP or an in-person consult when deemed necessary


  6. A first consult is usually when a patient seeks a telemedicine consultation for the first time without a prior in-person visit or if more than 6 months have elapsed from the first visit. A follow-up consult is when a patient consults the same RMP within 6 months of the earlier in-person consultation and is for the continuation of care for the same condition


  7. For conditions that can be managed via teleconsultations, the RMP can provide health education, counseling, and prescribe permitted medicines as required or refer a patient to the nearest healthcare facility in case of an emergency. Medicines should be prescribed only after a diagnosis/provisional diagnosis is made and the categories of medicine that may be prescribed are mentioned below.


List “O” includes those medicines which are safe and used for common conditions usually available over the counter. List “A” medications may be prescribed when the first consultation is in the form of a video consultation or as a refill for a patient who is undergoing a follow-up consult. List “B” medications may be prescribed for follow-up consultations for “add-on” medications in addition to those which have been prescribed during an in-person consult for the same medical condition.

A prohibited list of drugs comprising of those listed in Schedule X of Drug and Cosmetic Act and Rules, or any narcotic and psychotropic substance listed in the Narcotic Drugs and Psychotropic Substances Act, cannot be prescribed by an RMP providing consultation via telemedicine. An RMP will provide a digital copy of a signed prescription or an “e-prescription” directly to the patient or to a pharmacy (after explicit consent from the patient) as per the rules and regulations of the Indian Medical Council.

The framework also mentions the duties and responsibilities of the RMP including recommendations for the ethical use of technology and maintaining data privacy and confidentiality to provide a secure and definitive interaction. A detailed description, as well as working flow charts, have been provided as a part of the guidelines for the practice of telemedicine in various scenarios including first and follow up consults with the RMP initiated by the patient, consultation between the patient and RMP through a caregiver, consultation between a health worker and RMP, consultation between two RMP’s or RMP and a specialist, and in emergencies.

Over the years, people in India have embraced cellular and broadband technology making it one of the largest online markets in the world with currently over 500 million internet users. This serves as a huge potential to mainstream telemedicine technologies among healthcare systems across the country to provide timely access even in the rural setting where more than two-thirds of the Indian population is concentrated. The foremost advantage of telemedicine is to provide instant access without seeing the patient in person, protecting both the patients as well as healthcare workers from the transmission of COVID-19 and other infectious diseases. Furthermore, this in turn makes extra resources available at healthcare institutes and reduces secondary burden like organizing health camps or surveillance programs in remote areas. With a wide array of video, audio, and text features at one’s disposal, better patient compliance and follow-up are expected with the RMP being able to monitor vital parameters and lab results remotely. Provisions have been made for both caregivers and healthcare workers at primary health centers to assess patients and communicate with the RMP, thus providing assistance beyond the limitations of the primary healthcare setup including teleradiology and telepathology services.

Since a higher incidence of COVID-19 has been observed in patients with comorbidities such as diabetes, cancers, and hypertension, there has been a sudden rise in demand for the use of telemedicine in India for their management. In the case of diabetics, glycemic control has been managed virtually and has been found to be very efficient in reducing the burden of patient visits and uncalled admissions.[4],[5] It has also been noticed that there is a near-total cessation of elective surgeries, especially in ophthalmological practice. Only 27.5% of ophthalmologists attended emergency services in India. Most have switched to telemedicine to assist patients.[6] Management of rehabilitation and trauma via telemedicine is also being looked into. In trauma, most are suggesting preadmission triage with the assistance of telemedicine for rapid assessment. Rehabilitation and reinforcement of home-based activities can also be done virtually.[7]

Various outpatient services that were available earlier were suspended temporarily in the lockdown and have deprived a large population of the services for their noncommunicable diseases.[8] Neurology practice including the treatment of various life-threatening conditions like stroke has also been significantly hampered and can be aided with early diagnosis using telemedicine.[9] Remote use of modalities like transcranial magnetic and electrical stimulation has been assessed and monitoring of neurological conditions using noninvasive backscatter has been evaluated and encouraged.[10]

Currently, the Government of India in the form of the “Aarogya Setu” mobile application for iOS and Android platforms has tried to connect people with essential health services, screen and to give guidance to suspected cases of COVID-19.[11] With millions of people already using the app, it serves as a potential platform to integrate a national telemedicine service.

Telemedicine in the world

A significant number of countries worldwide have policies regarding telemedicine and are running telemedicine services.[12] Besides consults and patient follow-ups, telemedicine worldwide has also been used unconventionally like in the United Kingdom, telemedicine data was used to carry out surveillance and determine possible viral outbreaks.[13] In the United States telemedicine has been used for forward triage which segregates patients before reporting to emergency rooms. This has also helped patients to decide self-quarantine and it has reduced both doctor and patient exposure.[14]

The North Atlantic Treaty Alliance developed a Multinational Telemedicine System in 2013 which they used for disaster response.[15] In 2003, during the Severe Acute Respiratory Syndrome pandemic, China began integrating electronic medical systems for use in the future.[16] Australia also used telemedicine via video conferencing to provide healthcare during bushfires, a similar technique is now being used in Australia during COVID-19.[17]

Electronic intensive care unit (e-ICU) monitoring programs, which allow nurses and physicians to remotely monitor the status of 60–100 patients in ICUs in multiple hospitals are ideal for monitoring critical patients. Technological and staffing complexities make it impossible to create such a program on short notice, but rapid deployment of the two-tablet approach can reduce health care workers’ contact with infected patients in the ICU.[14]

Telemedicine merits and pitfalls

Telemedicine is still in its earlier stages and it has both its merits and demerits both of which need to be scrutinized in depth. Assessing the current use of technology and its pitfalls will help in guiding the future of telemedicine. The merits in the current scenario of lockdown outweigh the demerits largely. For known patients requiring a follow-up, routine consults are an easy option via telemedicine since the treating RMP is already aware of the patient’s history diagnosis and clinical progression. Drug prescriptions, opinions on investigations, and scheduling further appointments and procedures can be done virtually which reduces the burden on healthcare. Furthermore, the RMP can consult new patients via telemedicine where distance plays a key factor, especially for minor ailments. With the widespread use of internet services, remote access is achievable in both rural areas and in areas with a lack of specialist doctors. Surveillance and regular follow-up is also possible from a distance which will prevent significant exposure to healthcare workers and professionals.

Among the major drawbacks is obtaining consent which was earlier considered as implied. It has now been advised by MoHFW that one asks for explicit consent during the consultation, especially if access is initiated by a healthcare worker to gain specialist advice.[3] The lack of guidelines for charging consultation fees also is another area that needs to be addressed. The existing limited list of drugs that may be prescribed via telemedicine needs to be revised and extended promptly considering the vast scope of medical practice that telemedicine provides. Another major concern is data protection and privacy. Data leaks are common and could land the RMP in a possible legal entanglement. This is being improved frequently with the advent of data protection services and increasing platforms providing for telemedicine platforms. Documentation also needs to be maintained online in the form of cloud storage services or with the RMP in physical form which can at times be a hassle but is necessary for legal protection. In addition, lack of cover by professional indemnity coverage at present can be discouraging to RMP’s. The only disadvantage that telemedicine cannot resolve is the lack of human touch which can be a hindrance when certain scenarios may warrant a need for a clinical examination that may not be addressed currently. However, with the advent of newer technologies like telemedicine stethoscopes, otoscopes, and other equipment, this issue can be tackled soon.[18]


  Conclusions Top


The clarity in regulations provides a boost to the existing private startups that were operating under a grey area until now. These services when operating in full swing will help address the COVID-19 situation as well as provide healthcare access in remote areas. Even though telemedicine seems to be a viable option during this lockdown period, significant barriers have been noticed in this field across the world. The majority of the Indian population is accustomed to face-to-face consultations which could prove to be a key obstacle. Another stumbling block would be to get most of the rural population on the digital payment platform to pay for the telemedicine services. From the medical practitioner’s point of view, formal recognition of telemedicine services along with comprehensive training programs would instill a sense of confidence to use this platform and would also attract investors and e-health startups to provide the required push to establish these services in India. Telemedicine definitely provides a great stopgap solution in the current lockdown scenario to reduce healthcare burden and also provides a link between the patient, medical practitioner, pharmacies, and diagnostic services. The existing user base of the “Aarogya Setu” app provides an excellent opportunity to establish a national telemedicine platform and it also provides the scope of integrating telemedicine as a standard model of healthcare delivery in the imminent future.

Disclaimer: COVID-19 is an emerging, rapidly evolving situation and we recommend healthcare professionals to review the latest official and updated information from local governments and health organizations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kumar R, Pal R. India achieves WHO recommended doctor population ratio: A call for paradigm shift in public health discourse! J Family Med Prim Care 2018;7:841-4.  Back to cited text no. 1
    
2.
Chellaiyan VG, Nirupama AY, Taneja N. Telemedicine in India: Where do we stand? J Family Med Prim Care 2019;8:1872-6.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Telemedicine Practice Guidelines; 2020. Available from: https://www.mohfw.gov.in/pdf/Telemedicine.pdf. [Last accessed on 2020 Apr 28].  Back to cited text no. 3
    
4.
Singh AK, Gupta R, Ghosh A, Misra A. Diabetes in COVID-19: Prevalence, pathophysiology, prognosis and practical considerations. Diabetes Metab Syndr 2020;14:303-10.  Back to cited text no. 4
    
5.
COVID-19 and Diabetes – A View from India; 2020. Available from: https://journals.sagepub.com/doi/full/10.1177/1932296820928108. [Last accessed 2020 Apr 28].  Back to cited text no. 5
    
6.
Nair AG, Gandhi RA, Natarajan S. Effect of COVID-19 related lockdown on ophthalmic practice and patient care in India: Results of a survey. Indian J Ophthalmol 2020;68:725-30.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
COVID-19 and Remote Consulting Strategies in Managing Trauma and Orthopaedics; 2020. Available from: https://pmj.bmj.com/content/early/2020/05/13/postgradmedj-2020-137917.info. [Last accessed on 2020Apr 28].  Back to cited text no. 7
    
8.
Bettger JP, Thoumi A, Marquevich V, De Groote W, Rizzo Battistella L, Imamura M, et al. COVID- 19: Maintaining essential rehabilitation services across the care continuum. BMJ Glob Health 2020;5:e002670.  Back to cited text no. 8
    
9.
Sylaja PN, Srivastava MV, Shah S, Bhatia R, Khurana D, Sharma A, et al. The SARS‐CoV‐2/COVID‐19 pandemic and challenges in stroke care in India. Ann N Y Acad Sci 2020;1473:1-9.  Back to cited text no. 9
    
10.
Bikson M, Hanlon CA, Woods AJ, Gillick BT, Charvet L, Lamm C, et al. Guidelines for TMS/tES clinical services and research through the COVID-19 pandemic. Brain Stimul 2020;13:1124-49.  Back to cited text no. 10
    
11.
Aarogya Setu Mobile App; 2020. Available from: https://www.mygov.in/aarogya-setu-app/. [Last accessed on 2020 Apr 28].  Back to cited text no. 11
    
12.
Telemedicine: Opportunities and Developments in Member States: Report on the Second Global Survey on eHealth (Global Observatory for eHealth Series – Volume 2); 2009. Available from: https://www.who.int/goe/publications/goe_telemedicine_2010.pdf. [Last accessed on 2020 Apr 28].  Back to cited text no. 12
    
13.
Cooper DL, Smith GE, Regan M, Large S, Groenewegen PP. Tracking the spatial diffusion of influenza and norovirus using telehealth data: A spatiotemporal analysis of syndromic data. BMC Med 2008;6:16.  Back to cited text no. 13
    
14.
Hollander JE, Carr BG. Virtually perfect? Telemedicine for COVID-19. N Engl J Med 2020;382:1679-81.  Back to cited text no. 14
    
15.
Doarn CR, Latifi R, Poropatich RK, Sokolovich N, Kosiak D, Hostiuc F, et al. Development and validation of telemedicine for disaster response: The north atlantic treaty organization multinational system. Telemed J E Health 2018;24:657-68.  Back to cited text no. 15
    
16.
Zhao J, Zhang Z, Guo H, Li Y, Xue W, Ren L, et al. E-health in China: Challenges, initial directions, and experience. Telemed J E Health 2010;16:344-9.  Back to cited text no. 16
    
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Department of Health. Amended MBS Mental Health and Wellbeing Telehealth Items; 2020. Available from: http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-AmendedMentalHealth. [Last accessed on 2020 Apr 28].  Back to cited text no. 17
    
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