From being deeply resisted and declared illegal, we are well on the way to realize that Telehealth is here to stay. It not only balances widespread inequities caused by economic factors and poor access, but also bring about efficiency in care. Already preferred by patients, the resistance to its adoption by clinicians has gone. We hope that these changes persist for longer as the positive affects are huge and the few negative effects will get corrected over time.
Keywords: COVID 2019, Telehealth, Telemedicine
Healthcare delivery is a service which depends on a set of interactions with in-depth assessment. Most interactions were done physically in the past, wherein the healthcare provider would hear the problem (History), examine, investigate further, make a diagnosis and treatment plan, and then deliver the care. Telemedicine is essentially medicine but using a Information and Communication Technology (ICT) to facilitate the interaction allowing for the patient and care provider to not be face to face. This means making do without some assessment features like palpation altogether with a need for additional devices. A tele stethoscope for example can be used for hearing the heart and breath sounds.
Telemedicine has been portrayed as the next big change in medical care. It corrects health disparities related to socio -economic factors especially geography. Using ICT, Information travels seamlessly between patient and provider to facilitate medical diagnosis and care. Information can travel at nano speeds. However, ICT systems can do much more. There are rapid advances on a daily basis. These include widespread use and adoption of (Smart) Mobile phones, fibreoptic and broadband availability, 3G /4G/5G, long term memory and instant recall. Smart mobiles have inbuilt advanced digital sensors like for touch and vibration, high magnification cameras, Global Positioning Systems, gyroscopes, leading to a special offshoot called mHealth. This facilitate many additional features like Analytics, Clinical Decision Support Systems
(CDSS) and Artificial Intelligence (AI).
Current use of ICT in healthcare has expanded to much more than simple care delivery. Commensurately, the terms have been changing to Telehealth, eHealth and now -digital health. Within this article, we prefer to use the term telehealth as that better explains the scope and content. Telehealth also has a high role to play in any sort of disaster because in such situations the mismatch between reach and availability gets accentuated
Telehealth has various streams and processes.
Streams are related to the personnel between whom the information flows happens.
- Between Patient and Care Provider (direct)
- Between patient’s counsel /family and provider (Indirect)
- Between Health providers .
A health worker /junior doctor to someone senior ( difference in levels)
- Within a specialty (same level)
- Across specialties
The three processes are
- Realtime or Synchronous – here the two concerned personnel – see above – are talking remotely but without a time-lag. e.g. if the patient is in Nepal and the local time there is 4:45 PM, the doctor’s clock in Baroda will be showing 4:30 PM. Telephone calls and video consults take place in realtime, as also viewing of Ultrasound or pathology slides remotely at the time the probe or microscope is being manipulated.
- Store and Forward or Asynchronous – here information sharing allows for a time-lag. I.e. it is recorded either as text (history, examination findings, investigation reports prescription etc), sounds (heart, pulmonary), Images (Photos, X rays), video etc and shared as files. Viewing and comments are reshared as per convenience
- Tele-monitoring Here data production is ongoing, and is conducted through a device i.e. without human interference.
The original purpose behind Telemedicine was to use ICT to lessen, and for some, obviate, the need for travel. The attempts to obviate raised expectations irrationally and lead to resistance, more so from the clinicians who were asked to do a job with a higher degree of effort. Special training was required, information incomplete, there was less control, patients could call them insist for help at odd times. Remuneration was not commensurate with effort.
A few changes that have been done within the scope of healthcare delivery itself. Health provision is more dependent on Investigations. More and more payments are handled through insurance. Better imaging as well as investigation techniques have decreased the need for closer patient physician interaction. Entire ward rounds are being held without any patient being touched and sometimes talked to!
Alongside there is a focus on specialization as opposed to general practice. Overall care quality has improved but so have costs, in some cases on an exponential basis. Turf protection by specialists as well as higher incidence of Consumer Protection Act (CPA) cases means that most doctors are narrowing the scope of which patients they should handle. Team approach and cross referral has become important. Telemedicine facilitates the above and can lower costs –more so of the non-health related aspects like travel. Side by side, better access to information through the net, has made patients, especially the more educated ones, lay more emphasis on fitness and prevention.
Adopting telehealth is not an insignificant change. It requires not only costly equipment, but also much relearning. For a busy doctor, this relearning along with purchase of expensive equipment makes it daunting. Low usage leads to slower learning and higher average cost of each interaction. Rapid changes in technology meant that whatever had been learnt, quickly became obsolete. As a result, till around 2014/15, adoption of telemedicine worldwide, more so in India, had been low and restricted to extremely special situations like space travel, armed forces, arctic regions and commercial shipping. These are places, literally, which have no doctor. In a brief, albeit rough and inaccurate statement, it could be stated that “Telemedicine provides half a doctor, great when there is no doctor and useless when there is a doctor”.
Till recently, an IMA advisory[ii] along with the Karnataka Medical Council had decided to ban Teleconsultations altogether (See Box). These legislations have only added to the worries of clinicians even while the real unintended consequences [iii] have not really been openly discussed. To summarize, before COVID changed the scene drastically, telemedicine was considered high cost and maybe illegal. Definitely not worth venturing into, by the care providers.
Changes due to COVID
The first real change that COVID brought about was a deliberate one done by the interim Board of Governors (BoG) of the Medical Council of India. They accelerated the release of the Telemedicine Practice Guidelines (TPG) so that Telemedicine could be now considered legal. A farsighted effort. Even while done in a hurry, with clarity missing in many aspects, the positives have been immense.
The other change is that now doctors themselves are preferring remote care and tele-support as the less they confront the patient the better. There is no need for PPE! Patientshave already discovered the cost advantages of Telehealth – 76% of US citizens prefer remote care as opposed to physical consults in 20181. In April 2020 this had risen to 95%. In India too, the current numbers are similar. Patients are refusing to visit a clinic for a checkup and /or get investigations, let alone get admitted for any other problem for fear of contracting COVID.
A spate of telehealth and mobile solutions giving remote care have come up. Many are by fly by night operators. It is difficult to say on how long will they last. Even while the apps have much scope for improvement, but they are working to some extent. Telemedicine has a problem of the lack of validation of the care quality as well as the skill level of the clinician. This is getting accentuated.
But the positive effect is that home care with online consults are considered the done thing as opposed to a rush to hospital.