Table of Contents
As per the WHO, Telemedicine is defined as “The services of healthcare delivery, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.”
Telemedicine has been around for a considerable time, the Indian government has in the past run pilots and studied the benefits of Information and Communication Technology on healthcare delivery, including the Indian Space Research Organization’s (ISRO) first SATCOM-based telemedicine network project at Aragonda, Andhra Pradesh in 2001. There was a common understanding that this could revolutionise access to healthcare provided infrastructure was in place.
The shock to the health sector during the onset of COVID-19 in India saw resources being diverted to mitigate COVID-19, which came at the cost of outpatient visits to hospitals, hospitalisations for Non-Communicable diseases (emergencies) and the country’s immunisation drives. This also exacerbated inequalities, particularly the poor and people living in rural and remote areas who were cut off from healthcare due to the existing shortage of practitioners, especially specialists leading to stagnation of healthcare delivery in rural India.
Telemedicine applications can be classified into four basic types, according to the mode of communication (video, audio, text), the timing of the information transmitted (real-time, Asynchronous), the purpose of the consultation (emergency, non-emergency, first consultation, follow-up consultation) and the interaction between the individuals involved (patient to RMP, caregiver to RMP, RMP to RMP, Health worker to RMP).
Key technological elements
- Artificial Intelligence: AI in telemedicine has helped doctors with suggesting appropriate diagnosis and treatments for patients. Many telemedicine platforms use AI chatbots to address the patient’s queries. Gyant is one such AI-based telemedicine platform that helps to collect and analyse a patient’s medical history.
- Internet of Things: Telemedicine has significantly progressed since the advent of the internet. Data from digital stethoscopes and pulse oximeters can be sent to the doctors in real-time helping them to track their patients’ progress. Pillsy is a smart medication bottle that reminds patients to take their medication on time, through an app. Via teleconsultation services, doctors can even guide the patients on how to use said devices.
- Remote Patient Monitoring: Collecting information of a patient from one location and sending it to medical personnel at a different location constitutes Remote Patient Monitoring. RPM aids with access to healthcare in rural areas and can avoid the shortage of hospital resources as patients are treated while being at home. Babyscripts is one such remote patient monitoring platform that provides prenatal and postpartum care virtually.
- Cloud Storage: In telemedicine, data from patients such as their medical history, prescriptions, lab results, and scans are reserved in the cloud storage. Medical professionals can easily access these files from any device. Cloud Storage has also made telemonitoring and processing easy to perform.
- Blockchain: Many experts voiced their concerns over the privacy and security of cloud storage. Blockchain categorises the information into blocks that cannot be easily accessed by unauthorised individuals. Blockchain allows medical and personal information to be well protected and also assists with efficient data transfer.
- Big Data Analytics: Data analytics helps in health informatics, gathers genetics and -omics-based information and enables further research. Data Analytics also helps to predict future ailments by analysing patient history. Data Analytics enables doctors to accurately diagnose a patient’s illness, a task that was previously conducted by patients listing out their symptoms and doctors making a calculated guess.
- Augmented and Virtual Reality: Mixed Reality platforms can help technicians get real-time information about the patients and can improve remote diagnosis. Iflexion, an AR company, develops apps that aid clinicians to diagnose virtually. Telemedicine companies like Zipnosis and SnapMD have multimodal virtual care platforms.
- Robotics: Robotics is the first advent of technology into healthcare. Monitoring and caring for the patients is made easy thanks to telerobots. Robots can help assist the surgeons and help set up virtual visits with doctors. These robots are built with sensors that can recognise the changes in a patient’s moods and behaviours and gauge their recovery process. In some cases, an experienced surgeon at a remote location can teleoperate through a robot.
How can doctors set up a telemedicine practice?
Delivery of telemedicine can be done in three phases of the patient or journey of health and disease. So, the first is the Promotion of health. Telemedicine and digitally enhanced digital health care should be utilised to promote health. The next stage is Prevention. It should be ensured that people are healthy, then very specifically you prevent diseases. Prevention is always better than cure. Now, we have technologies that help to gather data and prevent disease or prevent the morbidity associated with the disease. Finally, when the person has already got the disease. There we will see the actual teleconsultation happening which will end up with having the Prescription and maybe the next stage would be to have a follow-up and rehabilitation.
Patient engagement levels
We see different levels of engagement that a practitioner can have with the patient. The engagement can be through basic voicemails, the internet (e.g- WhatsApp, Facebook, Skype, Zoom, Google meet), AI-based algorithms (e.g- ada, kahun), wearables (e.g- temperature tracker, period tracker, pedometer) and full-stack.
To get a complete picture, a practitioner has to have all kinds of data to come together from the medical wearables, electronic medical records and the medical opinion.
Required support systems
Where to start?
- Type of Telemedicine- Decide the technology you’re going to use. What is your practice? What is your speciality? So you decide the type of elements that you want to get into.
- Types of patients- You have to see the type of patients you’re getting into. So is it just new patients? Or will there be repeat patients? Or only the COVID patients will get into telemedicine.
How to start?
- Have a vision for what you’re trying to do. Set SMART goals.
- Try to see what kind of technology you’re going to use. Is it just one device or all kinds of devices?
- Try to find support systems. Are you going to do it alone? Are you part of a larger group? Do you have any nurses to assist you? Do you have any office people to assist you?
- You have to figure out a way to reach out to people. How are people going to know that you’re actually providing a service?
- If you are doing well, find out ways to expand your services.
Prepare a business plan. Do you want to do it for charity where anybody can call any time for free advice? Or you’re doing it commercially. If somebody was going to pay you, how are they going to pay you? What is the kind of tax system that you’re going to have? How are you going to receive money? So what are your commissions? How are you going to share it with the rest of the people in your staff?
Ground rules for practice
For any good practice, you must have some ground rules. How do you deal with the issues that crop up during practice? What are your SOPs (standard operating procedures)? How much time are you going to spend with each patient?
Handling legal aspects
All medical practitioners should get indemnity insurance. And that is applicable whether you’re doing telemedicine or physical practice. Your data security is very important. The data security of the platform which you’re going to use must be absolutely assured. Similarly, the privacy of the data has to be assured and you have to be aware of your rights and the patient’s rights as far as the Consumer Protection Act is concerned.
Some of the ways robots have helped out in hospitals and telemedicine are:
- Robots can take orders and deliver items to a patient allowing the nurses to take care of more pressing matters thus improving the supply chain management.
- Robots can act as round-the-clock sitters for frail and elderly patients. Assistive robots can also improve the lives of mobility-impaired patients by helping them get in and out of beds and onto wheelchairs.
- Robots have video-conferencing facilities through which patients can connect to doctors. VGo technologies have made a two-wheeled robot that allows admitted patients to contact doctors through this facility. Robots serve as a lifesaver for patients suffering from Cardiovascular Disorders by immediately connecting with doctors, thus offering timely interventions.
- Companies like VGo and InTouch have robots that act as stand-ins and serve as eyes and ears for doctors in clinics.
- Using UV light and advanced cleaning technology, robots can sterilise various hospital wards which can reduce contracting hospital-acquired infections like MRSA.
- A robot can help with registering patients, accessing medical records and providing clear directions in almost any language.
- Robotic arms are available to perform basic surgical procedures and these are usually guided by doctors who are miles away. In 2001, surgeons in New York were able to perform a complete laparoscopic cholecystectomy on a patient in France through the robot Zeus. In 2019, Dr. Tejas Patel of Apex Heart Institute in India performed five robot-assisted percutaneous coronary surgeries on patients who were more than 30 km away, with the help of a joystick and a video monitor. Surgeons can also use robots to do open surgeries to reduce exposure.
- Robots can help with Remote Patient Monitoring by observing patients who are being treated at home, especially in a time like the pandemic. Robots can also help in minimizing exposure by delivering drugs and food and measuring the vital signs of the patients. iRobot has partnered with InTouch to create a robot that helps out inpatient wards, ICUs, operating and procedure rooms
- A specialist at one hospital can connect to another hospital (hub and spoke model) through an AI-engineered robot.
- Miniature robots can be injected into the body which can help deliver drugs to specific organs or tumours (targeted drug therapy). Smart pills and bandages can record body temperatures, collect samples and take pictures of the affected areas.
- By incorporating principles of engineering, AI and infectious disease, research during the time of an outbreak can be done through a robot.
Critical care services require intense resources and process control. When we consider parameters like structure, operations, outcomes and costs, Tele-ICU seems to have a lot of potential. Tele-ICU platforms offer various services including remote video visualization of patients and biomedical devices, access to electronic medical records (EMR), scrutinize patient data, combining physiological parameters with clinical risk factors to predict deterioration and provide decision support. The platforms also embed risk-prediction algorithms to facilitate more efficient interventions to reduce ICU risk.
How does a Tele-ICU facility look like?
Operational structure of Tele-ICU
Platforms providing telemedicine solutions
Healthcare providers have realised the scope in the telemedicine sector and have come up with myriad solutions. One such platform is DOCKARE. The platform follows a B2B Smart Management approach. A single doctor is assigned to the patient thus getting rid of the hassle of visiting multiple doctors and finding the right one, thereby simplifying the healthcare delivery. The patients input their symptoms which is decoded by the analytics of the app and the assigned doctor will provide the treatment. DOCKARE also uses a hybrid model where both in-person and teleconsultation modes are implemented. Thus paving the way for personalised medicine.
The DOCKARE app can be used by any category of patients whether it be pregnant women, asthma patients, etc. In the app, the symptoms are compartmentalised into health modules of illnesses. The patient can choose the appropriate module and input their symptoms using an emoji scale. This allows the patients to track their illness in real-time without any prior medical knowledge. The app generates a trend of the illness when the patient regularly monitors their symptoms over a long period of time. This trend is then analysed by the respective doctor in real-time and decides on the progression of treatment. The doctor can also opt for long term treatment options (extended package)
Policy and structure
Digitising healthcare has been attributed to overcoming manpower shortage, numerous private hospitals and platforms have capitalised on providing distance telehealth facilities including, tele-ICU facilities in partnership with smaller hospitals in rural India. However, tele-ICU has not been regulated and is beyond the scope of the Telemedicine Practice Guidelines as it only focuses on the practice of outpatient telemedicine. There is a need to broaden the scope for telemedicine and include inpatient care, which is currently lacking in India.
The popularity of e-Sanjeevani shows that trust in the public healthcare system is growing and the demand is bound to increase with its expansion to the rest of the country. It is therefore important to ensure that the time of teleconsultation is optimised to the fullest and that patients are screened to be presented to appropriate doctors or specialists who are more likely to address their symptoms. It could also be designed to ensure a seamless referral system, where if one doctor is unable to diagnose a problem, the patient is referred to a specialist within a short span of time. This could prevent repeated login or visits to dedicated telehealth facilities, and prevent repeated advice from doctors.
Scope of telemedicine
The scope of Telemedicine in the country has been limited to outpatient consultancy and the whole concept of distance and medical application is what is thought of as telemedicine. As far as inpatient care is concerned, the common question is now, why do we need telemedicine if the patient is already in the hospital? But at the same time, we forget that in robotic surgery where the operating surgeon is in totally different geography and the patient is in another geography, we have daily intensive care. There are multiple intensive care units, especially in the United States, where the actual intensivist is sitting in something like a BPO office with multiple screens, and handling multiple intensive cares across the country. While at the remote locations, where the patients are they have good nurses to take care of, but the intensivist is not there. It’s more likely to be called ‘digitised medicine’ instead of telemedicine.
Advantages of Telemedicine
- Easy access to specialists
- Getting email or text reminders
- Social distancing
For healthcare providers
- Less overhead expenses
- Social distancing
- Additional revenue source
- Easy availability of e-health records
- Protection of medical data
- Emergency care delays
- Technological barriers
For healthcare providers
- Licensing issues
- Technological issues
- Lack of in-person diagnosis satisfaction