Dr Faiz Abbas Abidi | Clarion India
WITH Covid-19 cases increasing at an alarming rate in the country, and virtual shut down of daily OPDs in almost all major hospitals in the country viz AIIMS Delhi, PGI Chandigarh, KGMU among others, the call to switch to digital OPDs is gaining momentum as ever before. The daily burden of patients in India visiting hospitals for non-communicable diseases such as diabetes, hypertension, obesity disorders and others is huge. But ever since the imposition of lockdown the cases have come to a halt.
The Union Health Ministry itself, in the month of March, has advised deferring of all elective surgeries and restrict normal functioning of daily the OPDs for fear of Coronavirus transmission and increased exposure to suspected patients of Covid-19. Under the circumstances, remote consultations via phone calls, WhatsApp, SMSs, video-calling will prove a big relief for the patients who in need to access healthcare services while limiting their and physician’s exposure to the disease.
The situation has deteriorated mainly due to shutdown of regular OPDs and extension of countrywide lockdown. Patients suffering from different ailments, especially those of tuberculosis, HIV, and regular dialysis, feel helpless. Routine patients are bearing the brunt of lockdown in almost every part of the country. Same is the case with neurological disorders as patients suffering from anxiety, depression and schizophrenia are left in lurch.
The Institute of Human Behavioural and Allied sciences (IHBAS) in Delhi, one of the largest psychiatric hospital in the country has a daily intake of around 1200-1400 patients. The number now has fallen to zero. Same is the case with almost every public hospital and private OPDs. With the number of patients experiencing mental stigma during corona crisis is increasing regularly, the access to psychiatric help is very much limited due to closure of OPD services. One of the reasons for this is the scare of probable disease transmission and lack of adequate personal protective equipment for the doctors which is forcing them to shut services.
Tuberculosis, HIV, cancer and chronic kidney disease patients are worst hit due to difficulty in accessing medical services during lockdown. India reports around 25-lakh plus active tuberculosis patients yearly and more than 4 lakh deaths – the highest in the world. Same is the case with cancer and kidney patients as regular chemotherapy and dialysis services are not easily accessible, especially in public hospitals which caters to a large chunk of these patients and has presently shifted their focus to Covid management.
A better picture of it will emerge only when we have a combined data from all the major public sector and private sector hospitals on the condition of patients who used to visit their OPDs during normal times. Where they have gone for treatment, how they responded, and who took care of them can only be commented on if we have transparent post lockdown report from all individual hospitals. This will not only help in assessing the impact of closure of OPDs but also to devise future strategies in managing pandemic which poses high risk of contagious infection. Nevertheless, it will help public health experts address issues of managing large chunk of population suffering from different illnesses.
In the meantime, the Medical Council of India, along with NITI Aayog, came up with detailed guidelines on different aspects of safe telemedicine practices in the country, thus legalising the telehealth services in the country. These guidelines would prove a morale booster for doctors aspiring to shift partially to telemedicine not only during Corona Age but also in post-Corona world.
The guidelines, published, defines telemedicine as “the delivery of healthcare services where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of diseases and injuries, research and evaluation, and the continuing education of healthcare providers, all the interests of advancing the health of individuals and their communities.’’
The telemedicine in the country has seen rapid growth in recent times. Digital platforms like Cytopot, Practo, DocsApp, Lyberate, etc. occupy a good share in India’s telehealth space. Dr Abhijeet Upadhyay, founder of Cytopot, said, “Our aim is to provide faster and accessible quality health facility to all especially in remote areas by use of artificial intelligence and real time technologies with cost considerations.”
Cytopot caters to the needs of patients in the state of Odisha and surrounding areas.
Providing in-person healthcare is challenging both for medical fraternity as well as governments, particularly due to the large geographical distances and limited resources we have. One of the major benefits of digital OPDs will be cost saving especially for rural patients as the need for travel long distances for treatment will be minimised. Telemedicine, in this scenario, can provide an optimal solution to providing timely and faster access, reducing of the costs related. At the same time, it also reduces the inconvenience to family and caregivers and social factors associated.
For regular routine monitoring of cases and their follow-up, digital consultation will prove a boon. It will also ease the burden on secondary hospitals, PHCs and Mohalla Clinic type models running in the country where minor ailments are managed. With telemedicine, there is higher probability of proper maintenance of records and documentation and thereby minimising the risk of missing out on the advice of the doctor and healthcare worker. Digital consultation practices provide patient’s safety as well as that of health workers especially from contagious infections such as Covid-19.
Disasters and pandemics pose unique challenges for both the government and medical staff in providing healthcare. But with adversities, come the opportunities to convert weaknesses into strengths and serve the mankind. Though telemedicine will not solve all problems, it is well suited for scenarios in which teleconsultation can easily evaluate patients and provide them effective management plan without exposing the health staff to the risk of virus transmission. Broad speciality medical subjects such as dermatology, psychiatry, radiology, minor ailments in pediatrics medicine, ENT, etc. have already been focussing on telemedicine practices much before the emergence of Covid-19 pandemic.
Teledermatology and telepsychiatry were the two main domains which had a good consumer base before Corona. A good share of it was managed by digital health providing companies such as Remedico for skin problems based in Bangalore and MentDoc in Psychiatry. The Covid-19 pandemic is nowhere to go in near future before proper treatment protocol and vaccine comes out.
Nevertheless, it’s time for healthcare providers and government agencies to devise different ways in tackling the inflow of patients who are suffering from different non-communicable diseases as ignoring them for long and shutting of regular OPDs are not viable and sustainable options. Therefore, it is highly important to build up an effective system of telemedicine health services and digital solutions to counter the emerging problem.
Eminent medical practitioner and former national president of Indian Medical Association, DR KK Agarwal, is of the view that Covid-19 is somehow behaving like Spanish Flu and it might take around two years’ time to normalise things and, therefore, we must be ready for adaptations to Corona Age for quite some time.
The telemedicine practice guidelines published by the Board Of Governors in Suppression of Medical Council of India lays emphasis on following aspects:
1. According to the mode of communication, the telemedicine applications are classified into video (apps, video-on chat platforms, skype, face-time, etc.) audio (phone, VOIP, apps, etc) text based (including general messaging via SMS, messenger, Google Hangouts).
2. The Guidelines state, “The professional judgement of a registered medical practitioner should be the guiding principle for all telemedicine consultations. Seven elements mentioned under it to be considered before any telemedicine consultation includes context, identification of RMP and patient, mode of communication, consent, type of consultation, patient evaluation and management.
3. Prescribing medications, via telemedicine consultations is at the professional discretion of the RMP. It entails the same professional accountability as in the traditional in-person consult. Only those medicines categorised under list O, A and B falling under different criteria can be prescribed via telemedicine consultation. Drugs included under prohibited list could not be prescribed anyhow and may amount to legal proceedings.
4. One of the most important aspect of the guidelines include the implementation of principles of medical ethics, including professional norms for protecting patient privacy and confidentiality as per IMC Act shall be binding and must be upheld and practiced.
5. The guidelines separately address the tech platforms that enable telemedicine services. Such platforms can list a doctor only after due diligence verifying the doctor’s credentials. The guidelines also allow the use of artificial intelligence (AI) and machine learning tools to assist a medical practitioner in counselling a patient. However, AI cannot be used directly to counsel the patients.
However, along with the advantages, telemedicine has some negative aspects which cannot be ignored but analysed critically. As a doctor myself, just like the seniors from our community, we believe the first drawback of the telemedicine is its inability to address the issue of clinical examination of the patient in person. No technology could replace the examination skills and diagnosis made thereafter by an expert physician which gets limited while providing teleconsultation facility. Many patients prefer a more personal or face-to-face relationship for better understanding and treatment. This has limited scope with telemedicine.
Another point of concern is the availability and cost considerations of IT-based telehealth services. There are chances that for a provider, it can be expensive to set up these systems and maintain them annually especially for small healthcare facilities.
The accessibility to these services is also a major concern, especially in rural India. Today, the number of people who don’t have access to smartphones is huge. They are unable to utilise mobile app services effectively. Digital India is a distant dream not due to lack of mobile internet facilities but also due to improper usage, and drawbacks associated with it which needs to be fixed. It is possible for broadband connections to malfunction, video chatting gadgets functioning improperly, etc.
The issues of slow speed networks, mobile data theft, hacking, misuse of patient’s medical records and ethical considerations associated with it are some of the problems which could not be ignored at all before switching to telemedicine apps. It requires a robust system with the guidelines being provided by the government to both public and private telehealth providers so that trust building is developed, and more patients get benefitted from it. Health facilities providing these services also need to spend additional time as well as money for training the experts to enrich them with the much-needed technical knowledge. It will make healthcare recruitment a challenging task.
Despite all the odds, telemedicine is here to stay, and Corona crisis has given it a required push with more companies joining the ivy-league. Many of the stop-gap models for the next few months could become our new normal. This current push for telemedicine could lead to wide adoption of digital health services in the long run. It will not only help popularise remote consultations but also develop integrated network of digital health solutions that connect patients, doctors, diagnostic labs, and e-pharmacies.
As mobile pharmacies will boom, the biomedical health companies will generate more revenue as well as employment. Their success will largely depend on how cost-effective they will prove and on the scale of services being provided to address public health problems which the country is facing. Success will definitely be more if these solutions bring smiles on the marginalised sections of the country and not only end up becoming a capitalist profit generating module. 1 mg, NeTMeds and PharmEasy will have a bigger role to play in coming days.
The technological innovations in digital health domain and their immense potential for shaping clinical practices cannot be ignored. But without serious modifications to our healthcare delivery system and telehealth policy, it’s fair to ask how far mobile apps, artificial intelligence, big data and algorithms will take Indian health services forward. The country already has a National Digital Health Blueprint which was released last year by Health Minister Dr Harsh Vardhan.
This is an achievement as we are among very few countries to have a detailed published Digital Health Plan. Time is now to act upon it to address different issues crippling the public health system and how by the means of digital health tools we can fix them all.
Question is do our institutions and policy makers measure up to the task of striking a right balance between sharing of data and protecting patient’s privacy or will the breakneck speed of digital technology overwhelm them? Will automation and real time solutions help patients attain positive and long-term changes in their health domain, or will quick gains ultimately succumb to and be reversed by the same old obstacles of inadequate resources inside and outside our hospitals and clinics? Answers need to be searched for a better, healthier India!