Telemedicine- enhancing healthcare service through easy access

By Dr Subhrajyoti Bhowmick

World Health Organization defines telemedicine as, “The delivery of health-care  services,  where  distance  is  a  critical  factor,  by  all  health-care  professionals  using  information  and  communications  technologies  for  the  exchange  of  valid  information  for  diagnosis, treatment  and  prevention  of  disease  and  injuries,  research  and  evaluation,  and  the  continuing  education  of health-care workers, with the aim of advancing the health of individuals and communities.”

On March 25^th, 2020, The Ministry of Health and Family Welfare issued the Telemedicine Practice Guidelines, 2020 under the Indian Medical Council Act, 1956 and which superseded the Indian Medical Council (Professional, Conduct, Etiquette and ethics regulation, 2002)

Telemedicine aims to enhance healthcare service and access to all. The guidelines are meant for Registered Medical Practitioners ( RMP)  under the IMC Act 1956. The guidelines cover norms and standards of the RMP to consult patients via telemedicine. Telemedicine   includes   all channels   of   communication   with   the   patient   that   leverage   Information Technology platforms, including Voice, Audio, Text & Digital Data exchange.

Guidelines of telemedicine in India begin when an RMP is well positioned to decide whether a technology-based consultation is sufficient or an in-person review is needed. Practitioner shall exercise proper discretion and not compromise on the quality of care. Seven elements need to be considered before beginning any telemedicine consultation.

Seven Elements are considered before any telemedicine consultation is carried out and they are Context, Identification of RMP and Patient, Mode of Communication, Consent, Type of Consultation, Patient Evaluation and Patient Management.

Process for consultation between patient and RMP at the beginning of a Telemedicine Consultation for the first Consult includes Patient identification and consent, Quick assessment, Exchange of Information for Patient Evaluation and finally Patient Management.

An RMP  may  use  any  telemedicine  tool  suitable  for  carrying  out  technology-based  patient  consultation  e.g. telephone, video, devices connected over LAN, WAN, Internet, mobile or landline phones, Chat Platforms like WhatsApp, Facebook  Messenger  etc.,  or  Mobile  App  or  internet  based  digital  platforms  for  telemedicine  or  data transmission systems like Skype/ email/ fax etc.

Telemedicine applications  are of four types as  mode  of  communication, timing  of  the  information  transmitted,  purpose  of  the  consultation  and  interaction  between  the individuals involved—be it RMP-to-patient / caregiver, or RMP to RMP.

Multiple technologies can be  used  to  deliver  telemedicine  consultation. There  are  3  primary  modes: Video, Audio,  or  Text(chat,  messaging,  email,  fax  etc.) Each  one  of  these  technology  systems  has  their  respective strengths,  weaknesses  and  contexts,  in  which,  they  may  be  appropriate  or  inadequate  to  deliver  a  proper diagnosis.

It  is  therefore  important  to  understand  the  strengths,  benefits  as  well  as  limitations  of  different  technologies. Broadly,  though  telemedicine  consultation  provides  safety  to  the  RMP  from  contagious  conditions,  it  cannot replace  physical  examination  that  may  require  palpation,  percussion  or  auscultation;  that  requires  physical touch and feel. Newer technologies may improve this drawback.

Each technology comes with its own set of strengths and limitations.

The Video mode of telemedicine, Apps, video on chat platforms, facetime etc are closest to an in-person consult. Real time interaction, patient identification is easier, RMP can see the patient and discuss with the caregiver, visual cues can be perceived and inspection of patient can be carried out. The limitations of Video format is it is dependent on high quality internet connection at both ends, or else it may lead to a sub optimal exchange of information, since there is a possibility of abuse/ misuse, ensuring privacy of patients in video consults is extremely important

The audio platforms on phone, VOIP, Apps have the strength of convenience and speed, unlimited reach, suitable for urgent cases, no separate infrastructure required and privacy is ensured while the limitations are that non-verbal cues can be missed, this format is not suitable for conditions that require a visual inspection (e.g. skin, eye or tongue examination) or physical touch also patient identification can be an issue with imposters representing the actual patient.

Text- technologies as specialized chat based, telemedicine smartphone apps, SMS, Websites, messaging systems e.g. WhatsApp, Google, Hangouts, FB Messenger have the strength of being convenient and quick, where documentation and identification may be an integral feature of the platform, this mode is suitable for urgent cases, or follow-ups, second opinions provided RMP has enough context from other sources, Separate infrastructure is not required and it can be real time. The technology has its limitations as apart from the visual and physical touch, text-based interactions also miss the verbal cues, it is difficult to establish rapport with the patient and one cannot be sure of identity of the doctor or the patient.

ASYNCHRO-NOUS technology as e-mail, fax,   recordings have the strength of Convenience and easy to document with no specific app or download requirement, images, data, reports can be readily shared, no separate infrastructure is required and finally it is more useful when accompanied with test reports and follow up and second opinions. But the technology has its limitations as it is not real time interaction, only a one-way context is available, relying solely on the articulation by the patient, patient identification is document based only and difficult to confirm, non-verbal cues are missed and there may be delays as the RMP may not go through the e-mail immediately.

Among the advantages for patients who benefit through telemedicine are lower costs, improved access to healthcare, preventive care and convenience. The benefits for health care providers include reduced overhead expenses, additional revenue stream, less exposure to illness and infections and patient satisfaction.

Disadvantages for patients do not include Insurance coverage, Protecting medical data and care delays. Disadvantages for health care providers are licensing issues, technological concerns and inability to examine patients.

The writer is a Dr Subhrojyoti Bhowmick,MD, Clinical director, Peerless Hospital