Problems that exists in Rural India to Adapt Telehealth

Ms. Saranya Gupta
Mentor: Manvee Bansal / Abhimanyu Rathore
Pathways World School, Aravali (IB)

 

Telemedicine has recently emerged and gained popularity as a new hope to remove the bottlenecks in the healthcare seeking. While telehealth technology and its use are not new, widespread adoption among patients, especially in rural areas, beyond simple telephone correspondence has been relatively slow. Many professional medical societies endorse telehealth services and provide guidance for medical practice in this evolving landscape.

One such example are the incessant advocacy efforts of the Telemedicine Society of India (TSI) that have paid off with the approval of Telemedicine Practice Guidelines by Ministry of Health and Family Welfare, Government of India in March 2020. TSI, now with an enhanced vitality is determined to reduce Urban-rural healthcare disparity.

My detailed research has looked at the problem that exists in rural India and why people residing there are hesitant to adapt to telehealth as a prime medium to acquire healthcare services. Thereafter, it goes into further detail of how this can be destigmatised through solutions like overcoming the language barrier, hiring ambassadors for spreading awareness, and regularly updating the content on the company website.

Lastly, it also includes a state-wise analysis of the 11 states that TSI principally targets, which discusses the problem that a certain state faces and a recommended solution for that problem. For example, people in Maharashtra have concerns about the privacy guidelines around the uptake of telemedicine and to resolve this problem, a recommendation was to revise the guidelines to address the weaknesses and to establish an ongoing system of evaluation to permit future improvements in the guidelines to make them increasingly comprehensive.

The recommendations for adaptation of telehealth in rural areas include –

 1.  proper training of doctors and other healthcare professionals to deliver the telemedicine technology effectively, including vastly improved Internet services;

 2. A much higher level of public-private partnerships related to telemedicine activities;

 3. Developing more cohesive privacy policies and guidelines for TSI to ensure that patients feel secure and integrate telemedicine with the existing health system;

 4. An efficient management structure for monitoring quality standards of telemedicine practice in the country;

 5. Efforts should be made to educate public about telemedicine and its   related benefits.

This kind of research was necessary because of the growing relevance of telehealth services in today’s rapidly revolutionising, technology-dependent world. It is also prominent in the situation of the pandemic in which we are living in today, given the requirement to stay at home and reduce physical contact. In terms of focusing on rural areas of India as a prime target audience for this research, there was a crying need for habitants of these areas to accept newer approaches as the world progresses.

To obtain a full copy of my research, please write a mail to my mentors – aks1953@hotmail.com

Informed Consent for Telemedicine

Anay Shukla
Founding Partner, Arogya Legal – Health Laws Specialist Law Firm

Eshika Phadke
Associate, Arogya Legal – Health Laws Specialist Law Firm

 

The Telemedicine Practice Guidelines specify that consent may be implied when a patient initiates a teleconsultation; however, there are certain situations wherein a doctor is legally required to obtain consent from the patient.

Consultation not initiated by the patient
If someone other than the patient – including their family member, a healthcare professional, another doctor, or even the doctor who is consulting the patient themselves – initiates the consultation, explicit consent must be taken from the patient.

If a healthcare professional seeks a medical consultation for a patient through telemedicine, both the healthcare professional and the consulting doctor would need to obtain explicit consent from the patient. The healthcare professional would be required to counsel the patient on the risks and limitations of telemedicine, and the doctor would be required to seek the patient’s consent to proceed with the consultation.

No capacity to consent
If the patient is a minor or does not have the mental capacity to legally provide consent, the person’s caregiver is authorised to consult with a doctor and take decisions on their behalf. However, the doctor must first confirm that the person is the patient’s caregiver by asking to see either a formal authorisation to that effect, or a government-issued document that establishes the person’s relationship with the patient. This would not be required if the doctor has previously treated the patient in-person, and is aware of their relationship with the caregiver. For the sake of documentation in such cases, the doctor ought to record that they have treated the patient in-person prior to the teleconsultation, and may even request that the caregiver confirm the same through a text message or email.

Recording
If the doctor will be recording the consultation, they ought to inform the patient and seek their consent for the same. This is especially vital for specialists like psychiatrists, venereologists, gynaecologists, etc, who discuss highly sensitive and personal information and may receive private visuals from the patients.

Refusal to comply
If the doctor is of the impression that the patient ought to go for an in-person consultation for their condition but the patient refuse, the doctor should inform them of the risks and consequnces of not seeking in-person treatment. If the patient still refuses, the doctor should require the patient to send a statement that they were informed of the risks and elected to proceed with the teleconsultation against medical advice in writing or as a voice note, and the doctor should preserve the consent with the records that he/she maintains for the consultation.

Transmitting Prescription to Pharmacy
If the doctor issues a prescription post a teleconsultation and the patient wishes that the prescription be sent directly to a pharmacy of their choosing, the doctor must obtain explicit consent from the patient prior to doing so, since without consent, the act of transmitting a patient’s prescription to a pharmacy would constitute a breach of confidentiality.

Support groups
If the doctor starts virtual support groups for patients suffering from or people affected by a disease/condition where they will be sharing information and/or allowing the group members to provide emotional support to one another, the doctor must seek explicit consent from a patient/person before adding them to the group, since the patient’s identity would be revealed to other members of the group, and confidentiality would thus be compromised.

Limitations of Telemedicine
It is advisable that doctor’s refrain from tending to spontaneous teleconsultations unless it is an emergency; they should put in place a process whereby the patient takes an appointment. Along with the appointment confirmation, the doctor should send a brief statement outlining the risks and limitations of teleconsultation, and informing the patient that by proceeding with the consultation, they are providing their consent.

How to record consent
For the teleconsultation itself, the consent will be implied if a patient proceeds to initiate the consultation after being informed of the risks involved.

For situations where explicit consent is required or advisable, the doctor may ask the patient to record it in any form – they could send an email, text, audio note, video recording stating that they are providing their consent for telemedicine (and any other context that may be required). The doctor must always record the fact of receipt of consent in his notes which should be preserved with the patient’s records.

Source:
Telemedicine Practice Guidelines

History of Telemedicine @ Apollo Hospitals India

Prof. K. Ganapathy
Former Secretary and Past President Neurological Society of India, Telemedicine Society of India & Indian Society for Stereotactic & Functional Neurosurgery | Hon Distinguished Professor The TamilNadu Dr. MGR Medical University | Member Roster of experts Digital Health WHO | Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services | URL: https://kganapathy.in EMail: drganapathy@apollohospitals.com

 

 

Chronicle of events

  • Sep 16th 1996 – The compiler of this chronicle delivered an Institute Lecture @ IIT Kanpur at 8pm. . Prof K. Srivathasan then HoD EE introduced him to the word Telemedicine and persuaded him to jointly prepare a project report from 10.30pm to 4am immediately after the lecture !!!.
  • Nov 1996 – Made a formal proposal along with Prof Srivathsan to Dr P C Reddy, Chairman Apollo Hospitals to do a pilot project @ Apollo Hospital Nellore . Prof Srivathsan and I even chose the room in Nellore !! However it did not fructify . We were too far ahead of the times!
  • April 1998 – Dr Reddy asked the author if he was still interested in Telemedicine. Ms Sangita Reddy had persuaded ISRO to use a VSAT for Telemedicine purposes @ the new secondary level hospital in the village of Aragonda ( near Chitoor) the birth place of Dr Reddy.
  • March 24th 2000 – The world’s first Teleconsultation from a village hospital thro amn ISRO enabled VSAT was commissioned by the then US president Bill Clinton from Hyderabad in the presence of the then Chief Minister Sri Chandrababu Naidu
  • In 2001 – Apollo Telemedicine Networking Foundation was formally established as a not for profit Section 25 company. Spoke in the first intercontinental live multipoint telemedicine symposium on June 19 2001. Bill Gates was also a speaker . Initiated teleconferences with, Japan, USA, Saudi Arabia and Hong Kong.
  • Feb 15 2002 – Apollo SHAR Telemedicine project commissioned by Chairman ISRO . ISRO convinced that Telemedicine was doable and took it up as a major initiative.
  • April 2002 – Addressed 600 principals of Engineering Colleges @ Anna University on Telemedicine. Subsequently started Telemedicine units in 5 Engineering colleges !!
  • May 2002 – Assisted ATnKK Area in Southern Command. Indian Army to set up Telemedicine units
  • 2003 – First formal University accredited 4 week certificate course on Telehealth technology was started with Anna University. Featured in Govt of India Documentary India 2.0
  • 2004-05 – Clinically validated Telemedicine enabled peripheral medical devices for IITM start up REMEDI
  • 2005 – VSAT enabled Hospital on Wheels commissioned at Madurai . Became first Treasurer and Joint Secretary of TSI with Reg No 001 ATNF also became first institutional member of TSI
  • 2006 onwards – Evangelisation on mission mode ! Talks given all over India and overseas creating awareness . Large number of VIP’s and VVIP’s visited the Dept to see Telemedicine in action . ATNF became a member of the Standards Committee on Telemedicine, the National Task Force on Telemedicine, the Working Group on Telemedicine of the Planning Commission, and the SARC Committee.
  • August 2007 – Assisted Ericsson in demonstrating wireless transmission of heart sounds etc thro 3G for the first time in South Asia
  • Nov 2007 – International Conference on Telemedicine at Chennai 350 attended including 35 from overseas
  • 2009 – MEA Govt. of India initiated the Pan Africa e-Network project for teleconsultations ATNF was part of the steering Committee and an active participant
  • 2010 – Commenced “Transforming Health Care with IT” international conference held annually till 2019
  • 2010 – Creation of Apollo Telehealth Services Pvt Ltd with a full time CEO and support staff
  • 2011 – eHome Visits initiated in Chennai won Best Post Poster award Washington DC
  • 2012 – 527 patients in 13 different specialities were connected simultaneously to six tertiary Apollo hospitals, from a Hospital on Wheels @ a mega health camp in Ajmer 11th /12th February. A world record then.
  • 2014 – Patient empowerment in rural India – project with MS Swaminathan Research Foundation promoting eHealth Literacy thro internet enabled Village Resource Centers > 26,000 from 13 villages have attended
  • 2015 onwards International Educational Activities with various Management Schools including London School of Economics, Harvard , Columbia etc , Chosen as case study to illustrate Global Best Practices by Columbia University
  • eICU’s 20 smaller ICU’s connected to Apollo Hospitals Hyderabad 1200 plus teleICU consults in subspecialities given.
  • Public Private Partnerships a) Himachal Pradesh . Four Telemedicine Centres in the Himalayas and the world’s first 24/7 Tele emergency Services . About 30,000 teleconsults already provided . b) >1.2 million teleconsultations provided under the Mukhyamantri Arogya Kendram (e-UPHC)- project covering 182 Centres from October 2016.c) Jharkhand Digital Dispensaries programme In first 15 months 328,648 patients attended d) Uttar Pradesh Telemedicine programme in the first one year 141,793 patients visited 114 Government Community Health Centres e) Uttar Pradesh Teleradiology PPP program has 127 teleradiology centres in rural UP with 400 images reported daily with turn around time < f 4 hours f) Tele Opthalmology Through 115 existing Community Health Centres / Vision Centres in 13 districts,5 million patients screened in 2 years. Thro Mukhyamantri e-Eye Kendram or MeEK project 405,000 fundus examinations were done remotely by 30 Opthalmologists from Chennai.
  • 2019 Only medical paper presented @ International Conference on Human Spaceflight Programme organised by ISRO.
  • 2021 Since inception over 400 papers have been presented in various regional, national and international meetings held in India and 105 held overseas . Over 180 articles have been published on Telehealth besides 45 in peer-reviewed journals and 12 chapters in textbooks. Several national and international awards have been received.