#Telehealth In India: Slope of Enlightenment or Plateau of Productivity by Manish Sharma, @msharmas





Clayton Christensen coined the phrase disruptive innovation two decades ago as a way of embracing the deconstruction that is necessary when a new technology displaces an old one.

In healthcare most of the technology disruption has been driven by the adoption in the medtech space as also in the use of innovative techniques in surgery such as minimally invasive surgery and robotic surgery. 


One technology however has started to see more adoption from the Industry and the mainstream population, is Telemedicine or as I would like to use the term ... Connected Health. 

Alliance for Connected Care (http://www.connectwithcare.org/what-is-connected-care/) defines Connected Care as: 


Connected Care is the real-time, electronic communication between a patient and a provider, including telehealth, remote patient monitoring, and secure email communication between clinicians and their patients. Connected Care improves access to care, helps providers and patients avoid costly health care services, and increases convenience for patients.   

Despite the rapidly developing technology and increasing interest among patients and physicians in the use of Connected Care, legal and regulatory barriers continue to limit mainstream acceptance of this technology. To achieve the promise of Connected Care in health care system, there must be a renewed urgency among policymakers to develop a regulatory structure that enables safe and accessible use of this technology.

In one of the previous articles, I had discussed about what Connected Health means, and how today's advances in accessibility and affordability of connectivity and mobile Technology has allowed for disruptive power to be placed in the hands of more and more people in India (Mary Meeker in her 2017 report mentions about #DigitalHealth being at an Inflection Point)

Connected Health, Telemedicine or Telehealth technologies are all poised to be seen as an effective tool to enable the delivery of healthcare. And move from Sick-care to true Health-care. 

WHO defines Telemedicine as, “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for 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” (WHO definition). 


What is the Gartner's Hype Cycle?
Each Gartner Hype Cycle drills down into the five key phases of technology's life cycle. 
No.PhaseDescription
1Technology TriggerA potential technology breakthrough kicks things off. Early proof-of-concept stories and media interest trigger significant publicity. Often no usable products exist and commercial viability is unproven.
2Peak of Inflated ExpectationsEarly publicity produces a number of success stories—often accompanied by scores of failures. Some companies take action; most don't.
3Trough of DisillusionmentInterest wanes as experiments and implementations fail to deliver. Producers of the technology shake out or fail. Investment continues only if the surviving providers improve their products to the satisfaction of early adopters.
4Slope of EnlightenmentMore instances of how the technology can benefit the enterprise start to crystallize and become more widely understood. Second- and third-generation products appear from technology providers. More enterprises fund pilots; conservative companies remain cautious.
5Plateau of ProductivityMainstream adoption starts to take off. Criteria for assessing provider viability are more clearly defined. The technology's broad market applicability and relevance are clearly paying off.
The term "hype cycle" and each of the associated phases are now used more broadly in the marketing of new technologies. [1]




Gartner Hype Cycle - Telehealth Technologies

In healthcare the need to allocate resources (Doctors, Nurses, Hospital Beds) to treat the patient at a particular time and specific place plays an important role in delivery of care to the persons visiting the hospitals/ clinics. 


Connected Care, Telehealth, Telemedicine technologies can help in fundamentally altering the care delivery process outside of the brick-and-mortar structures that have been traditionally used to deliver care.

A 2017 study by American Well found that 50 million Americans would be willing to switch primary care providers if it meant getting access to video visits, up from 17 million in 2015. It will be an interesting to study similar trends in India, specially given the access to internet connectivity in India, with the context of the Mary Meeker report referenced earlier.

Today the patient has an option to pick up her phone and call her doctor and seek advice on the phone or via a message, to seek an advice on quick care (headaches and minor ailments), or get an advice on medication schedule and therefore, it's safe to predict that consumer habits will continue to look for convenience and cost. 

In some Healthcare Facilities, you would find a medical assistant recording the symptoms and the complaints once the patient visits the clinic. The information is recorded based on a questionnaire put together by the medical team for the specialty. When the doctor starts the consultation, the she reviews this information recorded by the medical assistant and proceeds to record her assessment and plan for the patient. 

After the consultation with the doctor, the medical assistant stays on, and continues to advice the patient regarding the next course of action and the medications that needed to be taken by the patient. The medical assistant ensures that the patient understands the instructions conveyed by the doctor. However, the move to creating new workflows that help in streamlining the patient engagement process also means asking, "what do patients think about non-physicians?" 

https://www.politico.com/agenda/story/2017/10/25/role-of-physician-in-healthcare-000554

In India, we have the ASHA - Accredited Social Health Activists, who have been doing a yeoman service to help reach healthcare services to the last mile. As part of the National Rural Health Mission, there was a plan for 250,000 ASHAs in every village in 10 states as of 2012. As of 2013, the number of ASHAs in India was reported in July 2013 to be 870,089 [5]. The Indian MoHFW describes them as:


"...health activist(s) in the community who will create awareness on health and its social determinants and mobilize the community towards local health planning and increased utilization and accountability of the existing health services."[5]

With the availability of improved network connectivity in the rural areas [1], improved digital tools with the ASHAs, can perhaps further improve the accessibility to primary healthcare.
The Key benefits of Telemedicine or Connected Care? [2]
  • Improved access to primary care, specialists, 
  • Cost Savings,
  • Reduction in emergency room utilisation, 
  • Improved clinical outcomes, 
  • Increased patient satisfaction with care
  • Reduces appointments, freeing up capacity
  • Clinicians have access to patient readings at any time.
  • Patients are not bound to Healthcare Organisation hours
  • Travel costs are reduced for both healthcare professionals and patients
  • Regular monitoring means changes in treatment can happen much sooner
  • It enables patients to understand their condition

Barriers to Adoption: 
A. India Internet Connectivity [3]:
The internet connectivity has been stated as one of the barriers to adoption of connected health and telehealth/ connected health services, "According to a joint study by ASSOCHAM India, Internet penetration in India is likely to double by 2020 (India’s Internet population likely to touch 600 million by 2020: study, 2016). As of now, 27 out of 100 Indians log on to the internet, because of 3G and 4G connectivity. In absolute numbers, this represents 343 million users of the internet. 

By 2020, the number is expected to increase to 600 million. According to a recent report on rural consumers (98% of connected rural users men; 79% from the city: report, 2016) “more than half of new Internet users in India is from rural communities, and rural users constitute almost half (48%) of connected users in India by 2020.” 

As per the report, “The number of Indian rural Internet users will increase from about 120 million in 2015 to about 315 million in 2020, registering close to a 30% y-o-y growth.” [3]

B. Healthcare Telemedicine Framework - Current Trends: [2]
India is facing shortfall of 32% & 23% in no. of community & primary health centres

India’s telemedicine market which has been growing at a compounded annual growth rate (CAGR) of over 20 per cent. It is expected to grow from USD 15mn to over 35mn by 2020, noted a recent study by apex industry body ASSOCHAM.

In the study conducted by ASSOCHAM, "Promoting Rural Healthcare: Role of Telemedicine" it was noted that Efforts need to be made to create an overarching framework covering three levels, i.e.,  

  • primary healthcare centres (PHC) to district,
  • district to referral/super speciality hospitals and
  • issues vis-à-vis hardware/software requirements,
  • and bandwidth and connectivity needs to be fixed

As per the report, the secretary general of ASSOCHAM while releasing the findings of the chamber’s study said, “With limited resources and much of population living in remote, rural areas (68%), telemedicine has the potential to revolutionise delivery of healthcare in India.”

Further he mentions, “Providing quality healthcare to a large segment of population which does not have access to speciality physicians because of factors like geographic limitations or socio-economic conditions is the greatest challenge faced by the healthcare sector in India.”

During the course of past decade (2005-15) the number of primary health centres (PHCs) has increased by about 1,800 and there has been a rise of over 2,000 in the number of community health centres, noted the ASSOCHAM study highlighting extent of growth and development of rural healthcare in India.

“There is a shortage of about 32 per cent in terms of the number of CHCs in India at present while there is 23 per cent shortage of PHCs in the country.”



Late discovery of ailments, lack of experience in healthcare providers in rural areas and huge amount of time being spent in reaching urban health facilities make rural populace more vulnerable than their urban counterparts.

As such there is an urgent need for speeding up the process of building up healthcare infrastructure capacities especially in the rural areas.

“This could also been looked upon as an unexplored opportunity by private healthcare industry, here telemedicine has an important role to play by offering the possibility for remote diagnostics as technology will extend the reach of healthcare services and ease the pressure on overburdened systems.”

C. Lack of Legal Framework: In the Telemedicon 2016 conference held last year in Bangalore, the experts discussed about the lack of regulations to help the adoption of telemedicine in India. The lack of legal frameworks have a lagging effect in the adoption of Telemedicine in India. 

“Growth of a sustainable telemedicine network in India depends upon introduction of legal frameworks, development of national e-health policies, trained human resource and regular funding,” highlighted the study prepared by the ASSOCHAM Economic Research Bureau (AERB).

Dr. Milind Antani from Nishith Desai Associates in a recently concluded conference, "Revolutionising Healthcare with IT" spoke about the legal frameworks governing eHealth and Healthcare in India. 






Dr. Susheel from the George Institute and President at IAMI highlights the need for studying the cost effectiveness of the Telemedicine Services, "We just did a systematic review of telemedicine implementation in India (and found) very little evidence regarding outcomes or impact, most telemedicine efforts just report volume of transaction, nothing at all on cost effectiveness."

Technology Initiatives from the Government: 

One of the initiatives from the government of India are the Common Service Centre is now spread over all the villages and is promoted by Ministry of Electronics and Information Technology. The information about the following service was shared by Dr. S.B. Gogia (Chairperson IMIA WG on Telehealth on the IAMI members group

It is interesting to note that Telehealth Services and Diagnostics have been initiated by CSC and Apollo Hospital is the Telecentre for this program. This is also interesting to note that PM Jan Aushadhi Scheme is linked this Telehealth program and the Generic Medicines to these Jan Aushadhi will be provided by Public Sector Pharma companies. Details are as below (the information is presented below is as per the updated provided):

Tele-health Consultations:
In order to provide grass root level access points for health consultation among communities through digital medium, CSC is offering video based tele-consultation service throughout India at affordable rates. CSC SPV partnered with Apollo Hospitals Limited in 2014 to allow the VLEs across the country to facilitate the tele-consultations with doctors from Apollo Hospitals. In 2016, CSC SPV launched its own tele-health consultation services throughout India through Allopathic, Homeopathic and Ayurvedic doctors across the country.

The ISRO’s Telemedicine Programme
The Indian Space Research Organisation’s (ISRO) telemedicine pilot project was started in 2001 to make telemedicine accessible to the population at the grassroots.This initiative was launched under the GRAMSAT (rural satellite) programme, in co-ordination with various system providers such as In nium, Apollo, OTRI, BEL- VEPRO, Tele Vital, etc. The telemedicine facility connects remote district hospitals/health centres with super speciality hospitals in cities, through the INSAT satellites for providing expert consultation to the needy and underserved population.

The valuable experience gained during the initial pilot projects encouraged ISRO to undertake further endeavours to enable speciality healthcare delivery to the rural populace. The focus has been to introduce satellite communications-based telemedicine technology in various parts of the country through pilot projects.

Pradhan Mantri Jan Aushadhi Scheme:
Pradhan Mantri Jan Aushadhi Scheme aims at making quality medicines available at affordable prices for all, particularly the poor and disadvantaged, through exclusive outlets called ‘Jan Aushadhi Medical Stores’. The scheme is implemented by the Bureau of Pharmaceutical Public Sector Undertaking (BPPI). CSC SPV partnered with BPPI in 2015 to set up generic medicine stores under the Jan Aushadhi Scheme at the CSCs across the country.

Diagnostic Services:
Hello Health Kits: Launched in September 2016 in collaboration with Hello Health, diagnostic kits are used to test parameters like Blood glucose, BP, ECG, BMI, Spyrometry, Pulse oximetry and Body Temperature. Hello Health kits have been piloted in West Bengal, Tamil Nadu, Punjab & Haryana.

3Nethra Kits: 
CSC SPV has partnered with Forus Health Private Ltd (3 Nethra) for eye testing services at CSCs. The service was launched in November 2016.

Tele-medicine Remote Diagnostic Kit – Control H: Control-H is an integrated wireless healthcare monitoring medical device that helps in monitoring Blood Pressure, Heart Rate, Blood Oxygen, body temperature, Total Cholesterol, Haemoglobin, and Blood Glucose.

Thyrocare: CSC SPV has partnered with Thyrocare to provide diagnostic services through CSCs. Thyrocare diagnostic services have been piloted in Aurangabad, Maharashtra and VLEs can offer following diagnostic tests at affordable prices:
• Blood Test - CBC, HBA1c & TSH
• Urine Test - Urinary MA, Creatinine and Albumin/Creatinine Ratio
• Water Test - Detection of physical & chemical impurities, elements, bacteria & pesticides in water

JIVA Ayurveda Scheme: 
CSC SPV has partnered with JIVA Ayurveda to bring Ayurveda consultation and over 150 Ayurvedic products to citizens through the CSC network. The service was launched in July 2016 in Haryana, Uttar Pradesh and Punjab. JIVA Ayurveda product sale is now live in Madhya Pradesh, Maharashtra, West Bengal, apart from northern Indian states.

Health Homeo 999: CSC SPV has launched a new service called Health Homeo 999 package, which contains the following:

9 doctor consultations via video call; after the 9th consultation, consultation fee of Rs. 50 will be charged for every additional consultation. Treatment for unlimited diseases and health problems throughout the year and unlimited German medicines for the patient for one year. No courier charges for up to six couriers of medicines; after six deliveries, Rs. 50 to be charged for every additional courier.

Free Homoeopathic Family First Aid kit.
Treatment provided by World’s largest Homoeopathy treatment portal, ‘welcomecure.com’.​

In addition to the above initiatives by the government, here is an article we published earlier on other Digital Health initiatives which will help in delivery of Affordable, Accessible, Accountable care to the patients as India aims to be a Global Leader in #DigitalHealth by Rajendra Pratap Gupta

Healthcare apps that help deliver telemedicine services to the patients are also part of the tele-medicine delivery network that have been in play since that past 5 years in india. The B2C nature of these apps ensures the delivery of care at the palm of the patient. However, the number of patients' that are covered by these apps from a Bharat I, II and III perspectives needs to be seen. We have seen the presence of these apps across the continuum of care, covering various categories such as appointment scheduling, medication adherence, etc.

In a report published by PWC


"India ranks 2nd among developing countries studied on maturity for mHealth adoption. Widespread adoption of mobile technology in healthcare, or mHealth, is now viewed as inevitable by more than half of doctors and healthcare payers in developed and emerging markets around the world, including 60% in India.  The pace of adoption will likely be led by emerging markets that rank highest among ten countries on a score of mHealth maturity, according to a new global study conducted for PwC Global Healthcare by the Economist Intelligence Unit (EIU)."

In the same report, David Levy, MD, Global Healthcare Leader, PwC, said:


“Despite demand and the obvious potential benefits of mHealth, rapid adoption is not yet occurring.  The main barriers are not the technology but rather systemic to healthcare and inherent resistance to change.  Though many people think mobile health will be ancillary or bolted on to the healthcare industry, we look at it differently:  mHealth is the future of healthcare, deeply integrated into delivery that will be better, faster, less expensive and far more customer-focused.”

Future of Telehealth & Connected Care Initiatives: 

In a talk delivered at the Singularity University event, Jeroen Tas, Chief Innovation and Strategy Officer, Philips; talks about the need to create an omni-channel care pathway to deliver healthcare 24x7 network around the globe. Similar to the experience the banking industry has gone through in terms of their digital transformation. Two interesting observations from that talk are shared below as an interesting point to bolster the need for telehealth or connected health tech:
"To identify a Digital Ventures Success: Fragmented consumer experience, friction and waste in the value chain - Jeroen Tas"
Technology in the near future will enable Digital Twins, using BioPhysical  Computer Models of Patients, using patients' health data using ambient intelligenceAI and analytics - Jeroen Tas
https://www.politico.com/agenda/story/2017/10/25/role-of-physician-in-healthcare-000554



Sangita Reddy, Joint Managing Director, Apollo Hospitals Group provided a compelling vision of Tomorrow's Technology enabled Healthcare.





According to Dr. S.B. Bhattacharyya, "Telemedicine technology helps bridge the physical distance between patients and their care providers and enable the two to remain in touch 24 x 7 irrespective of their physical location. Here in India, travel is always a challenge and in the major cities with traffic and pollution and the sheer number of patients visiting doctors, the requirement to physically visit the doctor by an ill person poses a significant challenge. 

Through the use of telemedicine technology, a number of patients can be remotely cared for, thereby cutting down not only on the need for travel that inevitably means incurring a certain cost in terms of both money and time spent in the activity, but also help in reducing the number of patients who visit their doctors just for reviewing of past results and current condition and to get the advice of "continue same treatment" or worse, "stop treatment as you have recovered now", something that can safely be done from a distance provided they and their doctors are able to interact using video technology to both see and hear. 

In case the doctor feels that the case merits a physical evaluation, a nurse can be sent over to do that and report back to the doctor through the video call. This way the specialists can concentrate on those cases that would benefit more from his careful attention, something that lack of time does not permit." 

In his recently published book "A DIY Guide to Telemedicine for Clinicians", Dr. S. B. Bhattacharyya (https://link.springer.com/book/10.1007/978-981-10-5305-4#toc) asks the questions, “How can I set up a telemedicine facility at my centre?” It does not however help provide the answer to “What is telemedicine and how can it be used in healthcare?”. Its important to note, today its not about the question, "Should I have a telemedicine center?", rather its about figuring out how can a doctor, care provider, ASHA worker put together a Telemedicine Service offering for the consumer. Further Dr. Bhattacharyya notes, "The primary focus (of this book) is to guide the reader in using telemedicine technology to provide a level of care that increases customer satisfaction, which in turn increases revenues" 

Dr. Milind Antani, however is hopeful of changes being made to the various laws governing Telehealth and Telemedicine services in India. I asked him about the changes he invisages in the legal framework governing Telemedicine services in india? 

Dr. Milind Antani: "I would consider e-Health more relevant than Telemedicine as e-Health has broader scope of activities. India has been witnessing significant upward surge in e-Health recently. However, regulations have not evolved completely or not matching the pace. However I am envisaging the following changes/new laws, in India, in near future

  • Electronic Healthcare Data Privacy legislation
  • E-Prescription guideline/ amendment to allow e-prescription
  • Amendment to allow e-Pharmacy
  • Telemedicine Act ( may not happen in near future but required)
  • Amendment in MCI Code to allow Audio Video consultation for doctors
  • Central license by MCI to practice in every state of India

With the Healthcare moving out of the four walls of the traditional hospital, its safe to assume that the Health and care will be delivered at the point of care for each patient. Therefore moving Telemedicine to the realm of connected care. We found some interesting usecases for Telemedicine Delivery based on our search for new age contexts for delivery of Healthcare to consumers: 

1. An often stated usecase has been the use of Pharmacies to be used to provide in-store telemedicine http://ow.ly/7imu30hdpCj

2. There are proposals for making the first visits or follow-up visits to the doctors as completely on-video, http://ow.ly/liUw30hdpFn. The NHS has rolled out such a service in the UK. We have seen some of the hospitals in india providing these services to their patients. 

3. With ASHA workers being at the front-line of Healthcare accessibility and delivery in India, they can be fortified with Digital Health tools to help provide Telemedicine services to the patient's they cover. They can be connected to the state/ district based hospitals with the "command center" that house specialists providing telemedicine services. With the help of the ASHA workers the doctors can provide their advice, order tests and prescribe medications.

4. Another important area that should be explored by the hospitals and healthcare organisations is the delivery of Telehealthcare to the Seniors. With convenience being the predominant factor for seniors efforts should be made to provide specialist services. With the Here's a guide to enabling senior care via telemedicine. However, a study found only 28% of senior citizens were users of social media, requiring efforts that need to be put in place by healthcare organisations to enable remote delivery of care to this population group.

5.  Healthcare Apps will continue to play an important role in creating new care delivery frameworks that will make provide a "Phygital" Transformation of Healthcare that comprises of a physical and digital collaboration of resources to help acheive the "3A's of Healthcare Delivery in India": Accessibility, Affordability, Accountability. By incorporating payment gateways in Telemedicine apps, another area of customer friction to use the services provided by the healthcare organisations can be removed and allow for a much streamlined approach to providing Telemedicine services.

6. "Thanks to the emergence of consumerism, patient-centricity is now at the core of healthcare delivery. Nowadays, patients increasingly prefer extended follow-up care delivered at their homes, or at a step-down facility rather than in a hospital. 

With the adoption of the technological trend of serverless architecture, the implementation of RPM solutions for healthcare service providers can be cost-effective and much faster than ever before. Beyond the obvious IT advantages, it also facilitates better patient engagement through real-time alerts and it also enables proactive care delivery resulting in effective and high quality of patient care in the 21st century." 
Guruprasad. S, Sr. General Manager, Business Domain Healthcare, Robert Bosch Engineering and Business Solutions Private Limited  [7]

7. Mayo Clinic's telemedicine offerings have significantly expanded since their inception in 2013. The health system's enhanced-intensive care unit uses video monitors and advanced technology that allow a team of specialists to remotely monitor ICU patients from eight regional sites. Sean Caples, DO, and his team staff the command center 24/7, adding additional physicians during the busier night hours. The E-ICU has improved Mayo's mortality index by 40 percent in the first year after its 2013 implementation. The Mayo program is also using telemedicine services to aid in prenatal and postnatal care. [8]


References

[1]: Gartner Hype Cycle: https://en.wikipedia.org/wiki/Hype_cycle

[2]: Telemedicine market in India may cross $32 mn by 2020: Study
http://www.assocham.org/newsdetail.php?id=5728

[3]:On The Road to Digitization:

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