April 24, 2020

It was an emergency in a hospital. A patient needed to be immediately operated for a surgery. A super-specialty doctor who could handle this situation was in another city far away from the hospital. Immediately, in-house doctors approached the surgeon over the phone and a video conference was arranged. On one side, the super-specialty surgeon was giving directions, on the other side, the in-house doctors were performing the surgery. The operation was successful, the patient was saved.

If that videoconference was not arranged to take the directions of the surgeon who was far away, the patient could not have been saved.

Another incidence. The whole nation was shut down as there was a call for a bandh in protest against a policy. In a village, a boy was severely suffering from fever.

Neither the public transport nor a private vehicle were available to take the boy to a doctor residing in the nearby town. The patient’s family members contacted the doctor. The doctor collected the information about the symptoms and other details speaking to the patient over the phone and sent the prescription. Taking the prescribed medicines, the boy was able to recover from the illness. Thank God, there was provision to keep the pharmacy open as an essential service.

On that day, if the phone connection was not there to contact the doctor, it would have been a difficult situation for the patient and family members. Not necessarily during an emergency or some special incidents like bandh. When a patient is in a remote area, no transport facility is available. Bedridden patients, lack of medical staff, shortage of funding and deficient infrastructure, telemedicine help to bridge the gap between patients and doctors.

The credit goes to the telecommunication technology with which a patient or patient’s party can contact a physician and the other way around. In the present condition of novel coronavirus chaos and people eagerly looking for one or the other medicine, laymen having heard the word ‘telemedicine’ may guess that a new drug is in the pipeline. No, telemedicine is not a medicine as such, nor is a medicine sent through the phone (Who knows? In the future, that technology may also be invented!). Just like television with which we can watch live events occurring somewhere else, with telemedicine one can access the healthcare services from a long distance (tele = distant). The World Health Organization (WHO) defined telemedicine as 'Healing from a distance'.

Obviously, for any physician, personal interaction and inspection of a patient using primary healthcare devices, including a stethoscope, sphygmomanometer, blood glucose meter, weight scale, and thermometer are indeed very much essential to diagnose and prescribe a proper treatment. Every time the situation is not the same, and patients may not be able to physically contact the doctors or doctors may be unable to rush to the patients. Under such conditions, telemedicine has a significant role.

Currently, telemedicine has so advanced that it is well equipped with many portable kits for monitoring vital signs of patients, such as a digital stethoscope, pulse oximeter, electronic stethoscopes, automated blood pressure monitor, otoscope, dermatoscope, eTime’s home endoscope and many more. With all these compact devices, patients’ health conditions can be accessed in real-time (live) enabling the doctors to prescribe the proper treatment. However, these digital tools have to be handled by trained persons or local medical practitioners. Under such a case, the data generated can be forwarded to specialists to seek further clinical advice. Not just general physicians, it may be cardiologist, ophthalmologist, psychiatrist, radiologist, dermatologist, pediatrician, neurologist, nephrologist, dentist and surgeon (accordantly, the services are said to be telecardiology, teleophthalmology, telepsychiatry,teleradiology, teledermatology, telepaediatrics, teleneurology, telenephrology, teledentistry and telesurgery) and so forth who can extend healthcare services depending upon their expertise. In support of telemedicine, there is also telepharmacy that looks into supplying the prescribed medicines and other healthcare items to needy people at their doorsteps.

Though telemedicine seems to be a recent version of healthcare service, it has a long history. Way back in the 1950s, during the civil war, an electrical telegraph was used to report the injuries and the causalities to place the order for medications. The adoption of bio telemetric system to remotely monitor the ECG in the hospital by Dr Linthoven in 1903 is a landmark invention in telemedicine. In fact, in 1879 only, an international peer-reviewed medical journal The Lancet has published an article forecasting the utility of telephone in the medical field. It was in the 1970s, Thomas Bird coined the term telemedicine. When all the terrestrial-based communications collapse during disasters like earthquakes, tsunamis, volcanic eruptions, landslides, hurricanes, floods and more, the role of satellite-based telemedicine plays a vital role. During the Mexico City earthquake in 1985, the Soviet Armenia earthquake in 1988, the role played by NASA using satellite-based telemedicine service is a remarkable one. As and when, new communication and other allied technologies such as the telephone, radio, television, semiconductor, transistors, video-telephony, digital telephone, wireless communication devices, smartphone, two-way interactive television, computer, remote sensor, satellite and computer networks have been invented, telemedicine also went on evolving at an advanced level. Thanks to the scientists who invented communication and other technologies that made the world a ‘global village’. Today, one can instantly communicate from one corner of the world to the other. As far as telemedicine is concerned, many hospitals in India have installed advanced communication systems for the mutual sharing of information and services across the world. A doctor in the USA or UK can extend his/her expertise to a hospital in India, and similarly, a specialist in India can share his/her knowledge with other countries.

Information technology has also been coupled with communication technology making telemedicine a more effective healthcare service. Centre for Development of Advanced Computing (C-DAC), Noida in 1966 deployed the first indigenously developed hospital information system software at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP.

Currently, there are many software programmes (AnywhereCare, eVisit, NexHealth, VSee, PatientPop, etc) accessible helping doctors to practice telemedicine with higher efficiency compared to earlier days. Ministry of Electronics and Information Technology – Govt of India recently launched a mobile app ‘Aarogya Setu’ to be installed in the mobile for helping the general public as a safety measure against the novel coronavirus infection. In the present ‘App era’, telemedicine has also been modernized with many apps (Telemedicine Apps: Lybrate; Portea; Practo, etc). An app like Skype, a communication tool for free calls and chat can be installed in the smartphones useful at both ends between doctors and patients. It is appreciated that some multispecialty hospitals and medical colleges in India, including Karnataka, initiated providing healthcare services to their patients with the aid of customized-apps. Today, the mobile phone has become an integral part of our life; a smartphone with its various facilities like camera, scanner, browser, embedded memory, text message, voice message, installed apps, net pack and many more, are very helpful to avail the benefit of telemedicine. Well-advanced communication technologies, apps, software, gadgets, service providers are available to implement telemedicine. Most of all, the end-users; if unaware of the concept of telemedicine, nothing becomes useful. Therefore, equally important is creating awareness on telemedicine and its significance to the general public, particularly people of rural India.

India is a large country (seventh biggest in the world) with a population of 1,352,642,280 (As per the WHO 2019 revision of the World Population Prospects). There is a shortfall in the doctor-population ratio. As per WHO recommendation, a minimum doctor-population ratio is 1:1,000 (minimum one doctor for 1,000 people). According to the World Bank 2017 data, the ratio in India is 0.8:1,000. Hence, it is a major challenge to provide healthcare services to all the people, particularly in remote places.

Moreover, most of the Registered Medical Practitioners (RMPs) prefer towns or cities rather than villages to lead their professional life. Under these circumstances, telemedicine can fill the gap, provided that a high range network facility for communication must be established. Nevertheless, India is not lagging in implementing telemedicine service. At the international level, India occupies a special position in adopting and developing telemedicine technology. In 2001, Indian Space Research Organization (ISRO) in a joint venture with Apollo Hospital successfully implemented the Telemedicine Pilot Project, to provide satellite-based healthcare service linking between the hospitals in Chennai and Aragonda, a village in Chittoor district of Andhra Pradesh. The Govt of India, Ministry of External Affairs, Ministry of Health and Family Welfare, Department of Information Technology successfully implemented telemedicine in rural India and some state governments also joined hands with the union government.

National Rural Telemedicine Network (NRTN), Integrated Disease Surveillance Project (IDSP), National Cancer Network (ONCONET), National Telemedicine Task Force (NTTS) by the Health Ministry in 2005 are some of the glaring examples for the efforts implementing telemedicine in India. The first successful tele-transmission of ECGs of a patient from his home to a hospital by a team of doctors in GR Medical College, Gwalior, in 1975 (by converting ECG output into high-frequency sound at the receiver end through telephone) is one more feather in the cap.

Launching of SEHAT (Social Endeavour for Health and Telemedicine) by the Government of India in collaboration with Apollo Hospitals to connect 60,000 common service centres across the country to a common network and provide healthcare access to millions of citizens was a big telemedicine initiative in 2015.

An advantage of telemedicine is that it avoids the possible spread of contagious diseases by infected patients to others waiting in the hospitals/clinics, in a crowd.

However, telemedicine is not the ultimate solution. It has some limitations as well. A community residing in a remote area where there are no modern facilities, telemedicine does not work. Most importantly, telemedicine is applicable only if a patient’s condition is mild or severe. If it is an emergency like cardiac arrest, brain haemorrhage, obstructed labour, poisonous snakebite, causalities and others, then patients have to be immediately hospitalized.

In the current COVID-19 pandemic scenario, the nationwide lockdown (of course, worldwide) has become a necessary evil. Nearly one month of lockdown period is over, and we do not know how many days of extension to avoid the risk of mass spread of the novel coronavirus disease is demanded. Many hospitals closed or restricted the Outpatient Department (OPD) services. Moreover, many physicians locked their clinics and stopped practicing for the last month to avoid the possible risk of getting infected by the novel coronavirus. In this critical situation, the role of telemedicine is very crucial. Now, everywhere, we hear about the novel coronavirus havoc; it does not mean that all other diseases ran away in fear of the virus or patients with one or the other chronic disease (asthma, arthritis, cancer, obstructive pulmonary disease, diabetes and so on) have recovered. No doubt, diagnosis and treating of novel coronavirus infected persons whoever and wherever they are, is the priority. In the meantime, patients suffering from other illnesses cannot be sidelined; they should equally be accessible to take the treatment. It is very sad to mention that during this lockdown period, many people passed away without getting timely treatment as reported by many print and visual media now and then. It is the right time for RMPs to help society through telemedicine. By employing any or all the three basic versions of telemedicine, namely, ‘Store and Forward’, ‘Remote Monitoring’ and Real-time Interactive, physicians can integrate telemedicine as a part of their service. In this crucial period, a public domain composed of a list of doctors providing telemedicine service can be generated region-wise that will be useful to people. From the economic point of view, anyway, there are many options for electronic money transfer like net-banking, Paytm, Phone Pe, PayPal India, Mobikwik, Google Pay and several others.

There is a popular saying in our culture, 'Vaidyo Narayano Harih', which means, a doctor is equivalent to God. Big hats off to all the doctors for their great service to mankind saving lives.

Registered Medical Practitioners (RMPs) willing to extend the service in terms of telemedicine have to follow the norms and regulations formulated by the Government of India. The Union Government under the Medical Council of India (Professional Conduct, Etiquette, and Ethics Regulation, 2002) in collaboration with NITI Aayog, recently (March 25) notified a revised framework ‘Telemedicine Practice Guidelines’. (https://www.mohfw.gov.in/pdf/Telemedicine.pdf).

Adhering to the guidelines, RMPs can now provide consultation through video, audio, email or text. There is also an interactive web-portal hosted by the Centre for Health Informatics under the auspices of the National Institute of Health and Family Welfare (NIHFW) and the Ministry of Health and Family Welfare (MoHFW) - Government of India (https://www.nhp.gov.in/telemedicine_pg).

A team of doctors led by Dr Vinoth G Chellaiyan of Chettinad Hospital and Research Institute, Chennai, published a research article focussing on the current status of telemedicine in India, in the January 2019 issue of the Journal of Family Medicine and Primary Care, and is also worth reading (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6618173/#!po=3.12500).

Overall, telemedicine is a time saving, secured, real-time, safe and cost-effective healthcare service not only to remote areas, but also during critical conditions like a lockdown. The impacts of the novel coronavirus pandemic are multi-dimensional, and one drastically affected area is the health sector. Therefore, telemedicine is a need of the hour. In this harsh situation of pandemic COVID-19 and nationwide lockdown, let the benefit of telemedicine reach rural and urban India with its full potential.

Photo courtesy:  Jonathan Borba on Unsplash.com