Evolution of Teleconsultation in India

India is entering a new era defined by telehealth, also known as telemedicine, by pushing beyond the old concept of in-person consultations to reinvent patients' primary healthcare experience. The COVID-19 pandemic was a turning point that reemphasized the need for digital technologies to deliver seamless patient care. As a result, doctors, patients, and other stakeholders in the healthcare ecosystem have adopted an incredible increase in digital practices. India is currently at a turning point in the development of the digital world with the sole objective of rethinking healthcare for every Indian, regardless of their social strata, gender, religion, age, and other factors. With a compound annual growth rate (CAGR) of 22%, it is predicted that India's overall healthcare industry will be worth around US$ 372 billion in 2022. With a 39% CAGR, India's health-tech business is surpassing practically all segments of the Indian healthcare sector. Furthermore, it is anticipated to grow to US$ 50 billion by 2047. With initiatives like the National Health Digital Mission, Ayushman Bharat Digital Mission, e-Sanjeevani, and others, India has been making great strides towards unlocking its potential and power in the digital health sector.

Furthermore, owing to the COVID-19 pandemic's repercussions, the Indian government also gave telemedicine the much-needed recognition it deserved by releasing "Telemedicine Practise Guidelines". These guidelines encourage the use of telemedicine as a standard clinical practice and detail how digital technologies can be used in conjunction with other clinical standards, protocols, policies, and procedures for the provision of care, acting as a strong foundation for telemedicine. Moreover, since the COVID-19 pandemic, social distancing has become the new norm, resulting in the increased uptake of teleconsultations and e-pharmacy sales across the globe and India. Telemedicine refers to the use of communication networks and digital solutions in the delivery of health care. It allows collaboration between healthcare professionals and patients across geographic boundaries for tasks related to patient management, promotion of good health, diagnosis, and follow-up.

Telemedicine Industry in India

E-health is a rapidly expanding field at the crossroads of medicine, public health, commerce, and modern technology. E-health services are delivered in an environment where healthcare practitioners and patients are not in direct contact, and the engagement is mediated through electronic means. It consists of many electronic health data exchanges like:

• Telemedicine
• mHealth (mobile health)
• Electronic Health Records (EHR)
• Wearable Sensors

Telemedicine is the application of information and communication technology to enhance patient outcomes by providing more access to healthcare and medical information. It is regarded as a tool for remote diagnosis and treatment of patients through the use of technology. The World Health Organization (WHO) defines it 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”. The Indian telemedicine market is likely to develop significantly, with the market size expected to increase from US$ 830 million to US$ 5.5 billion by 2025. Moreover, this expansion is projected to be fuelled by a 31% CAGR throughout the same time period. Several critical variables, such as increased healthcare demand, technical improvements, diagnosing convenience for patients, and improved patient retention, all contribute to the expansion of the telemedicine sector.

Types of Interventions

• Synchronous

In synchronous engagement, the telemedicine participants or stakeholders engage with one another dynamically in real-time. The communication is rapid, and it allows participants to answer questions (if any) in real-time. A video consultation, for example, is a type of synchronous teleconsultation.

• Asynchronous

The "store and forward" method of communication is another name for it. Here, people are free to respond or communicate at their own pace. The stakeholders do not communicate in real-time. It is appropriate when the consultation or communication is not time-sensitive. It is primarily utilised to send investigative results or to follow up on a regular basis. Email, text messages, and faxes are a few examples.

• Remote monitoring

This is also known as remote patient monitoring, and it refers to a technique of providing health care that employs developments in information and technology to monitor patients outside of healthcare settings. The patient's data is electronically communicated to the healthcare professional, who monitors the patient's health and the emergence of new disease states.

Modes of Communication

• Video

The closest thing to in-person meetings is a video consultation. Communication takes place in two ways, interactive and real-time. Identification of the patient is simple. In this mode, you can examine the subject and collect their visual cues. Additionally, it gives the chance to examine patients and show them how to perform specific tasks.

• Audio

Compared to video consultation, audio consultation is more practical and accessible. Real-time and dynamic engagement is taking place. The provider and the receiver can exchange the offered information repeatedly. Verbal signals are provided through audio consultation, but non-verbal indications are missed, therefore thus is not appropriate in situations where visual inspection is necessary.

• Text-Based

Consultations conducted by text are rapid and convenient. When there is simultaneous interaction, these can either be real-time or delayed, as in "store and forward" systems. These work well for follow-ups and second opinions. The text-based systems also facilitate more effective document delivery, including the transmission of test results and prior medical information. Text-based platforms, on the other hand, are deficient in both visual and verbal cues.

Medical Ethics

Patients' health-related data should be recorded and handled in accordance with Telemedicine guidelines published as Appendix 5 of the Indian Medical Council (Professional Conduct, Etiquette, and Ethics) Regulation, 2002 (6), which outlines a doctor's duties and responsibilities, misconduct rules, and ethical aspects of consent, data privacy, and confidentiality. Informed consent should also contain information about the scope, expected benefits, nature of the consultation, medical information and records, confidentiality, risks, and restrictions of the consultation.

• Consent

  The patient's or caregiver's consent is essential to the telemedicine consultation. For consent to be valid, the patient must be aware of the nature and extent of telemedicine as well as the type and extent of the ailment being studied.

• Data privacy and confidentiality
  • While providing telemedicine consultation, professional standards for data protection and confidentiality under the IMC Act 1956 and IMC (Professional Conduct, Etiquette, and Ethics) Regulations 2002 shall be adhered.
  • The teleconsultation is likewise subject to the same data protection and privacy legislation as an in-person consultation.
  • A system for documenting, storing, and retrieving medical records should be devised. All documentation required for in-person consultation should be kept on file for teleconsultation as well.
• Standards of care
  • The medical professionals who offer telemedicine services must adhere to the same high standards of care as those who conduct in-person consultations.
  • The doctors must make sure that the patients and their families are informed accurately and promptly about the type and severity of their sickness.

Opportunity

• Expanded access

By delivering healthcare directly to patients' homes and mobile devices, telemedicine overcomes constraints such as a shortage of medical staff and challenges with access to care. This is especially advantageous for patients in rural areas.

• Improved patient care

Telemedicine improves patient-doctor communication, enabling patients to voice their issues and get more information. It also eliminates gaps in health care caused by factors like location, ethnicity, and social standing.

• Increased efficiency

Long wait lists, rigid appointment schedules, transportation challenges, and frequent follow-ups are all decreased by telemedicine. Remote patient monitoring allows clinicians to deliver healthcare more effectively and affordably.

• Collaboration and knowledge sharing

Telemedicine facilitates collaboration among healthcare practitioners by allowing them to share knowledge and seek second views or contact specialists without regard for physical limits.

• Strengthening primary healthcare

By boosting palliative care, early disease detection, preventative tactics, and rehabilitation, effective telemedicine implementation enhances India's primary healthcare system.

Government Initiatives

• eSanjeevani

  The Health Ministry's countrywide telemedicine programme has aided many suffering patients who are unable to visit doctors owing to lockdown limitations, while also revolutionising healthcare and reaching individuals in the most remote of regions. It was released in November 2019. In February 2023, 100.11 million patients were serviced at 115,234 Health and wellness Centres (as spokes) via 15,731 hubs and 1,152 online OPDs staffed by 229,057 telemedicine-trained medical specialists and super-specialists. eSanjeevani has been expanded to support over 1 million consultations per day, with the platform reaching a peak of 5,10,702 patients per day. eSanjeevani has proven to be a blessing, especially for persons living in rural areas where access to treatment is more difficult. It has since found far broader applicability throughout the health spectrum and has revolutionised primary healthcare services in our country. The cloud-based eSanjeevani platform was introduced in two forms:

  • eSanjeevaniAB-HWC (a provider-to-provider telemedicine platform)

  A telemedicine system that connects patients through health workers and medical officers at Health and wellness Centres to doctors and specialists in hubs established in secondary/tertiary level health facilities or medical colleges. This variation is built on a Hub-and-Spoke design. 

  • eSanjeevaniOPD (a patient-to-provider telemedicine platform)

  It enables residents to obtain outpatient services from the comfort of their own homes via cell phones, laptops, and other devices.

• National Medical College Network (NMCN)

  The 50 Government Medical Colleges are being connected via the NKN (National Knowledge Network - high-speed bandwidth connectivity) with the aim of e-education and e-healthcare delivery. A National Resource Centre (NRC) with the necessary centralised infrastructure and seven Regional Resource Centres (RRCs) have been constructed, as shown below:

  • NRC cum Central RRC -SGPGIMS, Lucknow
  • RRC, North - PGIMER, Chandigarh
  • RRC-Central - AIIMS, New Delhi
  • RRC-South - JIPMER, Puducherry
  • RRC-East -IMS, BHU, Varanasi
  • RRC-West - KEM, Mumbai
  • RRC-Northeast-NEIGRIHMS, Shillong
  • RRC-South II- SCTIMST, Thiruvananthapuram
• National Telemedicine Network (NTN)

  The National Telemedicine Network (NTN) plan was established with the goal of improving existing government healthcare facilities (MC, DH, SDH, PHC, and CHC) in the States, in order to provide telemedicine services to rural areas. It is suggested that the first phase of the National Telemedicine Network project linked 500 PHC/CHC/SDH in outlying/rural areas with 100 District Hospitals and 50 Medical Colleges. All NHM mission directors have been asked to apply for funding under their respective State or UT's National Health Mission (NHM) scheme's Programme Implementation Plan (PIP) in order to enhance and promote the Telemedicine network.

• Tele-Radiology (NIC-Delhi)

  CORS (CollabDDS Online Radiology Services) is a web platform for resolving radiological and dental difficulties among various health communities. CORS is available to both local and distant doctors seeking advice from qualified radiologists. In exchange, radiologists offer doctors with diagnosis/diagnostic reports. Through the use of CORS, clinicians can either upload cases for the experts to review or they can collaborate in real-time with the experts, shortening the turnaround time. In an effort to address the lack of radiologists at primary healthcare institutions, the CORS project was started with the goal of providing Online Radiology interpretation on reports for Continuing Medical Education (CME) for Medical Officers.

• SATCOM-based Tele-Medicine Nodes at Pilgrim places

  Using space technology tools for telemedicine facilities between identified remote patient end health facilities and speciality hospitals in collaboration with the Department of Space for health awareness has been envisaged in line with the PM's vision of setting up new telemedicine nodes at Pilgrimage places. Noncommunicable disease (NCD) screening and speciality consultation will be available to devotees visiting the following locations.

  • Kashi Vishwanath Temple, Varanasi, (UP)
  • Maa Vindhyavasini Mandir, Vindhyachal Dham, Mirzapur (UP)
  • Sheshnag, Amarnath Pilgrimage (J&K)
  • Pampa Hospital, Ayyappa Temple at Sabrimala in Kerala

Currently, it is suggested that the discovered patient nodes be interconnected with the specialised nodes in their respective States. However, teleconsultation can be accessed from any of the country's super speciality nodes, including PGIMER (Chandigarh), SGPGI (Lucknow), AIIMS (Delhi), JIPMER (Puducherry), and others.

Road Ahead

India is known as the "pharmacy of the world" since it is the world's largest producer and exporter of generic medications, with a total revenue of US$ 42 billion. This has enabled a substantial proportion of the global population to gain inexpensive healthcare access, with Indian vaccines serving two-thirds of the world's children. India is making concerted efforts to achieve universal healthcare by 2030, indicating its commitment to the Sustainable Development Goals.

The epidemic has offered India and the rest of the world with a plethora of chances to accelerate technical breakthroughs in the healthcare industry. India's accomplishments in this field have proven beneficial to the country's advancements, especially due to the strong push from the government. The sector offers huge prospects and scope in the future due to India's enormous diversity and population size. In order to advance in releasing the power and promise of digital health, India is committed to bringing together public, health, and IT voices.