Take telemedicine forward in post-corona era

The novel coronavirus has engulfed the world, with over 35 lakh infected individuals and more than 2.45 lakh deaths so far. It has also inflicted unprecedented damage on the economy.

In this gloom, is there a silver lining or any lessons to be learnt from the medical point of view? The environment has surely benefited worldwide. Pollution levels have gone down. There has been a decrease in road accidents and resultant fatalities. At the PGIMER, Chandigarh, the number of patients coming to the trauma centre have reduced to one-third of the pre-lockdown days. Not unexpectedly, the number of patients of alcohol-induced acute pancreatitis and other ailments has come down drastically, as also those with allergies and secondary infections. This is being attributed to better hygiene being observed, and better home care. In Punjab, drug addicts have been thronging de-addiction clinics as the supply of drugs has dwindled due to the curfew.

There is a flip side also: many patients requiring urgent care have been avoiding reporting to the emergency for fear of getting exposed to the virus. More importantly, the Covid-19 pandemic has forced India to reassess and revamp its health infrastructure. India spends a mere 1.28 per cent of its GDP on health and the virus has prodded us to augment spending on health.

According to National Health Profile statistics, India has approximately 7,14,000 hospital beds in the government sector (0.55 beds per 1,000 population). A report of the Centre for Disease Dynamics, Economics and Policy (CDDEP, Washington, and New Delhi) on April 20 estimates 11,85,000 beds in the private sector with a combined total of nearly a lakh of ICU beds. The state governments have earmarked some hospitals as Covid-19 hospitals, which are predominantly in the government sector. Some states lack enough isolation beds and ventilators. Many states have also recognised a shortage of trained epidemiologists.

The government has acted with alacrity, with the PM leading from the front. The Indian Council of Medical Research has been formulating guidelines for testing, quarantining, treating and using personal protective equipment as well as coordinating research. The government has ramped up the production of protective gear. An effective command structure has been created, with frequent interactions between the health secretary and state health officials, with instructions being passed down to the tehsil level. This has resulted in an across-the-board coordination, leading to the optimum utilisation of infrastructure.

Covid-19, thus, has created an opportunity for the integration of public and private sector healthcare systems and a hierarchy of command being implemented. But there is scope for improvement. Of Tamil Nadu’s first 1,170 cases, only 20 were treated in private facilities and in Karnataka, 30 of the first 250.

The crisis should be used as an opportunity to identify deficiencies in our health system and plan a strategy to overcome them. The fact that from producing hardly any PPE in India till February, we are now capable of producing 50,000 to 1 lakh a day should encourage us to become a net exporter.

We should take it further and improve our healthcare delivery in the post-Covid era. For example, in Chandigarh, the coordination set in place recently for the fight against Covid-19 between GMSH, Sector 16, GMCH, Sector 32, and the PGIMER should be used for generating a referral system under which the PGIMER should receive only those patients who require tertiary care. The Chandigarh Administration recently proposed to formulate a system of referrals for Covid-19 from Punjab, Haryana and Himachal Pradesh to the GMCH 32 and PGIMER. This is a commendable step which needs to be carried forward in the post-Covid-19 period also. The PGIMER should attain its true tertiary care referral centre status so that it is not overwhelmed by sheer numbers, as has been happening till now.

With the OPDs of major hospitals shut or partly functional, patients are unable to seek specialised treatment. We should expand the use of telemedicine. It can overcome the issues of accessibility, inconvenience, affordability and social distancing, and it can also reduce the burden on tertiary care hospitals. Apart from direct patient-doctor consultation, it could be used between tehsil/district hospitals at the one end and medical colleges/multispecialty hospitals at the other for doctor-specialist consultation.

Telemedicine could be used mandatorily before referring any patient to the PGIMER. Umdaa Health Care, Hyderabad, run by a PGI alumnus, has launched three telemedicine concepts which give an idea of its potential and reach:

n Expert opinion, in which any doctor from a small nursing home/clinic or from a remote place can seek expert advice for his/her patient from specialists like a cardiologist or a neurologist from among the empanelled experts;

n Citizen tele-consultation, in which a patient can directly book a video-consultation with an expert doctor; and

n Umdaa Rural, in which healthcare workers/providers in remote areas can consult a central hub manned by doctors with inputs, including use of digital stethoscope with auscultation of lungs and heart. Using these platforms, PHCs can be linked to district hospitals, which, in turn, can be linked to medical colleges or tertiary care hospitals.

The MoHFW has acknowledged the importance of telemedicine. This has generated enthusiasm among the medical fraternity and spurred innovations. The recognition of telemedicine has offered much-needed clarity to the existing players and should boost its widespread use. It has also got legal sanctity, with the SC endorsing it recently. Telemedicine can be used for directing patients for first aid or reaching the nearest medical facility for emergency care. For non-emergency situations, it can be helpful for both diagnosis and treatment, as well as for monitoring and follow-up. The patient could register for a tele-consultation, pay online and fix a mutually convenient date and time. It can be organised through the hospital online portal (like what the PGIMER has started) or through a custom-made software integrated into the Hospital Information System (HIS), or through a mobile app. Patient confidentiality and data security have to be built in.

Technology can also be used to enhance tele-consultation experience. Using virtual reality (VR) headsets, VR can be integrated into telemedicine. The patient can get a real life-simulated experience, with the doctor positioned in his virtual chamber to overcome the psychological feeling of an impersonal interaction. VR has been used to help treat Parkinsonism, mental health issues and to detect early Alzheimer’s disease. It can also be used in surgical training and robotic surgery, besides in training healthcare professionals in small towns/villages, and the healthcare personnel for mass vaccination programmes. The current crisis can be converted into a chance to streamline healthcare in India and optimise our resources by using modern technology.