July 2024: How Telemedicine is Redefining Healthcare Access

S. Sood et al, What is Telemedicine?, Telemedicine and e-Health, 2007 

This extensive literature review, which collected and analyzed 104 peer-reviewed definitions of telemedicine, produced a comprehensive modern definition of the term, telemedicine.

Key Takeaways:

1. Telemedicine encompasses a wide range of applications, from simple email-based consultations to complex remote surgical procedures, bridging geographical distances to provide healthcare, thereby enhancing access and efficiency.
2. Definitions highlight medical, technological, spatial, and benefit perspectives of telemedicine.
3. The modern definition integrates telemedicine within e-health, emphasizing its role in addressing resource distribution challenges.

Comment from the Center for Global Digital Health Innovation: This review highlights the evolution and diverse applications of telemedicine. It offers a nuanced understanding by synthesizing various perspectives. Future research should focus on empirical studies evaluating telemedicine's effectiveness in different contexts and explore AI and machine learning's role in advancing its capabilities.

R. Parajuli et al, Exploring the role of telemedicine in improving access to healthcare services by women and girls in rural Nepal, Telematics and Informatics, 2017 

This mixed-method study investigates the impact of telemedicine on reducing gender-based barriers to healthcare access for women and girls in rural Nepal. 

Key Takeaways:

1. Telemedicine significantly reduced travel frequency and distance for women and girls to access healthcare in rural Nepal, improving the convenience of medical care while managing gendered responsibilities (i.e., caring for children, preparing food, etc.). 
2. The technology lowered overall treatment costs and enhanced privacy for women when consulting about sexual and reproductive health issues.
3. Issues such as mobile phone ownership and literacy constrain the full utilization of telemedicine services among women in rural areas.

Comment from the Center for Global Digital Health Innovation: This study’s strength lies in its comprehensive mixed-method approach for understanding how telemedicine improves gender equity in rural healthcare. Future research should assess the urban-rural divide in telemedicine efficacy and on strategies for overcoming the gender digital divide.

Below, we summarize four articles that assess the effectiveness of telemedicine for chronic diseases, primary healthcare, and infectious diseases. 

V. Mohan et al, Prevention of Diabetes in Rural India with a Telemedicine Intervention, Journal of Diabetes Science and Technology, 2012

This study evaluated the Chunampet Rural Diabetes Prevention Project (CRDPP), which uses telemedicine and personalized care to provide comprehensive diabetes screening, prevention, and treatment in rural India. Results showed significant reductions in mean HbA1c levels , from 9.3% to 8.5% within one year among diabetes subjects exposed to the comprehensive telemedicine-based project in rural India. The project demonstrated high patient engagement with less than 5% of patients requiring referral to a tertiary center.

N. Verma et al, Diagnostic Concordance of Telemedicine as Compared With Face-to-Face Care in Primary Health Care Clinics in Rural India: Randomized Crossover Trial, Journal of Medical Internet Research, 2023

In this rural India study that used a randomized, crossover design, telemedicine demonstrated a 74% diagnostic concordance and 79.8% treatment concordance compared to face-to-face consultations. The highest diagnostic concordance was observed in managing hypertension (95%) and diabetes (93%), while lower concordance rates were seen in cardiology (33%) and non-specific symptom cases (30%). 

R. Qin et al,  Reliability of a Telemedicine System Designed for Rural Kenya, Journal of Primary Care & Community Health, 2012

In this rural Kenyan study examining the reliability of the community health worker (CHW)-based Mashavu telemedicine system, the system demonstrated high reliability, with the nurse providing consistent medical feedback in 78.4% of the cases and the same patient action recommendations in 89.2% of the cases when comparing telemedicine consultations to face-to-face visits. This system supported task shifting by enabling CHWs to collect and transmit vital health data.

P. Guo et al, Telemedicine Technologies and Tuberculosis Management: A Randomized Controlled Trial, Telemedicine and e-Health, 2019

In this evaluation of the effectiveness and cost-benefit of video directly-observed therapy (VDOT) compared to traditional directly observed therapy (DOT), VDOT demonstrated similar treatment completion rates to DOT (96.1% vs. 94.6%). However, VDOT offered significant advantages in terms of time and cost savings. The average time per dose observed was 16.5 minutes for VDOT compared to 44.1 minutes for DOT, and the cost for VDOT was significantly lower. Patients in the VDOT group reported higher satisfaction, finding it more convenient, and more likely to recommend it. 

Comment from the Center for Global Digital Health Innovation: These studies collectively highlight telemedicine’s potential to revolutionize healthcare delivery, demonstrating its ability to maintain high standards of care while reducing costs and increasing accessibility. However, despite these promising results, telemedicine still faces challenges such as varying diagnostic accuracy and the need for robust infrastructure to support remote consultations. Future research should focus on integrating advanced diagnostic tools and AI to enhance accuracy, as well as developing training programs for healthcare providers. Additionally, longitudinal studies are needed to assess the long-term sustainability and impact of telemedicine interventions on healthcare systems.

J. S. Resneck Jr. et al, Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease,JAMA Dermatology, 2016 

This study assesses the quality of direct-to-consumer (DTC) teledermatology services by submitting dermatologic cases with photographs to various websites and apps. It evaluates clinician choice, transparency of credentials, data collection, diagnoses, treatments, and care coordination.

Key Takeaways:

1. Most DTC telemedicine services lack patient choice in selecting a clinician and transparency about clinician credentials; 42 (68%) encounters assigned a clinician without any choice, and only 16 (26%) disclosed clinician licensure information.
2. Diagnoses and treatments are often provided without adequate collection of patient history, leading to misdiagnoses and inappropriate treatments. Only 14 (23%) encounters collected the name of an existing primary care physician, and few offered to send records (6 [10%]).
3. Only a minority of encounters included information about adverse effects or pregnancy risks when prescribing medications; relevant adverse effects were disclosed in 10 of 31 (32%) diagnosed cases, and pregnancy risks in 6 of 14 (43%) cases.

Comment from the Center for Global Digital Health Innovation: This study’s detailed evaluation highlights significant issues in the quality and coordination of care provided by DTC teledermatology services. Gaps in patient-clinician interaction and transparency – crucial for accurate diagnosis and treatment – were identified. This study underscores the need for better regulation and quality assurance in DTC telemedicine. Future research should focus on developing standardized protocols for data collection and patient engagement to enhance the reliability of telemedicine services.

S. Sharma et al, Addressing the Challenges of AI-Based Telemedicine: Best Practices and Lessons Learned, Journal of Education and Health Promotion, 2023 

This article explores the integration of AI in telemedicine, highlighting its potential to enhance healthcare delivery through patient monitoring, intelligent diagnosis, and assistance. Lessons learned from implementing AI-based telemedicine, emphasize the importance of physician-guided implementation, regulatory compliance, and training for healthcare providers.

Key Takeaways:

1. The implementation of AI-based telemedicine should comply with existing clinical practices and regulatory frameworks to ensure trustworthiness, reproducibility, and cost-effectiveness.
2. Education and training for healthcare providers are crucial to the successful adoption of AI technologies in telemedicine.
3. AI can be applied in various telemedicine subsidiaries, like teleoncology, telecardiology, tele-ICU, and telepsychiatry.
4. Challenges such as technology access, human resources, data privacy, and financial constraints must be addressed, particularly in resource-limited settings.

Comment from the Center for Global Digital Health Innovation: The strength of this comprehensive overview on integrating AI in telemedicine lies in the detailed analysis of best practices and the emphasis on physician-guided implementation. However, the article could benefit from more empirical data – such as a meta-analysis – to support its recommendations. Future research should focus on real-world applications of AI-based telemedicine in diverse settings, including resource-limited environments, to validate its effectiveness and address specific challenges. 

Dr. Neha Verma: Your journey in telemedicine is remarkable. You are one of the foremost experts in the world and have built the world's largest telemedicine platform, impacting hundreds of millions of lives. Could you share a bit about your journey in health informatics and telemedicine? What inspired you to focus on these areas, and how did your journey start?

Dr. Sanjay Sood: Thank you, Neha. During my bachelor's in Electronics and Communications Engineering, I chose modules that had societal impact, specifically Biomedical Equipment Technology. This set the course for my career. I joined C-DAC in Mohali during its early foray into healthcare technologies, which allowed me to establish and lead the Biomedical Equipment Technology Division in 1995. In 1999, C-DAC was tasked by the government to pioneer the development of indigenous telemedicine technology. This led to the creation of Sanjeevani in 2002, which evolved into eSanjeevani. Over two decades, it has become India's National Telemedicine Service, the world's largest telemedicine implementation in primary healthcare.

Dr. Verma: What was the initial vision behind eSanjeevani? When did it start, and how has it evolved since then?

Dr. Sood: The vision for eSanjeevani began in 1999, aiming to develop indigenous telemedicine technology for the Government of India. Initially, we focused on establishing tele-radiology, tele-cardiology, and tele-pathology practices for tertiary-level institutions like AIIMS in New Delhi, PGIMER in Chandigarh, and SGPGI in Lucknow. This technology aimed to foster collaborations and tele-education among specialists at these premier hospitals, build capacities, enhance healthcare delivery, and improve accessibility to specialized services while optimizing resources.

Dr. Verma: What were some of the biggest challenges you faced during the development and implementation of eSanjeevani? From its inception in the 90s to its significant growth during the pandemic, what were the obstacles and how did you overcome them?

Dr. Sood: We faced two primary challenges. First, there was limited perception of telemedicine's potential, resulting in little buy-in. Second, from 2002 to 2020, patient-to-provider telemedicine consultations were not permissible in the country. The pandemic highlighted the necessity and effectiveness of telemedicine, addressing these challenges.

Technically, in 1999, we had no global examples to follow except a few implementations in Scandinavia and North America, which weren't particularly useful for developing telemedicine technology for resource-limited settings. Additionally, until 2010, internet access was a huge problem. We relied on ISDN lines, which were expensive and not widely available. It wasn't until 2013, when the Government of India revised internet access policies, increasing the minimum download speed to 512 kbps, that we felt encouraged. We overcame these challenges through persistent advocacy, technological adaptation, and leveraging the increased acceptance of telemedicine driven by the pandemic.

Dr. Verma: Growing connectivity, better digital literacy, and the ubiquitous use of smartphones have certainly driven adoption. How do patients and providers feel about eSanjeevani today? What do they think of its user-friendliness, and what are the incentives for them to use it?

Dr. Sood: The widespread adoption of eSanjeevani speaks volumes about its usefulness to both patients and providers. Initially, there were concerns that usage would drop post-COVID. However, the Government of India, through the Ministry of Health and Family Welfare (MoHFW) and the Ministry of Electronics and IT (MeitY), ensured its full potential was realized. As a result, growth continues, and we are making eSanjeevani even more user-friendly. States are devising ways to increase uptake by providing incentives to users, particularly health workers, improving connectivity, and increasing digital literacy. Last year, we rolled out eSanjeevani 2.0, built on a robust architecture that matches any secure and scalable platform globally. We consistently improve its functionalities to empower both patients and providers. The platform is now used in other national initiatives like Tele-MANAS, the national tele-mental health program. We've also replicated eSanjeevani for the Ministry of Defense and are working with the All India Institute of Physical Medicine and Rehabilitation to set up a national tele-rehabilitation network. We aim to reach around 1 million consultations daily on this platform.

Dr. Verma: How has eSanjeevani impacted healthcare delivery in rural and remote areas of India? Are there any success stories or data points that stand out to you?

Dr. Sood: eSanjeevani has significantly impacted healthcare delivery in rural and remote areas by providing accessible teleconsultation services and bridging the gap between patients and healthcare providers. There are many success stories highlighting the platform's effectiveness. For example, telemedicine practitioners on eSanjeevani have identified life-threatening conditions in patients and arranged for immediate transport to the nearest ICUs. eSanjeevani is now operational in orphanages, old age homes and prisons, allowing inmates to access health services more quickly and reducing the financial burden on these organizations. States are using various models to serve patients, from utilizing in-service practitioners to appointing dedicated telemedicine teams and engaging specialists full-time. This flexibility allows each state to adopt the model that best suits its needs.

Dr. Verma: Some states have enough doctors, but they are concentrated in urban areas, leading to an inequitable distribution. eSanjeevani can create public-private partnerships to bring in additional doctors on a contractual basis, boosting the total number of providers in the system. How do organizations like Intelehealth help strengthen eSanjeevani?

Dr. Sood: Organizations like Intelehealth complement eSanjeevani by providing on-ground support. We often lack the time to get into the field or talk to users, so Intelehealth's support is crucial. They help ensure seamless integration and support, particularly in states like Jharkhand, Odisha, and Maharashtra. Other organizations support us in Bihar, Uttar Pradesh, and Madhya Pradesh. These organizations fill a vital gap that we on this end cannot fill. Without organizations like Intelehealth, the reach and efficiency of eSanjeevani would not be as significant as they are now.

Dr. Verma: Thank you so much, Doctor. I wanted to share some case studies of patients using eSanjeevani. Many times, we see eSanjeevani being used for diabetes and hypertension care. After an initial diagnosis, consistent follow-up care is needed for blood sugar or blood pressure to come under control. We have many stories of patients with blood sugars of 140, 160, even 200, who have been consistently doing follow-up consultations near their homes. There are many stories of women, especially those who cannot travel due to lack of money or agency, finding it very helpful. Patients with tuberculosis are also receiving consistent follow-up care after initial diagnosis. We see a lot of dermatological health issues and common illnesses like cough, cold, and fever being triaged. This helps determine if the fever is due to malaria, COVID, pneumonia, or just an upper respiratory tract infection. Frontline health workers typically need this kind of support. We see growing use of eSanjeevani for public health issues. India has a growing burden of non-communicable diseases and is the diabetes capital of the world. Solutions like eSanjeevani are key for the health system to address these issues of national importance.

Dr. Verma: What has been the role of government and policy in driving the success of telemedicine? In March 2020, the Indian government came up with telemedicine guidelines. How did that change the game?

Dr. Sood: The telemedicine practice guidelines released in March 2020 played a crucial role in driving the adoption and success of telemedicine in the country, and eSanjeevani specifically. eSanjeevani is perhaps the only free-of-cost service available to the rural and isolated population in the country. The government's timely and proactive support enabled this. Since health is a state subject, both the central and state governments worked together, creating appropriate policies and providing necessary funding to promote telemedicine across the country. Without this coordinated effort, such widespread uptake of eSanjeevani would not have been feasible. The support from both federal and provincial governments was crucial for the adoption and success of telemedicine in India.

Dr. Verma: How do you address concerns related to data security and patient privacy on the eSanjeevani platform?

Dr. Sood: eSanjeevani complies with all the standards and regulatory requirements that any digital platform or public good must meet in the country. We prioritize data security and patient privacy through stringent measures. We adhere to the electronic health record (EHR) guidelines of the Ministry of Health and Family Welfare, which include implementing end-to-end encryption for all communications, ensuring secure storage and transmission of patient data, and strictly following government regulations and international data protection standards. Regular security audits are conducted to maintain the highest standards of data security and patient confidentiality on eSanjeevani.

Dr. Verma: What should the world learn from India's implementation of eSanjeevani? What advice would you give to other countries and regions looking to implement similar telemedicine initiatives?

Dr. Sood: For countries or regions looking to implement population-scale platforms like eSanjeevani, it is essential to identify forward-looking policymakers, health administrators, and champion digital health practitioners, as well as proactive health workers. Ensuring that the initiative is centered around the needs of the healthcare delivery system is crucial. One significant factor contributing to eSanjeevani's success is that the platform, from design through development, deployment, capacity building, and management, is handled by a single team. This increases efficiency. These experiences have helped us grow eSanjeevani from a new innovation in the health space to conducting over 600,000 teleconsultations in a single day. Other countries should focus on these aspects while planning similar initiatives for their healthcare delivery systems.

Dr. Verma: How do you ensure and promote high-quality teleconsultations on the eSanjeevani platform? What features and tools are built into the software to enable quality healthcare delivery?

Dr. Sood: In eSanjeevani 2.0, we have added multiple features based on user feedback from eSanjeevani 1.0. These include follow-up consultations, which were missing in the previous version. Now, for continuity of care, the same patient can consult the same doctor again, with that doctor having access to patient’s medical history and previous conditions.

We also introduced an innovative concept called the case completion score or EHR completion score. In eSanjeevani 1.0, many EHRs were left incomplete, hindering accurate and quick diagnoses. To address this, we assigned weighted scores to every field within the EHR, making some fields mandatory and others optional but valuable. Community health officers and health workers are directed to ensure that a case is at least 75% complete before sending it to a doctor. This has helped gather comprehensive data and empowered doctors to make precise diagnoses. Since the launch of eSanjeevani 2.0, the quality of data has improved, and we have received positive feedback from patients, doctors, and health workers.

Another feature we introduced addresses the non-availability of doctors. Previously, patients couldn't utilize eSanjeevani fully due to this issue. Now, eSanjeevani enables inter-state consultations. If a designated doctor is unavailable, the system searches for a similar specialist in neighboring states. If no doctor is available there, it expands the search to the rest of the country. This hub-and-spoke model has significantly reduced the issue of doctor unavailability.

We continuously add such features after discussions with the Ministry of Health and Family Welfare and various states. These enhancements are sure to further improve the quality of consultations on eSanjeevani.

Dr. Verma: We're also seeing better case completion scores due to the addition of a symptom-checking digital assistant. For example, when a patient comes in with a fever, it guides the community health officer or patient in the outpatient department to report how many days they've had the fever and whether they also have a cough. This greatly improves the quality of the consultation. Studies we have conducted show a lot of positive feedback from patients, with a patient satisfaction score of about 4.1 out of 5 for eSanjeevani teleconsultations. More than 60% of patients report complete recovery from their symptoms, and 25% report partial recovery.

We conducted a study in Jharkhand across five districts with 500 patients, using an adequately powered randomized sampling approach. We are now repeating this study in Odisha and are seeing very similar results. This shows that it's not just about the volume of teleconsultations, but also the quality of care delivered, which consistently keeps people coming back. Our survey found that 75% of patients who visited health and wellness centers for eSanjeevani had already done a consultation before in the past two years. This repeat use indicates patient satisfaction and reported improvement in health outcomes.

Dr. Verma: My last question, Dr. Sood: What's next for eSanjeevani? Do you have any upcoming features or enhancements you can share? Are there any emerging technologies like AI and machine learning being used in eSanjeevani?

Dr. Sood: We are trying out a couple of proof-of-concept projects at the backend here in Mohali. These include deploying AI and machine learning-based, speech-to-speech translation technologies developed by the Government of India in eSanjeevani to address language barriers. India is a vast country with many languages spoken across its length and breadth. For instance, institutions of national repute like NIMHANS, a mental health setup in Karnataka, serve the entire country. A patient from Punjab may not understand English, and the doctor may not understand the patient's local language.

With technologies like Bhashini, an indigenous speech-to-speech translation technology of MeitY, we aim to enable this concept. The patient can speak in their preferred language, and the speech will be translated on the fly into the language preferred by the doctor. Similarly, when the doctor speaks, their speech will be translated into the patient's preferred language. We are running a proof of concept for Hindi and English, and we are working on improving accuracy. We expect to see the outcomes of this experiment in about three months. If acceptable to the ministry and state administrations, we would love to push it into production.

Additionally, we are exploring the implementation of speech analytics and leveraging generative AI in eSanjeevani. We aim to transcribe the dialogue between the patient and the doctor, anonymizing patient identification. This transcribed dialogue will be archived and coupled with the eSanjeevani database. Policymakers, public health experts, and health administrators can then run complex analyses on the consultations conducted on eSanjeevani.

These enhancements and features have the potential to improve diagnostic accuracy, streamline consultations, personalize patient care, and contribute to the platform's evolution and effectiveness.

Dr. Verma: Is there anything else you'd like to share with the audience about the journey of eSanjeevani or the future of telemedicine?

Dr. Sood: We are eagerly looking forward to expanding eSanjeevani beyond Indian borders. We have been in touch with the governments of Fiji and the Philippines. Recently, the Nigerian government has also expressed interest and is sending a delegation to C-DAC Mohali to be trained and oriented on eSanjeevani. They will be exposed to the nuances of eSanjeevani and its implementation aspects. The project involving Fiji and the Philippines was funded by USAID and the Government of India, as part of a Triangular Development Partnership (TriDeP) Program. These countries have significant telemedicine needs, being island nations. After conducting needs assessments and understanding their healthcare delivery systems, we are now awaiting their specific requirements. We will customize the platform to suit their needs and start implementation. Similarly, we hope to begin work with the Nigerian government soon. We anticipate crossing Indian borders with eSanjeevani within a year or so.

Dr. Verma: Wonderful. We're excited to see the global impact eSanjeevani and telemedicine can create to improve health access and outcomes. We firmly believe telemedicine is a vital component of a resilient healthcare system and a necessary part of any healthcare infrastructure. We look forward to the continued and growing impact of eSanjeevani, not just in India, but worldwide.

Dr. Sood: Thank you. I must also thank you for always being available. At times, you and your team are our go-to for getting many things done that are otherwise challenging for us. Thank you so much for your support, and we will continue to rely on you.

Dr. Verma: Thank you so much. We are happy to help. We share a common mission to improve healthcare access, and we are grateful for the opportunity to collaborate with you. The open and collaborative environment you and C-DAC have fostered benefits not just Intelehealth, but many other organizations supporting healthcare in the country. It’s wonderful to see so many stakeholders working together to support this mission. It all comes down to your leadership.

Dr. Sood: Great. Thank you very much, Neha. Thank you.