Roots of telemedicine in India

29th July 2020
Roots of telemedicine in India

Part I of a series on e-medicine technologies  ignited by the Covid-19 lockdowns
Shruti Rajan is a clinical psychologist, attached to a private clinic in Mangalore, Karnataka. She sees a steady stream of patients, some of whom travel  over a hundred kilometres across the border. from Kasargod in Kerala – thanks to her command of the Malayalam language. The sudden Covid-19 lockdown in March deprived many such patients of their regular counselling sessions. Cut off for weeks from friendly contact, some developed mental stress. Shruti suggested that they might try a video session by  installing a free Skype app -- preferably on a laptop. Six outstation patients did – and in the months since then, they have found much needed solace – at the end of a video call.  “Eye contact doesn't always feel natural, and judging body language and mood is difficult in a video, compared to face to face sessions. But we could avert some crises. We retained that crucial link”, Shruti says.  Even after the lockdown restrictions were relaxed some of these patients asked if they could consult via video and save the time and expense of travel.
Gaffoor  is  75 and  lives in a village off the Pune- Ahmednagar  highway. He takes regular medication for his heart condition which is complicated by acute diabetes. His medication is not available nearby and he  depends on friends who came from Pune.  After 5 weeks of lockdown, Gaffoor ran out of his stock  and was in panic.  Then a neighbour’s son “Googled” to locate  an online pharmacy that could send him his medicines by SpeedPost (no couriers served the village). The boy scanned  and  ‘whatsapped’  Gaffoor’s prescription and  made the payment using his BHIM app.  A month’s stock of  drugs arrived three days later:   IndiaPost was making all essential deliveries
Sunil Roberts suffered from psoriasis all his adult life. His dermatologist helped control the periodic eruptions with a combination of ointments. But one month into the lockdown, Sunil found fresh patches on his back spreading rapidly and making it an agony to sit or sleep.  The clinic was shut.  'Not to worry', said his dermatologist, 'have someone take a photo of the affected area and mail it to me.' Within minutes, patient and doctor were  connected via Whatsapp and Sunil was advised a  salicylic acid-based cream to remove the dead cells that  were causing the irritation.  With the emailed prescription, Sunil could get the new medication – and huge relief. Footnote: When Sunil   requested   account details to send the fee, the dermatologist sent a link to the PMCares fund and asked him to send the amount as a donation.
Three real-life examples, three success stories, from the burgeoning field of telemedicine in India – triggered by the   coronavirus crisis that has enveloped the world. But they were made possible because the country had the infrastructure:  a nationwide Internet network and a smartphone in the hands of every third Indian. 
But that alone was not enough.  A regulatory framework was needed and with what in hindsight seems like a case of  amazing anticipatory planning,  it fell in place the very day that the first lockdown began in India on March 25 2020:  Government of India issued the Telemedicine Practice Guidelines, enabling registered medical practitioners to legally  provide online consultations to patients across the country, especially in rural areas. In a short time, medical consultation, diagnosis and prescription, via phone, whatsapp and video conference, was availed by millions, with ailments identified and treated without a hospital visit. This relieved the strain on hospitals, allowing them to concentrate on treating Covid-19.
On June 12 another important decision was taken: The Insurance Regulatory and Development Authority of India (IRDAI) asked insurers to allow telemedicine wherever regular medical consultation is allowed... as part of the claim settlement of their policies. This removed the last hurdle to the widespread practice of telemedicine.
That so many Indians  in recent weeks, could smoothly transition to telemedicine was because  the ecosystem of e-health  was already mature if not widespread: The Ayush Ministry, last year joined  the IT Ministry to launch multiple  e-medicare initiatives  such as e-Hospital, e-Aushadhi, e-Rakt Kosh, Online Registration System (ORS) and e-Sushrut.
Roots of telemedicine
Telemedicine in India  was launched 2 decades ago when leading private healthcare groups entered the field. Somewhat ahead of their time. Narayana   Hrudayalaya, famous for its heart care, found the going slow for its e-health initiative because the required infrastructure was not in place: Internet access was very slow; there was no electronic payment mechanism. Fees had to be sent by demand draft! The successful pilots, avoided these bottlenecks:
The first Indian telemedicine network is generally acknowledged to be the Apollo Hospital group’s collaboration with ISRO which saw the HEALTHSAT satellite used to bring the benefits of distance healthcare to Aragonda village in Andhra Pradesh in March 2000. The satellite went on to link 60-plus specialist hospitals with 300 health rural centres and 20 mobile units, taking Apollo TeleHealth to the world’s Top Ten list of telemedicine initiatives. The service  included cardiology, diabetic care, mammography, child and mother care.
By 2003, hospitals specializing in eye care like Sankara Netralaya and Aravind  Eye Hospitals harnessed telemedicine to reach the rural hinterland where 65% of Indians resided.
In the North, three leading hospitals -- AIIMS at New Delhi; PGIMER, Chandigarh and SGPGI, Lucknow --   linked with each other to share expertise and services. The Escorts Heart Institute and Research Centre Institute in Delhi, set up a trans-telephonic ECG system that enabled them to receive emergency signals from cardiac cases.  Today the All India Institute of Medical Sciences (AIIMS) continues such an ECG transmit service.
But these early players barely scratched the surface of distance health delivery, because they represented just one dimension of service. Today we define telemedicine or telehealth in broader terms: the remote delivery of health-related services and information via electronic information and telecommunication technologies. It allows long-distance patient and clinician contact, care, advice, education, intervention and monitoring. Allowing healthcare providers to evaluate, diagnose and treat patients  without an in-person visit, remains at the core; but the ecosystem now embraces three  types of interaction, clearly  defined in the government’s  Telemedicine guidelines:  patient to doctor; doctor to doctor; health worker to doctor. The ability of one medical practitioner to consult with a specialist who might be on a different continent – during a surgical procedure for example -- is a powerful dimension of telemedicine. And allowing nursing staff to collect in -patient diagnostic data and share with attending doctors, any time, is another common extension. ANAND PARTHASARATHY
( To be continued... Part II tomorrow)
(Based on an article by the author in the August 2020 issue of Science Reporter)