On a scorching day earlier this yr, a 30-year-old from far-flung Aangamoozhy in Pathanamthitta district in Kerala arrived at a main well being centre (PHC) to take a look at a patch of discolouration on his pores and skin. The medical officer on the PHC thought that the lesion seemed suspicious and advised a dermatology seek the advice of.
“If I had despatched him off with a referral to the specialist on the Konni Medical Faculty almost 50 km away, he would by no means have gone: he would lose a day’s work in travelling backwards and forwards, plus there can be a protracted ready line on the medical school hospital. Our nurse put him on a telemedicine seek the advice of by way of the federal government’s eSanjeevani portal the following day, and uploaded an image of the pores and skin patch. And identical to that, we had picked up a case of leprosy!” the medical officer mentioned.
Cases akin to this abound in experiences with eSanjeevani, the Nationwide Telemedicine Service of India, which can full 5 years subsequent month.
The expansion of telemedicine in India
Telemedicine in India has been evolving over the previous 20 years, after the primary telemedicine pilot venture was arrange in 2001, with the assistance of the Indian Area Analysis Organisation (ISRO), linking Chennai’s Apollo Hospital with the Apollo Rural Hospital at Aragonda village in Chittoor district of Andhra Pradesh.
In 2005, the Nationwide Telemedicine Taskforce was arrange by the Union Ministry of Well being. Telemedicine grew by way of a number of public-private partnerships till 2019, when the Covid-19 pandemic modified your complete situation. In March 2020, the Authorities of India launched the Telemedicine Practice Guidelines.
eSanjeevani, the Nationwide Teleconsultation Service, launched by the Well being Ministry in November 2019, turned out to be a vital service during the pandemic, providing a spread of outpatient consultations to individuals, when bodily entry to the hospitals grew to become severely restricted. A part of the broader Ayushman Bharat programme, eSanjeevani has an OPD (outpatient division) mannequin which permits direct patient-to-doctor consultations and a hub-and-spoke mannequin or the eSanjeevani Ayushman Bharat Well being and Wellness Centre (AB-HWC) mannequin, facilitating Physician-to-Physician (D2D) consultations.
Subcentres and PHCs function spokes, whereas district hospitals and medical schools (specialist centres) act because the hubs. In March 2023, the improved eSanjeevani 2.0 was launched, incorporating telediagnosis by integrating point-of-care diagnostic units (PoCDs).
eSanjeevani affords options akin to queue administration for OPD companies, audio-video consultations, and e-prescriptions. Sufferers additionally obtain SMS notifications for registration and prescriptions.
Nice statistics don’t match floor actuality
The eSanjeevani web site boasts spectacular figures — over 3.2 crore sufferers served at over 1,28,765 well being & wellness facilities (as spokes) by way of 16,360 hubs and over 130 specialities serviced by greater than 2,20,291 docs/healthcare staff as of October 30 this yr. Nonetheless, severe doubts have been raised as as to whether these numbers inform the true story on the bottom.
“Telemedicine fills a huge gap in our healthcare service supply: serving individuals in rural areas who seldom have entry to the service of specialists. However until the eSanjeevani platform is strengthened and extra docs come on board, we are going to by no means get previous the infancy stage. We have to perceive the massive demand for the service, the immense alternative that telemedicine affords us and scale it up,” mentioned A.R. Bhagyasree, nodal officer, e-health, Kottayam.
Dr. Bhagyasree added: “Additionally, e-Sanjeevani is a free service. Until we generate income, we will be unable to take a position cash in any enlargement initiatives or press extra docs into service. Medical doctors are overburdened in clinics and they don’t need to get held up on calls after they could possibly be treating individuals. With no revenue-generating mannequin and the proper incentives, it will be tough to scale up the service.”
Take the instance of Kottayam district in Kerala for example: the necessity for telemedicine companies is acute, and but the system is overwhelmingly understaffed: of the 400-odd docs in Kottayam district, no more than 4 or 5 docs are on board the eSanjeevani platform.
A recent paper in The Lancet, ‘Reimagining India’s Nationwide Telemedicine Service to enhance entry to care’, states that “reviews of dropping footfall have raised questions concerning the potential of eSanjeevani to bridge service provision gaps in India”.
The authors additionally spotlight many vital issues linked to the design and apply of triage and tele-referral nationally, inside eSanjeevani. A number of of those must do with the workers and expertise: the shortage of common practitioners or GPs throughout the tele-referral pathway; insufficient coaching of health-workers resulting in inappropriate and ineffective consultations; outdated or absent technological help; the absence of mechanisms for re-referrals; and lack of suggestions loops are a few of the elements the paper cites as coming in the best way of optimising the total potential of eSanjeevani .
“Everybody appears to equate the effectiveness of the portal with the variety of calls coming into the system. Nonetheless these statistics are blind to points like workers combating technical challenges, the final resistance of docs in addition to sufferers to adapt to the distant mode of consultations, poor reimbursement given to workers/docs, low ranges of e-literacy and the necessity for improved engagement with medical school hospitals. Whereas it’s true that tele consultations are filling a niche, way more must be executed in order that the tele companies could be escalated to medical schools and different tertiary degree/premier healthcare establishments, optimising the potential of the portal” says V.S. Divya, the previous nodal officer of e-Sanjeevani in Kerala.
Community and connectivity points imply that a physician could possibly be spending over 10 or 20 minutes on a single referral name, which doesn’t sit effectively with docs in busy medical schools, level out specialists
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Too many sufferers, too few docs
Low doctor-patient ratio within the public well being system is without doubt one of the elements leading to calls queuing up, sub-optimal consultations and referrals, and docs refusing to be a part of tele consultations as a result of their very own outpatient departments in hospitals could be overflowing. Community and connectivity points imply that a physician could possibly be spending over 10 or 20 minutes on a single referral name, which doesn’t sit effectively with docs in busy medical schools. Tremendous-speciality consultations are thus laborious to entry normally .
“Technical glitches are solely part of the issue. It’s administrative points and lack of enthusiasm on the a part of specialist docs which appear to forestall us from exploiting the total potential of eSanjeevani. Nobody appears to be trying on the bigger image, that the footfalls in busy OPDs in medical schools could be lowered if tele consults, particularly follow-up calls, are streamlined and built-in into common apply. It needs to be the duty of directors to make this simple for busy specialities,” factors out a public well being official
The Lancet examine additionally factors to the necessity to combine the common apply of docs into the referral stream inside eSanjeevani, which might permit for higher utilisation of assets at each ends of the referral chain, whether or not in-person or on-line.
The what’s it in it for me issue for docs
“WiiFM issue (What’s in it for me) is essential. In a telemedicine arrange, there’s a enterprise income mannequin for the bandwidth supplier, software program licence, {hardware}, peripheral medical units used and so forth however the common compensation for the typical physician remains to be inadequate . In 2024, to anticipate a city-based specialist on the peak of his profession to spend quarter-hour of his time for ₹25-50 per name is unrealistic. Medical doctors have to be paid by the hour for his or her time and should be mandated to spend 6-8 hrs per week to supply rural companies by way of telemedicine,” mentioned K. Ganapathy, neurosurgeon and pioneer of telemedicine within the nation and the founder-director of Apollo Telemedicine Networking Basis.
Infrastructural obstacles
Only a few docs on the system aside, numerous research have recognized different obstacles akin to unreliable web connectivity, inadequate infrastructure, socio-cultural preferences of docs for in-person consultations, lack of awareness and inadequate coaching, high quality of care considerations and worry of medico-legal points for the wholehearted acceptance of teleconsultations. That eSanjeevani nonetheless doesn’t cater to all regional languages is one other hurdle.
Making certain continuity of care is one other subject: a advisor has no entry to previous medical information of a affected person and whereas the Digital Well being Information (EHRs) service for residents has not materialised as envisaged by the federal government, it needs to be attainable to combine a affected person’s present well being information to the portal through e-health for docs to entry.
Dr. Ganapathy nevertheless, brushed apart considerations raised by docs concerning the dangers of assessing a affected person remotely, stakes raised by insurance coverage firms and attainable medico-legal points which may crop up. “The Central authorities has come out with a modified model 2.0 of the Telemedicine Apply Pointers notified in 2020 and it’s unlucky that almost all docs don’t learn or perceive this. The fears are completely unfounded. Telemedicine is a complicated triage directing a affected person what to do – it’s not prognosis and remedy on a regular basis. A teleconsultant is anticipated to be mature sufficient to grasp the restrictions of distant prognosis,” he identified.
Whereas there are considerations about defending the privateness of the well being data of sufferers, this has been lined below the Digital Personal Data Protection Act 2023, handed by the Centre final yr.
The long run plan of action
Within the almost 5 years since eSanjeevani was adopted because the nation’s tele-health platform, aside from counting the variety of calls coming in as a measure of the success of the initiative, there appear to have been no significant research to measure numerous points of utilisation, the extent of public consciousness concerning the platform, the standard or consequence of calls, the character and proportion of healthcare necessities being met or beneficiary satisfaction ranges.
“The return on funding for telemedicine can’t be quantified like it may be executed within the case of a CT or MRI machine. The returns are sometimes intangible. No correct scientific examine has been executed quantifying the precise satisfaction, financial financial savings, discount of mortality or morbidity, and so forth, which alone can measure the distinction that telemedicine has made concerning well being service supply. Viability and sustainability additionally issues, on the finish of the day. Sadly, a potential, well-designed examine can be time-consuming and labour-intensive, aside from the funding required,” Dr. Ganapathy mentioned.
Going ahead, The Lancet paper advised that healthcare staff, GPs, specialists and sufferers utilizing eSanjeevani needs to be surveyed to disclose elements that affect its optimum use. ”Insights thus gained can straight inform the design and implementation of eSanjeevani, its SOPs, and its coaching curriculum, together with efficient triage and referral…dynamic and clear knowledge assortment, processing, and evaluation should be built-in into eSanjeevani’s official dashboard. This may facilitate clear and efficient program analysis, past merely counting referral numbers as metrics of success.”
Whereas it is very important word that telemedicine alone can not bridge the city rural well being divide, it could possibly be one step in direction of addressing healthcare wants in areas that desperately want them. The Central and several other State governments are taking child steps however they will do way more to hasten the adoption of telemedicine, mentioned Dr. Ganapathy. Social, financial, cultural elements have to be addressed, whilst altering the mindsets of beneficiaries and healthcare suppliers stays essential, alongside making sufficient bandwidth obtainable with the intention to utilise the total potential of telemedicine in India.
Printed – October 31, 2024 10:00 am IST
