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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 4  |  Page : 178-183

Challenges in the implementation of telemedicine


1 Department of Cardiology, CARE Hospitals, Hyderabad, Telangana, India
2 Department of Telemedicine, CARE Foundation, Hyderabad, Telangana, India

Date of Submission03-May-2021
Date of Decision01-Jul-2022
Date of Acceptance04-Jul-2022
Date of Web Publication19-Dec-2022

Correspondence Address:
Prof. P Krishnam Raju
Department of Cardiology, CARE Hospital, Road No. 10, Banjara Hills, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicc.jicc_22_21

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  Abstract 


Background: There is a constant search across the globe for optimal healthcare solutions with affordability, accessibility, availability, and quality of healthcare services being the burning issue for mankind. The pandemic has further necessitated the need of use of the Telemedicine platform to address healthcare issues which are also non Covid related. Though Telemedicine has been in use for over two decades in India, there have been various challenges and adoption issues which have not yet made the technology an effective solution to address the current healthcare issues. There has been phenomenal growth in the Information and Communication Technology (ICT) over the last decade and its utilization in the healthcare field. Methods: Internet research on the various adoption strategies by healthcare providers coupled with our own experience for using this technology along with guidelines provided by the information and communication technology providers. The Telemedicine Guidelines of 2020 released by the Ministry of Health and Family welfare, India, provides a framework for the implementation of healthcare delivery through this technology. Results: This paper mentions our telemedicine experience in governmental and private institutes and highlights the implementation challenges of this technology and some solutions that made a difference in the execution. However, we discuss to a larger extent the possible challenges and barriers in the implementation of this technology in India. Conclusion: Despite successful work in the field of telemedicine, it is yet to become an integral part of healthcare system because challenges related to adaptability of healthcare users and lack of proper training to fast growing technologies. The future is going to compel the usage of this kind of technology and it is essential for setting up infrastructure and having trained personnel to man these departments to encash the full potential of the telemedicine technology.

Keywords: Artificial intelligence, information and communication technology, Internet of things, telemedicine


How to cite this article:
Raju P K, Sistla PG. Challenges in the implementation of telemedicine. J Indian coll cardiol 2022;12:178-83

How to cite this URL:
Raju P K, Sistla PG. Challenges in the implementation of telemedicine. J Indian coll cardiol [serial online] 2022 [cited 2023 Feb 8];12:178-83. Available from: https://www.joicc.org/text.asp?2022/12/4/178/364212




  Introduction Top


Increasing population in the developing countries has created more demand of health care. Demand of affordable and quality health care is increasing day by day. Rapid demand at the global level for health-care management is increasing over the past few decades, increasing emphasis on health-care quality.[1] Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status.[2] The World Health Organization defines telemedicine 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 health of individuals and their communities.”[3] The Institute of Medicine defines telemedicine as “the use of electronic information and communications technologies to provide and support health care when distance separates the participants.”[4]

Telemedicine applications vary greatly and can be divided into three major categories as shown in [Figure 1].
Figure 1: Broad classification of telemedicine

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The first is patient monitoring or home care that enables medical professionals to monitor patients remotely using various Internet of Things-based medical devices (IoT-MD), such as vital signs monitor and blood pressure monitor. The primary purpose is to facilitate management of chronic diseases such as heart disease, diabetes mellitus, and asthma. The second category essentially facilitates having online consultations both video and audio between patients and specialists. The third category includes store-and-forward applications that use noninteractive technology. This category involves acquiring medical data (such as medical images, biosignals, and laboratory results) and then transmitting these data to a doctor or medical specialist at a suitable time for assessment, as in teleradiology and telepathology.[5],[6],[7]

The application telemedicine technology was expected to reduce the burden of hospitals, suffering of patients, out-of-pocket expenditure, need of transport, hospital fear, and save the time and money of general public and more importantly facilitate in providing timely diagnosis. One cannot deny the partial development of telemedicine and few success stories in many parts of the world, but the leverage, which was expected from telemedicine, is still lacking. This leads to question the reasons behind why telemedicine has still not been adopted as an efficient viable methodology of health-care delivery among service providers as well among the patients.

The last three decades have seen a number of telemedicine pilot programs being launched. Many evaluation studies[8],[9] have been conducted to know the success and failure of telemedicine networks and programs across the globe. The success of these telemedicine programs was limited in developing countries as compared to the developed countries. This in fact is ironical as the demand for telemedicine is much more in developing countries than developed countries. This article discusses the various hurdles in the development of telemedicine and its operations in developing countries. Despite many benefits offered by the telemedicine, it has not been utilized fully to serve humanity and is underused.[10],[11],[12],[13],[14] There are many barriers in the adoption of telemedicine and adoption failure is a serious issue, which needs to be discussed and explored. According to a study, about 75% of the telemedicine projects are abandoned or failed outright and called as failed projects and this percentage goes up to 90% in developing countries.[15]

One of the key challenges in resource-constrained settings is the skewed distribution of health-care delivery infrastructure. While a large proportion of the population live in rural areas, health-care establishments are located in urban settings. Telemedicine has the potential to play the bridging role in overcoming these infrastructural challenges. The Telemedicine Guidelines of India, 2020, promises to pave a road map for regularization and diversification of teleconsultation services across the country. The Board of Governors, Medical Council of India (MCI), in partnership with the National Institution for Transforming India (Aayog) under the Ministry of Health and Family Welfare released the Telemedicine Practice Guidelines, which provides definitions, scope, and protocols with roles and responsibilities of the patients, RMPs, health-care workers, and telehealth platforms for enabling the use of this technology for effective health-care delivery.[16]

Challenges and perspectives

New technologies always come with challenges to implement as the resistance to change set practices in the health-care system is difficult to dislodge. The perspective of telemedicine as an effective health-care delivery model is dependent on the following stake holders:

  1. Clinician
  2. Patient
  3. Management.


Clinician perspective

Most clinicians believe that while telemedicine has brought about a reduction in primary care visits, it has impacted on the assessment of risk factors holistically. While technology has ensured that continuity in care can be maintained, the “lack of personal touch” is still considered a major drawback in assessing the clinical condition of the patient. The increasing accessibility to IoT-MD has benefitted in ensuring that patients are able to provide data in a quicker manner. However, this has also led to sometimes overuse of these devices and increasing the dependency of the data collected than actually assessing the clinical symptoms. The reliability on the usage of IoT devices for getting vital parameters can also be a challenge as there can be false positives that emerge more frequently due to lack of proper calibration of the devices. The “fear” factor because of abnormal values generated from these devices can trigger anxiety leading to an event. Clinicians are beginning to enquire whether more devices necessarily means more information and if some information may be redundant or even unnecessary.

Patient perspective

While patients feel a lot more secure and confident in reaching out to doctors because of telemedicine technology, it should be noted that not all patients are tech savvy, especially the geriatric population and too much dependence on technology does pose a challenge. The psyche of the patient when he is under distress is more on receiving medical attention at the earliest than on the usage of technology. It, therefore, becomes very important that these factors are weighed properly before one comments on the effectiveness of technology. The accessibility to specialists now with these technologies has also in a way compromised the seriousness of the doctor–patient interaction. Hence, the idea of either the doctor doing multitasking activities when having a consultation or the patient not making note of all the complaints before the consultation can pose a challenge to give a comprehensive and holistic approach to the diagnosis, leaving both of them dissatisfied.

Management perspective

While the management understands the effectiveness of the technology and also realizes that this could be an excellent step toward outreach to patients at remote steps, the investment needed into technology and the task (human) force required to run this as a separate department activity requires initial investment. As technology keeps evolving the time taken for the decision to adopt the right kind of technology and put into operational use poses a challenge. Telemedicine activity should be considered as a regular departmental activity with adequate staff to cater to the needs of the patient, specialist, and adapt to the technology being implemented for assessing the effectiveness of this platform.

Challenges: Adoption and adaption

Now having addressed some of the perspectives of the various stakeholders in the implementation of this technology, we shall now see the key concerns impacting the slow adoption of telemedicine in the health-care delivery system. The following factors are to be considered:

  1. Technology
  2. Operational
  3. Behavioral
  4. Legal.


Technology

While telemedicine technology provides an ideal platform for reaching out to patients without them having to travel or wait at clinics for long hours, there are certain risks (not all known at this point of time) associated with these virtual consultations as they become a bigger part of medical care. A complex and often unwieldy technical infrastructure may yield disappointing evaluations until it becomes more ubiquitous and user-friendly.[17] Currently, most providers lack the technical knowledge or the skill set to adapt to the technology and therefore the reluctance to use becomes more. None of the health-care setups provide focused sessions for health-care workers on the use of technology, so the fear and ignorance adds to their reluctance to use the technology. Security risks also lurk with telemedicine, including possible cyberattacks and patient privacy risks. These will now gain more importance once the usage of this technology becomes prevalent. The backbone of this platform rests with how robust the communication (Internet) technology operates and the reliability by ensuring minimum downtimes during usage. The advent of IoT devices and the rapid growth in this sector makes it difficult to continuously keep systems upgraded and provide training to health-care workers or the patients who need to use them. As per the telemedicine practice guidelines released by the Ministry of Health and Family Welfare, India, in March 2020, technology platforms (mobile apps, websites, etc.) providing telemedicine services to consumers shall be obligated to ensure that the consumers consulting with registered medical practitioners are duly registered with national medical councils or respective state medical council and comply with relevant provisions.[16] Technology platforms should conduct their due diligence before listing any practitioner on its online portal. Platform must provide the name, qualification, registration number, and contact details of every practitioner listed on the platform. The guidelines further state that new technologies such as artificial intelligence (AI), IoT, and advanced data science-based decision support systems should be considered as assistive and supportive in nature to the practitioner on patient evaluation, diagnosis, or management, but the final prescription or counseling has to be directly delivered by the practitioner.

Operational

Most times, technology implementations do not succeed because the workflow process is not adhered. It is always important to ensure that there is seamless integration of technology and medical devices in the health-care setup. Adequate training and staff should be involved in the initial setup of the standard operating procedures of any new technology to ensure that the implementations go smoothly. This “hand-holding” with the health-care workers in the hospital setup is very essential for successful adaptation to the technology being implemented. With this kind of technology available, the already long working hours of health-care workers is likely to get extended as it helps the patients to reach out for medical help at any point of time from wherever they are. It is, therefore, essential that operational issues should also address, that a model of compensation for nurses, health-care workers, and clinicians is built in, if we have to ensure that technology is fully and effectively utilized. One of the key aspects that get missed out when new technologies are being implemented is “the consent of the patient.” The telemedicine practice guidelines released by the Ministry of Health and Family Welfare, India, has given specific guidelines regarding the implied or explicit consent that is necessary. In an in-person consultation, it is assumed that the patient has consented to the consult by his/her actions. When the patient walks in an outpatient department, the consent for the consultation is taken as implied. Like an in-person consultation, for most of the teleconsultations, the consent can be assumed to be implied if the patient has initiated the consultation. However, an explicit consent (email, text, or audio/video message) from the patient needs to be taken and attached to his medical data if a health worker, a practitioner, or a caregiver initiates the telemedicine consultation.[16]

Behavioral

The reluctance to change mindset is one of the biggest constraints in the implementation of any technology. In today's scenario with potential investors coming forward to invest in health care, there has been a change in the way hospitals are looking into adopting new technologies. However, while adopting technology is relatively easier, adapting to these technological changes includes efforts from all stakeholders of a health-care setup for successful deployment and operationalization. Simple integrated workflow and periodic training session to nurses and paramedics must become an essential strategy if telemedicine has to be utilized to its full potential. Telemedicine should be viewed as a routine departmental activity rather than restricted only for accessing remote patients or for second opinion.

Legal

Until recently, there has been no specificity and standardization in the practice of telemedicine, which poses accreditation issue. Lack of accreditation of telemedicine facilities creates fear among the users as well as providers. There is a lack of uniformity in telemedicine regulations across the world. In the absence of definite regulatory policy and guidelines, there is an apprehension and fear to practice telemedicine both for clinicians and patients benefitting because of the lack of clarity on the accountability. There is no legal framework of e-prescription, digital prescription, or mobile-based SMS prescription. Digital prescriptions are not approved and accepted by MCI or any other regulatory authority.[18] Medical and health councils of different countries still find that proposed definition of telemedicine has deficiencies. These councils still do not consider telemedicine as a new discipline or a new branch of medicine. The Telemedicine Practice Guidelines issued by the Ministry of Health and Family Welfare in March 2020 addresses fundamental aspects in detail that need to be implemented for ensuring the legality for the adoption of this technology.[16] Telemedicine malpractice claims have risen in the past 15 years as its adoption has increased, “but its footprint within database remains small. Of the telemedicine claims seen, the most common allegation has been missed diagnosis, and the most commonly missed diagnosis was cancer,” which represented 25% of missed diagnosis allegations in telemedicine. Missed diagnoses of stroke were 20%, missed infection diagnoses another 20%, and orthopedic concerns made up 10%.[19] Therefore, the legal framework has to be looked into deeply for ensuring accountability when using this platform for health-care delivery. The COVID pandemic has brought about the quick adoption of the telemedicine platform by many providers. The legal framework can no longer be avoided since telemedicine practice has increased multifold over the last 2 years.

Adoption and adaptation concerns are summarized in the [Figure 2].
Figure 2: Concerns involving adoption and adaptation of telemedicine technology

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Our experience

We were one of the initial users of this technology in 2001 with the district hospital at Mahabunagar as a part of the public–private partnership program with Andhra Pradesh Vaidya Vidhana Parishad (APVVP). At that time, the communication technology was satellite based, which later was changed to leased line due to cost constraints. The APVVP provided a facility at the district hospital with a fully operational computed tomography (CT), X-ray, ECG and echocardiography units. Care Foundation was in-charge of providing in-house developed software, dissemination of training to a local field project executive, proving timely diagnosis with the help of the specialists and daily maintenance of the communication and IT network. Percolation of technology becomes that much easier if the end user which is the patient accepts this mode of health-care delivery system. In our initial days of the activity, we had senior cardiologists visit district hospitals every week for a period of 3 months before switching to the technology platform of teleconsultations and this process did help us as by then the familiarity of the face amongst the people was achieved making it easier to implement the digital platform for consultations. Our network further extended to district hospitals of Tandur and Nalgonda and private diagnostic centers and medium-sized hospitals. Tele-echocardiography, teleconsultations, and teleradiology services (conventional radiography, CT, magnetic resonance imaging, positron emission tomography, and XA) were the main activities of our telemedicine program. [Table 1], [Table 2], [Table 3] highlight the cases done through the telemedicine platform.
Table 1: Tele-echocardiography and teleconsultations

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Table 2: Teleradiology experience

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Table 3: Usage of Internet of things

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Salient points

  1. More than 120,000 cases have availed the benefit of this technology
  2. Sixty-five percent of them did not have to go for further investigations/interventions and could be medically managed
  3. Twenty percent needed further investigations/interventions
  4. Fifteen percent needed interventions and travel for further treatment
  5. Seventy percent cost benefit achieved to patients with the availability of this technology
  6. Follow-up of patients through this platform still poses a challenge.


Future concerns

The humongous amount of data that emerge from health-care applications naturally makes the application of AI on these datasets an obvious step forward in the delivery of quality health care. While the benefits of application of AI are significant, such benefits are not without challenges. Application of AI in the health-care sector will undoubtedly increase in the work efficiency and productivity. Efficiency will increase as now the AI systems can help in providing possible scenarios for a specific condition at a quicker pace for specialists to diagnose than depend only on information stored within them. AI can support, rather than replace physicians, generating time- and cost-saving benefits for them and their patients and enabling more compassionate and thorough interactions. However, this will in turn mean that the clinician will have many more differential diagnoses in front of him which may hamper him in making clinical decisions. The bigger question to ask is if the clinical acumen of clinicians, be compromised because of differential diagnosis propping up from AI. The architecture of the digital infrastructure supporting AI and machine learning across different localities and between applications and platforms needs to be carefully designed, to maintain the security and privacy of health-care data. Beyond the issue of seeking consent before any access and use of data, there are also issues around the transparency of algorithmic objectives and outcomes and of the accountability for the potential misuse of data. The most important factor to be considered is the clinical efficacy of algorithms and their use of data. Apart from security and privacy, the more critical question is to understand that the current algorithms are being based on independent inputs such as those from the clinician or imaging or laboratory reports. However, it is essential that all these inputs should be considered together holistically, especially by corroborating the diagnosis of the clinician with histopathology reports and imaging evidence before giving them as inputs for development of machine learning algorithms to ensure effectiveness of the usage of AI. Finally, although both AI and physicians can make errors in their clinical judgment, either because of not having seen a particular case before or because of bad training, in combining the two – AI and human expertise – the number of clinical errors can be reduced. It is important that we avoid placing “exaggerated hope” on the potential impact of AI, but also not to fall victims of “exaggerated fear” because we cannot identify with the technology. The real dangers of AI are no different from those of other existing artifacts and the danger of these systems is the potential for misuse, either through carelessness or malevolence, by the people who control them.

There is also an increasing surge in the design of IoT devices, which is making accessibility to capture vital information from patients easier. However, periodic calibration of these devices is essential to minimize false alarms being raised from these digital devices.

Despite the surge in the technology development, there has been an underutilization as shown in [Figure 3] in many sectors more because of lack of adaptability and cost factors.
Figure 3: Disparity technology versus service utilization

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It should be very well understood that technology acts as an enabler for having streamlined work flow processes and thereby increases efficiency, but not merely to replace human resource.


  Conclusion Top


Health care in developing countries is in the midst of a paradigm shift, from a traditional provider-centered, disease-oriented approach to a patient-centered, health management model. Telemedicine has influenced almost all aspects of health care, and many success stories have reported the role of telemedicine in improving health-care access, reducing cost of care, and enhancing the quality of care. Despite so much development and successful work in the field of telemedicine, it has yet to become integral part of health-care system because of some of the challenges that have been explained in this study. One of the main challenges is the unwillingness of the health-care users to adapt to these new technologies because of proper training and because telemedicine is still being viewed as a sporadic activity rather than a routine departmental oriented activity. The future is going to compel the usage of this kind of technology even more and it is about time that health-care providers start looking into the needs of setting up infrastructure and having trained personnel to man these departments to make full use of this platform and improve the effectiveness to all stakeholders, most important one being the patient.

Acknowledgments

The contribution of the management of CARE Foundation for providing valuable insights in the use of technology in health care, the consultant doctors for successful practice of telemedicine, and the technical staff of CARE Foundation involved in development of software and in execution of the program are duly appreciated and acknowledged.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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