Is Telemedicine Sector Ready to Replace Conventional Treatment System in New Digital India?
Dr Subroto Ghoshal, PhD
Senior Manager- Human Resources
Mindteck

Digital India is experiencing the rise in the online healthcare segment with major thrust in the growth of Telemedicine. Telemedicine is envisioned to become a viable model in the healthcare sector for the poor and non -insured people of India. Even though India has witnessed growth in the last decade, there are challenges which telemedicine service providers are facing related to the cost effectiveness, infrastructure and regulations. There have been a lot of support and many initiatives from the government of India , to help this sector move ahead. Even though rural India is still grappling with poor infrastructure and healthcare facilities, urban India has a huge potential and expect exponential growth of telemedicine in the coming years

In India, healthcare system has become one of the largest service sector in the country. According to FICCI report, this sector is emerging as the most progressive service sector in the country. It is anticipated that after information technology industry, healthcare sector will be the next big thing in India. Healthcare system covers hospital, medical devices, telemedicine, medical equipment, clinical trials and health insurance. The Indian healthcare industry has been seeing growth in the past few years. The population in India above 60 years which was estimated at 96 million in 2010 is expected to grow to around 193 million. Apart from this, Indian consumers are not just looking at proper healthcare but also for the services that can be personalized. These are some of the factors that is contributing to the growth of healthcare segment of India.

With exponential growth in the demand for healthcare services and the challenges experienced in gap which exists in offline healthcare, digital healthcare services evolved in bridging the gap. Online healthcare has the advantage and flexibility to meet the growing demand and handling the requirement for quality and better services.

The base for the concept of telemedicine is the easy access to remote areas and to bring down the time and cost of patient for the doctor consultation. The utility of telemedicine depends on the usage of technology to improve the communication between the doctor and patient who are separated by distance, providing e-medical records, ambulatory monitoring etc. "Telemedicine work best when the diagnosis is straight forward and the treatment is routine. It is fast and easy and the most important factor is the chances of spreading the infection from patient to medical personnel is reduced" avers Dr.Sriram Nathan, ENT Surgeon at Narayana Health Multi -specialty hospital, Bangalore. India faces challenge when it comes to relocate a doctor from urban to rural or suburban areas and therefore these areas are getting deprived of doctors. Under this situation, telemedicine will become a boon for the entire Indian population who can have easy access to any specialty doctor by using telecommunication and satellitebased technology.

History of Telemedicine

It is assumed that telemedicine has grown in the last 5 to 6 years but the truth is that this concept had been implemented around thirty years ago. The National Aeronautics and Space Administration (NASA) used this concept in the development of telemedicine when humans began flying in space. NASA developed the system where physiological parameters were transmitted from space craft and from the space suits during mission. "One of the earliest endeavors in telemedicine, Space Technology Applied to Rural Papago Advanced Health Care(STARPAHC) delivered medical care to Papago Indian reservation in Arizona. It ran from 1972 - 1975 and was conceived by the NASA" as quoted in the article published in ncbi.nlm.nih.gov.

In India, telemedicine has been existing over two decades now. The foundation on which online health or telemedicine works is the usage of telecommunication and information technology. The principle of telemedicine is to overcome distance barrier and reduce the time of waiting for clinical healthcare for individuals. In India, government, private hospitals and NGOs are trying to join hands to manage synergies in order to provide quality healthcare with the support of telemedicine for the population across the country.

'Union ministry of health signed a memorandum of understanding (MOU) with Indian Space Research Organisation (ISRO) to expand its telemedicine network to remote places.' In 2000, India's telemedicine centre at Apollo Aragonda hospital in Andhra Pradesh was inaugurated by the US president Bill Clinton. Today we have more than 500 centers linked with multiple specialty hospitals .

India Online Healthcare Market

According to Deloitte Touche Tohmatsu India it is estimated that Indian healthcare market is around USD 100 billion. It is expected that it will grow at 23 percent CAGR to reach USD 280 billion by 2020. As per the study of Assochem, this market is estimated at over USD 15 million and has the potential to grow above USD 32 million by 2020.

In India, online healthcare particularly in the sector of telemedicine, there has been active support from the department of Information and Technology (DIT), Indian Space Research Organisation (ISRO), NEC Telemedicine program for northeastern state, Apollo hospital and state government. Department of Information and Technology has the focus on long term objectives and provides assistance and guidance in the initiation of new schemes, standardization and framework for building the infrastructure of information technology in the sector of healthcare. There has been immense contribution by the center for development of advance computing, C -DAC in developing telemedicine software which support telecardiology, tele -radiology, tele-pathology etc. They have used technology to connect the three premier medical institute of the country viz. All India Institute of Medical Sciences (AIMS), New Delhi, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, and Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. Telemedicine services have been focusing on the various healthcare segments like radiology, consultations, ophthalmology, dermatology, pathology, psychiatry etc.

In Karnataka, telemedicine network project was initiated in 2001 in collaboration with Indian Space Research Organisation(ISRO) and the department of health and family welfare, government of Karnataka. In Bangalore National Institute of Mental Health and Neuro Science (NIMHANS) provides neurosciences specialty services, Sri Jaydeva Institute of Cardiology provides services related to cardiology, Kidwai Memorial Institute of Oncology caters to oncology while general healthcare services are supported by the Bowring and Lady Curzon hospital.

Initiative by Government

As per the report published in ibef.org under healthcare India, government of India is taking a lot of initiative to develop the Indian healthcare industry. As per the source of information collected 'India is initiating first ever Air Dispensary, helicopter based dispensary. It will be launched in the northeast and the ministry of development of northeast region has already contributed 25 crores (USD 3.28 million) for its funding. The Intensified Mission Indradhanush (IMI) has been launched by the government of India to provide immunization across the country and to reach children below two years of age and to pregnant women. Ministry of health and family welfare is targeting to cross more than their allocated budget of 955 crores (USD 148.22 million) to manage the diseases like diabetes, obesity and cardiovascular disease in India. The union cabinet approved setting up of National Nutrition Mission (NNM) with a three year budget of 9046.17 crores (USD 1.40 billion) to monitor, supervise and guide the nutrition related interventions across the ministries. The government of India aim to increase total health expenditure to 2.5 percent of Gross Domestic Product (GDP) by 2025 from the current 1.15 percent'.

Statutory Regulations in Telemedicine

Telemedicine has an advantage to connect doctors and the patients from different locations. In a situation like this, it is very important to have a specific regulation by the government authority to regulate telemedicine. Unfortunately, there is no defined law to govern telemedicine. Today this sector uses scattered regulations like Information Technology Act- 2000, Drug and Cosmetics Act- 1940, The Indian Medical Council Act-1956 and the Clinical Establishments (Registration & Regulation) Act - 2010. CERRA governs all clinical establishments. Though the definition of clinical establishments is broad and does cover the services provided by telemedicine but there seems to be lack of clarity. The liability of the doctors or the paramedics who fall under the segment of telemedicine is yet to be clarified . The lacunae which exits in the regulation of the telemedicine services is questioning the viability of this model of healthcare.

Contribution by Startups

India is experiencing the high growth of startup in India who are contributing in the digital healthcare space and carving out the online healthcare landscape. In the last decade, India has been witnessing the enhancement in the preventive healthcare and monitoring solution, medical devices, clinical trials, outsourcing, telemedicine, medical tourism, health insurance and medicine, connect them with doctor or chemist. There is DocApp technology solution to support patient engagement and appointment.

Hyderabad based Doconline started its journey in November 2016. This company provides unlimited online doctor consultation to subscribers and his family members by connecting the patients to the medical experts. The feature of this service provider is consultation through audio, video and chat mode with the medical practioners in the preferred language of the patient, get prescription and view all medical records using online healthcare platform. Doconline provides consultation solution using Android, iOS and web based technology platform. Rahul Paith, COO of Doconline says "We have around 25 ,000 corporate subscribers and around 100,000 medical equipment. Today smart phones are providing one stop solution to access a doctor, hospital or a diagnostic center.

As per the report published in 2016 under digital health startups, out of many healthtech startups who are contributing in this segment are Medikabazar, Medibox Technologies, eKincare, Rxpress, Doconline health and Thrymr software. Startups like Practo, Protea medical, Med Genome, Lybrate, Medwell ventures have already established themselves in the online healthcare segment. There are healthcare service providers who provide business to business or business to consumer solution for all hospitals, medical institution suppliers and home health medical devices and aids. There are comprehensive medical apps which provides services like buying medicines, uploading prescriptions, doctor consultation, reminding patients to take lives impacted altogether. Hyderabad is the India head quarter and we have fully operating satellite office in Pune. We are planning to expand to another 2 to 4 states by 2018."

The company is focused to provide online consultation with doctors, in-house doctor service in the corporates, facilitate customer to order medicine through app, discount in its network hospitals and diagnostic centers. Doconline caters to the preventive care and not for the emergencies.

As per the report published in The Telegraph News paper, 21 Februrary 2018, Kolkata, a UK based doctor is planning to set up digital dispensary to treat the patients through telemedicine in West Bengal. Their aim is to provide quick primary check up in the rural areas so that the treatment is not delayed as there is shortage of doctors in these areas. It is indicated that Agile Health care and Rehabilitation Service has collaborated with a city based health care service to offer telemedicine service. Five centers are operating in Bihar and 65 new locations are planned in the country. As informed, the capital expenditure per center will be 25 lakhs and the patients will be charged 200 for consultation and medicines. They will also provide tests at 50 percent cost and electronic medical records will be maintained. the mode of treatment would be carried out through video images. The treatment would focus on common condition and ailments and for any further or advance treatment, patients would be referred to hospitals.

Challenges in Telemedicine Sector

Even though telemedicine is booming in the Indian healthcare segment, there are still many hurdles which needs to be overcome to make telemedicine an integral part of India's healthcare segment. One of the challenges which needs to be confronted is the cost effectiveness of the technological equipment and manpower cost. It is also experienced that many doctors are not fully convinced with the concept of telemedicine. Many doctors cited that they prefer to see the patient for better diagnosis.

Dr. Sriram Nathan, ENT surgeon at Narayana health multi specialty hospital, Bangalore opines "telemedicine is still not suitable for emergency. It has robotic approach with less empathy towards the patient. Nothing can replace the direct visualization of the patient by the doctor". There are many patients who are also not convinced with the idea of treatment over phone. As per the data, only 65.38 percent of India's population is literate and around 2 percent well versed in English. This becomes a bottleneck to make telemedicine an integral part of healthcare all across the country. In the current scenario, 40 percent of population lives below poverty level. They are deprived of many basic needs and services. In a country with such high percentage of people under poverty level, making telemedicine successful is a big challenge. Even though the government is trying to give a push, it has its own limitations. Initiative has to be taken by building public private participation.

At present there are many unresolved legal and ethical concerns regarding telemedicine technology which restricts many doctors to venture into this mode of treatment. Since telemedicine services are mainly concentrated in the urban India, there is a need to do a lot to extend the services to the rural India. Telemedicine is still best suited for general consulting and their role in critical care still needs to be evaluated.