Benefits of Telemedicine and Barriers to its Effective Implementation in Rural India: A Multicentric E- Survey

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1 Indian Medical Gazette JANUARY Original Article Benefits of Telemedicine and Barriers to its Effective Implementation in Rural India: A Multicentric E- Survey Canna J. Ghia, Medical Advisor, Pfizer, Mumbai, India. Abhishek S. Patil, Clinical Fellow in Knee Surgery, Orthopaedics, Centre for Joint Disease, Chonnam National University, Hwasun Hospital, South Korea. Jignesh K. Ved, Medical Advisor, Pfizer, Mumbai, India. Rajesh K. Jha, Professor and Head, Department of Pharmacology, Jawaharlal Nehru Medical College, Wardha, Maharashtra. Abstract Introduction: Telemedicine has become an accepted concept in health care worldwide. The practice of health care using interactive audio, visual and data communications is the need of the hour. This includes health care delivery, diagnosis, consultation and treatment, as well as education and transfer of medical data. Objectives: 1) To estimate the benefits of telemedicine in health care system in rural Maharashtra. 2) To identify the barriers in effective implementation of telemedicine in rural Maharashtra. Materials and Methods: Study Type: E-survey using a validated structured questionnaire. Locus of Study: Department of Pharmacology, Jawaharlal Nehru Medical College, Wardha. Duration of Study: 3 months. Study Design:The questionnaire was sent to doctors of all specialities through . A total of 300 completed questionnaires were evaluated and statistically analyzed using SPSS software. Results: The results showed a significant association (p < 0.001) of high acceptance of telemedicine in doctors of teaching hospitals as compared to doctors from non-teaching hospitals and private practitioners. Preoperative services, discharge, referral, follow-up and obtaining second opinions are other facilities that can be offered through telemedicine to patients in rural areas. The benefits of telemedicine acknowledged by doctors through this survey include obtaining laboratory results; making appointments; transmission of ECG, X rays and still images; telephonic consultation for patients, health education, monitoring patients at home (follow up), preoperative services, obtaining second opinions and referral of patients for tertiary care. The important barriers to the effective implementation of telemedicine in rural areas, indentified through this study include heavy investments in equipments, technical difficulties, lack of staff educated in information technology and concern about legal responsibility. 48% doctors strongly agreed that telemedicine should be implemented in all hospitals with internet facility. 31% of the doctors strongly disagreed that telemedicine will increase the access of health care services for rural patients. 42% of the doctors strongly agreed that telemedicine will help to save the time and money of patients. 30% of the patients strongly agreed that drug information centers should be run through telemedicine. Conclusions: Web enabled telemedicine system can help in easy flow and better delivery of health care consultation to patients in remote areas who do not get access to a super specialized health care delivery system. However, good access to poor patients in remote areas has to be ensured. Keywords telemedicine, benefits, barriers, rural India Address for correspondence: Dr Canna Jagdish Ghia, 501, Krishna Kunj, 6th Road, Santacruz East, Mumbai

2 2 Indian Medical Gazette JANUARY 2013 Introduction Telemedicine is the use of electronic communication and information technologies to provide or support clinical care at a distance 1. Tele-health, a broader concept, is the use of electronic information and telecommunications technologies to support long-distance health care, patient and professional health-related education, public health and health administration 1. 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 2. A key concept in this definition is distance between the participants, a factor that makes this technology especially useful in rural settings. These systems represent one method of linking urban concentrations of physicians with widely dispersed groups of rural patients and their caregivers. Technological advances and price reductions both in computing and communications equipment and in transmission charges have made the use of these tools more feasible 3. The Report of the National Commission on Macroeconomics and Health indicated a highly skewed distribution of healthcare resources, mainly concentrated in the urban areas. The availability of healthcare personnel in India is way below the global norm, and the situation is made worse with nearly two-thirds being concentrated in urban towns. This distributional inequity is compounded by deep rooted issues, and resolving the same would require a paradigm change in healthcare policy framework. Use of information technology for medical care, may be one such avenue towards equitable distribution of healthcare services across India 4. Health professionals in rural primary care can gain more from telemedicine initiatives than their urban counterparts 5. The practice of health care using interactive audio, visual and data communications is the need of the hour. The awareness of health care providers, particularly physicians, towards telemedicine is pivotal to its development 6. An extensive study of the awareness and opinion regarding distance care through telemedicine for rural patients is therefore necessary. Hence, the present study was undertaken with an aim to assess the attitude of health care providers towards implementation of telemedicine in rural population. The objectives were to estimate the benefits of using telemedicine in health care in Rural Population and to identify the barriers in effective implementation of telemedicine in Rural Population. Materials and Methods The study was an E-survey using a validated questionnaire (Annexure 1). The locus of the study was Department of Pharmacology, Jawaharlal Nehru Medical College Sawangi (Meghe), Wardha (Maharashtra). Institutional ethics committee clearance was obtained. A validated close ended questionnaire to assess the acceptance, benefits and barriers to telemedicine was designed. The questionnaire along with the informed consent document was sent to different health care professionals- physicians, surgeons and pharmacologists through between 1st July 2011 to 30th September The inclusion criteria were Health care providers willing to give written informed consent and Health care providers who are willing to fill the questionnaire received by . The Exclusion Criteria were Health care providers not willing to comply with the procedures described in this protocol. The questionnaire was ed to different health care professionals and voluntary participation was encouraged. Strict confidentiality was maintained. The completed questionnaires were evaluated, the responses were scored and statistically analyzed using SPSS software. Data was analysed using SPSS software (version 17). Likert scale was used to analyse some of the responses. Results were expressed as percentages. Chi-square test was used to assess the statistical significance of differences between groups in the frequency distribution of categorical variables, unless the expected cell size was less than five, when Fisher s exact test was used. Results 300 questionnaires were ed out of which 223 were returned completed. Hence the response rate was about 75%. There was no significant association of age and gender with the acceptance of telemedicine. There is a significant association (p < 0.001) of high acceptance of telemedicine in doctors of teaching hospitals. The benefits of telemedicine acknowledged by doctors through this survey include obtaining laboratory results;

3 Indian Medical Gazette JANUARY QUESTIONNAIRE ANNEXURE 1 TITLE: BENEFITS OF TELEMEDICINE AND BARRIERS TO ITS EFFECTIVE IMPLEMENTATION IN RURAL INDIA : AN E SURVEY Which Clinical speciality do you belong to? Age: Sex: M F Location: Please indicate one of the following for each of the following questions: Which of the following applications of Telemedicine would be beneficial to patients? (Please tick Yes or No.)

4 4 Indian Medical Gazette JANUARY 2013 Which of the following are Barriers to the use of Telemedicine? (Please tick Yes or No.) making appointments; transmission of ECG, X rays and still images;telephonic consultation for patients, health education, monitoring patients at home (follow up), preoperative services, obtaining second opinions and referral of patients for tertiary care (Fig. 1). As acknowledged by the doctors; preoperative services, discharge, referral, follow-up and obtaining second opinions are other facilities that can be offered through telemedicine to patients in rural areas. Physicians perception remain one of the major barriers to the diffusion of telemedicine. The most common barriers to telemedicine implementation and sustainability in rural areas and the Fig. 1 Benefits of telemedicine developing world identified throught this study were provision and adequacy of band width and power and equipment maintenance. The important barriers to the effective implementation of telemedicine in rural areas, indentified through this study include heavy investments in equipments, technical difficulties, concerns regarding patient confidentiality negative attitude of patients, lack of user friendly software, lack of staff educated in information technology and concern about legal responsibility (Fig. 2). When analyzing the responses on Likert scale (Fig. 3) 1. A majority of doctors i.e. 48% strongly agree that telemedicine should be implemented in all hospitals with internet facility. Fig. 2 Barriers against telemedicine

5 Indian Medical Gazette JANUARY % of the doctors strongly disagree that telemedicine will increase the access of health care services for rural patients % of the doctors strongly agree that telemedicine will help to save the time and money of patients. Fig. 3 Responses on Likert s scale for specific telemedicine related questions Telemedicine should be implemented in all hospitals with internet facility Telemedicine will increase of health care services for rural patients Telemedicine will help to save time and money of patients 4. 30% of the patients strongly agree that drug information centers should be run through telemedicine. Discussion Telemedicine has become an accepted concept in health care worldwide. Primary care physicians in the rural sites are almost all family physicians. They provide care to a large number of rural patients, most of whom are located long distances from urban specialists 3. It is important to ensure that health care providers are ready to acknowledge and support the new radical instrumental and administrative changes, which will not only change current medical practice but also professional behaviour. Recent advances in information and communication technology, particularly telemedicine and tele-health, have been seen as key mechanisms by which these changes can be engendered 7. Telemedicine may be as simple as two health professionals discussing a case over the telephone, or as complex as using satellite technology and videoconferencing equipment to conduct a real-time consultation between medical specialists in two different countries. An Australian telehealth leader has proposed seven principles 8 for the successful development and implementation of a telemedicine system: 1. Telemedicine applications and sites should be selected pragmatically, rather than philosophically. 2. Clinical drivers and telemedicine users must own their own systems. 3. Telemedicine management and support should follow best practice business principles. 4. The technology should be as user friendly as possible. Drug information centers should be run through telemedicine 5. Telemedicine users must be well trained and supported, both technically and professionally. 6. Telemedicine applications should be evaluated and sustained in a clinically appropriate and userfriendly manner. 7. Information about the development of telemedicine must be shared. The result of this study suggested that the acceptance

6 6 Indian Medical Gazette JANUARY 2013 of our doctors in non-teaching and private practice concerning telemedicine was extremely low. However, the positive responsiveness of doctors from teaching hospitals who participated in the study indicates the readiness of these doctors to cooperate to further their knowledge. In other studies exploring physicians perception towards telemedicine in different countries, it was found that the physicians perception towards telemedicine vary from conservative to optimistic 6, 9, 10. Limitations of the Study Our study had certain limitations the main one being its relatively small sample size: The study sample, though small, represented most of the medical specialties and the main cities of India. In order to obtain a clearer picture, however, a comprehensive study involving a larger, randomized spectrum of physicians is required. Although this sample was sufficient to provide significant results in the subgroup analysis it was not sufficient to provide significant results in the other demographic variables such as age and gender. Replicating this study with a larger sample might uncover trends relating to the other demographic variables. For example, physicians in certain age groups might be more willing to use telemedicine services than others, depending on the comfort they have in the use of computers and other technology. Conclusion The patients of rural areas do not get access to a superspecialized health care delivery system. Web enabled telemedicine system can help in easy flow and better delivery of health care consultation to patients in remote areas. It is cost efffective and time saing as well. However good access to poor patients in remote areas has to be ensured. References 1. Scalvini S., Vitacca M., Paletta L., Giordano A., Balbi B. Telemedicine: a new frontier for effective healthcare services. Monaldi Archives for Chest Diseases. 61(4): , Field M.J., editor. Telemedicine: a guide to assessing telecommunications in health care.

7 Indian Medical Gazette JANUARY Committee on Evaluating Clinical Applications of Telemedicine, Division of Health Care Services, Institute of Medicine. Washington, DC: National Academy Press, Norris T.E., Hart G.L., Larson E.H. et al. Lowbandwidth, low-cost telemedicine consultations in rural family practice. J Am Board Fam Pract. 15(2): , Report%20of%20the%20National%20Commission.pdf 5. Meher S.K., Rath B.K., Chaudhry T. Telemedicine - Awareness and Attitude Among Rural Patients All India Institute of Medical Sciences, Utkal University, New Delhi, India. Ukraine Journal of Telemed. 7:15-19, Richards H., King G., Reid M. et al. Remote working: survey of attitudes to ehealth of doctors and nurses in rural general practices in the United Kingdom. Family Practice. 22: 2 7, Shershneva M.B., Olson C.A. Education through telemedicine networks: setting quality standards. Journal of Telemedicine and Telecare. 11: , Yellowlees P. Successfully developing a telemedicine system. Journal of Telemedicine and Telecare. 11(7): , Collins K., Bowns I., Walters S. General practitioners perceptions of asynchronous telemedicine in a randomized controlled trial of teledermatology. Journal of Telemedicine and Telecare. 10:94 98, Hannis M.D., Hazard R.L., Rothschild M. et al. Physician attitudes regarding telephone medicine. J Gen Intern Med. 11: , 1996.

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