The Future of Healthcare: Telemedicine in India
What is healthcare going to look like 50 years from now? Will our doctors be better able to predict and cure our diseases? Will we be more mindful about our own health? Will we exercise more, eat healthier, chew slow and sleep more? To speak optimistically, all of this has already started to happen. The most important change, however, will be the paradigm shift in systems that health psychologists have long been waiting for – from intermittent and reactive care – to continuous and proactive care.
Falling in line with the Moores’ Law which predicts that processor speeds will double every two years, we have been experiencing an exponential growth in science and technology in what is termed as the ‘Digital Revolution’. This necessitates the need for the healthcare sector to think and grow exponentially too, moving beyond its age-old traditions and tight-boxed definitions. A primary goal (and challenge) recently emerging for health psychology is to use these disruptive technologies in a way that leads to a new ‘Health Revolution’ – a world where the curative element is not the drug, but rather the informed and empowered patient.
At the heart of creating a ‘health revolution’ is telemedicine, an umbrella term used for all technologies that can be harnessed for creating better healthcare systems.
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 healthcare providers, all in the interests of advancing the health of individuals and their communities”. We see examples of telemedicine around us everyday – Practo, a website that has recently gained a lot of popularity among middle class Indians, allows you to book appointments, consult a doctor over chat or video calling, and gives patients a feedback mechanism (not otherwise available) to rate and review the doctors on the platform.
India’s healthcare systems have many hurdles to overcome, as can be statistically corroborated by its 145th rank in the Healthcare Access and Quality Index by the Lancet (2016) among 195 countries, behind its neighbours China, Bangladesh, and Bhutan. Parameters like “Access” and “Quality” need to be looked at from a psychological lens. Interestingly, at the intersection of Access, Quality and Health Psychology you find one solution – telemedicine.
In India, the problem of access to healthcare is complicated by discrepancies between the urban and rural, man and woman, the superior caste and scheduled caste. Health psychology steps in to understand the lived experience of a villager who spends majority of his meagre salary to travel to big cities only for a physical visit; who is denied treatment on account of being dalit; who is at the behest of overloaded government hospitals. All of these barriers (often socially created) can be surpassed by changes at the public health level. Some policy changes can include the setting up of ‘e-health’ points within 1 km of each household with the provision of a broadband network.
With respect to quality, various problems plague the sector – the lack of personalized and tailored care; interspersed meetings with the doctor over which the patient is likely to forget a large portion of significant symptom data (intermittent care); exorbitant costs; faulty diagnosis; and a complete lack of emphasis on creating healthy behaviours to prevent and mitigate illness. Creating healthy behaviours is one of the primary goals of health psychology which can be facilitated via telemedicine.
If we want to create ‘healthier’ citizens we need to start with the individuals sleep, nutrition, exercise etc. by leveraging the power of technology. Today, one can get data on almost everything going inside the body at each given second – heart rate, stress level, caloric intake – using a ‘FitBit’ and other wearable health trackers leading to the concept of ‘quantifiable health’. Most of these wearable devices work on proven psychological principles of behaviour change: goal-setting behavior, social comparison, prompts and cues, social and other nonspecific rewards etc. In the future we can imagine toothbrushes that track dental healthcare; a device which analyses how much you’re drinking, the minerals and contents of the water. The cumulative data from these devices can then be integrated to wearable ‘microchips’ – a storehouse of our medical history – acting us early warning systems if something goes wrong.
However, understanding the all-pervasive impact of telemedicine also raises important questions for health psychology – If you can’t touch a patient, how can you accurately diagnose his condition? Can a patient and doctor who see each other on a TV screen actually bond? Does the patient ‘feel’ he got a satisfactory medical consultation?
A survey conducted on the tele-follow up program run by the government for the patients of Odisha revealed that 99% patients were satisfied with using telemedicine technology. Acharya et Al (2014) conducted a study among 122 participants on impact of telemedicine in Apollo Tele Health Services of Telangana which showed that majority of people (89%) consider telehealth services as more ‘feasible and convenient’ as compared to physical meetings with a doctor. As high as 90% of the specialists (doctors) reported that telemedicine was beneficial for them, and patient’s inflow increased by 61% since the commencement of telemedicine practice.
Perhaps the most important question is whether telemedicine acts an adequate alternative by itself to traditional patient-doctor meet ups. Studies answer with a resounding yes, even in the exceptional cases of high complexity.
In a high-volume emergency room setting, patients in the Brennan et al (1999)study reported equivalent levels of satisfaction between telemedicine (treated by a nurse in person and a doctor via telemedicine) and traditional care (diagnosed and treated by a physician). The two groups had equivalent rates of return visits or need for additional care.
The reasons for such a high patient satisfaction rate across multiple studies were common among the following factors: easier access to specialists and experts; reduced travel; shorter waiting times for appointments; financial savings; a wider interaction system; personalized care; and rather interestingly, the ability to address cultural issues. The last point is particularly relevant for stigmatized illnesses where the patient might face reluctance in physical meetings in the public forum – which explains the rise of online tele-counselling and telepsychiatry services for mental illnesses such as YourDost.com.
However, solutions do not start and end with technology. They need to be blended with a psycho-social understanding of the world in order to be applied in the most optimum manner possible. Studies show that the usage and dissemination of telemedicine is not without its challenges.
In rural settings and underserved communities, these applications are not being adopted on a significant scale due to a complex of human and cultural factors as highlighted by Ghia et Al (2013) – lack of awareness (technical difficulties); concerns regarding patient confidentiality; lack of user-friendly software; lack of staff educated in information technology; illiteracy; diversity in languages concern about legal responsibility, resistance to change from indigenous/traditional approaches; and faulty misperceptions of telemedicine being ‘too costly’.
Research from the National Institute of Medical Research (NIMR) telemedicine facility in Uttar Pradesh (2018) shows that trust is critical for successfully implementing medical systems in remote areas, pointing to the need for involving already existing Accredited Social Health Activists (ASHA) workers in angadwadi centres who enjoy a rapport with the community and can be trained in telemedicine. Acceptance of the method increases with repeated follow up, as suggested by the same study; a doctors qualitative interview reads:
“Initially these patients are slightly skepticale about the use of telemedicine but you see with repeated follow ups they become pros. They will proactively tell their TSH levels, calcium levels. . You can’t guess that these patients are illiterate and uneducated.”
The NIMR study also claims that in order for them to be successful, telehealth methods require the proactiveness of the patient and thus a shift in perception from the patient being a ‘passive’ recipient of the healthcare system, to an active co creator of his medical regime.
Innovation is not just about having technology in place; it should have an identifiable, approachable and well qualified human interface to interact with. The ultimate test of technology lies not in building it, but rather making it assimilate comfortably into the daily life of an individual. The implementation of telemedicine today is conducted primarily as a stand-alone intervention, and rarely as an integrated part of the public and private healthcare systems. Telemedicine needs to be perceived not as a magic bullet revolutionizing healthcare on its own, but instead as yet another facilitator of healthcare improvements, to be applied in conjunction with existing avenue.
Anusheela Ghosh
