eHealth and Telemedicine in India: An Overview on the Health Care Need of the People

Received: January 21, 2019 Revised: May 28, 2019 Accepted: July 30, 2020 Published Online: August 10, 2020 We have reached far ahead today when it comes to the telemedicine technology which was first installed in Boston in 1967 that made a regular interaction between physicians and patients at distant locations. Being a developing and lower-middle income country, currently India faces shortage of doctors, nurses & midwives, and healthcare infrastructure. Around 70% of Indian population lives in remote and rural villages lacking access to basic healthcare facilities. In such situations telemedicine plays a great role in providing quality and affordable healthcare to India’s poorest people, and is expected to bridge the rural-urban health divide. Whether telemedicine technology meets its objective to provide adequate healthcare services to the poor remote and rural population is matter of great concern. This article aims to provide an overview on this issue.


Introduction
India spends 3.8% of GDP (2015) on health which is far below other major countries like USA (16.83), Canada (10.43), UK (9.87), Brazil (8.91), Russia (5.56), China (5.3), Myanmar (4.94) but ahead of other countries like Indonesia (3.3), Laos (2.8) (https://data.worldbank.org/ indicator/SH.XPD.CHEX.GD.ZS?year_high_desc=false). Even the doctor's density per 1000 population in India is 0.6 which is also behind other major countries like USA (2.7), UK (2.1), Brazil (1.7), and China (1.4). In fact the global average of doctor density per 1000 population is 1.23. Moreover, 70% of the Indian population lives in underserved rural areas, where only 2% doctors practice and most of them are registered medical practitioners (Patnaik & Patnaik, 2015). While 23% doctors practice in semi-urban areas and towns, and 75% qualified doctors (specialists) practice in urban areas or in metro cities (Patnaik & Patnaik, 2015). Thus, there exists a huge manpower gap in the health sector in India. In such a situation, emergence of telemedicine technology in India provides new possibilities to overcome the existing shortfalls in the healthcare sector. The first telemedicine center of India was opened by Apollo Hospital in Aragonda village of Chitto or District in Andhra Pradesh and it was connected to Apollo Hospital in Chennai through telemedicine. This first telemedicine center of India was inaugurated by then president of USA Mr. Bill Clinton. Since then, the Indian government is providing funds from time to time for the growth of the telemedicine facilities. The objective of the allocation of this money for telemedicine is to "access all the inaccessible parts" of the Indian subcontinent. Having low doctor to population ratio and low hospitals to population ratio, the telemedicine seems to be only possible and effective solution to overcome the current disease burden and mortality rate (Chandwani & Dwivedi, 2015). The question arises whether telemedicine has really met its objectives of providing adequate and affordable healthcare to the country's poor population? The question is yet to be answered.

Recent Developments
The government of India has taken many initiatives like National Medical College Network (NMCN)-to establish a national grid to connect medical colleges through high speed internet for medical education; National Rural Telemedicine Network (NRTN)-to design, develop and implement low cost telemedicine infrastructure in rural areas; and mHealth for covering entire country with telemedicine network to bestow rural peoples with tertiary healthcare facilities (Mishra et al., 2012). ISRO has played an imperative role in deployment of telemedicine services by providing satellite services through GRAMSAT, EduSat and INSAT satellites. Currently ISRO covers 384 telemedicine centers with 60 super specialty hospitals, Department of Information Technology (DIT) covers over 100 telemedicine nodes and OncoNet India project has been started by Ministry of Health and Family Welfare (MoH & FW) to connect 108 Peripheral Cancer Centers (PCCs) with 27 Regional Cancer Centers (RCCs) (Mishra et al., 2012). The Karnataka Internet-Assisted Diagnosis of Retinopathy of Prematurity (KIDROP) and the Revised National Tuberculosis Control Program (RNTCP) have been initiated to cure diabetic retinopathy and tuberculosis respectively, in both urban and rural partsof the country (Sheet, 2016). Government of Andhra Pradesh has started MukhyaMantri e-Eye Kendram under National Health Mission (NHM) to provide teleophthalmology services to the people (http://enethraap. phc.ind.in/cmdashboard/). Currently teleophthalmology services are being provided from 116 Active Centers of MukhyaMantri e-Eye Kendram, and more than 975000 people have visited these centers for their treatment (http:// enethraap.phc.ind.in/cmdashboard/). Government of Andhra Pradesh has also started MukhyaMantri Aarogya Kendra mulu under NHM to provide healthcare services to the people through telemedicine, and more than 38000 teleconsultations have been provided till date through these centers (http://www.euphc-ap-gov.in/Default PGIMER Chandigarh has also been made Regional Resource Center of Telemedicine for North India under NMCN (http:// nmcn.in/rrcnorth/about.php). Currently India has more than 600 telemedicine centers widely distributed across diverse geographic and socioeconomic settings ( Figure 1 and Table 1). Table 2 describes about the eHealth and mHealth systems developed for better Healthcare Delivery across India.

Telemedicine: Is it an Alternative Option for Conventional Face to Face Consultation?
A cross-sectional study has revealed the satisfaction for telemedicine among 80% patients and all the doctors on the basis of evaluation of perception of patients and doctors towards the use of telemedicine at Apollo Tele Health Services (Acharya & Rai, 2016). Additionally, 90% of the participants have found telemedicine to be cost-effective and 61% of the doctors who have participated in the survey have found an increase in inflow of patients apart from the regular number of patient's visits (Acharya & Rai, 2016). Besides these advantages there are several major concerns that hinders the complete use of telemedicine. For example,  (Mishra et al., 2012; http:// nmcn.in/; http://www.sgpgi-telemedicine.org/;https://www.nhp. gov.in/; Mathur et al., 2017;Ray et al., 2017). privacy was not maintained during teleconsultations done at Himalayan Institute Hospital Trustin Uttarakhand (Suresh & Nath, 2013). Sometimes the doctor needs to analyze the patient by putting his/her hand on patient (or by observing patient physically), in such a situation telemedicine approach becomes limiting. Even if the doctors prescribe a particular medicine to the patients via tele-consultation, it becomes difficult to access the medicine in remote areas of the country due to their non-availability (Ganapathy et al., 2016). How do the patients help themselves in such a situation besides having telemedicine facilities in these remote areas? Even now a days the patients in remote areas have to travel miles from their home (or village) for reaching the teleconsultation facility. More focused approach towards telemedicine is needed so that they patients need not to travel much for availing telemedicine services. In addition, although several evidences indicate telemedicine to be cost-effective, this might not be affordable for the poorest of the poor in India. Telemedicine in fact may be considered complimentary to fulfill healthcare need ofthe poor. Thus, the Indian government needs to recognize the factors hampering utilization of telemedicine along with its limitations.

Policy Majors Taken for Telemedicine Development, Deployment and Promotion
To strengthen the e-health and Telemedicine services and to empower people with better healthcare services Government of India has framed and implemented many policies from time to time. The major policy initiatives taken for telemedicine in India are described below:  (Mishra et al., 2012).
in case of diagnosis and surgery by using telemedicine, same quality of care as compared to conventional face to face care is not possible. Studies have shown that, despite having positive teleconsultations patients felt that telemedicine cannot be alternative to conventional face to face consultation (Meher & Kant, 2014). Others have demonstrated that out of 114 patients interviewed, 43 respondents said that telemedicine cannot replace face to face consultation and 14 said that they could not rely on tele-consultation (Meher et al., 2009). Also it has been shown that out of 115 patients 56 did not feel comfortable during teleconsultation and 77 said that their  3. "The framework for Information Technology Infrastructure for Health" has been prepared by DIT for addressing the information needs of people (Mishra et al., 2012). 4. "National Task Force on Telemedicine" has been set up by MoH&FW, Government of India in 2005 to fulfill multiple objectives of telemedicine and eHealth, such as to resolve interoperability issues, to define national telemedicine grid, to prepare pilot projects for connectivity of hospitals, to prepare curriculum and projects for Continuing Medical Education (CME), and most importantly drafting of a national policy for "Telemedicine and Telemedical Education" (Mishra et al., 2012). 5. MoH & FW has notified EHR standards for country with a view to their requirement and applicability in country. These were supported by major telemedicine providers and stakeholders (https://mohfw.gov.in/sites/ default/files/17739294021483341357_1.pdf ). 6. MoH&FW has also led initiative to constitute "National Digital Health Authority (NDHA)" in National Health Policy 2017. NDHA will act as promotional, regulatory and standard setting organisation for eHealth and Telemedicine in India (https://mohfw.gov.in/sites/ default/files/9147562941489753121.pdf ).

Challenges and Barriers
About 75% doctors in Kangra District of Himachal Pradesh (HP) revealed that hospitals lack diagnostics facilities for Acute Myocardial Infarction (AMI) and 94% agreed to the fact that Telecardiology services can improve healthcare services for AMI patients (Vivek & Vikrant, 2016). A study has shown that 3 out of 14 ISRO established telemedicine centers at District hospitals (Betul, Shajapur and Khargone) in Madhya Pradesh (MP) did not have adequate electric supply (Bali et al., 2016). This problem is not limited to only MP, but affects functionality of telemedicine all over Indian subcontinent. Another study has revealed that frequent power failure occurred at four telemedicine centers (Nagthat, Kwanu, Lakhamandal and Thano) in tribal hilly areas of Uttarakhand (UK) (Suresh & Nath, 2013). Similarly, because of power failure out of 194 teleconsulations planned with SGPGIMS Lucknow, 9 sessions at base hospital Almora and 19 sessions at base hospital Srinagar were held cancelled in hilly areas of Uttarakhand (http:// www.sgpgi-telemedicine.org/). Likewise, in HP, Wireless connectivity (WiFi and WiMax) was not possible because of high Himalayan range altitude and Terrestrial optic fiber connectivity was not possible due to cable cut (Ganapathy et al., 2016). Though ISRO has provided satellite connectivity to more than 100 hospitals, many remote villages are still to be connected to super specialty hospitals (http://www. neurosynaptic.com/wp-content/uploads/2014/12/GIM-India-2012-Telemedicine-in-Rural-India-Challenges-Opportunities.pdf ). In addition, although, the government of HP was willing to pay three times of the salary what doctors usually get, even then doctors do not want to work in hilly Himalayan areas of HP (Ganapathy et al., 2016). Almost 80% of the telemedicine infrastructure provided by ISRO is not in use because of mismanagement (Jarosławski & Saberwal, 2014). Undoubtedly, telemedicine has penetrated in remote areas, but its functionality is a matter of great concern. The Indian government needs to pay attention towards such emerging issues. Table 3 describes major challenges hampering use of telemedicine in India.
However, to resolve these challenges various initiatives are being taken by the central and state governments. Recently released National Health Policy 2017 has envisioned that, a National Digital Health Authority (NDHA) will be constituted to implement, promote and regulate the telemedicine in India (https://mohfw.gov.in/sites/default/ files/9147562941489753121.pdf ). Further, under National Telemedicine Network (NTN) the high-speed internet connectivity will be provided through National Knowledge Network (NKN), National Optical Fiber Network (NOFN), SATCOM (satellite communication) and terrestrial highspeed internet to boost the telemedicine services in the country (http://nmcn.in/pdf/Final%20Concept%20Note %20of%20National%20Telemedicine%20Network.pdf ). To resolve other challenges government has initiated to provide telemedicine service in Public Private Partnership (PPP) mode (http://nmcn.in/pdf/Final%20Concept%20 Note%20of%20National%20Telemedicine%20Network. pdf ). Telemedicine services in PPP have been effective and successful under diverse geographic and socio-economic settings in the country including inaccessible and remote areas of Himachal Pradesh (Ganapathy et al., 2016;Ganapathy, 2014;Ganapathy et al., 2018;CSC Annual Report 2015-16). Apollo Telehealth Services (ATHS), Medanta Hospital are the leading stakeholders in providing telemedicine services in PPP mode (Ganapathy et al., 2016;Ganapathy, 2014;Ganapathy et al., 2018;CSC Annual Report 2015-16).

Recommendations
• More emphasis is required on education and training of health workers, programs to promote telemedicine awareness needs to be started. • Health workforce should be motivated and promoted for using telemedicine, and government doctors should be provided with extra emoluments for using telemedicine so that their participation in telemedicine can be enhanced. • Issues like low bandwidth and lack of interoperability standards for software that reduce the efficiency of this technology need to be rectified along with legal, ethical and social issues. • An integration model based on mobile App including teleconsultation services, video conferencing, patient's diagnosis details, pathology and alert system can be designed and developed to provide quality healthcare services to each and every individual through telemedicine. All healthcare services and facilities can be provided through single mobile App, this may resolve the problem of specialist's non-availability and delay in treatment. • Telemedicine facilities in the area of neurology and neurosurgery must be deployed to extend their reach to patients residing in rural areas. A public-private partnership model may be promoted as a viable option for telemedicine to be successful. • Awareness among both the stakeholder's viz. patients and healthcare providers may be created about telemedicine for delivery of quality healthcare services in rural and remote areas. • Efficient revenue models should be designed for developing infrastructure, training of manpower and research and development for successful implementation and utilization of telemedicine.

Limitation of the Study
Although thorough search has been made to find out n umber of telemedicine centers (Both public and private) in India (Figure 1 and Table 1), eHealth and mHealth

Ethical Approval
Being this is a review article manuscript, obtaining ethical approval was not required. Since this is a review article and information provided herein are totally based on prepublished articles and information accessed from various health web portals, and no new empirical data were collected for writing this manuscript.