During the COVID-19 pandemic, telemedicine has been promoted extensively by the Indian government as a long-term solution for Indian healthcare. However, telemedicine predominantly helps only the middle class, restricted by 36% internet penetration in India. Despite these limitations, telemedicine has encouraged both patients and doctors to consider novel processes for consultations. This therefore provides opportunities to deliberate more useful changes in outpatient consultations (OPC) in India.
OPC are the main patient-doctor interface in medicine, accounting for 85% of clinical activity in healthcare systems. There are three types of OPC: new, initial follow-up and routine follow-up. In a new OPC, assessment, diagnosis and investigations are offered. In initial follow-up, test results, treatment and monitoring strategies are discussed. In routine follow-up, clinical circumstances and treatments are monitored, complications prevented and addressed, and patient well-being promoted.
The Ministry of Health and Family Welfare’s telemedicine guidelines (March 2020) endorse the WHO definition of telemedicine. They emphasise “the exchange of valid information for diagnosis, treatment and prevention of disease … and advancement of the health of individuals and their communities.”
These principles actually apply to both virtual and face-to-face consultations. Such values are also highlighted in the Code of Medical Ethics Regulations (Medical Council of India, 2002).
What do patients want from OPC? Patients chiefly desire clean organised outpatient facilities, treatment with respect and dignity, the main clinical issue being addressed and good doctor rapport.
Punctuality is essential. New, initial follow-up and routine follow-up appointments require protected time, allocated proportionate to clinical complexity. Allied diagnostic services such as radiology and laboratory tests facilitated on the same day as OPC help reduce hospital trips and overcrowded waiting areas.
Patients also need personalised advice on their condition. They desire supportive treatments being coordinated with allied professions such as physiotherapy and psychology. If further specialist opinion is needed, patients request referral with comprehensive written case summaries. In between OPC, patients need reliable and timely access to address clinical deterioration and adverse effects of treatments.
Prescriptions are invaluable to patients as they are often the only paperwork patients receive after consultations. India’s Code of Medical Ethics stipulates doctors prescribe legibly, appropriately, rationally, and as far as feasible, use generic drugs. However, audits consistently demonstrate inadequate dosage regimes, disproportionate use of expensive drugs, and excessive broad spectrum antibiotic use. Half of medical expenses incurred in India are on unnecessary or irrational medicines and investigations.
This reflects patchy regulation, extraordinary multiplicity of branded medications and patient pressure. Poor prescriptions also contribute to the estimated five million medical errors annually in India.
It is mandated that Indian medical records be kept in a standardised format for 3 years, and patients provided their records within 72 hours of requesting them. However, record-keeping remains sub-optimal in India. The Indian government issued guidance on electronic health records (EHR) in 2016, but uptake has been patchy to date.
Indian doctors are stipulated to agree fees prior to OPC and an invoice has to be provided. However, patients often find this obligation unfulfilled. Fair invoicing is even more important as two-thirds of healthcare expenditure in India is borne personally by households pushing 3.5% to 6.2% of the population into poverty each year. As public expenditure on healthcare remains low at 1.28% of GDP, patients would benefit from reasonable, consistent and transparent tariffs.
So how can OPC be improved in India?
First, all healthcare providers and healthcare systems, private and public, must adopt the Charter of Patient Rights (National Human Rights Commission, 2018). They must develop frameworks to meet the aspirations of the charter, including the right to information, accessible and comprehensive records, data protection and confidentiality, and the best clinical and cost-effective care.
Second, there must be investment in infrastructure, physical and digital, via public-private partnership. Outpatient appointment booking systems, tariffed billing and EHR systems must be developed. The National Health Portal’s EHR system could be rolled out across India to help achieve this.
Third, standardised digital prescription systems should be introduced by the government as internet connectivity expands across India. This would enable monitoring of prescribing practices, reduce prescription errors, monitor pharmacy dispensing data and lower costs.
Fourth, generic training on the importance of good medical practice incorporating ethics, communication skills, record keeping and safe prescribing must be a mandatory part of medical training and continuing professional development for all registered doctors.
Fifth, a new national patient feedback and complaints system must be introduced. Currently, patients have bewildering recourse to either medical councils or consumer and civil courts. Ideally, an independent organisation with representation from patients, clinicians, lay persons and the government should be developed. It could work to strict time frames, investigate complaints, issue strictures and publish recommendations derived from learning from mistakes. This would help both patients and doctors.
To conclude, telemedicine is a mere band-aid on the ailing outpatient consultation system in India. It complements but cannot replace face-to-face clinical care in a pandemic or beyond, as emphasised in the Code of Medical Ethics, and as witnessed when doctors abandon their face-to-face duties. To truly transform the health of the Indian population, a range of structural and cultural improvements in outpatient care need to be introduced and guaranteed in the future.
Saif Razvi, MD, FRCP, is a consultant neurologist in the UK, where he has piloted, developed and introduced multiple telemedicine services.
The views expressed here are the author’s own and don’t represent those of the organisations the author works for.