|Ahead of print publication
Digital health and rheumatology: The Indian context
Suchitra Kataria1, Vinod Ravindran2
1 Melange Communications Pte Ltd, Singapore
2 Centre for Rheumatology, Kozhikode, Kerala, India
|Date of Submission||20-Jun-2021|
|Date of Acceptance||08-Jul-2021|
Centre for Rheumatology, Kozhikode - 673 009, Kerala
Source of Support: None, Conflict of Interest: None
India as a country of contrast and diversity has witnessed digital evolution in different waves and stages. The technology is already an integral part of lives of millions in India; however, its application in the health management remains limited unlike developed economies. COVID-19 pandemic has plunged the country into universal, regional, or local lockdowns repeatedly since the last year. An unexpected and unforeseen impact of this has been the usage of technology for doctor–patient interactions through telemedicine. Hitherto limited to certain pockets, virtual interactions with doctors, ordering laboratory investigations through an application or procuring medicines through internet, are now part of mainstream patient behavior. This is a crucial change in the mindset but requires a lot more to be done at various levels to tap its full potential with rheumatologists being at the forefront and leading the change in their specialty. The pool of rheumatologists is very small and mostly concentrated in few urban areas, leading to diagnostic delay, suboptimal treatment, and poor outcomes. Technology could, therefore, become a catalyst for change and harbinger for greater clinician access. There are plenty of discussions about the impact and potential of deep learning, artificial intelligence, remote monitoring with wearables, etc., but plenty of them may not be relevant to Indian patients in the current scenario. Hence, the context, relevance, and applicability are the key for rheumatologists when making a judgment.
Keywords: Digital health, disease management apps, e-pharmacy, fifth-generation, patient data, remote monitoring, telemedicine, virtual care, wearables
| Introduction|| |
In the past 2 decades, India has leapfrogged in digitization and connectivity throughout the nation. Be it internet connections or app downloads, the volume and growth of digital adoption in India outstrips most of the countries in the world. All the key stakeholders of digital world, government, private sector, and, most important, the consumers, have been responsible for this phenomenon. Digitization has had a huge impact on health-care sector in multiple forms, leading to immense benefits. While we had dealt with the impact of digital health on rheumatology previously, in this perspective, we have focused on its application in rheumatology specifically in the Indian context.
| Digital Landscape and Health Care in India|| |
According to global consultant McKinsey, India had 560 million internet subscribers, 354 million smartphone users, and 1.2 billion mobile phone subscriptions in 2018. The mobile data usage by an Indian consumer on an average is 8.3 gigabits (GB) each month compared 5.5 GB in China and 8.0 GB in South Korea. The study comparing 17 mature and emerging economies conducted by McKinsey Global Institute found that India was digitizing faster than any other country.
Given the huge geographical spans in India, the health-care system is expansive; however, challenges galore with massive gaps particularly in rural areas and poor states. India currently has one million doctors and two million nurses and midwives. This translates into 2.2 health-care professionals (HCP) for every 1,000 individuals. Almost 60% of hospitals, 75% of pharmacies, and 80% of doctors in India are catering to 32% of urban population residents, underscoring a glaring urban vs rural divide. The nation has less than one-fifth of the required specialists such as cardiologists, pediatricians, and psychiatrists including rheumatologists. There are only about 1000 qualified rheumatologists serving a population of 1.3 billion. In this context, core areas of patient access, outcome measurement, and patient satisfaction could be addressed to a fair extent by digital technologies.
As India is a unique multicultural and multilingual society with immense diversity, any digital technology relevant to rheumatology howsoever state-of-the art or cutting-edge, to make an impact needs to be– contextual and applicable and must have the ability to create an impact.
Contextual because the rheumatologist and the patients should be comfortable using the digital tools in their socio-economic settings. For instance, voice and vernacular are playing a greater role. As per global consultancy Bain, by 2021, compared to 200 million English speakers almost 500 million vernacular speakers are expected to be online. The number of voice searches on Google has almost tripled in the last year. Applicable since the technology shouldn't put additional cost burden or complicate the workload of a rheumatologist. Impact creation comes from the fact that the stakeholders should be able to see perceptible or meaningful difference. Visual elements especially video are gaining huge traction. Video consumption in tier-2 and smaller towns grew ×4 in the last year. These trends point toward huge patient education and awareness building opportunity for rheumatological diseases utilizing audio podcasts and videos besides doing them in multiple Indian languages to create a major difference.
| Rheumatologists and Patient Care – What are Applicable in Current Scenario?|| |
Technology per se is merely a tool unless the individuals use it in the milieu around them to make lives better. In [Figure 1], we propose a several levers for enabling optimal patient care in rheumatology setting specific to Indian scenario.
Broadly, the key technologies which could make rheumatology care more accessible, cost-effective, and efficient are telemedicine, electronic health records (EHR), rheumatology disease management applications, and rheumatology care analytics. As outlined in [Figure 1], each of these is interrelated and creates value proposition
| Telemedicine Consultations and E-prescription with Fulfillment|| |
Telemedicine technology involves digital interactions between patients, clinicians, and support staff, through a video on any smart device or clinical consultation/conversation via mobile phone. Face-to-face interactions between the clinician and patients can never be replaced by any means; however, the follow-ups, symptom alleviation, drug compliance, dose adjustments, etc., can be done by rheumatologists remotely. Virtual visits are cost-effective and time-saving and bridge the distance. Furthermore, this is an effective mechanism for patient referrals by the GPs, especially from semiurban or rural areas, which does not have access to a rheumatologist
Telemedicine trials have demonstrated that remote consultations improve patient outcomes. McKinsey estimates that telemedicine may supplant 50% of in-person outpatient department consultations in India. Another study conducted by Royal Philips which interviewed senior health-care leaders reported that 75% of them indicated a shift to remote and virtual health care in India. If all these plans come to fruition, critical shifts could enable patients in rural areas to save time and money in travel to urban areas for seeking specialist care and also eliminate the dependency on unqualified medical practitioners. With significant room for growth in smartphone ownership by a vast majority of population coupled with broadband internet connectivity, a large untapped avenue for telemedicine consultations has become available. The Digital Information Security in Healthcare Act-government of India program is a framework to enable the privacy and reliability of digital health data. This is critical to ensure how the health data are collected, stored, transferred, and deployed.
Practo offers a suite of services through an application combining remote medical consultations with EHRs, linking networks of doctors and hospitals, schedule laboratory tests, home delivery of medicines, and health equipment. Apollo Health is setting up “teleclinic centers” in rural areas. At these clinics, patients can interact with the clinicians through video chat and health workers present at the clinics shall perform simple yet important tasks such as checking blood pressure. When COVID-19 pandemic hit the country last year, Apollo 24/7, a holistic digital health platform, was created comprising >7,000 clinicians and 30,000 other HCPs. Within 6 months of launch around mid-2020, the platform had enrolled 4 million individuals clocking 30,000 downloads per day. According to Apollo Hospitals, 50 million Indians accessed health care online between March to May 2020. Out of all telemedicine users and patients, 80% used it for the first time. By mid of 2020, there were 4 million users of Apollo 24/7 with almost 25% of them returned continuously for subsequent use of this platform. Apollo backed the health service with e-prescribing and enabled deliveries within 2 h from their dedicated pharmacy network. By the aforementioned examples, we can conclude that COVID-19 pandemic has amplified digital application in all walks of patient care substantially. Various health-care organizations around India are now setting forth technology agendas to harness digital technologies that provide the right infrastructure to help serve the patients better.
1 mg has created a healthcare platform where users can buy discounted medicines online which can be delivered at their doorsteps and patients can tele-consult doctors spanning >20 specialties. The platform facilitates >2,000 lab tests by collecting the samples from home. The blood samples are taken by well-experienced phlebotomists visiting patient's home at the scheduled time. The testing is done at >120 top and verified labs at the best available prices. Since then, several other e-pharmacies have emerged.
At a practical level, for any rheumatologist looking to add a virtual consultation to patient care, we recommend using simple, free to use chat applications with end-to-end encryption on a smartphone, tablet, or laptop. However, making a short summary of key outcomes in e-prescription is important for future reference.
| Electronic Health Records|| |
Digitization of patient records is a global phenomenon and the rewards are manifold to patients, clinicians, and health-care system. As Indians comprise heterogenous individuals with diversified genetic pool, profiling the rheumatological disorders in India to pinpoint peculiarities and applying pharmacogenomics patient data at a granular level is extremely important. Unless rheumatologists apply and capture crucial patient data in EHR, obtaining harmonized and systematic data would remain a pipedream. In 2016, Indian government set forth standards for the effective use and interoperability of EHRs, which was meant to gather patients' entire medical history in a singular file with uniform format. India's HCPs including rheumatologists except for a few metropolitan pockets are yet to inculcate EHRs in their clinics or hospital systems. A strategic and systematic approach would be the key to larger adoption and implementation of EHR. Specialty-specific EHR systems could be applied with an eye on adhering to government standards with flexibility to obtain insights through data analysis. Patient privacy is not a serious matter in India at the moment; however, it would be necessary to safeguard privacy and maintain confidentiality with robust cyber security.
| Rheumatology Disease Management Applications|| |
Affordable smartphones, availability of 4G, and greater internet penetration with connectivity present unique opportunity for the rheumatologists across India to engage directly with their patients. For example, a multilingual smartphone application in rheumatology can go a long way to educate (ArthritisID), monitor (RheumaHelper) and measure disease understanding (LiveWithArthritis), drug compliance, lifestyle modifications with essential behavioral nudges to adhere to medicine, exercises, and mental health., These applications could complement the rheumatologist-prescribed courses of management. As we have already stressed upon the concept of contextuality, making the apps multilingual with content as per cultural beliefs, food practices will be key to acceptability and adherence. The user experience of these apps can be further enhanced with hands-on videos, animations, eye catching graphics, and easy-to-understand explanations in simple patient friendly tone.
| Rheumatology Care Data Analytics|| |
Only a limited number of patients have access to a qualified rheumatologist; therefore, a vast majority of clinicians trained in internal medicine and allied specialties need rheumatologist's direct and indirect support. If a working group could be put together and by partnering with digital health startups, they could put together a data collection system, process to analyze them, and come up with evidence-based care for Indian patients in the local settings. Plenty of unmet needs could be addressed in this manner by enabling doctors and nurses to augment their clinical expertise. Multiple sources of data from mobile apps, wearable/ambient sensors, social media posts, and sensors etc., backed by expanded internet connectivity and faster devices have the potential to make this possible. Clinicians can deploy evidence-based care tools by adopting recommendations on most effectively approaches to manage chronic inflammatory ailments. Further sophisticated methodologies would be able to apply advanced analytics and AI-powered algorithms to help diagnose patients through data inputs provided by images, blood samples, etc., and correlate them with disease biomarkers. As there is no dearth of software engineers and data scientists in India, a structured approach with a joint working group comprising diverse technology professionals and rheumatologists is the key.
Manipal Hospitals has embarked upon analyzing cancer patients' medical records and creating a range of potential diagnoses with personalized treatment options for oncologists through a cognitive computing platform, IBM Watson. Qure.ai,, Indian digital health start-up has partnered with Fujifilm for leveraging its proprietary AI-powered software for screening of diseases such as COVID-19 and tuberculosis. Qure.ai, AI software called qXR when paired with Fujifilm's portable X-ray FDR Xair system enables the device to analyze radiographs and detect abnormal findings within seconds. This could enhance tuberculosis screening in India and other developing countries with limited resources.
The above two examples aptly illustrate that similar models can be very well applied in rheumatology. Furthermore, advanced technologies such as AI-driven solutions are being developed and applied in Indian setup.
| The Potential of Digital Health-care Solutions in India|| |
The ongoing COVID-19 pandemic has had profound effect on the physical and mental health of people around the world and India is no exception. This has also challenged the earlier beliefs, norms, and practices on sense of well-being and has accelerated the desire and determination to be more active, engaged, and involved in managing overall health. Some of the key reasons behind the change in mindset are the following:
- Greater comfort in using technology by clinicians and patients
- Acceptability of virtual interactions and convenience
- Openness to deploying technology for health monitoring
- Changing attitude toward adopting and experimenting with latest technologies.
There have been several technological advances, which when combined with human forces could lead to advancement of care at all levels in India. Examples include the following:
- Fifth-generation (5G) technology is the next upcoming advancement in mobile technology designed to support ultradependable, low-latency, and bulk data communications competencies. This will support better video and immersive environment for doctor–patient interactions and ability to transfer heavy files like radiological images easily
- Cloud computing solutions offer more adaptability and portability than in-clinic or institutional computing platforms in helping busy clinicians streamlining tasks, digitizing key data and better communication abilities with the care provider delivery team colleagues
- Robotics is already a part of the mainstream in surgical practice streams. These software-powered devices help immensely in performing complex procedures with greater accuracy and flexibility. When coupled with augmented reality it provides performing surgeons instant access to digital images and data maximizing decision-making abilities
- Sensors are integral components of consumer and medical grade wearables that monitor patient health and capture important health parameters data. These vital data help develop algorithms for various purpose, for example, recognize and flag abnormalities, reminders for exercise, medication, or other treatment recommendations
- Internet of Medical Things (IoMT) is a connected ecosystem of health system and services involving medical devices and software applications that brings together various stakeholders (patients, caregivers, and clinicians), data points (patient or performance data), processes (care delivery and patient support), and enablers (sensors and medical devices) to deliver better patient outcomes
- Natural language processing (NLP) is an output of verbal or written elements as key inputs that are comprehended and fed in the algorithms for deep learning and AI
- Big data analytics involves analysis of large, unstructured datasets to divulge patient patterns or interrelations and data visualization that represents data in easy-to-comprehend manner streamlining decision-making process
- AI is a simulation of human thinking and decision-making by machines which are trained with plenty of data (deep learning/machine learning). The AI algorithms are being developed to help support diagnostic accuracy, clinical decision support, etc
- Blockchain systems are a digital ledger or record of transactions interlinked and operated in decentralized fashion. Some of the key applications of this technology are for monitoring and tracking supplies of medical products, share clinical trials data, insurance claims, medical system performance, etc
- Learning platforms enable flexible and immersive learning for health-care professionals through software and servers/cloud computing.
In [Figure 2], we have listed these technological enablers and provided our estimate on their relative potential to impact patient care in rheumatology in India on a 5-year horizon and beyond. Our assessment is based on Indian scenario, adoption and off take of technology, and maturity of various technologies by patients, clinicians, and administrators/allied decision-makers.
We foresee 5G technology to be making bigger impact in Indian conditions as bandwidth and connectivity are the biggest obstacles to smooth roll out or execution of telemedicine, especially in remote areas. We are assuming that leading telecom service providers will launch and make available 5G technology across India at affordable prices in the next 1-2 years. Despite much hype AI scores low in creating any or small impact in the next 5 years due to lack of structured data and avenues in India.
| Unmet Needs of Digital Health Care in India|| |
Being a developing country, Indian patient has certain peculiarities which may be deterrent to technology adoption. Some of these are as follows:
- Hesitation with usage of digital devices and applications
- Digital devices especially for health purpose are mainly urban phenomenon
- Trusting the devices with reliable and predictable performance is limited to individuals of higher education qualifications
- Awareness about global health trends and changing health-tech landscape is usually lacking amongst majority of patients
- Upkeep of devices and continuous adherence/compliance is lacking
- Gadgets are more of status symbol than deriving actual utility out of various functions embedded in them
In addition, rheumatology patients have their own nuances, traits, behavioral patterns, and responsiveness to external stimulation. These features are further accentuated or suppressed by cultural, socioeconomic, ethnic, or environmental factors inherent to India. In this context, we have listed some of the unmet needs and their potential digital solutions in [Table 1].
We would like to emphasize that while planning any digital initiative, long-term vision and panning are vital. Digital engagement and creation of critical mass to show the impact require time and continuous investment. Regular updates, fresh content, and crisp messaging geared to provide rich user experience play important roles in ensuring any digital initiative's success.
While handling patient data, some important considerations at the baseline are; creating de-identified datasets, setting forth data governance mechanism and putting standards for exchange in place.
| Conclusion|| |
Digitization is a global trend and India is an integral part of this global village. Rheumatology is a set of complex diseases which require multipronged strategy at all levels for ideal management. Digital health technology could play a vital role in rheumatology patient management. It is important on part of rheumatologists in India to understand upcoming technologies and learn their key advantages to be able to adopt them in their patient care. In addition, they should be prepared to take initiative and provide leadership for pilot projects to experiment what works and then scale them up across the country.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]