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 Table of Contents  
COMMENTARY
Year : 2020  |  Volume : 1  |  Issue : 1  |  Page : 10-12

Health system strengthening during COVID-19 pandemic through virtual out-patient clinics: An experience from India


1 Department of Community Medicine, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
2 Chief Executive Officer, Jiyyo Innovations, Chandigarh, India
3 Department of Community Medicine and School of Public Health, PGIMER, Chandigarh, India

Date of Submission17-Nov-2020
Date of Acceptance07-Dec-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Sudip Bhattacharya
Department of Community Medicine, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jphpc.jphpc_9_20

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  Abstract 


Whenever any pandemic accelerates, e.g., the corona virus disease 2019 (COVID-19), it is commonly observed that health care systems face tremendous workload in terms of infectious patients seeking testing and care. During such public health emergencies, besides logistics, there is shortage of trained personnel. In this COVID-19 pandemic Government of India is doing its level best for minimizing the impact of COVID-19. Multiple stringent measures are already taken like nationwide lockdown, social distancing, in hospitals-closing of out-patient services, postponement of elective surgeries, creating dedicated COVID-19 treatment hospital, one third of health staff is working on rotation basis and many more, for prevention of COVID-19 and minimizing the impact. Despite of this, the looming communication gap between people living in remote areas and the specialist doctors has always been in the picture. Due to COVID-19, as most of the routine OPDs are closed it is it has become very tough for people specially who have chronic diseases to consult their doctor. In this scenario artificial intelligence enabled Virtual OPD (VOPD) can be boon to the Indian population. The existing problems related to lack of access to OPD care for a major proportion of population can be solved by some extent by virtual OPD care services, in which patients consult with doctors in a virtual platform via mobile phone, computer and other e-devices. It is supposed to offer a number of advantages over traditional medical consultations in terms of convenience and cost. First and foremost, leverage of video consultation is “Therapeutic presence” that it is reassuring for the patients when they see doctor on video. The second advantage is that it helps in diagnostic assessment of the patients. Not only virtual OPDs solve the issues of delays and self-medication. This not only give benefit of availing the service as per the convenience but also provides the utmost medical consultation directly from the expertise. Alongside, the waiting period of minimum 3-4 hours can be reduced by simply audio-video consultations. It becomes easy to generate electronic prescription and can be emailed. However, evidence of clinical outcomes of VOPD is limited in Indian context. Furthermore, if integrated smartly into existing health care systems, VOPD care have the potential to manage the problem caused by the COVID-19 pandemic.

Keywords: COVID-19, digital health, pandemic, tele-medicine, virtual out patient care


How to cite this article:
Bhattacharya S, Sharma N, Angrish S, Singh A. Health system strengthening during COVID-19 pandemic through virtual out-patient clinics: An experience from India. J Public Health Prim Care 2020;1:10-2

How to cite this URL:
Bhattacharya S, Sharma N, Angrish S, Singh A. Health system strengthening during COVID-19 pandemic through virtual out-patient clinics: An experience from India. J Public Health Prim Care [serial online] 2020 [cited 2021 Jan 28];1:10-2. Available from: http://www.jphpc.com/text.asp?2020/1/1/10/305991



COVID-19 is a severe acute respiratory infection which is caused by SARS-CoV-2 i.e., severe acute respiratory syndrome coronavirus 2. This SARS-CoV-2 is the seventh coronavirus and appertains to subgenus “Sarbecovirus” of Coronaviridae family. It was established that this virus was similar to SARS-like coronaviruses from bats but dissimilar to SARS-CoV and MERS-CoV. In December 2019, at Wuhan City, Hubei Province, China, this virus was first identified, and its link was found to be associated with seafood market which led to an outbreak of pneumonia of unknown cause.[1],[2]

The clinical symptoms range from a mild common cold-like illness, to a severe acute respiratory distress syndrome. On 30 January 2020, WHO first declared this as a public health emergency of international concern and on 11 March 2020 it was declared as global pandemic. Prevention becomes the mainstay to avert the virus exposure. The preventive measures that can be adopted by people are washing hands for at least 20 sec with soap and water or using alcohol-based hand sanitiser having more than 60% alcohol, using face masks, following cough etiquette and respiratory hygiene, avoid touching face, mouth, nose and eyes. Maintaining social distance of at least 1 metre, refraining hand shaking and immediately contacting health personnel if symptoms like fever, cough, and difficulty breathing arises, disinfecting touched surfaces frequently will also help in breaking the chain transmission.[1]

Till the time vaccine or definite drug come up against COVID-19, extreme social distancing through “lockdown” becomes important intervention to halt chain transmission. It also gives time for preparation to deal with it. Apart from mitigation that slows epidemic by protecting high risk individuals from developing infection and isolating the suspected cases and their contacts, the main concept behind lockdown is to reduce secondary cases and keep basic reproduction number i.e., R below one (R <1). The goal of this suppression i.e., closing all schools, universities and avoiding mass gathering is to reverse epidemic growth and decrease case numbers to lower level. The study from the Imperial College London COVID-19 Response Team states that there might be peak mortality in three months if strict lockdown and social distancing measures are not followed. They further stated that for achieving R <1, combined efforts of isolating cases, maintaining social distancing of the entire population through schools and university closure and household quarantine are necessary. The lockdown effects proved to be beneficial for China and even for some parts of Italy like Lodi which helped in flattening the curve.[3]

During any pandemic, there is serious disruption in the routine functioning of community, and help is often required from the external agencies.[3] Although multiple sectors play an important role in pandemic management, health professionals play a vital role in pandemic preparedness and response. Timely and efficient intervention to the health-care needs of the pandemic-affected populations is one of the highest priorities in its overall management.[3]

Whenever any pandemic accelerates, e.g., the corona virus disease 2019 (COVID-19), it is commonly observed that health care systems face tremendous workload in terms of infectious patients seeking testing and care. During such public health emergencies, besides logistics, there is shortage of trained personnel. In this COVID-19 pandemic Government of India is doing its level best for minimizing the impact of COVID-19. Multiple stringent measures are already taken like nationwide lockdown, social distancing, in hospitals-closing of out-patient services, postponement of elective surgeries, creating dedicated COVID-19 treatment hospital, one third of health staff is working on rotation basis and many more, for prevention of COVID-19 and minimizing the impact.[4]

The looming communication gap between people living in remote areas and the specialist has always been in the picture. Due to COVID-19, as most of the routine OPDs are closed it is it has become very tough for people specially who have chronic diseases to consult their doctor (3). In this scenario artificial intelligence enabled Virtual OPD (VOPD) can be boon to the Indian population. The existing problems related to lack of access to OPD care for a major proportion of population can be solved by some extent by virtual OPD care services, in which patients consult with doctors in a virtual platform via mobile phone, computer and other e-devices. It is supposed to offer a number of advantages over traditional medical consultations in terms of convenience and cost. First and foremost, leverage of video consultation is “Therapeutic presence” that it is reassuring for the patients when they see doctor on video. The second advantage is that it helps in diagnostic assessment of the patients.[5],[6]

Not only virtual OPDs solve the issues of delays and self-medication. This not only gives benefit of availing the service as per the convenience but also provides the utmost medical consultation directly from the expertise. Alongside, the waiting period of minimum 3-4 hours can be reduced by simply audio-video consultations. It becomes easy to generate electronic prescription and can be emailed.[7]

However, evidence of clinical outcomes of VOPD is limited in Indian context. Furthermore, if integrated smartly into existing health care systems, VOPD care have the potential to manage the problem caused by the COVID-19 pandemic.

In India, the AI enabled Virtual OPD (VOPD)/Jiyyo e-mitra clinic is a social business model innovated by Jiyyo Innovations a Chandigarh based start-up. Jiyyo e-mitra clinic aims to outreach rural and interior parts of India and provide primary as well as specialist healthcare services by connecting local practitioners and health workers visiting patients with qualified allopathic and specialist doctors in city through video call. Jiyyo has changed the scenario of telemedicine and made it available to areas with poor infrastructure. There is no need of costly equipment. A simple smartphone is the primary requirement. Additional devices like screen and printer are added so that patient can visualize the doctors, communicate their health problems, and can have printed authentic prescriptions as provided by the medical practitioners.[8]

Initial findings of this e-clinic (last six months data) suggest that most of the patients were given consultations by general physicians but specialist and super specialist consultations were also provided including paediatrics, orthopaedics, dermatology, urology, nephrology, cardiology, and neurosurgery. The data of five centres were analyzed and around 800 consultations were done. Among those 157 patients belonged to age group 60 years and above.[9]

The participants (n = 157) willingly participated and completed the entire sessions of consultation, which illustrate the acceptability of the VOPD/e-mitra clinic system. Also, the dispatched prescriptions revealed diagnosis, offered treatment, and referred advanced or complex cases, which highlight the feasibility of the VOPD in the context of rural India. The preliminary findings of this study indicate the acceptability and feasibility of Virtual OPD in rural India, which may improve access to qualified healthcare providers for a massive population. The existing efforts show that the e-clinics becoming popular in a rapid pace, which may help to alleviate the burden of primary care centres by offering remotely available virtual services without compromising access to qualified providers. The acceptability from provider side and recipient side was good, which implies potential sustainability and possibilities for expansion of such services in a wider geographical area. The patient turnover is getting high and most of the patients are satisfied which is indicated by re-visits in these e-clinics. Thus, e-clinics can contribute to addressing inequity issues in healthcare in India. It is expected that this e-clinic concept is also very helpful in pandemic situation like COVID-19.

Nonetheless, in this COVID-19 pandemic period, there is indeed a lot of constraint on doctors to tackle this situation even with the help of video consultations. One such notable botheration is “Email tsunami”, responding to the mails whether the email is from some patient or any other healthcare professional becomes cumbersome when already doctors are giving consultations even if communication is not face to face. Second thing that has come up is many doctors might not be digitally advanced, these technical glitches and lack of experience lowers the confidence of doctors in using this tele consultations. This also hampers their communication skills when interacting with patients.[10]

Thirdly, it is not possible to do full physical examination through video consultations. Even for assessing breathlessness, sometimes people who suffer from hypoxia are skipped due to the burden of unnecessary patients.[11]

In a country like India, the quality of care should be placed at the heart of digital revolution in primary care so that quantitative measures like how much population does not affect the health rights of individuals and populations. VOPDs should be further developed and adopted upholding the ethical and clinical values to promote OPD care in India in humanitarian crisis as well as in normal situations.

Earlier it was just an option but to handle any disease during health crises time, these virtual OPDs concept can be very favourable and minimise the time. They have now become the need of an hour. keeping this in mind, with combined efforts of Board of Governors, Medical Council of India and NITI Aayog have made Telemedicine Practice Guidelines for Registered Medical Practitioners to provide healthcare using this facility.[12] These guidelines can be used with national protocols and standard operating procedures. Thus, these mandatory virtual OPDs round the clock will certainly benefit not only people residing in remote areas but also to doctors and will escalate Government's economy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html. [Last accessed on 2020 Apr 24].  Back to cited text no. 1
    
2.
Coronavirus Latest: First Infection Reported in Sub-Saharan Africa. Available from: https://www.nature.com/articles/d41586-020-00154-w. [Lase accessed on 2020 Mar 02].  Back to cited text no. 2
    
3.
Bhattacharya S, Singh A, Semwal J, Marzo RR, Sharma N, Goyal M, et al. Impact of a training program on disaster preparedness among paramedic students of a tertiary care hospital of North India: A single-group, before-after intervention study. J Educ Health Promoti 2020;9:5.  Back to cited text no. 3
    
4.
Bhattacharya S, Hossain MM, Singh A. Addressing the shortage of personal protective equipment during the COVID-19 pandemic in India-A public health perspective. AIMS Public Health 2020;7:223-7.  Back to cited text no. 4
    
5.
Wharton GA, Sood HS, Sissons A, Mossialos E. Virtual primary care: Fragmentation or integration? Lancet Digital Health 2019;1:e330-1.  Back to cited text no. 5
    
6.
FutureLearn. The Data Lab Driving Value from Data Online Course. Future Learn. Available from: https://www.futurelearn.com/courses/driving-value-from-data. [Last accessed on 2020 Apr 24].  Back to cited text no. 6
    
7.
70% of OPD Consultations Can be Replaced Through Virtual Healthcare: Amit Munjal, Health News, ET Health World. Available from: https://health.economictimes.indiatimes.com/news/industry/70-of-opd-consultations-can-be-replaced-through-virtual-healthcare-amit-munjal/51436677. [Last accessed on 2020 Apr 24].  Back to cited text no. 7
    
8.
Jiyyo Mitra e-Clinic-Multispeciality Online Consultation Center Jiyyo. Available from: https://www.jiyyo.com/jiyyo-mitra-e-clinic-online-consultation-center. [Last accessed on 2019 Aug 18].  Back to cited text no. 8
    
9.
How Effective is the Virtual Primary Healthcare Centers? An Experience from Rural INDIA. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7113938/. [Last accessed on 2020 Apr 24].  Back to cited text no. 9
    
10.
Malhi S. Good Communication Will Help Beat COVID-19. The Hill; 2020. Available from: https://thehill.com/opinion/healthcare/490410-good-communications-will-help-beat-covid-19. [Last accessed on 2020 Apr 24].  Back to cited text no. 10
    
11.
Greenhalgh T, Wherton J, Shaw S, Morrison C. Video consultations for covid-19. BMJ 2020;368;m998.  Back to cited text no. 11
    
12.
e-Health & Telemedicine Ministry of Health and Family Welfare GOI. Available from: https://main.mohfw.gov.in/Organisation/departments-health-and-family-welfare/e-Health-Telemedicine. [Last accessed on 2020 Apr 24].  Back to cited text no. 12
    




 

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