Hrev_master [page 24] [Healthcare in Low-resource Settings 2022; 10:9928] COVID-19 pandemic and quick evolution of telemedicine: A gap analysis Jayagandan Jayamani,1 Pugazhenthan Thangaraju,2 Ravish Gowda,3 Srinivas Huchegowda4 1Laboratory, New Mowasat Hospital, Al- Salmiya, Kuwait; 2Department of Pharmacology, All India Institute of Medical Science, Raipur; 3Department of Neurochemistry, NIMHANS, Bangalore; 4Department of Biochemistry, Shri Atal Bihari Medical College and Research Institute, Bangalore, India Abstract Telemedicine though not a newer con- cept to healthcare community, it is relative- ly a new acquaintance to both healthcare providers and the general public. Since 11th of March 2020, the day when WHO declared COVID-19 infection as pandemic, the telemedicine services had achieved quick popularity. In fact this pandemic boosted a solid foundation for telemedicine and now it is one among the scope of ser- vices offered by any reputed healthcare organization globally. This article aims to emphasize how a symbiosis between telemedicine, POCT and mobile health units can help to deliver a high quality healthcare eliminating the risk of infection spread to both patients and health care providers. The methodology adopted includes collective viewpoints of authors which are based upon working experience gained during the current pandemic and lit- erature review of recent and relevant arti- cles related to process and pitfalls of telemedicine. Literature search was con- ducted by searching using key words and phrases like ‘Telemedicine’, ‘COVID-19 and Telemedicine’ and ‘Non- Communicable Diseases management dur- ing pandemic’. The scope and gaps observed by literature survey and personal experience included infrastructure, aware- ness and training of both health care providers and patient population, utilization of POCT devices, internet connectivity, need for an nationwide unified Health Information Management System (HIMS) to aid easy access to patient health informa- tion and easy referrals to higher centers. In summary telemedicine is an absolute neces- sity during this on-going pandemic and its enhancement by integration with artificial intelligence and machine learning algo- rithms is a real need of hour. Introduction The unprecedented COVID-19 pan- demic situation and its coexistent risk of contracting infection during hospital visits actually had given a kick start to telemedicine services which was otherwise not so popular among the general public. Even before this COVID-19 pandemic, actually health systems worldwide were very actively managing the silent pandemic of non-communicable diseases. Health poli- cies and programs of both developed and developing nations gave greater emphasis to control Non-Communicable Diseases (NCDs) namely diabetes, cardiovascular diseases like coronary artery disease, stroke and cancers.1 Now the biggest question is that “Are these non-communicable diseases left unmonitored focusing only on COVID- 19 pandemic?” and a very simple answer to this question would be “No”, because this is where telemedicine evolved quickly form- ing a major pillar of support. Most nations adopt the concept of ‘health for all’ and are striving to deliver equally higher quality healthcare to all levels of community. Now with the existing pandemic situation it is a challenging task for nations to maintain continuity of patient care especially to their rural population. Also now we know that the COVID-19 virus is constantly mutating and mutated variants are capable of causing fresh waves of infections. So it becomes an absolute necessity that countries should improve their telemedicine infrastructure in order to provide uninterrupted healthcare services. This article aims to reflect and reveal why we are in need of expansion of scope of telemedicine services; what do we currently have in terms of technology to deliver this service to general public; what initiatives can improve the delivery of telemedicine services at all levels of health system starting from tertiary centers to pri- mary care centers and finally having addressed the existing gaps, how potential is telemedicine to emerge as a definitive allied medicine science in nearest future. Materials and Methods The material and method is achieved by the exploring the working experience and literature review of recent and relevant arti- cles related to process and pitfall of telemedicine. The article constitutes the col- lective opinion of the authors based on indi- vidual experience gained while working during the current pandemic situation. However published literature search were also conducted by searching using key words and phrases like ‘Telemedicine’, ‘COVID-19 and Telemedicine’, NCD man- agement during Pandemic. Articles focus- ing current telemedicine scenario in India and other similar developing countries were referred preferentially the literature review is mentioned in Table 1. What we have and what we need In developing countries like India telemedicine services at present have achieved a considerable popularity and awareness in urban areas and among its res- idents.2 A vast majority of healthcare orga- nizations both government and private are currently offering telemedicine consulta- tion.3–5 Most of video consultations are through free video call platforms like Facebook, WhatsApp, Skype and Zoom. Though few of these applications offer end to end encryptions these are per user’s selection of privacy settings during installa- tion in their Personal Computer (PC) or smartphones which may be inappropriate. Few private hospitals have their own dedi- cated telemedicine software applications that are sophisticated and handcrafted to Healthcare in Low-resource Settings 2022; volume 10:9928 Correspondence: Srinivas Huchegowda, Department of Biochemistry, Shri Atal Bihari Medical College and Research Institute, Hospital road, Shivajinagar, Bangalore, Karnataka state, 560001 India. E-mail: drsrinibiochem@gmail.com Key words: Covid-19, Pandemic, Telemedicine, Point of care testing, Healthcare Conflict of interest: The Authors declare no conflict of interest. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Ethics approval and consent to participate: Not applicable Informed consent: Not applicable Received for publication: 21 June 2021. Revision received: 21 February 2022. Accepted for publication: 22 February 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2022; 10:9928 doi:10.4081/hls.2022.9928 Non -co mmerc ial us e o nly ensure the privacy and patient data safety but come with a huge initial investment which may translate into hefty consultation charges.6,7 In contrast to urban cities and towns in most rural areas and villages the sole provider of healthcare services is gov- ernment run chain of Primary Health Centers (PHCs) and infrastructure to imple- ment telemedicine practices really a distant dream. Major challenge for effective implementation of telemedicine practices at rural areas starts from its awareness and education about refraining visiting PHCs for simple ailments that can be treated by home remedial measures. Discussion about devising strategies to implement telemedicine in rural areas would be beyond scope of this article. Currently healthcare providers through telemedicine services manage to cater variety of consultations ser- vices like physician follow-up for NCDs, diet advice from nutritionist, demonstration of home based physiotherapy exercises, all forms of expert counseling etc.2,5,7–10 It is evident that effective disease management through telemedicine services is impossible without conducting relevant medical inves- tigations. These investigations may be nec- essary for initial assessment of the patient or as follow-up to previous consultations. Blood investigations required may be any- thing starting from simple glucose monitor- ing for diabetes to complex therapeutic drug monitoring for chemotherapy. Similarly non-invasive investigations may include blood pressure, electrocardiography (EKG), echocardiography, ultrasonography etc.11,12 Currently to overcome this challenge there are plenty of FDA approved and CE marked In Vitro Diagnostics (IVD) Point Of Care Testing (POCT) available in markets for tests like glucose, including Continuous Glucose Monitors (CGMs), ketones, cholesterol, haemoglobin, creatinine, urine routine strips etc. that are easy to use and maintain domestically at home.2,11–13 Most of POCT manufacturers have come out with step by step demonstration videos that are indexed and freely available in social net- work platforms like YouTube.14–19 Though such equipment adds additional expenses at the beginning, however in a long run this would workout cheaper as it saves time and resources spent for hospital visits. Likewise there are many FDA approved ECG moni- tors that are capable transmitting the results to treating physician’s PC and smartphones.20 In situation where continu- ous monitoring of EKG is required online sellers like Amazon have started renting medical devices like Holters monitors, which appears to be a promising initiative. Similarly scope of such renting services shall be broadened to include certain portable POCT devices like i-STAT Alinity that are capable testing wide spectrum of blood analyses. In case of complex investi- gations telemedicine services must hand- shake with mobile health units, which again have evolved swiftly during this pandemic. Developed nations provide province wise a fleet of mobile health units starting from ground ambulances to air ambulances that are fully equipped with a comprehensive set of POCT devices. Scientific societies like American Association for Clinical Chemistry (AACC) and Canadian Society of Clinical Chemists (CSCC) have issued guidance for POCT testing in such mobile health units21–24. Similar guidance and poli- cies must be issued or adopted and compli- ance of the same needs to be monitored in developing nations. Technology based strategies Telemedicine services in order to be considered as a sustainable solution, it requires a strong support of technology. As the name implies firstly telemedicine requires an internet connected communica- tion devices. Governments of developing nations should start investing to improve their communication infrastructure. Countries like India, which claims rural areas and villages as its backbone, should achieve 100% internet connectivity to all its PHCs irrespective of its location. This should be the first initiative to be prepared for any upcoming waves of existing COVID-19 or any such pandemic in future.25 Every nation should develop their own unified HIMS and sufficiently large databases for archiving health records of its entire population. The records of each indi- vidual can be linked to their social security number like Aadhar number in India or to medical insurance numbers. Clear policies and protocols should be established to access such archived health records by a governing medical council registered treat- ing physicians working for either public or private healthcare organization. Data secu- rity and patient confidentiality shall be ensured through safe authentication proce- dures as demonstrated in Figure 1. Next step would be investing in large- scale production of short range and long- range drones and establishing adequate number of control rooms to monitor drone traffic. These drones shall be deployed for swift delivery of prescription medications26 (even portable oxygen cylinders) to patients and for pickup of samples like dried capil- lary blood, urine samples, variety of swab samples packed in appropriate storage con- tainers. Patient identification before drone based deliveries and pickups shall be ensured with help of biometric data or face recognition or QR code based software developed incorporating artificial intelli- gence and machine learning. Virtual software technology have tremendously improved and scaled up to meet the increasing demand of telemedicine Article Figure 1. Safe Authentication enabled Health information management system (HIMS). [Healthcare in Low-resource Settings 2022; 10:9928] [page 25] Non -co mmerc ial us e o nly Article Table 1. Literature review of the prior studies related to telemedicine adaptation. Article Authors and year Conclusions and remarks 1. Telemedicine during the COVID-19 pandemic: Hong, Z, et al. ( 2020)27 The authors explains the success of telemedicine experiences from Western China. Journal of medical in western china using the network synergizes Internet research with 5G service, a smartphone app, and an existing telemedicine system 2 Exploring the adoption of telemedicine and virtual Bokolo, A. J. (2021)28 The author have explored the factors impacting software for care of outpatients during and after the adoption of telemedicine and virtual COVID-19 pandemic software platforms and highlighted funds, training, workforce integration, Data privacy, Wi-Fi quality , Licensure requirements and Health insurance and reimbursement policies 3 Use of telemedicine and virtual care for remote Jnr, B. A. (2020)29 The authors have provided practical guide to use treatment in response to COVID-19 pandemic virtual care during the COVID-19 pandemic an also highlighted the gaps such as necessary infr structure, inadequate funds, lack of experience among health professionals in optimal use of telemedicine 4 Telemedicine in neurosurgery: lessons learned Mouchtouris, Nikolaos, et al. The study is focused on use of telemedicine and transformation of care during the COVID-19 pandemic (2020)30 in surgery field and describes various adaptation of effective utilization 5 Telemedicine in India: Current Scenario and the Future Mishra SK, et al. They have described Indian Space Research (2009)31 Organization mediated SATCOM-based telemedicine network and also mentioned the inclusion curriculum in telemedicine training programs at various levels 6 Telemedicine: History and Success Story of Remote Yadav SK, et al.(2021)32 They emphasized on tele-education in surgical Surgical Education in India field in Indian scenario and propose integration of telemedicine within the framework of routine medical education. 7 A survey of awareness, knowledge, attitude, RakeshDatta, et al. They have analyzed the “Telemedicine Practice and skills of telemedicine among healthcare (2021)33 Guidelines were promulgated in India professionals in India in 2020” for AKAS and concluded the requirement of training and education about the skills and provisions for effective use to avoid medico-legal issues 8 Current scenario, future possibilities and NidhiKaeley, et al. They have highlighted the need of telemedicine applicability of telemedicine in hilly and remote (2021)34 in hilly and remote area and to implement areas in India: A review protocol telehealth by effective collaboration of primary and secondary health care setups and to reach population staying in underserved areas 9 Telemedicine as techno-innovation to tackle COVID-19: Carlo Drago, et al. (2021)35 They describe a “semantic cores” A bibliometric analysis in the literature which represents the relevant results on telemedicine themes which will aid in evidence based literature analysis, necessary for policy making and implementation 10 Are state telemedicine parity laws associated with greater Kori S. Zachrison, et al. The authors examined the use of telemedicine in use of telemedicine in the emergency department? ( 2021)36 emergency and the payment policy from issuers, effect the use of telemedicine and also described factors for implementation, such as regulatory environment, ease of interstate credentialing, and even the extent of payment parity 11 Africa turns to telemedicine to close mental health gap Paul Adepoju (2020)37 The article draws attention to increase use of telemedicine during pandemic in most African country as seen by increase in traffic in help-lines and effectiveness of telemedicine for mental health is on par with one-on –one counseling 12 Telemedicine for Mental Health in the United States: Michael L. Barnett, et al. The authors have explore facility adoption of Making Progress, Still a Long Way to Go (2019)38 telemedicine using national survey conducing in united state and suggested telemedicine as most effective option to utilize the workforce and provide service to patients needing to reach the health centers by hours away in vehicle [page 26] [Healthcare in Low-resource Settings 2022; 10:9928] Non -co mmerc ial us e o nly [Healthcare in Low-resource Settings 2022; 10:9928] [page 27] in order to deliver quality medical opinions on outpatient basis even to the remotest areas during Covid-19 pandemic. Brief review of the literature describing utility and limitation of various aspect of telemedicine done in many countries such as Norway, Africa, Australia, USA, India and China is presented in (Table 1).27-42 Conclusions We authors believe that for sustainable successful telemedicine practice a perfect blend of technology and medical science is mandatory. In addition an improved aware- ness and education to public about benefits of telemedicine also plays a vital role. Imparting computer education into curricu- lum of all medical and allied medical sci- ence should be considered on highest prior- ity as a way forward. During this pandemic developing countries are redistributing their healthcare workers serving in rural villages to urban areas in order to handle high patient loads in thickly populated cities. Such redistributions to a greater extent crip- ple delivery of primary health care services in villages. Such crisis can be to some extent managed with help of having well connected video conferring rooms in PHCs for outpatient consultations. With advent of newer technologies in the field of biomedi- cal science it is evident that telemedicine has huge scope to transform into an unavoidable field of medical science. Now it’s right time to well integrate all advance- ments in information technologies, artificial intelligence and machine learning technolo- gies and medical sciences to fill existing gaps in current telemedicine practices. References 1. Srivastava RK, Bachani D. Burden of NCDs, policies and programme for pre- vention and control of NCDs in India. Indian J Community Med 2011;36:S7– 12. 2. Dinakaran D, Manjunatha N, Kumar CN, Math SB. Telemedicine practice guidelines of India, 2020: Implications and challenges. Indian J Psychiat 2021;63:97. 3. Agarwal N, Jain P, Pathak R, Gupta R. Telemedicine in India: A tool for trans- forming health care in the era of COVID-19 pandemic. J Educ Health Prom 2020;9:190. 4. Ministry of Health and Family Welfare, GOI. e-Health & Telemedicine. Accessed 2021 Jun 13. Available from: https://main.mohfw.gov.in/Organisation /departments-health-and-family-wel- fare/e-Health-Telemedicine 5. Chellaiyan VG, Nirupama AY, Taneja N. Telemedicine in India: Where do we stand? J Family Med Prim Care 2019;8:1872–6. 6. Zhang K, Liu W-L, Locatis C, Ackerman M. Mobile videoconferenc- ing apps for telemedicine. Telemed J E Health 2016;22:56–62. 7. Sood SP, Bhatia JS. Development of telemedicine technology in India: “Sanjeevani”’-An integrated telemedicine application. J Postgrad Med 2005;51:308. 8. Reimagining The Indian Government’s Telemedicine Platform [Internet]. Microsave 2021. Accessed 2021 Jun 13. Available from: https://www.microsave.net/2021/02/10/ reimagining-the-indian-governments- telemedicine-platform/ 9. Dasgupta A, Deb S. Telemedicine: A New Horizon in Public Health in India. Indian J Community Med 2008;33:3–8. 10. Govt. of India’s telemedicine service completes 3 million consultations. Accessed 2021 Jun 13. Available from: pib.gov.in/Pressreleaseshare.aspx?PRI D=1705358 11. Sherling D, Sherling M. The promises and pitfalls of telemedicine. AJMC. Accessed 2021 Jun 13. Available from: ht tps: / /www.ajmc.com/view/the- promises-and-pitfalls-of-telemedicine 12. Iyengar K, Jain VK, Vaishya R. Pitfalls in telemedicine consultations in the era of COVID 19 and how to avoid them. Diabetes MetabSyndr 2020;14:797–9 13. Mehta SJ. Telemedicine’s potential eth- ical pitfalls. AMA J Ethics 2014;16:1014–7. Article Table 1. Literature review of the prior studies related to telemedicine adaptation. Article Authors and year Conclusions and remarks 13 Telemedicine Adoption during the COVID-19 Pandemic: Jake Luo, et al. (2021)39 They study was done in Milwaukee area of Wisconsin, Gaps and Inequalities United States and identified several reasons for disparities in telemedicine adoption such as income, education level, race, and insurance type. 14 Telemedicine Across the Globe-Position Paper From SonuBhaskar, et al. The Consortium has looked into telemedicine related the COVID-19 Pandemic Health System Resilience (2020)40 issues during the pandemics across various region PROGRAM (REPROGRAM) International Consortium (Part 1) including India, they team has pointed out the lack of infrastructure and lack of regulation is the major drawback in India. However they have concluded the positive role for telehealth or telemedicine in improving health systems 15 Revisiting health information technology ethical, legal, Bonnie Kaplan The author describes extensively the ethical and legal and social issues and evaluation: telehealth/telemedicine (2020)41 issues and how to develop the framework for and COVID-19 effective utilization of telemedicine in USA and also highlighted the need for cyber security and informatics infrastructure 16 The COVID-19 Catalyst: Analysis of a Tertiary Academic Clayton Davis, et al The authors analyzed the patients’ utilization Institution’s Rapid Assimilation of Telemedicine (2020)42 of telemedicine in Virginia. USA. The observed 82% of patients surveyed were the view to use telemedicine over a face-to-face encounter for a routine visit during future flu seasons. Non -co mmerc ial us e o nly [page 28] [Healthcare in Low-resource Settings 2022; 10:9928] 14. Francis AJ, Martin CL. A practical example of PoCT working in the com- munity. ClinBiochem Rev 2010;31:93– 7. 15. Shaw JLV. Practical challenges related to point of care testing. Practical Lab Medi 2016;4:22–9. 16. Malcolm S, Cadet J, Crompton L, DeGennaro V Jr. A model for point of care testing for non-communicable dis- ease diagnosis in resource-limited coun- tries. Glob Health Epidemiol Genom 2019;4:e7. 17. St John A, Price CP. Existing and emerging technologies for point-of-care testing. ClinBiochem Rev 2014;35:155–67. 18. Hayward G, Dixon S, Garland S, et al. Point-of-care blood tests during home visits by out-of-hours primary care clin- icians; a mixed methods evaluation of a service improvement. BMJ Open 2020;10:e033428. 19. Clifford LJ. The pros and cons of point- of-care testing vs laboratory testing. Medical Laboratory Observer, 2018. Accessed 2021 Jun 13. Available from: https://www.mlo-online.com/continu- ing-education/article/13017084/the- pros-and-cons-of-pointofcare-testing- vs-laboratory-testing 20. Bansal A, Joshi R. Portable out-of-hos- pital electrocardiography: A review of current technologies. J Arrhythm 2018;34:129–38. 21. Füzéry AK, Kost GJ. Point-of-care test- ing by ambulance teams: an opportunity for a new standard. AACC.org. Accessed 2021 Jun 13. Available from: https://www.aacc.org/cln/articles/2021/ may/point-of-care-testing-by-ambu- lance-teams-an-opportunity-for-a-new- standard 22. AACC. Guidance document on man- agement of point-of-care testing. AACC.org. Accessed 2021 Jun 13. Available from: https://www.aacc.org/science-and- research/aacc-academy-guidance/man- agement-of-point-of-care-testing 23. Nichols JH, Alter D, Chen Y, et al. AACC Guidance document on manage- ment of point-of-care testing. J Appl Lab Med 2020;5:762–87. 24. Yip PM, Venner AA, Shea J, et al. Point-of-care testing: A position state- ment from the Canadian Society of Clinical Chemists. Clin Biochem 2018;53:156–9. 25. Jayamani J, Thangaraju P, Thangaraju E, Venkatesan S. Decentralisation of healthcare system due to COVID-19 and its impact on hospital based labora- tories - Pandemic panic patients’ reflec- tion? J Responsible Technol 2020;1:100003. 26. Hii MSY, Courtney P, Royall PG. An evaluation of the delivery of medicines using drones. Drones 2019;3:52. 27. Hong Z, Li N, Li D, et al. Telemedicine during the COVID-19 pandemic: expe- riences from Western China. J Med Internet Res 2020;22:e19577. 28. Bokolo AJ. Exploring the adoption of telemedicine and virtual software for care of outpatients during and after COVID-19 pandemic. Irish J Medical Sci 2021;190:1-10. 29. Bokolo AJ. Use of telemedicine and vir- tual care for remote treatment in response to COVID-19 pandemic. J Med Syst 2020;44:132. 30. Mouchtouris N, Lavergne P, Montenegro TS, et al. Telemedicine in neurosurgery: lessons learned and trans- formation of care during the COVID-19 pandemic. World Neurosurg 2020;140:e387–94. 31. Mishra SK, Kapoor L, Singh IP. Telemedicine in India: Current scenario and the future. Telemedicine and e- Health 2009;15:568–75. 32. Yadav SK, Mishra A, Mishra SK. Telemedicine: History and success story of remote surgical education in India. Indian J Surg 2021; Available from: https://doi.org/10.1007/s12262-021- 03020-9 33. Datta R, Singh A, Mishra P. A survey of awareness, knowledge, attitude, and skills of telemedicine among healthcare professionals in India. Med J Armed Forces India 2021; Available from: https://www.sciencedirect.com/sci- ence/article/pii/S0377123721002550 34. Kaeley N, Choudhary S, Mahala P, Nagasubramanyam V. Current scenario, future possibilities and applicability of telemedicine in hilly and remote areas in India: A review protocol. J Family Med Prim Care 2021;10:77–83. 35. Drago C, Gatto A, Ruggeri M. Telemedicine as technoinnovation to tackle COVID-19: A bibliometric anal- ysis. Technovation 2021;102417. 36. Zachrison KS, Boggs KM, Cash RE, et al. Are state telemedicine parity laws associated with greater use of telemedicine in the emergency depart- ment? J Am Coll Emerg Physicians Open 2021;2:e212359. 37. Adepoju P. Africa turns to telemedicine to close mental health gap. Lancet Digital Health 2020;2:e571–2. 38. Barnett ML, Huskamp HA. Telemedicine for mental health in the United States: Making progress, still a long way to go. Psychiatr Serv 2020;71:197–8. 39. Luo J, Tong L, Crotty BH, et al. Telemedicine adoption during the COVID-19 pandemic: gaps and inequalities. Appl Clin Inform 2021;12:836–44. 40. Bhaskar S, Bradley S, Chattu VK, et al. Telemedicine across the globe-position paper from the COVID-19 pandemic health system resilience PROGRAM (REPROGRAM) international consor- tium (Part 1). Front Public Health 2020;8:556720. 41. Kaplan B. Revisiting health information technology ethical, legal, and social issues and evaluation: telehealth/telemedicine and COVID-19. Int J Medical Inform 2020;143:104239. 42. Davis C, Novak M, Patel A, et al. The COVID-19 catalyst: analysis of a ter- tiary academic institution’s rapid assim- ilation of telemedicine. Urol Pract 2020;10.1097/UPJ.0000000000000155 Article Non -co mmerc ial us e o nly