|Year : 2021 | Volume
| Issue : 2 | Page : 364-367
Delivering telemedicine services in otolaryngology through “Mohalla” clinics in remote areas and in resource-constrained settings: A viewpoint
Soumyajit Das, Satvinder Singh Bakshi, Seepana Ramesh
Department of ENT, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
|Date of Submission||19-Jun-2021|
|Date of Decision||06-Aug-2021|
|Date of Acceptance||10-Aug-2021|
|Date of Web Publication||29-Dec-2021|
Dr. Satvinder Singh Bakshi
Department of ENT, All India Institute of Medical Sciences, Mangalagiri - 522 503, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Telemedicine services in India are underutilized. Otolaryngology provides a unique opportunity to adopt telemedicine services. Otolaryngology has seen a drastic surge in teleconsultation due to the COVID-19 pandemic. However, the challenge lies in sustaining the services and making them affordable and acceptable in the remote corners of the country. The concept of “Mohalla clinics” offers a scope to integrate and adopt telemedicine in otolaryngology and expand its outreach effectively and with minimal resources. It is high time we start training ourselves and investing in telemedicine and develop the modality across our specialties.
Keywords: Community clinic, COVID 19, Mohalla clinic, otolaryngology, telehealth, telemedicine
|How to cite this article:|
Das S, Bakshi SS, Ramesh S. Delivering telemedicine services in otolaryngology through “Mohalla” clinics in remote areas and in resource-constrained settings: A viewpoint. Arch Med Health Sci 2021;9:364-7
|How to cite this URL:|
Das S, Bakshi SS, Ramesh S. Delivering telemedicine services in otolaryngology through “Mohalla” clinics in remote areas and in resource-constrained settings: A viewpoint. Arch Med Health Sci [serial online] 2021 [cited 2022 Jan 24];9:364-7. Available from: https://www.amhsjournal.org/text.asp?2021/9/2/364/333998
| Introduction|| |
Telemedicine is “the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interest of advancing the health of the individual and their communities.” Ever since the concept of telemedicine has been implemented in healthcare delivery, it has found acceptance in public healthcare, particularly in monitoring chronic diseases. Telemedicine may be delivered using either or both of a dual strategy. In real-time teleconsultation, the patient and the consultant exchange the health information in real-time and provide solutions to patients' healthcare needs simultaneously. The other strategy is a store and forward strategy which may be undertaken through E-mails where in the consultant studies the already collected patient's health problems and provides solutions to such problems.
| Telemedicine and Ent Practice|| |
Telemedicine services were initiated in India by the Indian Space Research Organization (ISRO) way back in 2001. Later on ISRO, Department of Information Technology, Ministry of External Affairs, Ministry of Health and Family Welfare, Government of India, and various state Government and private sector healthcare institutes, etc., took significant steps to expand the reach of telemedicine in India. However, telemedicine services in India are still underutilized and have been plagued by limitations in technology and inadequate workforce resources.
The COVID-19 pandemic and the nationwide lockdown that followed led to a drastic reduction in hospital visits for nonemergency cases. During the same time, India witnessed an increase of 500% in teleconsultation across all specialties, 80% of whom were first-time users. A dramatic rise of a 600% increase in teleconsultation was noted for otolaryngology consultation.
Otolaryngology provides a unique opportunity to adopt telemedicine due to the dependence on endoscopic visualizations. Almost 62% of otolaryngology consultations are eligible for telemedicine services. The first subspecialty to adopt telemedicine in ENT was otology. In Alaska, remote consultations were provided by the specialist based on information sent by a trained audiologist who was trained and equipped to perform basic ENT examination and endoscopies apart from routine audiological tests. The project resulted in “dramatic” cost savings in terms of the consultant's time, and other infrastructural and travel requirements. Further, it reduced the waiting time of the patients. A similar experience was also seen after the devastation caused by Hurricane Katrina, where specialists offered teleconsultation in neurotology.
| The Need for Telemedicine In Otolaryngology|| |
ENT disorders in rural India are on a rising trend and an estimated prevalence range from 4.2% to 11%. Nearly 36% of the rural population who have limited access to specialist care suffer from ear disorders. Skilled workforce is scarce with an overall doctor-patient ratio of 0.62 per 1000 population which makes it practically challenging to impart healthcare services to remote locations. This shortage is further aggravated by the nonavailability of skilled specialists in remote locations due to various reasons. This is where telemedicine can play a big role in delivering specialized care in otolaryngology. Although telemedicine services are available in India since 2001, yet its widespread application and utilization in otolaryngology is still not seen. At present, there is no data on the utilization and outreach of telemedicine services in otolaryngology. Integrating such services in routine practice and making it available and acceptable to remote locations in an affordable manner remains a challenge. A fine balance needs to be achieved between easing the burden of the tertiary care centers and avoiding additional expenditure on the already strained health ecosystem of the country.
| Mohalla Clinics: A Potential Centre for Adopting Telemedicine In Otolaryngology and Expanding the Outreach of Telemedicine Services|| |
The Government of Delhi implemented community clinics or “Mohalla clinics” in July 2015. Such clinics are strategically located in the community so that the average distance is 2-3 km from the patient's place of residence. These clinics are staffed by a doctor, a technician, a nursing staff and cater to basic investigations, and health needs of the community along the peri-urban areas of New Delhi. This model of healthcare delivery has been fairly successful in providing healthcare services in the deprived population, which is evidenced by the number of footfalls in such a clinic., The Mohalla clinics have found acceptance among the general population and have eased out the burden on the tertiary healthcare systems in Delhi. Utilization study has shown that there is a higher satisfaction level among the patients receiving services in these clinics. At present, such clinics are functional in New Delhi only. The urban local body led community clinic (Basthi Dawakhana) was started in Hyderabad, Telangana along similar lines in 2018 with the same objectives as that of Mohalla clinics. A few other states have shown keen interest in such clinics. These community clinics can be expanded in rural and peri-urban areas and have the immense potential to integrate telemedicine services.
“Mohalla” clinics provide us with an opportunity to adopt and integrate telemedicine services. Such community/Mohalla clinics can be linked with a district hospital and super-specialty centers where specialized care can be provided through telemedicine. We believe that the existing infrastructure and workforce provided for such clinics can be effectively utilized for adopting telemedicine practice in otolaryngology. The advantages of such an arrangement are manifold. In India and other third-world countries; where remote healthcare delivery is plagued by infrastructural and workforce deficits, telemedicine can be a panacea. For the successful outcome of telemedicine, such clinics need not be manned by a medical professional who can further ameliorate the scarcity of medical professionals in remote areas. A paramedical staff can be easily trained to take an endoscopic picture of the nasal cavities, larynx, and ears using readily available low-cost and effective speculum or scopes which can be attached with a smartphone. Smartphone-based otoscopy has been found to have a sensitivity of 100% in identifying tympanic membrane pathologies and 96% of specificity and can be used as a useful tool for tele-otology services. The patients were also comfortable in allowing a paramedical healthcare provider to obtain the otoscopic images using nonmedical equipment like the smartphone. Screening for otological diseases by trained community-level workers or technicians using a telemedicine device is a reliable and cost-effective way in a study conducted in an urban slum area in New Delhi, India. It is possible to identify middle ear disorders by the remote specialist using telemedicine as was seen in the successful outcome of a project in Tamil Nadu. In this project, the community healthcare providers were successfully trained to use video-otoscopy for providing good quality images to the remote specialist. Synchronous telemedicine consultation have been found to have high diagnostic concordance rates and patient satisfaction as compared to face-to-face consultations. A remote assessment of speech pathology is also possible and successful speech therapy can also be provided by a speech-language pathologist. Notwithstanding all these advantages, there are few limitations of teleconsultation in ENT practice. Teleconsultation is not effective in emergency settings and as such any emergency teleconsultation should be avoided. A routine ENT consultation entails many procedures which are regularly performed in outpatient settings. These procedures should be undertaken by the trained personnel and such procedures should be avoided in the community/Mohalla clinics in the absence of specialist/trained personnel.
The major limitation and barrier in adopting telemedicine services in India have been infrastructural requirements such as equipment cost and technology. The network connectivity, particularly in remote locations, is another bottleneck in the successful implementation of telemedicine services in remote areas. However, there has been a promising upward trend in Internet connectivity and usage among the rural population. Decrease in cost, improved connectivity, continued demand can make telemedicine a self-sustaining program as is seen in many countries. A study on cost analysis in a geographically remote area in the United Kingdom had interesting findings. It was seen that as the number of teleconsultations crossed a threshold of 35 cases per year, telemedicine services became profitable for the service provider as it cut down remarkably on the travel expenditure for the service provider. Even though it will be unwise to extrapolate the findings of the study to the Indian setting, yet it provides us an insight into the cost-effectiveness of teleconsultation in ENT particularly in remote locations of India, where healthcare delivery has always been a challenge. Telemedicine in India and the third world countries can also be made self-sustainable if the existing resources are utilized to the optimal level and telemedicine services are incorporated and integrated into Mohalla clinics.
There are various legal issues related to the practice of telemedicine. These include potential liabilities of the healthcare professional, standard of care, accreditation, training, and reimbursement for teleconsultation. A major concern has been raised regarding the confidentiality of patient data and the legal jurisdiction for cross border consultations. The legal framework within which telemedicine will work needs to be worked out. As there are no specific laws at present on telemedicine practice, the guidelines framed by the Medical Council of India can be adopted as guiding principle. At the same time, training of the existing workforce resource in delivering telehealth services will help provide maximum services with the existing infrastructure.
| Conclusion|| |
The utility of telemedicine in otolaryngology is not limited to the times of the COVID-19 pandemic. The disruption of routine otolaryngology services by the COVID pandemic has been an eye-opener for us. At the same time, it has opened up a window of opportunity to popularize telemedicine in otolaryngology and provide the benefits of specialized healthcare services to the remote areas and for the common people with minimum infrastructural and workforce resources. Expanding the outreach of telemedicine services in the field of otorhinolaryngology is necessary for the wider penetration of the services. The concept of “Mohalla clinics” offers a scope to integrate telemedicine in otolaryngology effectively in resource-limited settings. It may be worthwhile to consider replicating this model of healthcare delivery from the peri-urban to the rural and remote locations. At the same time, this model for delivering effective and affordable telemedicine services for otolaryngology needs to be tested in the ground scenario in other countries or regions where resources are limited. It is high time we start training ourselves and investing in telemedicine and develop the modality across our specialties.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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