Fairhurst, Karen

McKinstry, Brian

Juvekar, Sanjay

Patil, Rutuja

National Institute for Health and Care Research (NIHR)

2022-12-08T18:19:36Z

2022-12-08T18:19:36Z

2022-12-08

BACKGROUND: Chronic respiratory disease (CRD) is a major public health problem in India with high prevalence and mortality. However, remote rural places have often experienced inequity in access to health care facilities and services. Even where places are equipped with facilities, the availability of trained healthcare providers, particularly respiratory specialists, is challenging. These specialists tend to be concentrated in cities many hours travel from rural patients. Recent technological advances have enabled doctors to deploy telemedicine in remote locations, potentially allowing specialists to support local generalist clinicians. However, multiple barriers still exist to implementing and scaling such technology. It is unclear what services could be delivered and what equipment and clinical and support staff would be required. Nor is it known what the attitudes of specialists, generalist clinicians and patients would be to providing such a service. My study aimed to assess the feasibility of using an established teleconsultation facility (Micro-Health Centre) to provide remote specialist respiratory-physician support to rural primary-physician in CRD diagnosis and management in a resource-constrained rural area. I sought the views and experiences of national and local opinion leaders in telehealth and service delivery in India and the perceptions of local specialist and generalist clinicians on using technology for specialist to non-specialist advice to strengthen existing underutilised teleconsultation services. I then explored how they felt the system and services worked and how they thought it could be further improved. RESEARCH QUESTION: What are the barriers and facilitators to providing remote, specialist respiratory-physician support to rural primary-physician for CRD diagnosis and management? PRIMARY OBJECTIVE: To assess the feasibility of using an established teleconsultation facility (Micro-Health Centre) to provide remote specialist respiratory-physician support to rural primary-physician in CRD diagnosis and management in a resource-constrained rural area. SECONDARY OBJECTIVES: • To explore the evidence for the effective use of specialist to non-specialist teleconsultation in the management of CRDs in adults in remote areas • To determine the requirements, including equipment and skills to support local primary physicians in remote CRD diagnosis and management; • To explore barriers to and facilitators of successful implementation of specialist to non-specialist teleconsultation at Micro Health Centre (MHC) in CRD diagnosis and management from the viewpoints of patients, opinion leaders, primary and respiratory physicians; •Following the use of the teleconsultation service to understand the perception of the patients and health care providers of remotely supported consultations; •To facilitate the strengthening of the existing teleconsultation facility for CRD diagnosis and management. METHODS: I used three main methods; a systematic review of the available literature; one-to-one interviews and focus groups with stakeholders to explore the barriers and facilitators to telehealthcare and what was required to run a successful telehealthcare service that could support local clinicians. I helped design an improved service and negotiated government support and local support based on this. A further series of qualitative interviews and structured questionnaires were conducted to determine the views of Primary Physicians (PP) and patients after they had experienced the system. SYSTEMATIC REVIEW: I systematically searched for articles in Embase, Medline, PubMed and CAB Global health till November 2020, which focused on specialist to non-specialist teleconsultations for CRD diagnosis or management. With a colleague, I assessed the quality of relevant papers using the Joanna Briggs Institute's (JBI) tool. I used a descriptive and narrative approach to analyse these due to the heterogeneous nature of the selected studies. QUALITATIVE STUDY: I interviewed eight opinion leaders who included people already in telehealthcare, experts, researchers and policymakers working in teleconsultation in India. I interviewed healthcare providers, including six Respiratory Physicians (RP), ten Primary Physicians (PP), and 30 patients attending the teleconsultation clinics for respiratory ailments. The data from patients were collected at two time points, pre and post-teleconsultation. I also interviewed the PP coordinating the teleconsultation post their experience using telehealthcare services to consult specialists for patient treatment. Analysis was inductive and iterative. STRENGTHENING OF THE EXISTING FACILITY: The KEMHRC Pune runs a Micro Health Centre (MHC) that provides primary health care to the population. However, it was an underutilised centre that ran only face-to-face outpatient consultations by local PP despite the availability of teleconsultation. I aimed to improve the facility based on the literature and the views of stakeholders. RESULTS: In my systematic review, I found 1715 articles that met the initial search criteria, but after excluding duplicates and non-eligible articles, I included ten research articles of moderate quality. All but one of which were conducted in high-income countries. The teleconsulting systems used in the included papers primarily used audio or video modes. The included studies reported primarily non-clinical outcomes, including effectiveness of using the system, feasibility, acceptability, and usability of the teleconsultation systems and only three described the clinical outcomes. The teleconsultation was predominantly conducted in the PP’s office, with the specialist located remotely. The review concludes that, despite the literature being limited and not generalisable, specialist to non-specialist teleconsultation for diagnosis and management of CRDs should be encouraged, particularly where face-to-face consultations are challenging or unavailable. The results of my qualitative study informed the requirements for the set-up and implementation of a telehealthcare system for CRD diagnosis and management in remote areas. Further, I identified the barriers and facilitators in the diagnosis and management of CRD using telehealthcare. I also documented the stakeholder perspective in using telehealthcare solutions for CRD diagnosis and management. According to the respondents, to be successful, a telehealthcare system must be appropriately located, ideally driven by interested leadership and particularly an inspired coordinator to run the centre with dedicated and motivated human resources and finance. Further, local stakeholder engagement and advertisement was considered essential. The training was observed as one of the most important requirements in the set-up and implementation of telehealthcare. The RPs further thought that primary physicians needed additional training in the diagnosis and management of CRDs, although the RPs did not consider they needed training for teleconsultation. However, not all respondents thought training would be acceptable by both primary physicians and specialists. A similar array of clinical skills and equipment required for a traditional face-to-face consultation was considered necessary for teleconsultation, including patient history, clinical examination and auscultation by a trained physician, and spirometry. Some participants also expressed the need for X-rays, electrocardiograms (ECG), and a facility for blood diagnostics. The participants said that the challenges of telediagnosis are ameliorated not only by training and adequate equipment but also by good record keeping and the ability to share electronic records with a specialist. These findings iteratively informed the strengthening of the existing telehealthcare system. I arranged numerous institutional and regulatory approvals, and I arranged for the functioning of the teleconsultation service by appointing a bi-weekly visit by a primary physician and a technician. The primary physicians were further trained by the respiratory specialists at the tertiary care hospital (KEM Hospital) as the qualitative data informed the training needs for the PPs. Additionally, appropriate diagnostic tools were made available, and the telehealthcare system and software were updated as per the requirements suggested by the doctors and also because the then-existing system was due for maintenance and required repairs which the original service provider was unable to provide. Based on a comparative analysis of existing options I identified a start-up named A3RMT (Anytime Anywhere Access Remote Monitoring Technologies) (https://www.a3rmt.com/), incubated in the Indian Institute of Technology Bombay, which provides technology solutions for telehealthcare to undertake the upgrade. The A3RMT systems have facilities to capture clinical information and transmit this information to doctors using internet connectivity. The installation funding was raised through donations. I also engaged the community by conducting face-to-face meetings with the community leaders and further advertised the facilities available at the centre. This process resulted in a higher patient load and a larger number of teleconsultations. This service was provided free to patients and based on goodwill from clinicians, and scaling would require payment arrangements to be negotiated for primary and secondary care, as would the proportion paid by patients. In conclusion, my PhD has addressed the aim of the study and has generated data to understand the process of setting up and implementing a telehealthcare centre, especially for the diagnosis and management of CRD. The results will help create guidelines for establishing and managing a telehealthcare centre. The COVID pandemic has changed the scenario of the use of telehealthcare globally. The WHO strategy on digital health published in 2020 lays down general and specific principles to implement digital health globally. Telehealthcare will now be widely implemented in low-resource settings given the increase in infrastructure for digital health and the availability of updated technology. Given this background, my study has provided some practical implications for implementing telehealthcare centres for specialists to non-specialists teleconsultations in low-resource settings. These practical implications can be incorporated in the specific guidelines for functioning.

https://hdl.handle.net/1842/39580

http://dx.doi.org/10.7488/era/2830

en

The University of Edinburgh

Patil R, Shrivastava R, Juvekar S, McKinstry B, Fairhurst K, RESPIRE,(2021) Specialist to non-specialist teleconsultations in chronic respiratory disease management: A systematic review’, Journal of global health, 11(04019). doi: 10.7189/jogh.11.04019.

Patil, R. Agarwal, D, Kaur, H, et al (2021) ‘Engaging with stakeholders for community-based health research in India: Lessons learnt, challenges and opportunities’, Journal of Global Health, 11, p. 03072. doi: 10.7189/jogh.11.03072

teleconsultation facility

Micro-Health Centre

MHC

CRD

Chronic respiratory disease

rural

telehealth

telehealthcare

Respiratory physicians

Feasibility of using a teleconsultation facility (Micro-Health Centre - MHC) in management of CRDs in remote rural area

Thesis or Dissertation

Doctoral

PhD Doctor of Philosophy