A study published recently in The Lancet journal has flagged problems faced by the national telemedicine service launched by the Centre, which claims to have successfully provided 276 million consultations till the beginning of August 2024.

Consultation requests unrelated to the doctor’s field of expertise, avoiding the use of video and audio systems at primary health centres, which forces doctors to rely on written notes about the patient, and deficiencies in the design and staffing of the tele-referral pathway are some of the major impediments faced by Ayushman Bharat eSanjeevani programme, the study has pointed out.

The lead author of the study, Biswanath Ghosh Dastidar, is an obstetrics, gynaecology and fertility expert at SSKM Hospital in Calcutta.

Ghosh Dastidar, who has been taking part in the telemedicine programme for nearly three years, analysed his tele-referral patterns for six months between May 1, 2023, and October 31, 2023.

Most of the patients referred to him from primary health centres in Bengal complained of problems not related to his field of treatment. They should have been referred to general physicians or specialists in other fields.

“…. 65·6% of all consultation requests were unrelated to his speciality (including 21·6% of calls on behalf of male patients). Moreover, over 90% of consultation requests were written requests, which do not allow the doctor to make the little examination a telemedicine platform allows. Of these, 13·5% of requests comprised only a few words of text, such as ‘pain’ or ‘contraception’, from which it is challenging to reach any diagnosis and almost impossible to safely prescribe medications or provide other advice, bearing in mind the medico-legal and ethical obligations of safe medical practice. During this period, only 20·9% of consultation requests were speciality appropriate and accompanied by audio-visual support/adequate written details,” said the study published in November 2024 in The Lancet Regional Health – Southeast Asia.

“To check whether these patterns persisted, we analysed his most recentteleconsultations during May 2024. Out of 100 referredpatients, 58 requests received were inappropriate forhis speciality (including 21 men), including complaints such as ‘toothache’ and ‘knee pain’.”

All of these were written requests, of which Ghosh Dastidar returned 55 patients to the “Spoke” or rural primary healthcare centres by selecting the “Wrongly addressed call— this case is not related to my specialisation” option (which generates a blank prescription) and referred three patients for in-person care as the need for emergency intervention could not be ruled out.

“Of the 42 requests which were speciality appropriate, 22 comprised just a few words of text. Of these, in 11 cases, the consultant was compelled to generate a blank prescription by choosing the ‘Inadequate case details’ option and asking the health-worker to call back with more information or an audio-visual call, effectively rendering the consultation useless,” the study said.

“Telemedicine can be a game-changer when it comes to improving access to care. In our previous paper published in the Nature journal, we have shown how it can leapfrog traditional care delivery to expedite Universal Health Coverage in India, towards meeting our Sustainable Development Goals 2030,” Ghosh Dastidar told The Telegraph on Monday.

“However, it seems health workers in the referring units need better training in triage and tele-referral to make more appropriate referrals. These improvements are important to make eSanjeevani more effective.” The other three co-authors of the paper are Anant R. Jani, Shailesh Suri and Vikranth Harthikote Nagaraja, who were based at the Oxford India Centre for Sustainable Development of the University of Oxford while undertaking the study.

Nagaraja is currently a Fellow at the University of Salford, Manchester, focusing primarily on rehabilitation technologies and global health. During the study, he was a postdoctoral researcher at Oxford University, developing affordable prosthetic hands.

“It appears programme evaluation is currently based on the number of consultations delivered. For a better impact on public health, eSanjeevani should move away from such target-driven approach to evaluate the actual benefit delivered to patients. This would reduce the load on the big hospitals that are burdened with patients, many of whom may not need tertiary care,” said Nagaraja.

The study also provides some solutions. These include developing a skilled workforce through suitable training, developing standard operating protocols to guide the referral process and speciality-specific set formats for recording mandatory information for written consultation requests.

It has also suggested developing and integrating algorithmic or artificial intelligence-based technological upgrades to make referrals more appropriate.

The study also highlighted the importance of integrating general physicians within the system and developing constructive feedback transmission pathways to referring units for continued learning which would make the telemedicine programme more
effective.