Executive Summary

India is a large country with a population of more than 1.35 billion. About 70 % of healthcare infrastructure is in cities, which cater to ~30% of the country's population. India spends only 3.9 % of its GDP (2017-18) on healthcare, which is less than the world average expenditure of 6%. India has shortage of doctors (1: 1457), and hence the healthcare facilities are not accessible uniformly to all. Doctor to patient ratio in India is approximately 1:1500 which is lower than WHO (1:1000) recommendation. The doctor to patient ratio is more skewed in rural areas (1:2500), and ~89 million population in India is below the poverty line, which poses a serious challenge in delivering the health care services efficiently and uniformly throughout the country.

Rising health care cost in India is also a major concern as ~ 60% of the health care expenses in India are out of pocket expenditure, which is highest among the other BRICS nations. India therefore needs a sustainable, connected, low-cost, efficient and secure model for inclusive healthcare delivery.

With this in view, adoption of new and emerging Information and Communication Technologies ( ICT) would help in bridging the gap by making the reach of healthcare services to unreachable in a cost effective and efficient manner and also empower the doctors and researchers in this area to innovate new drugs/ vaccines, cells etc.

In recent decades, the world has witnessed an unprecedented increase in the use of information and communication technologies, thanks to the dwindling costs of the hardware and the availability of many free and open-source software solutions. As in other technological innovations, the medical industry adopted the new potential to improve efficiency and extend its reach to more areas.

The COVID-19, pandemic has stressed the importance and necessity of using telemedicine services and also showed its advantages and limitations to the physicians and patients in medicine and surgery. There are various technological and implementation challenges that we need to overcome to make telemedicine widely applied in our society. The digital communication infrastructure is the need of the hour. There is a great divide between rural and urban areas. Telemedicine could be instrumental in removing this gap greatly in health care sector.

This study is an attempt to cover Current Telemedicine Practices in India, Government programs policies, Regulations, and also evaluated the technology platforms, the socio- economic benefit, available infrastructure current technological trends as well as the challenges and issues in large scale implementation of Telemedicine in India.

A review of the status of Telemedicine in India and globally was conducted covering both public and private players. This also includes Current trends and practices of Telemedicine globally.

Several telemedicine services in India are launched by the government as well as by private agencies few are very recent ones like eSanjeevni, Services eHealth Assistance and Teleconsultation - SeHATOPD, Swasth –app :(Launched in June, 2020) AYUSH Sanjivani’ App ( Launched in May 2020) Tele- Mental Health : ABHA (Ayushman Bharat Health Account) , South Asian Association for Regional Cooperation (SAARC) and Pan- African e-network Project: Global Telemedicine Projects Initiated by India to name a few.

Several start ups started working in the area of Telemedicine like : Tata 1mg, NetMed, Pharmeasy-Medlife ,CureFit, DocOnline , Netmeds , Lybrateto name few and they are working in various applications of telemedicine which are covered in the report as like Tele- Consultation Tele- Diagnostics, E- Pharmacy, Tele- Monitoring, Tele- Homecare, Tele-ICU, Tele-Rehabilitation, Robotics assisted, Tele- Physiotherapy

To analyse the current technology trends in Telemedicine in India ,a Survey of Start ups working in the area of Telemedicine was also conducted. Details of startups on various parameters were collected for example Business Verticals, Impact of COVID-19, Turnover Technologies used, Remote Data Management, Challenges Faced, Future plans, Business started in the year etc. With respect to technological adoption and usage trends, it was found that most of the companies are using the technologies like Artificial Intelligence/machine learning just for commercial purpose i.e. to understand customer preferences, connecting them with relevant doctors, forecast demand & procurement requirements and accordingly suggest the product of their choice. However, advanced technologies like Blockchain, Robotics, Computer vision are the technologies that were used by the companies who have started their business in the last 3-4years.

Advanced emerging IT tools like Artificial Intelligence, Machine Learning, Big Data analytics, Blockchain, cloud etc. will enable doctors to make faster and more accurate decision about patient’s health and also ensure secure data transfers and data storage. These advanced emerging technologies will play a crucial role in the advancement of Telemedicine system in the country. India being recognized as IT superpower in the world, should utilize its strength to become globally competitive in Telemedicine.

Major drivers of demand of Telemedicine in India identified in the report are: COVID 19, societal demand, higher mobile and Internet penetration, supportive government policies , advanced and emerging technologies , role of private players , accessibility, affordability and convenience. 

Regarding the policy and regulatory issues, the National Digital Health Blueprint (NDHB) of Government of India defined also minimum set of standards to be adopted for ensuring interoperability and the standards required in the major areas of healthcare, e.g.: diagnostic content, terminology and codes for statistics and laboratory tests these includes: FHIR, DICOM, SNOMED, CT ICD‐10, LOINC, Standard for EHR, TLS / SSL, SHA‐256, AES‐256 etc. and are covered in the report in detail. The report also talks about the medical device standards followed and adopted in the country and also touches upon the challenges in adopting and implementing the Telemedicine standards in the country. 

Major challenges for Telemedicine in India include lack of availability of Infrastructure, Broadband connectivity 24X7electricity and need to standardized electronic medical records (EMR) to enable Interfaces to be interoperable to each other for seamless connectivity. Policy needs to be framed for securing personal information w.r.t. (with?) confidentiality, authentication, authorization of data etc. which is imperative to gain the confidence of users w.r.t sharing of their data and large-scale acceptance of Telemedicine. Building and setting up the Indigenous cloud is important so that the data can be stored in a cost-effective and safe manner. The cost of hardware/ software should be such that it can be accessible to every citizen of the country. With the emergence of new and advanced IT tools, the skilling of manpower plays a very instrumental role in the advancement and adoption of telemedicine in India.

The following are the major recommendations of the report:

•  Connected Healthcare System: Need for seamless integration amongst various available platforms and various services required by the patient.
• Interoperable Standardized Secure Data: Need for adoption of standards like FHIR, DICOM, SNOMED CT etc.,
• The security and privacy of data need to be compliant with the national and international legal framework.
• Facilitation of deployment of 5G and Satellite-based network (LEO) will enable seamless accessibility 
• 5G : Scope for new venture and Telemedicine applications like Telesurgery, Tele ICU will be practiced efficiently. 
• Affordable and efficient : Need for the private players and Government to join hands (PPP).
• Platform integration: Hospital to Hospital to Diagnostics to Pharmacy is needed.
• Integration with homecare: Telemedicine services from a hospital should have seamless integration with homecare services.
• Advanced Technologies ( Health 4.0) : Need to leverage more applications of : AI , Analytics , IOMT, Cloud , Blockchain , Robotics, Computer vision etc.
• Ensuring equity: Care should be taken for inclusive implementation of telemedicine services to ensure that the most deprived sections of the community are not left behind. 
• Use of open source library: OSL will lead to reduce the cost of deployment of the software for the Telemedicine system.
• Medical insurance: Need for the endorsement of Telemedicine with the medical insurance system.
• Tele Health standards to conform with the world standards.

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