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A Collaborative Tele-Neurology Outpatient Consulation Service in Karnataka: Seven Years of Experience From a Tele-Medicine Center
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.280644
Keywords: Collaborative care, Karnataka, outpatient care, Tele-Medicine, tele-neurology
India is undergoing a rapid transition in its healthcare sectors. An increasing trend in the incidence of Non-Communicable Disorders (NCDs) has also been observed. This may be due to changes in lifestyle and increased life expectancy of the general population.[1] Neurological disorders account for a major proportion of NCDs and have been recognized to lead to significant mortality, morbidity, and economic impact due to limited therapeutic options and lack of specific treatment.[1],[2],[3] The global prevalence of neurological disorders in the year 2005 was 155.36 per thousand.[4] The prevalence rate of neurological disorders ranges from 9.67 to 40.7 (mean of 23.9) per thousand in India.[1],[2] In India, there is a gross mismatch between availability of services for the treatment of neurological disorders (presence of trained neurologists, other essential health professionals and infrastructural facilities) and the existing prevalence of the neurological disorder. The neurology specialist services are mainly located in the major cities of India and just as noted worldwide, there is a notable lack of these facilities in rural and semi-urban areas of the country.[1] There is difficulty in retaining specialists in non-urban areas due to inadequate infrastructure and difficulty in accessing recent medical advances.[5] Also, the logistics of travelling long distances to access specialist care, the costs for the same and the disability associated with chronic neurological conditions also frequently adds to the difficulty faced by the rural population in need of specialist neurological services. All this indicates that there is definitely a significant health gap for neurological disorders at primary and secondary care levels.[6],[7] Thus, neurological disorders have been recognized as one of the major public health problems in India.[1],[4] Previous studies have advocated the need for providing alternative models of neurology care accessible to the entire population of the country. The training of specialist neurologists in tertiary institutes, establishment of satellite clinics to provide neurological care, training of existing medical professionals working in the peripheral centres in neurology and formulation of a separate national program for neurology are methods that have been proposed to tackle this emerging problem. Although these alternatives have been conceived previously, not much change has taken place.[1] Hence, the Government of India has taken certain policy measures to provide specialist services which may cater to the population that has heretofore remained unreached—such as (a) Mandatory rural service for medical practitioners for a period of 1 year in order to acquire a medical license to practice in their respective state, (b) service bond for a duration from 1 year to 10 years, during postgraduate/super specialty training, (c) offering special quota to medical graduates in specialty training entrance exams, if they have served in rural areas for more than 3 years at a stretch. However, these measures have not been entirely successful. In the last decade, there has been unprecedented growth in satellite transmission in India. Along with this, there is a widespread network of fiber-optic cables, increased bandwidth to provide high-speed internet connectivity, and the rise of private internet service providers. In turn, this has made internet services available to an increasing section of the populace. This platform, if used appropriately, has provided improved quality of services in various fields such as commerce, banking, education, and entertainment by translating into needs-based technology,[8] but its use remains very limited in the healthcare sector.[5] In the last decade, there has been an attempt to delivery health services via the technological medium in India. This initiative was taken by the Indian Space Research Organization (ISRO) in 2001 to provide technical support to healthcare. Presently, this support is being provided to around 100 hospitals in India, the majority being rural hospitals along with 22 speciality hospitals in major cities.[9],[10] Tele-Medicine has been defined as the use of information and communication technologies to provide medical services from a distance. Tele-Neurology can be considered as a sub-specialty under Tele-Medicine, which can be used to provide specialized neurological services. It can be considered as an effective tool for reducing the treatment gap and has the potential to serve geographically isolated rural areas as well as urban areas with lesser numbers of neurology specialists.[5],[11],[12] A study by Misra and group from Lucknow in 2004, examined the tele-neurology services delivered in the northern part of India at a distance of 1500 km. They were successful in delivering services in the majority of cases while 27% of cases were not linked to technology due to power failure.[13] The tele-stroke project from the northern part of India by Sharma shows that they are able to deliver services to the community by thrombolysing 26 patients in nine district hospitals without the on-site presence of a neurologist and with the help of trained medical officers.[14] They also conclude from their experience that smartphone-based tele-stroke services may be a much cheaper alternative to video-conferencing-based tele-stroke services and are more portable with less technical glitches.[10],[14] The numbers of interventional studies in tele-neurorehabilitation through tele-medicine in India are very limited. A study from Delhi shows that Tele-rehabilitation as a Home-Based Geriatric Care Service for 22 patients is feasible and was acceptable to clients with 70% having improvement at the end of the intervention.[15] A recent study finding from a Government-run Tele-Medicine center shows that prison tele neurology services, prison tele-psychiatry services, prison tele-neurosurgery services, and tele-neurorehabilitation services are definitely feasible, effective, and less resource intensive in delivering quality telemedicine care.[7],[16],[17] It is on this background that the Tele-Medicine Centre at National Institute of Mental Health And Neuro Sciences (NIMHANS), Bangalore has started providing tele-neurology services from 2010 to all the district hospitals of Karnataka in collaboration with Department of Health and Family Welfare, Government of Karnataka through Karnataka State Wide Area Network (KSWAN) and Department of Neurology, NIMHANS, Bangalore. The aim of this study was to review the socio-clinical parameters of patients who received outpatient-based collaborative tele-neurology consultations across Karnataka over a 7-year period.
In the Tele-Medicine Centre, Tele-Neurology services were provided through HSM (Hub and Spoke Model of Tele-Medicine) using electronic health record-based video conference mode enabled for the synchronous mode. It is a collaborative-care model (CCM), where clinicians from the district hospital (Spoke Centre), who desire to seek tele-neurology consultations from specialists at the Department of Neurology, NIMHANS would contact their respective telemedicine technician. They would provide basic socio-demographic and clinical details of patients which would be entered in their Electronic Health Record (EHR) maintained in the KSWAN network. The technician would then fix an appointment based on the availability of clinicians who were neurologists at the Hub Centre with the patients using the telemedicine services. The patients were then seen or discussed with respective district hospitals doctor in live, real-time video conference mode. The average time for a single consultation ranged from 15 to 20 minutes. The district hospital doctors would provide treatment using a prescription to their patients at the end of the consultation. For the purpose of the study, data were collected from the file review of tele-neurology consultations register. This was done using a proforma consisting of socio-demographic details of patients, details of the spoke-side center, clinical details including investigations, diagnosis, treatment, and referrals. Collected data was analyzed using descriptive statistical methods. This study was approved by the institutional ethical committee of NIMHANS, Bangalore.
There were 189 tele-neurology consultations provided from December 2010 to March 2017. Missing data from some of the variables has been mentioned at respective places. Overall, around 90% of all variables could be analyzed. [Table 1] shows details of the sociodemographic and clinical profiles of patients. The mean age of the patients is 39.63 (±19.01) years, ages ranged from 4 years to 80 years and 50.8% (n = 96) were males. Of the total, 31 (16.4%) had acute, 16 (8.5%) sub-acute and 99 (52.4%) had chronic presentations. The most common diagnosis was made in tele-neurology consultations was seizure disorder in 33 (17.5%), followed by Cerebrovascular Accident/Stroke in 28 (14.8%) and others were Traumatic Brain Injury (TBI) sequelae in 6 (3.12%) and neuro-infections in 11 (5.82%). In terms of treatment, 24 (12.7%) of patients were advised to continue the same treatment and 57 (30.1%) of patients had their medications changed. Totally, 30 (15.8%) required specialist referrals for primary consultation or review and 15 (7.93%) further evaluation of illness and inpatient care. Out of these, 15 (7.93%) required neurology, 12 (6.3%) required neurosurgery, 3 (1.6%) required psychiatry, 3 (1.6%) required neurorehabilitation, 1 (0.5%) required speech and audiology and 14 (7.4%) required general hospital consultations.
[Figure 1] shows the number of tele-neurology consultations of respective districts of Karnataka. 66.6%(20) of districts of Karnataka had utilised tele-neurology consultation service at their respective place. The Chamarajanagar and Bagalkot districts of Karnataka used 61.3% of tele neurology consultations while remaining districts of Karnataka used limited tele-neurology service.
This is the first service of this kind in India. It was provided in collaboration with Government-run District Hospitals, under the Department of Health and Family Welfare, Government of Karnataka and National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore through Karnataka State Wide Area Network (KSWAN) of Karnataka. Under this platform, our Center provided Tele-Neurology, Tele-Psychiatry,[15] Tele-Neurorehabilitation,[7] Tele-Radiology, and Tele-Ayurveda outpatient consultations and Tele-collaborative psychiatric consultations for inpatients of a rehabilitation centre in Bengaluru attached to a public primary health centre.[16] These services have been provided since 2010 and cater to populations located up to a distance of around 700 km from Bangalore, across Karnataka. It has been a successful run of a Government-sponsored Indian program. The tele-collaborative care model is Doctor-Doctor–Patient Model.[15],[16],[17] Thus, not only do patients derive benefit, but doctors at the spoke-side also receive the requisite training to provide services for neurological disorders with similar presentations. They can also discuss difficult cases with specialists at the Hub center. This model not only provides clinical service to patients but also has been successful in the training of primary care doctors in treating neurological disorders. This model may be effective in training the medical professionals in the peripheral centres in neurology in a very low resource setting while simultaneously not hampering services in both hubs and spoke Center. Tele-neurology consultations services even though available for all districts of Karnataka, 66.6% of services were utilized by Chamarajanagar and Bagalkot districts whereas other districts had an uneven distribution. The gap in providing Tele-Neurology needs to be explored and there is a scope for effective collaboration in delivering quality service for difficult-to-reach patients, which needs to be bridged along with the training of primary doctor in neurology. The large gap in providing these services may due to following factors, (a) lack of awareness, (b) poor motivation from district hospitals physicians, (c) additional burden of conducting the program, (d) non-availability of technical staff to connect to technology at periphery Center (e) the lack of adequate infrastructure, (f) power failures, and (g) availability of neurologist at district hospital and private sectors. So, there is a need for a qualitative study for factors influencing patients, technical and trained staff for delivering tele-services in the country. In our sample, representation from all age groups and both sexes was observed. The majority of the patients had chronic, long-standing NCDs rather than acute or hyperacute onset illness. This was considered to be one of the public health concerns in the country.[1] The common diagnoses are those of epilepsy, followed by CVA (stroke). Interestingly, 87.3% had needed interventions with only 12.7% not needing treatment change. Tele-Neurology consultation were successful in providing care which is comparable to previous studies from Indian and worldwide regarding care in tele-stroke, emergency thrombolysis in stroke care, neurotrauma, neuro emergency, movement disorder, Parkinson's disease, epilepsy, developmental disorder through Tele-medicine.[5],[11],[13],[18],[19],[20],[21],[22],[23],[24],[25],[26] To compare our patient profile with other studies in India on tele-neurology consultation, there are no existing studies available; however, a study from Apollo Hospitals, Chennai has shown 21% of teleconsultations were in neurology and neurosurgery, accounting for 8840 consultations by October 2014.[27] Previous studies from India about specific disorders suggest that there has been successful delivery of tele-neurological services in the treatment of status epilepticus, stroke, and other neurological disorders. Clinical experts were able to carry out a virtual neurological examination that was sufficient to assist the local doctor and treat the patients.[14],[27] In this collaborative care model, we observed that tele-neurology services provided that—(a) patients at their locality received the standard treatment and care, (b) a medical officer could develop a better practical understanding of the clinical care and positively influenced their management of neurological disorder, (c) it reduced the cost, time is taken to reach higher centres, and (d) it reduced the unnecessary investigations and consultations for patients. These models highlight how we can reduce the health gap in treating a neurological disorder and also increasing the neurology work force at the primary and secondary care level to treat the neurological disorder in India. Establishing and running telemedicine services in Low and Middle Income Countries like India is feasible with available low resources and technology. The minimum requirement for realtime Tele-Medicine consultations possible with an inexpensive smart mobile phone [28],[29],[30] with Zoom, Skype, and even WhatsApp Video Conference software. Other being KSWAN, Government of Karnataka [31] and Network and Education and Research Network (ERNET) run by Ministry of Electronics and Information Technology, Government of India.[32] This connecting geographically separated center can be possible with 3G/4G high-speed internet connectivity provided by a Government and Private internet service providers. Use of Zoom, Skype, and even WhatsApp software for Video Conference purpose is simple and can be learned without expertise guidance. However, telemedicine has its own limitation, challenges and barriers based on the availability of resource and manpower.[16],[28],[33],[34],[35] These are (a) patient and clinician acceptance and satisfactions about Tele-Medicine consultation are not equivalents to real consultation, (b) cross-cultural acceptance of services, (c) privacy and confidentiality of patient's records while providing telemedicine service, (d) availability of uninterrupted Internet and Electricity, and (e) Countries like India lack the Tele-Medicine Act, which looks into consent, policy issues, licensure, privacy, and confidentiality.[36],[37] Recent National Health Policy of India 2017 also advocates use of telemedicine. Hopefully upcoming National Digital Health Authority shall have answers for these regulatory questions about telemedicine in India. There is an urgent need for Guidelines and Standard Operating Procedure to run a telemedicine facility in India. Strengths and limitations of the study This study provided the profile of patients was seen through the collaborative care tele- neurology outpatient consultation services from India. However, it is limited by lack of data on continuity of care and the clinical outcome of patients. Implications and future direction The effective collaboration between local hospital staff, a specialist and telemedicine center can help in the treatment of populations in need and universalize healthcare for all sectors of the population. It may help medical officers in better practical understanding of the clinical case and in positively influencing the management of neurological disorders by them. The prospective research in this area can take place on the effectiveness of the tele-neurology model over conventional models, economic, cost-effectiveness, legal implications on care, acceptability and satisfaction of model by patients, caregiver, and professionals.
This study has demonstrated the successful implementation of outpatient-based collaborative tele-neurology consultation in Karnataka. There is a need for more studies to elucidate its acceptability by patients, caregivers, and professionals. Author contribution All the authors have contributed and approved the final manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1]
[Table 1]
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