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Table of Contents
Year : 2020  |  Volume : 2  |  Issue : 2  |  Page : 41-52

Patient goes online: Consideration of patient safety and quality-related factors in telemedicine

1 Independent Researcher, Digital Health India Association, Bengaluru, Karnataka, India
2 Department of Information Systems, School of Management, Mahindra University, Hyderabad, Telangana, India
3 Independent Researcher, Digital Health India Association; Chairperson, Digital Health India Association, Bengaluru, Karnataka, India

Date of Submission07-Mar-2022
Date of Decision24-Mar-2022
Date of Acceptance26-Mar-2022
Date of Web Publication14-Apr-2022

Correspondence Address:
Dr. Avinash Kumar Gupta
Independent Researcher, Digital Health India Association, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/QAIJ.QAIJ_6_22

Rights and Permissions

Telemedicine services have existed for a few years for providing remote care, but now due to well-known reasons, its use skyrocketed during the pandemic, playing a critical role in providing care to everyone and preventing health-care systems worldwide from collapsing. The sudden surge in adoption of teleconsultation by all the stakeholders and speeding efforts by the government on the policy, legal aspects, and guidance to the users helped telehealth to grow in the right direction for the benefit of patients as well as the global health-care community. Ensuring patient safety is as important as in any other scenario in health care and to ensure the same; there need to be various factors that must be kept in check in any telemedicine solution implementation. This article covers patient safety in remote health-care technologies in detail for helping decision-makers for choosing the appropriate telemedicine solution for implementation in their workplace with a focus on patient safety aspects.

Keywords: Patient safety, remote health, teleconsultation, telehealth, telemedicine evaluation framework, telemedicine

How to cite this article:
Gupta AK, Tandon A, Nambiar U. Patient goes online: Consideration of patient safety and quality-related factors in telemedicine. QAI J Healthc Qual Patient Saf 2020;2:41-52

How to cite this URL:
Gupta AK, Tandon A, Nambiar U. Patient goes online: Consideration of patient safety and quality-related factors in telemedicine. QAI J Healthc Qual Patient Saf [serial online] 2020 [cited 2022 Dec 9];2:41-52. Available from: https://www.QAIJ.org/text.asp?2020/2/2/41/343313

  Introduction Top

Telehealth, i.e., delivering health care using information and communication technologies as a mode of connecting patients in remote areas with health-care providers at a distant location, has existed for a few decades with its own set of challenges in incremental growth and adoption across the globe.[1],[2] Telemedicine, as a subset of telehealth, has been available for more than 20 years in India as a modality for consultations with physicians from remote and inaccessible locations as well as during disasters when populations get isolated during floods, earthquakes, or other calamities. However, for various reasons, it never became a mainstream modality in the public or private health-care delivery systems in the country. The sequential lockdowns imposed during COVID showed a surge in the use of telemedicine mainly because of the inability of the patients to physically visit the hospital.[3] Further, a push was provided by the legal recognition of telemedicine services at the national level by the issue of Telemedicine Practice Guidelines (TPG) in March 2020 by the Ministry of Health, Government of India.

This increase in the need for remote consultations showed a plethora of solutions mushrooming in the market, many of them lacking in the basic understanding of the needs of patient safety and quality as it applies to health care. The health-care providers also lacked a comprehensive tool to evaluate the right solution for their needs, which would ensure that safety of the patient is not compromised in any manner when using the telemedicine platform. We, at Digital Health India Association (DHIndia) along with our alliance partners such as Consortium of Accredited Healthcare Organizations (CAHO), Healthcare Information and Management Systems Society (India) (HIMSS-India), and College of Healthcare Information Management Executives-India (CHIME-INDIA) and supporting partners such as National Resource Centre for EHR Standards (NRCeS) and X-Scale Innovations, engaged in creating a telemedicine registry for India. During this exercise, an evaluation framework was designed to assess the maturity levels of the telemedicine solutions. The evaluation framework thus conceptualized was mainly to be used by the end users to select the right solution for their hospital. During our research and in discussions with our alliance partners, it was revealed that there needs to be an emphasis to address the concerns on patient safety while the doctors and patients were engaged in teleconsultation.

We conducted a relevant literature review and extensive interaction with stakeholders from across the industry to conclude that in any telemedicine consultation, patient safety and quality of health-care delivery could be at risk in the following situations:

  1. Identity management
  2. Consent management
  3. E-Prescription management: Medication errors in E-prescription
  4. Data security and integrity
  5. Continuity of care: Compromise on treatment and care trajectory
  6. Digital and health literacy
  7. Clinical audit.

When creating a tool for evaluation of the telemedicine solutions available for use, we have worked on incorporating features that will enable a hospital Chief eXperience Officer (CXO) or decision-makers to confidently decide on the right solution for their need. The final framework thus developed is the Digital Health Maturity Model Framework for Telemedicine Solutions (DHM2-TS). Overall, the aim of this article is to present different elements of DHM2-TS framework and specifically highlight the features that address patient safety and quality of care delivery.

Background literature

To identify patient safety risks and quality of care issues related to the use of telehealth services, a systematic evaluation of the literature was conducted. This assessment is part of a larger research initiative to create a framework for assessing teleconsultation platforms. The following were the review questions relating to patient safety and quality of care:

  1. What are the patient safety risks connected with the use of telehealth?
  2. Can the identified patient safety risks be mitigated by the solution provider?
  3. Are these risk-mitigating measures/features demonstrable to a potential user?.

In general, in our literature review, we found numerous previous researches on developing assessment frameworks and adapting existing frameworks. We recognized the relationship between our framework and other proposed studies, such as the Model for Assessment of Telemedicine (MAST), EUnetHTA Core Model, Donabedian's model for quality of care, and the National Telehealth Outcome Indicator Project (Canada),[4] but one major difference is that in the extant literature, the main focus is on evaluating the use of telemedicine for the patient (outcomes) and not on the usability of telemedicine within doctor–patient interactions, which is where we designed this research project to address this particular gap. The previous literature review studies argued that the most critical component for ensuring patient safety and quality care delivery with the use of telehealth is simulation-based and case-based training.[5] Most studies identified patient quality as a deliverable of capacity building, but some studies pointed out limitations that exist in technology and its context of use.[6] In this section, we provide a summary of articles that investigated patient safety and quality of care when evaluating the use of telehealth technology.

Identity management

Information technology governance and policy scholars have discussed in detail three aspects of identity management: identification, authentication, and enrollment (creation of digital and/or physical records).[7] Decentralized identity management is critical as it allows patients to share data, and at the same time, complete records are also accessible to health-care providers.[8] Patients are to be identified by unique identifiers or multiple identifiers such that identification and authentication are not exclusionary. Identity management is crucial for ensuring continued care as records are linked using identifiers, making them interoperable.[9] It is critical that patient identification mechanisms do not jeopardize patients' privacy and confidentiality. The challenge highlighted by Soenens with the design of digital identification systems is that the understanding required is not only technical but also of particular social practices and socioeconomic history of the people.[10] Human factors such as limited understanding and bias rooted in cultural context could also result in identity-related issues for patients.[11]

Consent management

Consent of patients and consent-taking procedures are vital aspects of ensuring quality care. The steps needed to get the right degree of permission are predicated on a basic assumption about the level of access that the patient desires to provide any caregiver about their personal information. For example, adolescent confidentiality is jeopardized by the ease of access to electronic medical information as well as patient (and/or parent)-controlled health records.[12] Although physician pledges of secrecy boost teenagers' willingness to divulge sensitive health information, these assurances are rarely backed up by technology that mediates doctor–patient interactions. Consent management in health care is a government-regulated topic and many nations have policies on sharing and use of patient data.[13] It is to be understood that the patient is the primary owner of all data related to their health. At the global level, these guidelines and policies are derived from patients' rights, women's rights, and rights of disabled people and people with marginalized identities.[14] To offer patient-centered quality treatment, informed consent from patients or their caregivers is required; otherwise, health-care practitioners may have limited information and may compromise patient safety.[15]

E-Prescription management: Medication errors in E-prescription

Medication errors are classified as serious and often preventable errors in prescription writing (WHO, 2016).[16] Medication errors can be related to prescription, dispensing, and administration. In teleconsultation, the main concern is about errors in prescription. Document by the WHO concludes by recommending the use of electronic systems to prevent the errors but at the same time lists the factors associated with the errors that are persistent or multiplied manifold with the use of telehealth as found during literature review. The medication error with the use of computerized order entry systems is the preferred mode of sharing prescription in telehealth solutions.[17] The issue of incomplete summary and medication is more pronounced in telemedicine systems where doctors have reported fatigue with the use of computers for electronic recordkeeping. The harm caused by medication error is unavoidable with high patient volume, as was reported during the COVID pandemic in the mid-2020 by health-care organizations.[18] The utility of telehealth technologies for conducting medication reviews became evident as post-COVID-19 cases increased globally for the first time.[19],[20] This calls for advanced solutions that prevent medication errors in E-prescriptions through proper clinical decision support system as well as incorporation of good prescription practices. In addition to this, with the advancement of technology, teleconsultation solutions rely on various equipment (to capture and share data), and error or malfunctioning in medical equipment could adversely affect the quality of care delivery.[21]

Data security and integrity

The use of security measures, privacy legislation, and communication standards has also been proven to improve patient health information interoperability at the technological (TI), semantic, and organizational levels within hospitals.[22] In the case of telehealth, multiconnection capabilities between the electronic patient record (EPR) systems of institutions that treat patients in a remote-access architecture are necessary. Aside from privacy issues, vulnerabilities in health information security have a significant financial cost and can cause a threat to individual patients and organizations and even impact national security. Data theft can have a negative impact on the quality of care. Incorrect information might enter the beneficiary's medical record and taint future medical decisions. Conventionally, hospitals displayed posters in elevators, cafeterias, and other public areas cautioning employees not to discuss patients openly to reduce incidents of physical eavesdropping. The potential of electronic eavesdropping complicates the responsibilities of health-care practitioners to maintain patient privacy.[23] The precise standards for data security and patient health data protection that apply to a cross-institutional EPR are drawn from the country's legislative frameworks. Unfortunately, however, practice often falls short of intended statutory protections. In addition to health-care providers, patients may be valuable allies in the fight against identity theft and privacy violations. It is expected that telehealth providers and organizations educate patients on how to protect themselves.

Continuity of care

Technology-mediated routines in case of teleconsultation often leave less time for doctors to go through detailed patient notes before consultation 10. The study by Mehrotra et al. on E-visits for sinusitis and urinary tract infections shows that doctors take conservative approaches when prescribing treatment in remote care.[24] Ray et al. also highlight related concerns with quality care delivery when investigating teleconsultation sessions of children having respiratory infections, as they found higher prescription of antibiotics and less communication about follow-up and investigations required.[25] Telemedicine has been found very useful for following a patient, especially in remote areas, which has a positive impact on the continuity of care.

Digital and health literacy

Doctors providing remote consultation have to rely on patients themselves or people present in their proximity to provide details of symptoms and vital measurements useful for diagnosis. This often increases the communication gap between doctors and patients resulting in either partial or incorrect information.[26],[27] The findings of the ethnographic study show that care routines that emerge at the site of patients are often complicated and demand coordination between doctors and caregivers. The problem gets more nuanced because of limited understanding of health and human anatomy and the difficult-to-use technology artifacts, such as blood pressure monitors requiring proper elevation and placement.[28] In the homecare setting, there are instances where patients missed on reporting of adverse events or lacked the ability to articulate their experiences to communicate with doctors during teleconsultation sessions.[29],[30] The study by McGraw et al. provides a list of patient-related factors, such as dementia, depression, and relationship with caregivers to be considered for ensuring the quality of remote treatment at home.[30] This can be further compounded by inadequate digital literacy.

Clinical audit

In the digital health ecosystem, the challenges of health data integrity are of utmost concern. Equally challenging is the fact that data alteration and manipulation can be a serious concern in patient's disease management. An important part of solving the problem of integrity would require accountability for every data modification; this is where audit trails as well as interaction and communication logs come into play.[31]

The above-mentioned factors were identified by us as important patient safety-related considerations during a teleconsultation process, and thus, we ensured that these are addressed in appropriate detail in the evaluation framework (DHM2-TS) that has been developed.

We provide the methodology used for developing this framework in the next section.

  Methodology Top

The article is based on the outcomes of a study that was carried out between April 2020 and October 2021 with a group of stakeholders in the telehealth ecosystem supported by a rigorous literature review. The stakeholders who were engaged to evaluate telehealth systems/platforms to develop a database of telehealth solutions are domain experts in their respective fields. The stakeholders include clinical experts from CAHO, technology and implementation experts from CHIME, health informatics experts from HIMSS, health-care standard experts from NRCeS, cybersecurity experts from XScale, and the core team from DHIndia (including representation from health-care delivery experts, hospital managers, health-care IT expert, health-care administration student members, patients, and other experts from health-care and IT industry). All the experts had exposure to telemedicine as users in their respective workplace or as patients. We deployed a rapid multiple user-centered walkthrough method – an adaptation of a widely used cognitive walkthrough method for usability evaluation.[32] The walkthrough method has been used to investigate the associations between various components of telehealth platforms with functional goals and tasks of health-care providers' and patients' interactions.[33] One among many key goals was to incorporate aspects related to patient safety and quality of care, often called patient-centered care. In brief, the process began with preliminary data collection and was followed by an online demonstration of the product and a detailed online evaluation by domain experts in technology, cybersecurity, digital health standards, and end users (clinicians and patient representatives and academicians). The evaluation focused on various perspectives, such as ease of use, statutory compliance, analytics and integration of health IT standards, data security, and interoperability. In addition to this, for solving the CXO community's challenge of finding the right telemedicine solutions for their institutions, we have developed the telemedicine registry (https://telemedregistry.in/), consisting of a list of available solutions in the Indian market evaluated on the DHM2-TS framework (DHM2-TS). [Figure 1] summarizes the process followed. In this article, we present the findings of the project and particularly various elements of our evaluation framework that deal with patient safety and quality considerations when selecting and using teleconsultation solutions.
Figure 1: Summary of methodology

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  Findings and Discussion Top

We discuss our findings in three parts: (1) elements of DHM2-TS framework that are critical to address the concerns around patient safety and quality of care when evaluating telehealth technology, (2) additional considerations critical for adapting telehealth solutions by any health-care organization, and (3) how DHM2-TS framework complements another popular framework/MAST.

The findings across these categories could also be considered as practical advice to CXOs, enabling them to utilize the framework as well as the registry.

DHM2-TS framework is shown in [Figure 2]. Abridged versions relating to the specific features are shown under the relevant headings. The features that are not relevant to the said para have been replaced by “x” in abridged tables to retain specific focus and clarity.
Figure 2: Comprehensive Framework of Digital Health Maturity Model for Telemedicine Solutions for evaluation of Telemedicine solutions

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Identity management

The first step toward ensuring safety of the patient leveraging the teleconsultation ecosystem is managing the identity of all the stakeholders involved. Based on the review of available teleconsultation platforms, the expert panel identified the key users requiring identity management features and support as follows: patients or their caregivers, patient's circle of care (family member/nurse who may or may not be colocated), doctors, and other members of the clinicians team where relevant. The aspects of management of identity that should be mediated via technology features include determining identity through relevant documents, authenticating the same and creating a record of the establishment of validated identity of the stakeholders participating in the encounter of teleconsultation, and saving details for future reference.

In teleconsultation systems, identification and authentication work together and features to enable both are required. The identity of doctor and patient should be confirmed to each other to prevent errors from happening like preventing the doctor (specialty)–patient (gender) mismatch. Identity of the doctor is also critical to establish to avoid situations where a person impersonating a licensed doctor could compromise the consultation. Thus, solutions must support uploading of verified credentials of the doctor. In addition to this, for additional security, the credentials should be verified by uploading the required credentialing documents and validating them against the data available with the state medical councils. In the context of India, health professionals' registry is being developed under the aegis of the Ayushman Bharat Digital Mission. This registry is expected to serve as an important step toward establishing a unified registry for all health-care providers in India. This registry is expected to provide an easy and automated validation of credentials of health-care providers in future via easy to call API.[7]

Identity of the patient and caregiver or the “circle of care,” as the case may be, is important to establish to ensure that it is not some impersonator or sometimes a person trying to unnecessarily harass the doctor by pretending to be a patient. This requires features to support the upload of identification-related documents such as recent picture, Aadhaar Card/UHID/passport, and other government-approved identity-verifying documents. [Table 1] Further, solutions should enable patients to register by displaying the physical copy of the identifying document in the video call or uploading images during the consultation. This is expected to help in correct identification of the patient.
Table 1: Identity management

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At the most basic or simplistic level, identity is established verbally with names, addresses, and simple demographic identifiers where in a more mature system, more advanced identifiers such as credentialing documents, usage of biometric systems, retina scans, and facial recognition features are considered useful for validating the identity.

Consent management

It is widely accepted that the owner of the health-care data is the patient, while at the same time, health and related data of any patient could have multiple custodians and users. In the teleconsultation ecosystem, the expert panels agreed that the key custodians of patients' data could be health-care providers, the digital technology providers, and patient's circle of care. Therefore, in recording of data and use of data, all require the consent of the patient. E-Consent systems have gained popularity since health-care practitioners are increasingly relying on information technology and management to plan and provide high-quality, cost-effective treatment in the digital health ecosystem. These systems are designed to guarantee that patients are informed about the repercussions of therapeutic intervention or the use of their personal health information, as well as create a log of consent conditions and generate an audit trail. It is critical to use implicit, explicit, and informed permission correctly, and it must be clearly understood by the patients and in their own language. No consultation should take place without the patient's permission, also including the consent to the consulting doctor to do physical examinations via video, images, and IoTs, which are a vital aspect of any teleconsult with the patients. Consent-related features are required for the following situations in technology-mediated remote consultation:

  1. For using the telemedicine application/software: This consent is executed between the telemedicine platforms providing technical partner and the patient. This could be a one-time consent for one version of the same platform
  2. Between the doctor and the patient: This consent is necessary before each virtual encounter between the doctor and the patient. This is considered implicit if the patient calls the doctor and considered explicit if the call is made by the doctor to the patient. It goes without saying that explicit consent is infinitely far safer for both parties concerned
  3. Consent to be taken is for the usage of patient's data by the third parties; be it the access to patient's relatives/circle of care, other clinicians, and health-care providers for cross-consultation or sharing of data for research/AI and such other purposes. Some of these consents can be one time and some others are encounter specific.

[Table 2] The telemedicine solution providers and users must be aware of and should incorporate these into the process of consent management. Consultation for special patients/specific conditions having risks of stigmatization, for example, mental health evaluation and patients suffering from HIV, needs higher security considerations in consent management.
Table 2: Consent management

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E-Prescription management: Medication errors in E-prescription

While telemedicine practice greatly enables clinicians to reach out to the patient in remote areas with help of technology, it brings various new and unique challenges with it. In telemedicine consultation, the possibility of medication error is mainly at the prescription level. After a detailed discussion with the expert panel, we identified that the solutions must have capabilities to prevent medication error by incorporating rules for prescription writing, such as validating patient identity; verifying name of the drug; and ensuring correct dosage, formulation, frequency, route of administration-related details, and signature of the doctor. In the evaluation framework, we have considered compliance with TPG guidelines with respect to restricted drugs, drug formulary interface with drug databases (proprietary versus standard drug databases available commercially or the one being developed by NRCeS and alerts related to alerts regarding allergy, drug-to-drug or drug-to-food interactions. [Table 3] These features are considered in increasing levels of complexity with each incremental level of maturity of the solution.
Table 3: Prescription management: Medication errors in E-prescription

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Data security and integrity

Data of the population of the country are required to be kept under immense security since breach of the same can have disastrous consequences not only at an individual level but at a national level. Data of the health of people are almost to be considered at the same security level as perhaps the data in the defense department.

Besides consent management, we have considered various TI features related to complexity of data security(e.g., OTP, password protection, encrypted data storage and transmission (Secure Socket Layer/Transport Layer Security), communication trail and interaction logs, data nonrepudiation, and data provenance. [Table 4] We have considered an evolutionary format of ensuring data security by including simple to more complex features with each increasing level of maturity of the telemedicine solution. To further enhance data security and integrity, federated storage, features for anonymization/deidentification of data, blockchain technology, and edge computing are also considered for evaluation in this framework.
Table 4: Data security and integrity

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Continuity of care

The care continuity is very critical for patients to get the most appropriate treatment and to enable the clinicians to provide the best. This can be ensured by providing access to all available health-care data in both the teleconsult and the offline consult, i.e., integrated patient records. In the teleconsultation ecosystems, any solution promising an overall care must include process and features to facilitate cross-consultations and multidisciplinary team consultations.

To sum up, the digital health record of a patient needs to be a single longitudinal electronic record and every encounter whether it be offline or online should be stored in easy to access mode for accessibility by the concerned stakeholders during any health-related intervention. The sharing of records must not be limited by geospatial restrictions but shared with appropriate consent where indicated. [Table 5] In this context, it is necessary that the teleconsultation solution must comply with the defined requirements for interoperability and comply with necessary standards such as HL7 and FHIR, ICD10 or 11. Systematized Nomenclature of Medicine Clinical Terms. LOINC, etc., for the same. The solutions must also cater to requirements of integratability with equipment and devices wherever relevant.
Table 5: Continuity of care

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Digital and health literacy

Limited digital literacy as well as lack of health literacy can be an impediment in successful adoption of teleconsultation as a mainstream modality by the patient as well as the doctor.

Proper onboarding training for the clinicians and the patients is needed to enable use of the platform by both of them to get the maximum benefits. The training may be simple interactive tutorial of an app to be used for the patients, an in-depth planned demonstration session for doctors getting started with the full-fledged teleconsult platform or other suitable methods. The training may not limit to only teleconsultation but go further in enabling patients for their health tracking/monitoring and care management with a better and shared decision-making. [Table 6] In addition, the solutions must have minimum learning time, be interactive, utilize machine learning for autosuggestion, have a user-friendly and intuitive interface, and preferably support multilingual capability.
Table 6: Digital and health literacy

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Clinical audit trail

[Table 7] Proper interaction and communication logs, trail for access, and modification of the data by the users must be recorded. Best practices for prescribing must be followed and there should be a mechanism to audit the clinical care quality, communication quality, and feedback of the patients. In the telemedicine solution, data life cycle should be managed in a manner to enable safe encrypted data storage for medicolegal and clinical audit purposes. The IT enablement of these aspects is considered critical for evaluating any teleconsultation solution.
Table 7: Clinical audit trail

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Preconsultation preparation

Preconsultation preparation, although not directly linked to patient safety, has an impact on the quality of the experience of teleconsultation. It helps ensure a smooth and hassle-free good-quality experience for the patient and the doctor alike and encourages follow-up teleconsultation sessions instead of in-person visits.[34] Technical quality and good connectivity are shown to positively influence teleconsultation-related experience of patients.[35] Thus, being able to ensure that equipment and the telecommunication network are functioning properly is important for the clinical practitioner, so there should be a way to ensure good quality for the audio, video, network speed and connection, power supply, and backup. In addition to this, solution providers must have a standard practice to manage the challenges if they occur before or even during the consultation for minimizing the hassle to the patient and prevent any harm.

Nonclinical factors impacting patient safety and quality during teleconsultation

For any teleconsultation to be successful, the features related to telecommunication network, information technology, and computer accessories and peripherals along with adequate backups for technical and geographical limitations should be an integral part of the preconsultation checklist compiled by any teleconsultation provider. A baseline check of nonclinical factors impacting patient safety and quality is provided below [Figure 3]:
Figure 3: Nonclinical factors impacting safety and quality during teleconsultation (checklist)

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Tech support personnel are important for smooth functioning and quick troubleshooting and are needed not only by the clinicians at hospital but even required to assist patients remotely when they face difficulties with the telemedicine solution.

Webside manners

Telemedicine practice had never been a part of medical school training, but for many, it became the only way to be able to reach out to their patients and provide care during COVID-19. Good quality of clinical encounters in telemedicine modality depends on good webside manners. Webside manner is the digital equivalent of clinical bedside manner, in which a health-care professional interacts with patients remotely in telehealth or telemedicine setting. This should be considered as a parameter and improved by proper onboarding and training of clinicians and the patients by the telemedicine solution provider. An astute clinician providing teleconsultation following the correct website discipline and practice could significantly increase the adoption of telemedicine usage by the patients.

Digital health maturity model for telemedicine solutions framework vis a vis Model for Assessment of Telemedicine

MAST[36],[37] is one of the widely adapted frameworks. During our discussion with stakeholders when planning for this research project, we identified that MAST framework falls short on three key aspects:

  1. MAST focuses on evaluation of outcome of implementation of telemedicine when mentioning assessment of maturity of solution as a prerequisite without listing points to be considered for evaluating maturity. The development of our framework is motivated by the fact that at the beginning of COVID-19 pandemic, all the CXOs in the health-care sector had to adapt to the tremendous speed of change and tackle many challenges to ensure the continuity of health care to the patients without any scale or framework to assess the maturity of available solutions.[38] In addition, the Government of India also helped accelerate the use of telemedicine in the mainstream by bringing out the TPG. However, there was no guidance on solutions available or recommended list of solutions that could be adopted for quality of remote health-care delivery. This gap around assessing the maturity (we define it as capability to ensure quality care and safety of patients) of the teleconsultation ecosystem is what we have addressed in the DHM2-TS framework
  2. MAST considers patient-related factors that are either clinical or economical and discounts the social context of the patient. We take into account patients and their circle of care as key stakeholders when identifying different TI capabilities that a patient-centric solution must have
  3. Finally, MAST-based evaluation is considered static as the model does not talk about possibilities of TI advancement or change in legal obligations. DHM2-TS framework is grounded in policies and guidelines around health data, data privacy, and telemedicine and hence subject to change. It is dynamic and provides space for evolution by including aspirational TI features in the higher levels. Thus, overall, we acknowledge the relationship between our framework and other proposed assessment studies, such as MAST, EUnetHTA Core model, Donabedian's model for quality of care, and the National Telehealth Outcome Indicator Project (Canada),[4],[39] but one main difference is that their focus is on evaluating the use of telemedicine for a patient (outcomes) and not on the process of telemedicine consultation and the maturity levels of features inclusive to all stakeholders.

  Conclusion Top

Patient safety is a complex subject, and the nuances of the same in the era of digital health have become further complicated, many of them unraveling with each new development in the digital health ecosystem. Safety and quality in health care is of utmost importance in all spheres of health-care delivery, telemedicine being no exception. Considering that telemedicine is an essential building block of the digital health ecosystem, and telemedicine adoption has skyrocketed with the extremely high demands by the patients and the health-care providers since the beginning of COVID-19 pandemic, the best practices in patient care should be stringently followed and enabled by for teleconsultation solution providers. DHM2-TS is proposed to be used as an evaluation tool by the health-care providers and has been vetted and approved by our alliance partners which included representatives from all relevant stakeholders. After it has been released, some hospitals as well as some telemedicine solution providers have requested us for evaluating their telemedicine solutions. Some of the telemedicine companies that have been assessed before have improved on their product based on the feedback given to them during the initial evaluation and have made changes in their original solution, requesting us to evaluate the new version as well for upgrading to the next higher maturity level. This is an early indication of value addition that this framework may bring to the stakeholders. We propose this framework for CXOs (CEO, CIO, CQO, CMIO, medical directors, and senior decision-makers) to assess the features of telemedicine solutions they intend to use as an evaluation tool to satisfy themselves on the ability of the concerned telemedicine solution/product/platform to meet the criteria for patient safety and quality in their respective organization. We also propose that the telemedicine solution providing companies can use the framework as a road map to incorporate features of patient safety and quality in the telemedicine solutions being developed by them.


We would like to thank all the stakeholders, interns, and organizations that helped us in creating the evaluation framework. The organizations include CAHO, HIMSS-INDIA, CHIME-INDIA, NRCeS, and X-Scale Innovations.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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