By enabling access to quality healthcare with a near-zero contagion risk, telehealth witnessed accelerated adoption during the Covid-19 pandemic, finding its niche among the emerging digitally enabled India. That said, its acceptance as a mainstream health service model requires care providers, technology providers, home-grown entrepreneurs, multinationals, and government to come together to build a robust and integrated telehealth ecosystem that can be both profitable and socially responsible.

The telehealth market

Growing at a CAGR of 39.6%, the telehealth market encompasses tele-medicine, tele-ICU, online pharmacies, mobile health, home diagnostic services, etc., and is the fastest-growing segment within healthcare. According to a recent study, the market is expected to reach $10.6 billion by 2025. With the telemedicine practice guidelines published by the government on March 25, 2020, legalising the practice, the market has increasingly focussed on providing quality services at reduced costs and more convenience, helping India leapfrog from a provider-centric volume-based model to a patient-centric value-based one.

What makes this segment exceptionally attractive is its strong potential to address key health challenges that have plagued India for decades. According to a 2019 study by the Centre for Disease Dynamics, Economics & Policy, India has a shortage of 600,000 doctors and 2 million nurses, a gap that telehealth aims to combat.

An acute rise in telehealth enterprises

With strong public sector support, many startups and investors have built profitable businesses in telehealth. According to a recent report, India is now home to more than 133 funded telehealth startups and 5,295 health tech startups.

Leading telemedicine startups such as Practo, 1mg, mFine, iCliniq, and myUpchar witnessed a 4-9 times surge in doctor consultations between March and June 2020, with close to 80% first-time users on their platforms, it was reported. According to a FICCI report, online pharmacies added over 6 million new customers and doubled sales during the first few months of lockdown, attracting the interest of the country's largest e-commerce investors.

Another trend during the pandemic has been the adoption of 'Tele-ICU,' a technology model which allows an intensivist to remotely manage ICU patients across multiple locations from a command centre, rather than at the patient’s bedside. With Tele-ICU, an intensivist can manage 60-80 patients, as against 10-12 patients earlier, and deploy diagnostic tools to improve patient outcomes. With only 6.8 ICU beds for every 100,000 people and less than 5,000 intensivists, Tele-ICUs have proved to be a game-changer for India. Leading Tele-ICU startups Springer Healthcare and Cloudphysician have brought over 600 ICU beds under their service and delivered remote intensive care to over 15,000 patients during the pandemic.

Popular multi-specialty hospitals in metro cities have started collaborating with device manufacturers to set up ICUs in rural areas. Tattvan E-clinics is working to upgrade local doctor clinics in villages to tele-medicine clinics to bring specialist care to small towns. While these are positive trends, poor Internet connectivity and the high cost of tele-equipment setup continue to limit rural penetration of telehealth. Although, with India's Internet users crossing 500 million in 2019 and rural Internet users expected to increase by 58% annually, according to a PwC report, India should record a continued penetration of telehealth in the coming decade. Platforms, such as India's National Health Stack, are expected to further boost the growth of telehealth, as patient records become digitised and portable.

Key challenges

Alongside its growth, the Indian telehealth market is beset by challenges. First, navigating technology incompatibilities while ensuring the correctness of patient data has been a key challenge, including system security issues arising from patient-provider confidentiality, fluctuating results with different technology tools which could lead to inconsistencies in health outcomes, and platform integration challenges for patients visiting multiple providers.

Second, digitisation of health records with mobile applications that can read data across devices pose data security challenges that demand attention. For example, gaining data from individual devices such as a heart rate monitor, digital thermometers, blood sugar detector, etc., without the concerned individual’s consent in an emergency setting can be both unethical and illegal. Additionally, decentralisation of patient data across multiple telehealth providers leads to a lack of interoperability, making governance more difficult.

Third, telehealth being a virtual health delivery system, inherently poses a risk of dual-way information misinterpretation between the care provider and the patient. On the one hand, information from the patient if misunderstood by the doctor could lead to a risk of erroneous diagnosis or prescription. On the other hand, information provided by the clinician, if misunderstood by the patient, could cause psychological distress.

A need for governance

If not governed via an eco-systemic framework, the inherent challenges in the telehealth industry with the rise in telehealth enterprises could lead to chaos within the healthcare sector. The government’s ‘Mitr’ telehealth platform and the schemes subsidising capital to technology startups marked the first steps in India's digital health journey. The introduction of the Aarogya Setu app, which saw 100 million downloads within 40 days of launch during the Covid-19 pandemic, was a noteworthy effort towards digitisation. Further, strategic partnerships with tele-ICU startups to bring government medical colleges under tele-ICU have helped increase India’s digital footprint to rural areas.

However, a lot more needs to be done to enable a governed telehealth ecosystem in India. There is a need for entrepreneurs, conglomerates, healthcare providers, and the government to work in tandem to boost the telehealth market. Policymakers need to develop comprehensive frameworks for clinical governance in the telehealth market, define reimbursement models for telehealth services, and manage liability concerns, especially in cases of data security and misinterpretation. Technological innovation needs regulatory boundaries to enable a healthy telehealth ecosystem.

The post-pandemic era is likely to witness a significant increase in digitised healthcare that needs nourishment with solid governance. Acceptable quality, safety monitoring, and confidentiality are imperative to scale up adoption of these services. Platform integration needs strengthening to ensure care continuity for patients visiting different providers for teleservices. Technologies like blockchain, natural language processing, and artificial intelligence should be leveraged in governance for improving transparency and interoperability of telehealth services.

While many developed countries opted for telehealth much earlier, the lack of defined regulatory frameworks and ambiguity in legal and jurisdiction largely impeded its growth. India is standing at the cusp of a digital health transformation, which can propel the country's economic growth and set an example for emerging economies if managed well.

Views are personal. Vijaya Sunder M. is Assistant Professor (Practice) in the Operations Management Department at the Indian School of Business (ISB) and affiliate faculty with Max Institute of Healthcare Management at ISB; Meghna Raman is a consultant with Max Institute of Healthcare Management at ISB.

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