How is Telemedicine perceived? A qualitative study of perspectives from the UK and India

With increasing globalisation countries have been opening their service sectors to international trade. Health services are no exception to this. Although most trade in health services occurs through regional and bi-lateral routes [1], research on this topic has centred on multi-lateral agreements signed under the World Trade Organisation's General Agreement on Trade in Services (GATS) [2]. This multi-lateral agreement is a system of rules through which international trade in services occurs, and by which all member countries trade with each other. There are fears that trade in health services will accelerate privatisation of health systems [3] and hinder domestic health policy decision-making [4]. On the other hand, some studies have highlighted that increased health services trade and outsourcing can facilitate the sharing of ideas and reform, and improve the sustainability of health systems [5]. However, there is little data to support or refute these claims.

This study is set in the context of a specific mode of trade in health services, telemedicine. Telemedicine is the application of telecommunications technology to deliver health services at a distance [6]. Telemedicine trade is already taking place on a large scale, with the global market estimated to be worth $5.8 billion in 2007, and projected to grow to $13.9 billion by 2012 [7]. There are different types of health care services that can be outsourced, although the most important ones are tele-radiology and tele-pathology. These involve scans or samples being sent to radiologists or pathologists for interpretation in a remote location, who then send the results back to the physician. A sector of telemedicine that has received increasing attention is tele-care. Tele-care involves the use of information and communication technologies to monitor patients (often suffering from chronic diseases) from their home. It has already been trialled in United States [8], Chile [9] and Taiwan [10]. Further, there are plans to establish tele-care initiatives in remote parts of Scotland and Canada.

The growing use of telemedicine has prompted a body of literature on the benefits and concerns associated with it. The authors have previously conducted a literature review on telemedicine, exploring the issues that arise from cross-border trade globally, and specifically using the UK and India as a case study [11]. This review found that while trade in telemedicine services has the potential to benefit both the exporting and importing countries by allowing for faster service delivery and raising foreign exchange, there are concerns regarding data security, recognition of qualifications and legal liability [12]. The literature review had two main conclusions. First, very little data was found on the amount of trade in telemedicine that is currently taking place or on the issues associated with it. It is therefore important that more studies are carried out on this, both at the global and at the country level. Second, that were countries to consider this type of trade in health services from a bi-lateral perspective, they could maximise the benefits and minimise the concerns. This is because a contract would be drawn out between the two countries, where conditions can be agreed upon, such as outlining data regulations and security, litigation procedures and liability, and regulation and recognition of qualifications.

With the aim of contributing to the limited evidence base on cross-border trade of telemedicine services, the authors conducted semi-structured interviews with stakeholders in both India and the UK, to seek their opinions on the prospects for a telemedicine trade relationship between these two countries, where India would provide telemedicine services to the UK. Further, the potential benefits and barriers that may arise from this type of relationship were assessed. In doing this, the authors have undertaken a social science perspective to address a gap in the knowledge available regarding telemedicine trade, and hope to contribute to the limited data available to inform countries considering opening their health services to international trade. This paper describes the methodology used to carry out the research, followed by the results from the interviews and the discussion. The paper concludes with key messages.

A total of 19 interviews were carried out with stakeholders; of these, eight were from the UK and 11 from India (see table 1). The stakeholders that took part in the study were identified as important from the literature review carried out previously [11]. A snowball sampling technique was then used to identify the other stakeholders. The interviews were semi-structured [13] to allow for additional issues not identified in the literature review to be included in the study. As such, a qualitative instrument was designed based on the findings from the literature review (see Additional File 1 for an example). The instrument was adapted for each stakeholder as appropriate.

The interviews were carried out by one of the authors in India (RC) and another author in the UK (MMA). The interviews were mainly conducted face-to-face, although some of the Indian participants were interviewed over the phone. Answers were recorded by hand and typed up. The interviewers were in regular contact during the interview process to discuss emerging themes. The interviews were examined using content analysis [14]. Briefly, each script was reviewed and coding categories were identified. The scripts were then analysed using these coding categories. The coding framework consisted of both emergent and a priori coding categories [14]. Coding categories were designed based on the themes identified during the literature review [11]. The transcripts were then reviewed and any new coding categories that arose was incorporated. Any new themes that emerged were explored across all the interview transcripts. This process was iterated until no more new categories emerged (see table 2 for a full list of all coding categories). The coding framework was developed by MMA and reviewed by the other authors until an agreement was reached. Once the list of coding categories was compiled, the interview transcripts were analysed using these codes. The coding units were any sentences or paragraphs that fell under any of the coding categories. The analysis was conducted by MMA, although any ambiguities identified were discussed with the other authors.

A summary of all the coding categories and their frequency according to stakeholder is shown on table 2.

The views of the stakeholders on the prospects for a bi-lateral trade relationship between the UK and India are summarised in table 3. The results from the semi-structured interviews show that there are a number of issues where stakeholders in both countries agree. These include good global prospects for trade in telemedicine services, the key sectors being diagnostic (mainly tele-radiology and tele-pathology), concerns regarding quality and litigation, the main advantages being saving time and money from the UK side, and generating revenues from the Indian side, and protectionism and lack of recognition being key barriers. These are also in agreement with the findings of the literature review previously carried out by the authors [11].

On the other hand, the participants disagreed on a number of issues. For instance, most of the UK and some of the Indian stakeholders believed that there were good prospects for a bi-lateral relationship in telemedicine services between the UK and India, whereas many of the Indian stakeholders were less optimistic. One important issue where there was disagreement was on the current activities of telemedicine cross-border trade taking place between the UK and India. Whilst some of the UK interviewees and most of the Indian participants believed there was no such trade taking place, other UK stakeholders argued that major contracts had been agreed by the NHS with Indian firms. This is an important issue to resolve as if this type of trade is indeed taking place, data can be collected on its viability and impact on both countries. It would also mean that these agreements have taken place despite the barriers mentioned in this study, and how this can take place should also be examined in more detail.. Other areas where there was disagreement include the importance of tele-care, which the Indian stakeholders were not aware of, whether data safety was a real barrier and what policy measures would be needed for a bi-lateral telemedicine trade relationship between the UK and India to be agreed.

It is interesting to see that some of the stakeholders called for a bi-lateral relationship to address some of the concerns and barriers involved with telemedicine trade. This is in agreement with the results of the literature review carried out by the authors [11], which concluded that in a bi-lateral relationship between the UK and India, both countries would sign a contract which would pre-establish the data safety procedures to be followed, the qualifications needed to provide services to UK patients, protocols in the event of malpractice, as well as mechanisms to ensure the local population in India and their health system benefit from the revenues such arrangement would bring. This would not be possible under a GATS-based multi-lateral trade scenario, where all countries can trade with each other and are not able to pre-establish this sort of pre-conditions.

This research is subject to several biases. First, although a common interview tool was used, the interviews were carried out by two different researchers, one based in India and one in the UK. This could have lead to questions being asked with different emphasis and answers recorded differently. Additionally, the sample size is small, and the opinion of the stakeholders that refused to take part, or any that may have not been identified, is therefore not included.

Nonetheless, some important policy recommendations can be made from the findings of this research. The main barrier reported was data safety and EU restrictions on dealing with India. It is therefore essential for the Indian government and companies planning on providing telemedicine services to the UK to ensure they are complying with the regulations and that other restrictions on this type of trade are lifted. Additionally, India should establish national data protection legislation and the UK (or the EU) should set up a system of accreditation for telemedicine providers. Other barriers include concerns regarding quality, regulation and litigation. Here, the UK should streamline and ease the processes required to be registered with the GMC, and India should aim for accreditation and quality assurance. In terms of sectors, it appears that telemedicine will mainly succeed for diagnostic services. Additionally, the UK stakeholders identified tele-care as a key sector, which the Indian health service providers should capitalise in. Further, if both countries were to enter into a bi-lateral agreement on trade in health services, they would need to outline litigation procedures to be followed should a case of malpractice arise, ensure the revenues generated are spent on India's health system, so the local population benefits, and choose the sectors where public resistance will be minimal (i.e. those where there is no interaction with the patient, such as pathology). Finally, telemedicine should also be raised in the ongoing EU-India trade negotiations, which cover trade in services between the EU and India.