996- India- Exploration of Morbidity Profile and Clinical Quality Assessment of the eSanjeevani Odisha for Assessing the Quality and Effectiveness of Teleconsultations.

The primary objectives of this impact evaluation are as follows:

1. To understand the shift in morbidity profile of clients availing telemedicine.
2. To understand the value addition for clients accessing telemedicine.
3. To conduct a clinical quality assessment of the telemedicine experience to evaluate the
quality and effectiveness of teleconsultations.

Methodology

Study Design:

To achieve the study objectives, a mixed-methods approach will be employed, combining quantitative and qualitative data collection and analysis. The proposed study design adopts a deliberate mixed-methods approach based on several key considerations. Firstly, recognizing the multifaceted nature of the eSanjeevani telemedicine program, the study aims to gain a comprehensive understanding by integrating quantitative (clinical audit) and qualitative aspects of the providers and patient’s experience.

Qualitative with Providers-Exploratory study for morbidity profile, value addition of eSanjeevani, facilitators and barriers, and capacity building.

In this qualitative research, our primary objective is to comprehensively investigate the use of the eSanjeevani platform in the healthcare ecosystem. The sampling for qualitative research will be done using convenience sampling, allowing us to efficiently gather insights from readily accessible participants. We will conduct in-depth interviews with 20 doctors, comprising 10 general physicians, and 10 specialists from various departments. Furthermore, we will select 20 Community Health Officers (CHOs) to gather their unique perspectives on provider satisfaction, issues faced, current morbidity profile of the client, value addition of eSanjeevani, training and capacity building of health care providers and client perceptions concerning eSanjeevani. These interviews will yield qualitative insights into the profiling of clients, skill building of providers, value addition proposition, advantages, challenges, and the factors influencing the adoption and sustained use of telemedicine for routine care delivery. Our data collection process will continue until saturation is reached, ensuring that our findings are representative of diverse healthcare experiences. This qualitative analysis will complement our quantitative data, providing a well-rounded understanding of the eSanjeevani platform's impact and areas for improvement.

Qualitative with Clients-Interview on morbidity profile, health seeking behavior, impact of telemedicine and utilization of platform

This section focuses on evaluating the acceptability, satisfaction levels, value addition to telemedicine, treatment-seeking behavior, adherence and morbidity profile of the clients utilizing the eSanjeevani platform. Qualitative data will be collected through in-depth interviews with 30 clients who have sought at least one teleconsultation in the last 3 months, employing a convenience sampling method for diverse representation, and data will be collected until saturation is reached. Additionally, sufficient attention will be paid to gathered insights in both high-touch and low-touch districts.

Data collection

Provider Qualitative Interview Guide:
The qualitative questionnaire is subdivided into three sections. The first part seeks to elicit providers' experiences with telemedicine and how they feel about clients' acceptance of telemedicine services, including an exploration of the morbidity profile of clients availing telemedicine. The next section aims to comprehend providers' perceptions of the healthcare model and how they intend to make this sustainable and normal for clients. Additionally, it delves into understanding the value addition for clients accessing telemedicine. Subsequently, the final component explores their need for capacity building and training, as well as their level of confidence in using this platform.

Client Qualitative Inquiry:
The data collection will encompass three key areas: understanding the morbidity profile of clients availing telemedicine, exploring the perceived value addition for clients accessing telemedicine services, and analyzing treatment-seeking behavior along with expectations related to the quality of care. Our data collection process will continue until saturation is reached, ensuring a comprehensive understanding of clients' experiences with the eSanjeevani platform and providing valuable insights for ongoing enhancement and refinement.

To conduct a clinical quality assessment and quality assessment of the telemedicine experience to evaluate the quality and effectiveness of teleconsultations.

To assess the effectiveness of clinical quality and teleconsultations, baseline and endline assessment is suggested to measure the impact of the efforts made by the Government under eSanjeevani along with the Intelehealth strategic inputs via program intervention. Based on the suggested model district from the Government of Odisha, Intelehealth will provide the critical inputs related to the Capacity Building, training and knowledge campaign in this district.

Methodology for Clinical Quality Assessment of Consultation (Clinical Quality Tool of Intelehealth):

In this clinical quality assessment, direct observation of in-person teleconsultations will be conducted and clinically audited by a team of doctors. Data will be collected from same eight Health and Wellness Centers where MCs assessment is carried out. A clinical practitioner will observe the consultation for the individuals who have consented for the study. Specifically, two adult males, two adult females and one child from each of these HWCs will undergo observation. A total of 40 clients will be observed, covering the top 10 morbidities. The primary goal of this observation is to ensure that the diagnostic accuracy of telemedicine matches the standards set by in-person visits.
Additionally, following the baseline there will be intensive interventions jointly carried out by the Government of Odisha and Intelehealth in the same selected eight HWCs and connected sub-hubs to improve the clinical quality of consultation provided by the health workers to improve the various domains of clinical quality leading to improvement screening, early detection, better triaging and diagnosis for the following six months. Then, there will be an endline carried in the same eight HWCs for an additional 40 cases of top 10 morbidities. From each HWC, two adult males, two adult females and one child will undergo observation. Clinical audit will be carried out and compared with the baseline to register any change in clinical decision-making and continuum of care.

Data Collection Approach:

The assessment will utilize a Clinical Quality Index consisting of 47 Clinical Quality Indicators (CQIs) across 7 domains. Each consultation will be evaluated based on these indicators, with a maximum score of 100 achievable. The domains include:
1. Adherence to Standardized Clinical Processes: Evaluating the consistency of clinical procedures and protocols during teleconsultations [5 parameters].
2. Client-Centered Care Coordination: Assessing the effectiveness of care coordination, ensuring a client-focused approach [8 parameters].
3. Safe Clinical Practices: Verifying adherence to safe and hygienic clinical practices during consultations [5 parameters].
4. Client Satisfaction: Gauging client satisfaction levels through feedback and interaction quality [2 parameters].
5. Completeness in Clinical Data Collection: Ensuring thorough and accurate collection of client data for comprehensive assessments [8 parameters].
6. Quality of Consultation: Evaluating the effectiveness, accuracy, and depth of clinical consultations provided [12 parameters].
7. Program Quality: Assessing the overall quality of the telemedicine program, including administrative and technical aspects [6 parameters].

Every domain has its own standard parameters on which these domains will be scored on a scale of 0-2 (here 0 means Not at all, 1 means partially, 2 means Completely) other than the client satisfaction. Client satisfaction followed by a five-point scale ranges from 1-5 (Here 1 means the Strongly Disagree and 5 means Strongly Agree). Aggregate scores of every domain will be calculated and analyzed.
Incorporating these primary and secondary data collection methods, this study aims to provide a comprehensive and nuanced understanding of the impact of eSanjeevani telemedicine services on users' experiences and outcomes. This data-driven approach will play a pivotal role in fulfilling the objectives of the impact evaluation study, guiding future healthcare strategies, and ensuring efficient, accessible, and client-centric healthcare delivery.

Data Analysis:

A data analysis plan will be developed to perform the data analysis. Data collected for this study will be analyzed using STATA, Excel, and ATLAS.ti. These tools are instrumental in managing and analyzing the extensive dataset gathered from both the quantitative and qualitative research components. We will utilize descriptive statistics to summarize and present key characteristics of the study sample, including demographics, health issues consulted, and clinical quality of consultation.
For the qualitative data collected through in-depth interviews, we conducted a thematic analysis. This involved identifying recurring themes, patterns, and narratives within the qualitative responses to gain deeper insights into client experiences and perceptions.

1. Analysis of the Qualitative data to create a report on morbidity profile and value addition of TM
2. Visiting field to gain deeper understanding of the data collection (if required)
3. Carrying out the data analysis of the clinical quality assessment of the program
4. Preparation of the report based on the above mentioned objective

Collaborative, non-hierarchal, peer-review process, mentorship is provided, creative environment

Has a background in public health, maybe some of idea about telemedicine and regulations around it. This is not mandatory but a bit of idea about Indian primary health care should be good. The applicant should have a sound qualitative skills for analysis and some knowledge of clinical quality assessment with be beneficial.

Name: Neha Verma, Center for Global Health, suchandrima@intelehealth.org

I would describe my communication and mentorship styles as... 

Consulting Style: where there is a partnership and a lot more dialogue on ideas between the mentor and mentee, which reflects a strong sense of collaboration and consensus.

A complementary student would have a working style and mentorship expectations that are..

Understanding of the task at hand, openness to ask questions and clear doubts, flexibility, timeliness, having a problem-solving mentality, being a team-player

Housing per month around $250-300 USD, Local Transportation $120-150 USD, Field Visit (flight and stay)- flight $180-200 USD (return trip) accommodation for 5 nights- $300 USD, Food Cost- $350-400 USD per month. Total Around- $1200-1350 USD per month