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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Awareness and Skills of Modern Telemedicine Practice among Doctors in Kerala- A Cross-sectional Study
Correspondence Address :
Dr. Anil Bindu Sukumaran,
Professor, Department of Community Medicine, Sree Gokulam Medical College
and Research Foundation, Trivandrum, Thiruvananthapuram-695607, Kerala, India.
E-mail: dranilbindu@gmail.com
Introduction: In this modern era of technology, Information and Communication Technology (ICT) has made a very big revolution. Telemedicine is an emerging concept in healthcare services in Kerala, its implementation has not been satisfactory and successful. It is cost effective and provides easy access to healthcare services for people anywhere and especially during pandemic situations like this. A study is required in the domain of awareness and skill of doctors to facilitate its adoption and implementation. There was an urgent need to devise means for patients to consult doctors during Coronavirus Disease 2019 (COVID-19) pandemic.
Aim: To assess the level of awareness and skill among doctors practicing modern medicine during COVID-19 pandemic.
Materials and Methods: A cross-sectional study was conducted among 535 modern medicine doctors of Kerala from June 2020 to May 2021, using a structured self-administered questionnaire designed for the study. The total scores of awareness and skill calculated and categorised as poor, moderate, and good. Data was analysed by Statistical Package for the Social Sciences (SPSS) version 20.0 software by IBM. The Chi-square test/ Fisher’s-Exact test was used as test of significance.
Results: Mean age of the study participants was 40.44±10.66 years, with majority 326 (60.94%) being females. Among the 535 doctors participated, 68.22% had moderate skill, 27.85% had good skill and only 3.92% had poor skill. Years of experience of doctors ranged from 1 to 48 years, with mean of 13.47±10.46 years. In majority, 431 (80.56%) of the participants, had moderate awareness and 15.89% had good awareness, about the telemedicine practice. Poor awareness was present in 19 (3.55%) doctors. About 46.54% believed that specific software training is required for practicing telemedicine.
Conclusion: Even though, awareness and skill of doctors practicing modern medicine are favourable, more webinars or workshops are needed to improve their knowledge. Telemedicine is an emerging technology in the health sector in India, so it requires study to know health professional’s awareness and skills towards telemedicine.
Coronavirus disease 2019, e-health, Healthcare workers, Teleconsultation
The Information and Communication Technology (ICT) enabled medical services are developing fast in today’s world, especially after the COVID-19 pandemic. They are cost effective and provide access to healthcare services for people in remote areas (1). There are many possible reasons why implementation of telemedicine is a challenging (2). In a country like India, with large geographical distances and limited resources, providing healthcare can be challenging (3). About 80% of doctors in India, are located in urban area (4). Patients living in rural areas can save expenses on long distance travel for obtaining consultation. In some instances, where only a routine follow-up check is required patients can consult doctors using telemedicine, without much inconvenience or impact to the family or caregivers (5). Telemedicine can decrease burden on hospitals by decreasing re-admission rates. By using telemedicine services patients can communicate with doctors from the comfort of their own home and take care of themselves in certain instances following the doctor’s advice (6).
Telemedicine can give safety to patients, healthcare workers and doctors in situations where there is a risk of a contagious disease. The use of telemedicine services during this Coronavirus Disease 2019 (COVID-19) pandemic is a prime example (5). Providing equal access to quality care and to digital health is essential for the overall development and improvement of health systems; hence, mainstreaming telemedicine in health systems can minimise inequity and barriers to access. Lack of clear-cut guidelines is one of the reasons why some doctors are reluctant to practice telemedicine. Most doctors in India are not aware of the guidelines for the practice of telemedicine, through video, phone, and internet-based platforms (web/chats/app). Gaps in legislation and the uncertainty of rules can pose risks for doctors, healthcare workers, and patients when using telemedicine services (5).
During the COVID-19 pandemic, to promote contact-less consultation, Ministry of Health and Family Welfare (MHFW), Government of India published guidelines for practicing telemedicine on 25th March 2020 (5). The success of any new technology depends on many factors including the knowledge and understanding of the concept, skills acquired, attitude and the working environment by the concerned professionals (2). Technology anxiety is one of the reasons doctors are reluctant to adopt telemedicine (2). Telemedicine is an emerging technology in the health sector in India, so it requires study to know health professional’s awareness and skills towards telemedicine. Travancore - Cochin Medical Council (TCMC) on 31st March 2020 in their circular (Order No: A1: 6898/2020/TCMC Dated: 31.03.2020) mentioned use of telemedicine in COVID-19 pandemics as “temporary measures” (7).
The TCMC also put forward a lot of conditions on how doctors should consult patient using telemedicine (7). The COVID-19 pandemic has brought forth a renewed focus on the role of telemedicine services. Telemedicine seems to be an appealing option for patients and doctors for medical consultations in this pandemic time, as there are severe movement restrictions throughout the state in an effort to control COVID-19. Even physicians who are in quarantine, can make use of telemedicine services for consulting patients. Follow-up check-ups for patients will also become easier (5). The new telemedicine guidelines by MHFW provides norms and protocols relating to physician-patient relationship, issues of liability and negligence, management and treatment; informed consent, referrals for emergency services; medical records; privacy and security of the patient records and exchange of information; prescribing; and reimbursement; health education and counselling. A study on the awareness of these new guidelines and the skills on telemedicine among doctors are urgently required to achieve the full utilisation of the advancements in technology for healthcare delivery.
Hence, present study was conducted to assess the awareness level of doctors in Kerala for practicing telemedicine, to assess the skill level of doctors in Kerala for using ICT in digital health delivery and to study the association between awareness and skills necessary for practicing telemedicine with various socio-demographic variables.
A cross-sectional, questionnaire-based study was conducted in Kerala among doctors to assess the awareness and skill of telemedicine practice. Study period was from June 2020 to May 2021. Before conducting the study, Institutional Ethics Committee approval was secured from Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala (SGMCIEC No 37/523/10/2020).
Inclusion criteria: All doctors practicing modern medicine in Kerala were included in the study.
Exclusion criteria: The doctors who were not willing and did not give consent were excluded from the study.
Sample size calculation: The sample of the present study was calculated by using the formula:
Where, α=5%, Z(1-α/2)=1.96, p=41% (2).
Proportion of doctors having knowledge about telemedicine, d=20% of p, with 10% non response rate. The calculated sample size was 152.
Non probability chain referral sampling technique was performed to select participants from different districts of Kerala. All 535 doctors who participated by filling the questionnaire were included in the study.
Questionnaire
Data was collected by using a self-designed, structured questionnaire designed for the study by the investigators. The questionnaire was prepared after reviewing previous studies (2),(3) pertaining to telemedicine and consultation with professionals with expertise in the field of telemedicine. Most of the questions for the domain of awareness section were constructed from the guidelines published by the MHFW, Government of India (5). The self-administered questionnaire consisted of three main parts.
• Part one includes socio-personal information of the participants- 8 items and three questions on the training requirement, attendance in webinars/seminars about telemedicine, and their important concern about telemedicine.
• Part two is related to skill of ICT-5 items.
• Part three investigates the awareness level of the participants- 36 items. The content validity of the questionnaire was done by a panel of experts.
A pilot study was done among 30 doctors to assess the reliability of the tool, which was assessed using Cronbach’s alpha and was obtained as 0.788. The questionnaire was made into a Google form and was disseminated through Messenger (Facebook), WhatsApp and e-mail to doctors from all districts and they were requested to send to further subjects from among their acquaintances. Consent was appended to the questionnaire. All doctors who agreed to participate were directed to fill the questionnaire. A total of 535 doctors participated in the study.
Responses: The responses in the skill part were scored as:
• never-0,
• rarely-1,
• sometimes-2,
• often-3 and
• most often-4
with minimum score of 0 and maximum score of 20.
Awareness of respondents was assessed by questions with answers “yes”, “no” or “don’t know”. After collection was done, the data were checked, cleaned, edited and analysed. In the domain of awareness, correct answers were given a score of one and incorrect answers and “don’t know” were given the score of 0, with minimum score of 0 and maximum of 36. The raw total scores were calculated for skill and awareness. The total scores were converted into percentage and were classified as:
• poor: <25%,
• moderate: 25%-75% and
• good: >75% [Annexure-1].
Statistical Analysis
Qualitative variables were expressed in frequency and percentage. Mean and SD calculated for quantitative variables like age. Analysis of data was done with Statistical Package for the Social Sciences (SPSS) version 20.0 software by IBM. Chi-square test was done to test the association between the socio-personal variables and skill and awareness. If 20% of the cells have expected frequency less than 5, Fisher’s-Exact test was applied. Spearman’s correlation coefficient was calculated between scores of skill and awareness. The p-value <0.05 was considered as significant.
Mean age of the study participants was 40.44±10.66 years. Majority 326 (60.94%) were females. Characteristics of the sample were described in (Table/Fig 1). Years of experience of doctors ranged from 1 to 48 years with mean of 13.47±10.46 years. In the present study, 535 doctors participated, among this 389 (72.71%) were working in a teaching hospital. Out of the 535, only 183 (34.20%) reported to have facility for telemedicine in their hospital. A total of 365 (68.22%) had moderate skill and only 21 (3.92%) had poor skill and the rest, 149 (27.8%) had good skill. Level of awareness among doctors about telemedicine guideline is given in (Table/Fig 2). In majority, 431 (80.56%) of the participants, had moderate awareness about the telemedicine practice. Poor awareness was present in 19 (3.55%) doctors.
A higher proportion of females (72.39%) had moderate skill compared to 61.72% in males. Also, skill for telemedicine was found to be significantly different in doctors with different years of experience (0.025). A higher percentage of doctors with 5-10 years of experience had poor skills compared to others. None of the variables had a statistically significant association with awareness. (Table/Fig 3),(Table/Fig 4),(Table/Fig 6) shows the response to awareness questions regarding telemedicine practice guidelines.
A toal of 374 (69.99%) participants, knew that the patient consulting with the registered medical practitioner for the first time is called first consult. All the participants knew that the medical record from each consultation need not be sent to medical council. Only 198 (37.01%), knew that the patient who has consulted with the practitioner earlier, but more than six months have lapsed since the previous consultation is included as first consult. Only 246 (45.98%) knew that the patient has consulted with the practitioner earlier, but for a different health condition is included in first consult. A total of 401 (74.95%) knew that “Follow-up consultation” can be done in situations of a chronic disease or a treatment (e.g., renewal or change in medications) when a face-to-face consultation is not necessary.
A 75.70% knows that telemedicine should be avoided for emergency care to the possible extent especially when in-person care is available.
There was no statistically significant difference in awareness about telemedicine according to variables like age group (p-value=0.512), gender (p-value=0.365), years of experience (p-value=0.315), their postgraduate qualification (p-value=0.144), type of hospital working (p-value=0.887). In the ongoing COVID-19, scenario, many webinars and seminars were conducted all around the world regarding telemedicine. Question regarding how many webinars and seminars have the respondents participated within the last six months were asked. The following were the results: “0”-325 (60.75%), “1”-74 (13.83%), “2”-65 (12.14%), “3”-19 (3.55%) and “more than 3”-52 (9.71%). Total 249 (46.54%) believed that specific software training is required for practicing telemedicine. About 262 (48.97%) were concerned about being sued, if something goes wrong with the patient in telemedicine practice. To assess, whether there is any correlation between scores of awareness and skill, Spearman’s Rank correlation was done, and found to have a significant weak positive correlation (Spearman’s coefficient=0.20, p-value <0.0001).
In the present study, 235 (43.93%) of the participants had less than 10 years of experience. In the domain of skill, there were 21 (3.92%) of the participants with poor skills, while 149 (27.85%) with good skill, while 365 (68.22%) had moderate skill. Skill necessary for using ICT is very much essential for providing telemedicine services. The skill is higher when compared with the study done by Zayapragassarazan Z and Kumar S, in which the majority of participants that is 56% were having poor skill (2). The current pandemic situation where there is increased need for telemedicine, must have contributed to the increase in the skill level. In the domain of awareness, 3.55% (19) had poor awareness.
The questions regarding the domain of awareness were constructed from the guidelines published by MHFW (5). According to the current study in the domain of awareness, 431(80.56%) of the participants had moderate awareness about the telemedicine technology. This result is in par with study by Ashfaq A et al., in which the awareness among doctors in terms of remote diagnosis and treatment of patient by means of telecommunication technology was 80.4% (8). In the current study, only 85 (15.89%) had good awareness. Lack of awareness regarding telemedicine is one of the reasons why doctors are reluctant to provide telemedicine services (2). The present study, also warrants the need for training for the practice of telemedicine (8),(9),(10),(11).
No significant relationships were seen between socio-personal variables and awareness. In the present study, only 183 (34.20%) of participants said they have availability of telemedicine facility in the current working hospital, so there is a need for increasing these facilities in hospitals. In the study by Meher SK et al., they found that doctors were more interested in using telemedicine if it was available at their desktop (3). So provision of more infrastructure and facilities can improve the knowledge and usage of telemedicine. Majority of participants in each age group had moderate level of awareness and moderate skill with regard to telemedicine. This finding was at par with the study by Meher SK et al., in which doctors were asked about whether telemedicine was essential, majority of study participants felt, that it was important and their opinions were similar in all age groups (3).
According to Dash S et al., there is a skewed healthcare force distribution in India, where in 60% of the force caters to 30% of the population that lives in urban India and the urban to rural doctors ratio is 3.8:1 (12). This difference in healthcare can be solved to an extent by telemedicine. Remote access to Registered Medical Practitioners (RMPs), or those who have a MBBS degree, using telemedicine can reduce widespread quackery (12), which is still
a major problem in rural areas where heath care needs are not met adequately. There are many uses of telemedicine. Many such benefits are explained in an article by Agarwal N et al., such as ongoing management of chronic diseases such as bronchial asthma, hypertension, and diabetes mellitus, particularly during a time when social distancing is encouraged (13). Telemedicine can also be used for providing psychological support to patients and their family members without getting exposed to the infection. During COVID-19 pandemic, telemedicine can also help in reducing the burden on the tertiary hospitals by providing diagnosis and treatment to patients in their own geographical location and reducing chances of patient’s exposure due to hospital visits. Telemedicine can also help in providing training to the care providers of sick and disabled children and elderly (13). There is a high demand for expanding the telemedicine services during the COVID-19 pandemic and the recent expansion of information and communication technologies around the country has helped a lot in managing the healthcare delivery during pandemic period. Telemedicine services can be a solution to the challenge of inadequate access to healthcare services in the developing nations, especially in rural areas and in situations like the current pandemic.
Limitation(s)
The present study was conducted during COVID-19 pandemic period in Kerala, the questionnaires were sent, via online platforms and all the responses obtained were included in the study. The study had a non probability chain referral sampling method, but authors had included higher number of doctors than calculated sample size. Only those who filled the questionnaire sent, via online platforms were included. The participation of doctors above 60 years was comparatively lesser. This could be a limitation and future research studies are required to generalise results to the whole healthcare professionals.
Majority of doctors (80.56%) had moderate awareness in telemedicine guidelines in the present study and more than two third (68.22%) had moderate skills. Also from the present study, it is found that 46.54% believed that specific software training is required for practicing telemedicine and 48.97% were concerned about being sued, if something goes wrong with the patient in telemedicine practice. By providing adequate training, addressing the concerns of doctors and with implementation of adequate infrastructure facilities, telemedicine can be used as a solution in healthcare delivery system.
Additional Information
Data collection for the study started during the lockdown months of COVID-19 pandemics in the year 2020. The guidelines for the practice of telemedicine were published in March of 2020 by the MHFW. These guidelines were used for assessment in the domain of awareness. Since the data collection for the study was initiated three months after its release, many doctors were unaware about many aspects in the guidelines.
DOI: 10.7860/JCDR/2022/51754.16209
Date of Submission: Aug 24, 2021
Date of Peer Review: Nov 26, 2021
Date of Acceptance: Jan 06, 2022
Date of Publishing: Apr 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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