Development and impact of a telemedicine platform with a task-shifting digital assistant to support frontline health workers and its dissemination as a Digital Public Good

Telemedicine improves access for women and helps reduce the geographic, financial, and social barriers that women face in receiving the care they need. In this dissertation, I describe the design and development of an open-source telemedicine technology platform, Intelehealth, through a user-centered bioengineering innovation and design process. I describe the desiderata of a provider-to-provider telemedicine approach connecting rural frontline health workers with remote doctors to facilitate teleconsultations for patients. I describe the development of a digital assistant, called Ayu, to enable this health worker to doctor teleconsultation and task shift the process of collecting a comprehensive medical history and physical examination. Through an evaluation of the information retrieval ability of this digital assistant I show that a nurse using Ayu can capture 65% of patient history information and 42% of physical exam information that a doctor would collect. This information was deemed sufficient to arrive at the correct diagnosis in 68-74% of patient cases and a correct triage decision in 88% of cases. I demonstrate that health workers can successfully use the digital assistant and the telemedicine platform and that they have a high degree of acceptability towards its use. One of the key concerns in telemedicine is whether telemedicine-based care is comparable to in-person care for patients and whether it should be used in settings where in-person care delivery is not possible. I conducted a randomized crossover trial comparing telemedicine with face-to-face care and observed a 74% diagnostic concordance and an 80% concordance in the treatment plan between the two. Patients reported a 98% decrease in distance traveled and a 99% decrease in average spend. We also found that these benefits were higher for women who spend 1.5 times more than men to get health care services. Thus, telemedicine can provide comparable outcomes to in-person care at lower cost and greater convenience for patients, especially women. Finally, I present the Telemedicine Program Design Canvas - a framework to aid in the design of sustainable telemedicine programs and their implementation and present a telemedicine project case study through the eyes of a female community health worker in rural India