June 13, 2024
Health

Barriers to implementation of digital transformation in the Indian health sector: a systematic review


Study selection

A total of 1129 articles were returned in search of the electronic databases. Of these, 250 were from PsycINFO, 182 were from PubMed, 331 were from Science Direct, 217 were from Web of Science, and 149 were from Google Scholar. The PRISMA flow diagram depicts the complete search process for this systematic review (Fig. 1). After deduplication, the title and abstracts of 867 records were screened according to the inclusion and exclusion criteria. Subsequently, title and abstract screening resulted in the removal of 772 studies. Nine of the 95 records searched for retrieval could not be obtained because the full text was inaccessible. Hence, 86 reports were assessed for selection, and 60 studies were removed because they did not meet the eligibility criteria (no focus on the barriers to implementation of digital transformation in the health sector (n = 27), other types of studies, such as conference proceedings or review papers (n = 18), and no focus on health sector in India (n = 15)). Thus, the final synthesis included 26 studies emphasizing the barriers to implementing various digital technologies in the health sector.

Fig. 1
figure 1

PRISMA Flow Chart for this systematic review.

Study characteristics

The final sample for the present review included 26 studies conducted across India from 2017 to 2022 (Table 1). Two studies in 2022 (Prakash and Das, 2022; Sampathkumar et al., 2022), 16 were published in 2021 (Bairapareddy et al., 2021; Banerjee et al., 2021; D’Souza et al., 2021; Garg et al., 2021; Ghoshal et al., 2021; Kumar et al., 2021; Mathew et al., 2021; Menon et al., 2021; Nair et al., 2021; Naveen et al., 2021; Raheja et al., 2021; Sandhu et al., 2021; Satgunam et al., 2021; Shambu et al., 2021; Faujdar et al., 2021; Ullas et al., 2021), four in 2020 (Biswas et al., 2020; Pandey et al., 2020; Puliyath et al., 2020; Thenral and Annamalai, 2021), two in 2018 (Bhatt et al., 2018; Sinha Deb et al., 2018), and two in 2017 (Mohan et al., 2017; Powell et al., 2017). Included studies consisted of quantitative/cross-sectional studies (n = 10) (Bairapareddy et al., 2021; Sinha Deb et al., 2018; Ghoshal et al., 2021; Kumar et al., 2021; Mohan et al., 2017; Nair et al., 2021; Pandey et al., 2020; Powell et al., 2017; Raheja et al., 2021; Ullas et al., 2021), quantitative/cohort studies (n = 8) (Biswas et al., 2020; D’Souza et al., 2021; Garg et al., 2021; Naveen et al., 2021; Puliyath et al., 2020; Satgunam et al., 2021; Sandhu et al., 2021; Shambu et al., 2021), qualitative studies (n = 5) (Banerjee et al., 2021; Bhatt et al., 2018; Menon et al., 2021; Faujdar et al., 2021; Thenral and Annamalai, 2021), and mixed-methods studies (n = 3) (Mathew et al., 2021; Prakash and Das, 2022; Sampathkumar et al., 2022). Participants included the general population, delivered women, healthcare professionals, patients and caregivers, experts from academia, smartphone users, and technology experts. The current study findings offer a comprehensive understanding of barriers to the implementation of digital transformation in the health sector of India.

Table 1 Summary of study characteristics.

Risk of bias in studies

The risk of bias in quantitative cross-sectional studies (n = 10) and qualitative studies (n = 5) was low, while the risk of bias for cohort studies was generally low to moderate (see Supplementary information). The detailed results of the quality assessment of mixed-methods studies (n = 3) can be found in the supplementary table (see Supplementary Table 4). Also, no studies were excluded based on the level of quality assessment.

Barriers to the implementation of digital transformation in the health sector

Several previous studies have identified potential barriers to implementing digital transformation in India. Identifying the country’s barriers to digital health transformation is necessary to fulfill the need for successful transformation to digital health. As a result, the findings were synthesized into the following themes: lack of network coverage and information technology (IT) infrastructure, high installation and operating cost, lack of medical records and experts, lack of physical examination, data accuracy and misdiagnosis, data privacy and confidentiality, language and communication barriers, user barriers, and ethical, legal, and accountability concerns.

Lack of network coverage and IT infrastructure

Weak network coverage (Banerjee et al., 2021; Desingh and Baskaran, 2021; Menon et al., 2021; Puliyath et al., 2020; Raheja et al., 2021; Sampathkumar et al., 2022; Sandhu et al., 2021; Ullas et al., 2021), and lack of IT infrastructure (Desingh and Baskaran, 2021) were described as key barriers to digital transformation in the health sector. Relatedly, a lack of basic technical infrastructures, such as smartphones, is a potential barrier to implementing digital health in India (Kumar et al., 2021; Puliyath et al., 2020; Sandhu et al., 2021). In this context, patients had to use their family members’ smartphones to attend teleconsultations (Garg et al., 2021).

High installation and operating costs

Financial concern was identified as a barrier to implementing and adopting digital transformation in the health sector (Bairapareddy et al., 2021; Bhatt et al., 2018). A study by Powell et al., (2017) revealed that hospitals that had EHR systems perceived several barriers to implementation, including the capital required to buy and implement an EHR, concerns about the ongoing cost of maintaining an EHR system, and the ambiguity on the return on investment (ROI) from an EHR (Powell et al., 2017). Relatedly, the lack of repair facilities at installation sites also acts as a major barrier (Menon et al., 2021). On the other hand, the qualitative interviews in a study revealed the high cost of smart devices as a barrier to using mobile-based apps for health care (Sinha Deb et al., 2018).

Lack of medical records and experts

Digital health is a novel platform in India that has been developing recently. Rapid implementation of digital transformation can lead to difficulty in the availability of EHRs (Menon et al., 2021; Puliyath et al., 2020) and experts in the country (Bairapareddy et al., 2021). A study reported that the main difficulties for clinicians in the use of teleconsultation include a lack of expertise in operating technology (Sandhu et al., 2021). Similarly, in another study, 53% of healthcare professionals identified a lack of expertise to be the chief barrier to the effective implementation of smartphone-based telerehabilitation programs for chronic obstructive pulmonary disease patients (Bairapareddy et al., 2021).

Lack of physical examination

One of the key barriers to the acceptance of digital health is the absence of physical examination, a necessary prerequisite for an effective doctor-patient relationship (Kumar et al., 2021; Mathew et al., 2021; Puliyath et al., 2020; Raheja et al., 2021; Ullas et al., 2021). Besides, patients expressed dissatisfaction with the rapport they otherwise established following an in-person consultation (Garg et al., 2021). Similarly, in a study by D’Souza et al. (2021), elderly patients prefer face‑to‑face consultations. This flaw of digital transformation might be remedied by referring any patient whose symptoms or reports necessitate a physical examination to a nearby healthcare center (Kumar et al., 2021).

Data accuracy and misdiagnosis

Another possible barrier to the successful implementation of digital health practice is the accuracy of data transmission. In a study by Raheja et al. (2021), six percent of participants faced difficulties during teleconsultations because of misinterpretation of prescriptions by patients or pharmacists. Similarly, it was difficult for the patients to comprehend the medical advice and medicines attributed to limited connectivity (Banerjee et al., 2021), unfamiliar technology (Sinha Deb et al., 2018; Ghoshal et al., 2021; Sandhu et al., 2021; Ullas et al., 2021), illiteracy (D’Souza et al., 2021; Kumar et al., 2021; Naveen et al., 2021), and lack of clarity of advice given by clinicians (Sandhu et al., 2021).

Data privacy and confidentiality

Compared with in-person consultations, digital health is more vulnerable to security and privacy risks. Data protection is threatened in a digital health system due to the leakage of confidential information and data sharing with third-party apps (Biswas et al., 2020; Menon et al., 2021). Concerns about data security and confidentiality pose significant challenges to the adoption of digital health transformation since the healthcare industry is one of the most critical sectors owing to the very sensitive patient data that has to be secured (Desingh and Baskaran, 2021; Powell et al., 2017; Prakash and Das, 2022; Puliyath et al., 2020; Thenral and Annamalai, 2021; Ullas et al., 2021).

Language and communication barriers

Effective patient-provider communication is essential and is often connected to the success of digital health. This is indeed a challenge during the implementation of digital transformation in the health sector (Menon et al., 2021; Mathew et al., 2021; Naveen et al., 2021; Raheja et al., 2021). Language is one of the critical issues of digital transformation (Sinha Deb et al., 2018; Mohan et al., 2017; Naveen et al., 2021; Sandhu et al., 2021). In their study, Satgunam et al. (2021) reported that although most respondents found downloading and using teleconsultation apps comfortable, patients who could not follow the English language may face some difficulty dealing with the applications. Further, Pandey et al. (2020) reported that poor means of communication on the patient’s side could be a possible reason for reduced teleconsultations. Relatedly, another study by Kumar et al. (2021) showed that the unavailability of proper surroundings for communication is a major barrier to integrating teleconsultations into practice. Notably, two studies reported that video-based teleconsultations are patients’ most preferred mode of communication (Raheja et al., 2021; Nair et al., 2021).

Usage barriers

Several user challenges in digital health serve as barriers to adopting digital transformation in the healthcare industry. Findings highlight various barriers to the use of teleconsultations, such as difficulty in getting an appointment with a routine doctor or obtaining medicine on time (Ullas et al., 2021), long-distance travel for lab tests and reports uploading, at least two in-person consultations before transiting to digital mode (Shambu et al., 2021), dependence on computers and digital technicians (Faujdar et al., 2021), lack of repair facilities at installation sites (Menon et al., 2021), and challenges in availability of drugs (Kumar et al., 2021).

Ethical, legal, and accountability concerns

A common reason for not using digital consultations was the concern for possible legal implications. While implementing teleconsultations, there is a risk of misdiagnosis, which might have severe medicolegal repercussions (Pandey et al., 2020). Relatedly, in a study by Thenral and Annamalai (2021), the problems related to ethical, legal, and accountability implications were cited as challenges to digital consultations by almost all respondents. Additionally, another study reported that the increased transparency in implementing the digital health system made healthcare professionals feel insecure because it increased their work stress and they had to be more careful with data entry (Faujdar et al., 2021).



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