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Tele-evidence: A videoconferencing tool as a viable alternative to physical appearance of doctors for the judicial summons S Bari, P Arora, AK Gupta, M Singh, AK AggarwalDepartment of Hospital Administration, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/jpgm.JPGM_243_17
Keywords: Carbon footprints, physician satisfaction, resources, summons, videoconferencing
Patient care is the primary role of any clinical specialist. However, a doctor is also expected to assist the judiciary in deliverance of justice by way of expert opinion on the legal aspects of treatment given by him or by someone else. For this purpose doctors are summoned to the court of law for giving testimony as per the provisions of Evidence Act[1] in India. It is mandatory for the doctors to honor the court's summons and appear on the scheduled date and time. Doctors, usually have to take duty leave for the day to appear in the courts. Even though it is an important aspect of roles and responsibilities of a physician in particular and health sector in general, yet it has an undesirable effect: absence of physician from hospitals for varying periods affects patient care. The problem is accentuated if a substitute is not available during the absence, often the case in Primary Health Centers and Community Health Centers, leading to dissatisfaction among all the stakeholders and possibly adverse outcomes. Muralidharan et al.,[2] in a study to understand the factors for medical worker absence, have shown that doctors reported official duties as a reason for absence from work in 22% of cases in India. Shortage of doctors further compounds the problem. It has been reported that there is 83% shortage of specialist medical professionals in community health centers. Public health centers across India's rural area are short of 3000 doctors.[3],[4],[5] Anand and Bärnighausen[6] have identified doctor density as an important factor in accounting for maternal mortality, infant mortality, and under five mortality rate. It can be safely deduced that absence of doctors will have adverse impact on the health of the community. Additionally, resources spent can put a severe drain on the exchequer. The resources consumed pertain to the manpower in terms of man-hours, travel expenditure, vehicular maintenance, and as a by-product, carbon footprints. For a healthcare provider, the travel involved and personal expenditure incurred leads to dissatisfaction. Many times hearing is cancelled or postponed and the entire effort goes waste and then doctors will be required to appear again at some future date leading to frustrations and agony (unpublished observations). “Tele-evidence” or giving evidence through videoconferencing provides an alternative to the physical appearance of healthcare worker in the courts. Tele-evidence can also be considered a form of telemedicine, because it is an application of technology to the healthcare process whereby service is provided remotely by means of audio–visual technology.[7] Studies have shown that telemedicine and its applications can yield savings in terms of cost as well as carbon footprints.[8],[9] Ours is a tertiary care institute in North India and is the pioneer institute in initiating the tele-evidence facility. It was facilitated due to the availability of functioning telemedicine facility at the institute, but more importantly due to the willingness of the judiciary to accept testimony by videoconferencing. Intuitively, tele-evidence seems to be very convenient and cost-effective. However, there is no data available on this, and there is no published study from India showing satisfaction of doctors with tele-evidence as it was not implemented anywhere in the country. As our institute was transitioning to tele-evidence, and had used the facility for about 7 months, it was envisaged to study the utilization, gains, and satisfaction of doctors with this facility compared to their earlier experiences. Thus, a study was done from October to December 2014, to answer the following questions:
Study area and setting This was a hospital-based study done in a tertiary care medical institute. Study population The study population comprised faculty and resident doctors who were summoned to appear in courts as professional or expert witnesses irrespective of mode of appearance. Time of introduction of intervention (Tele-evidence) March 2014. Study design The study was carried out in two stages:
To understand annual load of summons in the institute, data of complete one year (Jan to Dec 2014) were collected from the records available in the MRD, which is the nodal department for receiving summons. Institute has central transport department. Vehicles available are multipurpose and not exclusive for court duty. However, requisition officer mentions the purpose of journey in the requisition form and the same is also mentioned in the vehicle log book. To retrieve data from vehicle log books for travel time and fuel consumption, there were 9 months time available after introduction of tele-evidence. Tele-evidence was started in March 2014 and data collection time was fixed from October to December 2014. We collected data of similar 9 months prior to the intervention (April to December 2013). To gather data from doctors attending summons through physical mode or tele-evidence, about 2 months time was available from mid October to December 2014. Semi-structured questionnaire was administered to doctors to document their experience with the current mode of testimony as well as any past experience of the alternate mode of testimony. Person on duty in the telemedicine cum tele-evidence center was briefed about the study. The doctors' feedback forms were kept with him. Whenever any doctor used to come for tele-evidence [Figure 1], he used to brief the doctor about the study, get the consent form and questionnaire filled from the doctor. First author (S.B.) demonstrated the process for initial five forms, and then visited the telemedicine center every second day to collect the forms and to supervise the tele-evidence staff. For physical mode of evidence, doctors have to submit vehicle requisition form to the transport department. Latter used to inform the first author about the requisitioning doctor. Then the author used to establish telephonic contact with the doctor and his/her head of department if required, and brief them about the study. If required, personal visits were also made. First author used to deliver the doctors feedback form through the transport department and used to collect the forms through the same route. It was not cohort study. One doctor's feedback form was filled once.
Collection of data The data collection from the records of MRD and transport department using structured proforma was done as mentioned above. A questionnaire to take feedback from doctors who gave testimony by either mode was developed. Because this type of study was being carried out for the first time and no prevalidated questionnaire was available, the questionnaire was designed after discussion with the authors and select users and face validity was ensured while designing the tool. The satisfaction of doctors was recorded on a Likert scale of 0–10 with “Zero” being least satisfied or not satisfied and 10 being the maximally satisfied. Various authors have used Likert scales using 2-point, 4-point, 6-point, 7-point, and 10-point scales including 0–10 scale. We chose to use 0–10 scale as it gives maximum width of choice to express satisfaction. The variables included were Time consumed in attending courts in response to summons, Physical and Mental strain undergone during the process, Personal expenditure incurred in attending courts, Professional duty loss in terms of patient care at the hospital, Communication with the Hon'ble Judges in terms of effectiveness and clarity to present their expert views before the court and the overall experience in the whole process. The satisfaction scores for the above-mentioned variables with respect to both modes: physical appearance and tele-evidence, were supposed to be filled by all the participating doctors. For example, if a doctor appeared physically, his current mode of evidence was physical evidence. However, if he had attended some evidence through tele-evidence in the past, then he was asked to record his past experience of tele-evidence and vice-versa. Simultaneously, reasons for not attending to the court summons as well as difficulties faced while attending court summons physically were also sought to understand the possible advantage tele-evidence facility may have other than cost (intuitive), if any. Quality assurance This research work was a dissertation work of first author. Protocols were approved by Institute Thesis Committee. Work was done under supervision of co-guides. Weekly review of work was done. Filled data collection forms were cross checked. All data were cross checked using data cleaning techniques. Data analysis
From these data, total expense incurred during physical appearance has been calculated and described to understand the magnitude of possible cost saving with tele-evidence. The data were analyzed comparing the preintervention period (April to December 2013) with the postintervention period (April to December 2014). In summary, it was pre–post type of analysis to see the impact of intervention on total kilometers traveled, fuel consumed, and number of hours spent for testimony. It was descriptive analysis for total summons received and accepted, and was comparison of mean satisfaction scores with both modes of testimony. For statistical interpretations, 95% confidence intervals were calculated for various mean satisfaction scores. Statistical analysis The statistical analysis of the satisfaction level scores has been carried out using Statistical Package for the Social Sciences. All the variables were estimated using measure of central location (mean) and measure of dispersion (95% confidence interval).
A total of 1883 summons were accepted during the period from January 2014 to December 2014. On an average, around 157 summons were accepted per month. The majority of summons (61%) were for the doctors from the specialty of Orthopedics, Neurosurgery, and Forensic Medicine. About 9% summons belonged to the MRD, which were for the clerical staff for production of medical documents only and no doctor was expected to accompany for the testimony. Rest of the departments constituted remaining 30% of the total summons [Figure 2].
Vehicle log book analysis There was 43.4% drop in average mileage per month, 49.5% drop in fuel consumption per month, and 28.4% drop in hours spent for court duties per month after the intervention of tele-evidence in March 2014 [Table 1].
Survey results During the study period, 130 doctors participated in the study, out of which 83 attended the court summons through tele-evidence and 47 physically attended the courts. 29% of the participants were from the Department of Neurosurgery, while 19% and 12% participants were from the Department of Orthopedics and Plastic Surgery, respectively. The satisfaction score of doctors in both the modes is given in [Table 2].
The mean satisfaction score is significantly higher in tele-evidence mode as compared to physical appearance in courts, with respect to all the satisfaction parameters assessed as seen by nonoverlapping 95% confidence intervals. As mentioned, information regarding the reasons for not being able to respond to court summons were also sought. The most common reasons for not honoring summons are as shown in [Figure 3].
Doctors also reported varying amount of out-of-pocket expenditure for physically attending the court summons; 53% reported spending up to Rupees 1000 (approximately $20) and 8% spent more while physically appearing in the courts. The most common difficulties reported while physically attending court were on account of time spent away from hospital, cancellation/postponement of proceedings, nonavailability of presiding judge/advocate, and nonprocessing of reimbursement of expenditure incurred.
Telemedicine and its applications have long been a matter of discussion and its horizons are expanding with the improvement of supportive technology.[10],[11] Wallace et al.[12] referred to the possibility of sharing medical records while discussing future of telemedicine in NHS. Testifying in court through videoconference, i.e., tele-evidence is an application of telemedicine. Courts in India have accepted testimony through videoconferencing as a legitimate way of giving evidence.[13],[14] Our hospital is the first in the country to institutionalize the mechanism of tele-evidence with courts in two states under the guidance of Hon'ble High Court. The study done to understand and compare the experiences of physical appearance and tele-evidence for court summons has thrown some important insights. Overall and on each parameter assessed, the satisfaction with tele-evidence is far more than testifying in courts physically [mean score 61.23 (59.14–63.32) versus 22.17 (19.46–24.88)]. The satisfaction scores and difficulties faced while physically attending the court summons reveal a common thread; physical attendance puts a lot of strain (physical and mental) which is contributed in part by the difficulties faced at court premises. Other than time consumed in traveling to different locations leading to physical stress, the major problem highlighted was cancellation of evidence due to any reason rendering the whole effort of reaching the courts, compromising everything, a futile exercise. Although the cancellation and postponement of hearing for various reasons happened during tele-evidence also, but the corresponding issues, i.e., loss of professional time, physical stress of traveling, and monetary expenditure were not there, leading to more satisfaction. The other question that was attempted to be addressed was if there is any cost saving associated with tele-evidence as compared to physical appearance. The results show that there was a significant drop of 43% in the average monthly running of the institute vehicles following tele-evidencing and 49% reduction in the average fuel consumption for court duties. The physical appearance of doctors causes significant use of official vehicles. Annually, close to 60,000 km were being traversed exclusively for the court duties consuming approximately 5500 litres of fuel, costing more than Rupees 3.5 lacs (equivalent to around $5500 per annum @ $1 per litre of fuel). After the introduction of tele-evidence in the institute in March 2014 and with a significant number of summons being attended for evidence remotely through videoconferencing, the fuel and mileage consumption nearly halved. The savings due to telemedicine has always been a matter of discussion. Wallace et al.[12] have also highlighted this issue two decades ago. More recently, Mistry[8] in a systemic review of studies of cost effectiveness of telemedicine also highlighted the difficulties in arriving at a definitive conclusion one way or the other. However, tele-evidence differs from other applications of telemedicine because outcome measure is testimony rather than diagnosis or treatment modality where carrying out cost-effective analysis may be more complicated. Another spinoff from our findings is the positive impact on environment in terms of carbon footprint because tele-evidence reduced fuel consumption and mileage. According to Holmner et al.,[9] merely assuming reduced transportation as leading to reduced carbon footprints is not appropriate, yet they have also concluded that telemedicine generates fewer carbon emissions taking into consideration lifecycle assessment of the telemedicine equipment. Tele-evidence resulted in significant saving of time also for the doctors, which was earlier spent in commuting to various courts. The average hours per month spent in physical appearance for court summons reduced by 29% following the introduction of tele-evidence. Nearly 2200 hours were spent during the study period (April to December 2013 and April to December 2014) in the physical appearance of doctors to the courts. On an average of 8 working hours per day, this is equivalent to around 275 “physician days,” out of which a huge part is consumed in commuting and a very low percentage in actually giving evidence. On the contrary, tele-evidence involved only the evidence time before the judge and the traveling time is insignificant because the tele-evidence facility is located within the hospital complex. There was hardly any waiting time as the videoconference time is allotted by the court and the doctor arrives for the tele-evidence at the scheduled time only. Considering that in 46% cases surgeons from the Departments of Orthopedics and Neurosurgery were summoned, time saved from appearing in courts would have been useful for patient care in the A and E Department, which is extremely busy in our institute working at 200–300% of its optimal capacity and attended to nearly 90,000 patients in the financial year 2015–2016.[15] The major limitation in our study was that we did not estimate the cost of setting the infrastructure because the existing infrastructure was used. Additionally, the present study did not capture the acceptability of the other stakeholders. However, an evaluation study of e-courts demonstrated that lawyers urged the introduction of videoconferencing facility in the courts. The project coordinators tasked with overseeing the e-court project also recommended the availability of videoconference facility.[16] However, because our study has shown enormous tangible and, more importantly, nontangible benefits namely saving in terms of “physician day” and carbon footprints, it would not be out of place to justify the establishment of infrastructure for tele-evidence. Another limitation was that many a times summons are not accepted due to wrong details or on account of doctor having left the institute and their proportion has not been determined.
In our study, the evidence is overwhelming that tele-evidence will result in cost saving on transport and saving of doctors' precious time in a tertiary care setting with high patient load. This is acceptable to doctors and results in high doctor satisfaction. This is likely to have a positive effect on patient care. Additionally, it will help in speedier deliverance of justice. The top leadership of the country has also alluded to the use of videoconferencing and other IT solutions toward this end.[17] We therefore recommend adoption of tele-evidence through integration of telemedicine and telejustice which will be a path-breaking initiative and will go a long way in establishing a system for the benefit of both the judiciary and the healthcare setup of our country. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]
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