This cross-sectional study was conducted on telemedicine centre of West Bengal which is situated in IPGMER Hospital. For convenience and clarity, “telemedicine” is used as an inclusive term throughout this report to refer to the delivery of healthcare via information and communication technology. The study was conducted from 1^st May to 31^st May, 2021 during COVID-19 pandemic. Approval from the ethics committee of Medical College, Kolkata was obtained for the study (MC/KOL/IEC/NON-SPON/1905/06.2021 dated 08.06.2021).

During study period, one investigator was posted in the telemedicine support cell according to duty roster. This duty roster was made by the State Health Advisory Board. The tenure of this posting was 1 month. Duty roster consisted of three shifts, ‘Morning Shift’ which was 9.00 am to 3.00pm, ‘Evening Shift’ which was 3.00 pm to 9.00 pm and ‘Night Shift’ which was 9.00 pm to 9.00 am. All faculties had to perform only one shift per day. During data collection period of three weeks, the investigator got total of 15 sets of duty in which six sets were morning shifts and evening shifts and three night shifts. In three weeks, the investigator had 108 hours of duty in total.

A predesigned pretested interview guide was used to conduct the study. Pretesting was done on the same centre before the study began and face validity was achieved with the help of experts from public health and communication. After receiving the call, the investigator first assessed the problems of the callers and then tried to solve their problems. Then the investigator took permission from the callers to ask the set questions.

The interview guide consists of ‘Is it your first time call to the telemedicine centre’, ‘If no, how many times you called before’, ‘relationship of the caller’, ‘Age of the caller’, ‘RT-PCR positive- Yes/No’, ‘Date of sample collection’, ‘Date of first appearance of first symptom’, ‘What is your first symptom’, ‘What is your query’. Satisfaction was measured on a scale of 0-10. Based on quartile values ‘0-2’ was categorised as unsatisfied, ‘3-5’ as undecided, ‘6-8’ satisfied and ‘9-10’ as very satisfied.

Data were compiled in MS-excel and analysed to find out frequency, percentage, mean and standard deviation. To find out intergroup association Chi-square test was performed. Type I error for significance testing was taken as 5% for Chi-square test. To find out difference in satisfaction score among groups of callers Mann-Whitney U test was done in Statistical Package for the Social Sciences (SPSS) version 16.0.

During this study period of three weeks, the investigator attended a total of 215 calls. Among the 215 calls, 33 calls were not relevant to this centre, 18 calls were for vaccine availability and 12 calls were for hospital admission. Excluding these, total 152 calls were ultimately considered for analysis.

A total of 93 (61.2%) callers were from rural areas of West Bengal. A total of 114 (75%) callers were male and mean age of callers was 37.25 years. No patient called the telemedicine centre him/herself. Mostly the callers were fathers of the patients (64). Seventy eight (51.3%) callers were repeat callers. Maximum number of repeat call was 12 times, made by one caller [Table/Fig-1].

A total of 140 (92.1%) of the 152 patients had already been tested positive for COVID-19 before the call was made to the telemedicine centre. Seventy six (50%) of them went for RT-PCR test for COVID-19 and 64 (42.1%) had rapid antigen test done for COVID-19. When enquired about the first symptoms that appeared in these 140 COVID-19 positive patients, most of the patients said they had fever (114) followed by dry cough (34) [Table/Fig-2].

Seventy four (48.68%) callers wanted to know which drugs needed to be taken after being tested positive. Ninety (59.21%) callers wanted to know after how many days of being positive, they should go for next RAT/RT-PCR. Fifty six (36.84%) callers wanted to know for how long medicines for COVID-19 should be continued [Table/Fig-3].

Mean satisfaction score was 6.29. Mann-Whitney U test suggested no significant difference of satisfaction score between male and female (p=0.15), and between first time caller and repeat caller (p=0.85).

Satisfaction score was then categorised into a dichotomous variable as very/satisfied and unsatisfied/undecided. Number of unsatisfied callers were 22 (14.5%), undecided were 30 (19.7%), satisfied were 54 (35.5%) and 46 (30.3%) callers were very satisfied. Chi-square test suggested no significant association of satisfaction with repeat calling. Significant association of satisfaction was found with gender, female gender being less satisfied. Significant association of satisfaction was also found with area of residence, where callers of rural area were more satisfied [Table/Fig-4].

Telemedicine was not well established in India before COVID-19 pandemic. A systematic review that considered studies related to use of telemedicine till June 2020, found only one Indian article among total 43 articles from worldwide [13]. That Indian study was on use of telemedicine on chronic pain management and they also mentioned different hindrances in implementation of telemedicine in India including legal problems [14]. Articles on the use of telehealth on management of COVID-19 is not very common as pointed out by a systematic review which started with 142 telemedicine related articles and finally found only eight articles on management of COVID-19 [15].

Telemedicine was shown to be helpful in previous outbreaks, including former coronavirus outbreaks such as Severe Acute Respiratory Syndrome–Associated Coronavirus (SARS-CoV) and Middle East Respiratory Syndrome Coronavirus (MERS-CoV) [16]. One of the most important strategies to reduce and mitigate the advance of the respiratory epidemic is social distance measures; this is where telemedicine can help and provide support to the healthcare systems. After the rapid rise of cases in India during 2^nd wave in April-May 2021 health workforce was swamped with COVID-19 cases. To reduce the burden of minor cases and to protect healthy family members of the patients from exposure to the disease in hospital settings telehealth services for COVID-19 was initiated in West Bengal. In many parts of the World telehealth services served more or less similar objectives in context to COVID-19. A systematic review on eight studies conducted on telemedicine services specifically for COVID-19 concluded that the impact of telehealth was significant in prevention of morbidity by decreasing presence of the public in high-risk areas such as hospital premises [15]. Other studies also pointed out towards minimisation of unwanted exposure to both patients and healthcare workers by use of telemedicine in the USA [17] and China [18].

Telemedicine is especially effective in those areas where the healthcare facilities are not established properly or hard to reach. From present study, it was observed that the 61.2% callers were from the rural areas. From here, it can inferred that the establishment of telemedicine centre served its purpose in reaching out to the people of remote areas.

Inaccessibility of healthcare services was found to be key motivation for acceptance of telemedicine services in other parts of World also. A study done in Australia concluded that telehealth services are born of necessity-arising from rural remoteness and island locations [19]. Another study which compared implementation of telemedicine services in Australia, UK, and The USA also reported that in spite of cultural differences and implementation plans of three Governments, two things were consistently related to acceptance of telemedicine; older age group and harsh geography [20].

It was found that the repeat callers were more than 50%. From this, it can be inferred that the callers trust this new set-up that’s why they are seeking assistance again.

The callers consulted with the telemedicine support cell regarding which drugs to be taken for how many days, home isolation duration, repeat RAT/RT-PCR test, what type of food should they take etc., State government promoted home isolation during this pandemic time and this telemedicine centre provided all the information necessary for home isolation. Similar pictures were found all over the World. A study in China showed that teleconsultation is helpful in gaining knowledge regarding the prevention control of COVID-19, about best practices during home quarantine [21]. With proper guidance regarding disease as many as 69% of patients who had a telehealth encounter during the early pandemic period in 2020 were managed at home in The USA [11]. Another one mentioned that telemedicine communicated accurate and clear information, at a time when older adults and their family were bombarded with contradictory and confusing message, thus facilitating proper home care and prevention [23]. A Chinese telemedicine centre helped callers to get access on prevention and treatment guidelines, and guidance on drug use and management of coronavirus patients [24]. Many studies also pointed out that use of telemedicine helped in early diagnosis of COVID-19 thus avoiding hospitalisation [17,18]. With the help of telemedicine a person can continue to self-monitor symptoms at home while recovering. It can also be applied for regular check-ins such as respiratory, blood pressure and oxygen level rate needed in home isolation. So, it can be concluded that telemedicine had a big role for promotion of home isolation.

From the present study, it was found that fever (81.43%) was the commonest symptom followed by dry cough (24.29%) and 90% patients were already tested positive. From this it can be infer that those who contacted telemedicine centre were aware about the symptoms of the COVID-19 and COVID testing. In a study, in China it is seen that 60.4% callers to telemedicine centre consulted on respiratory symptoms such as cough, sputum, and fever [22].

A 65.8% of the callers were satisfied or very satisfied after consultation with telemedicine centre. It can be the proxy indicator in success of telemedicine service. Data analysis also shows that, respondent of rural areas are significantly more satisfied than urban area. It indicates that the telemedicine setup is more successful for those people, where access to healthcare facilities are limited. In USA also, a rapid rise of use of telemedicine services was seen after the pandemic. A study done in Ohio, USA mentioned that in a few weeks, telehealth went from under 5% of patient visits to almost 93%, while maintaining high levels of patient satisfaction [25]. Another study reported that, though already well accepted, telemedicine use increased by 154% in March 2020, compared to March 2019 [22]. Finally, it can be said that COVID-19 has provided impetus for usage and acceptance of telemedicine which is increasing sharply worldwide including India.

The study was conducted on the callers to telemedicine centre for the time period of second wave of COVID-19 pandemic in India, when hospital beds, oxygens, Intensive Care Unit (ICU) beds all became inadequate in supply compared to huge demand. Callers trying to access help from telemedicine centre were probably desperate to seek medical advice for home isolation which might have increased their acceptance for telemedicine. A study conducted in relatively less emergency time may give clearer picture regarding people’s acceptance towards new treatment modality. The satisfaction of the callers was assessed by the executives of telemedicine centre, which may lead to tendency of callers towards positive feedback. A third-party evaluation of satisfaction level may have given more unbiased opinion.

The COVID-19 pandemic will probably be a landmark for telemedicine history. Present study shows that this pandemic has transformed the provision of medical services, with applications for telemedicine in various fields of medical practice. Health systems are faced with an unprecedented opportunity to learn from the current situation and draw lessons for the future. To enable low and medium income countries to widely rely on this tool, more information is needed regarding costs and necessary resources to ensure effective implementation.