In this retrospective study, we found that telenephrology was a feasible and acceptable option that decreased healthcare costs and out-of-pocket expenditure for the patients and has promising scope for the future as well. Further, the issues faced by patients in terms of social support and physician availability can also be circumvented through telenephrology. Our findings are similar to those obtained in developed countries wherein teleconsultations reduced travel costs and carbon dioxide emissions related to travel, ensured medication adherence with fewer hospitalizations and is acceptable to the majority of patients [12, 13]. Telenephrology has shown to be useful in many observational studies especially in improving patient access to specialist care without compromising on clinical outcomes [14]. Long term sustainability over 2 years for managing patients with kidney disease has also been addressed in a recent case–control study [15]. Albeit small, a randomized controlled trial confirmed that telemedicine in addition to standard care reduced hospitalization and improved adherence to medications in renal transplant recipients [16]. Telenephrology has been successfully carried out for patients on peritoneal dialysis at the Mount Sinai hospital, New York and also in Columbia [17, 18]. Telehealth videoconferencing has been included in reimbursement claims in most developed countries thereby easing the economic burden of medical consults. Routine kidney care with video-based telemedicine is growing around the globe and has been accepted by patients across the entire spectrum of kidney disease [19].

Successful telenephrology services had already been provided in India for patients with kidney disease who were on peritoneal dialysis. Remote patient monitoring in patients on automated peritoneal dialysis (APD) significantly reduced hospitalization rates with better adherence, early detection of catheter dysfunction, reduction in the frequency of clinic visits, and enhanced communication between the patient and the clinical team [3]. Reports on the feasibility of telenephrology, including video consultations in a single center, though available have not been evaluated for patient satisfaction and acceptance [20].

Most of the patients in our study cohort were young or middle aged and belonged to the middle socioeconomic class; almost half were unemployed and dependent on family members for financial assistance. This reflects the category of patients visiting our hospital and likely in any other major public sector hospital in India and most other developing countries. Our patients were strongly supportive of the telenephrology service. Almost all the patients were confident reporting their complaints and comfortable sharing reports over the phone. It is also encouraging that there is widespread availability of telecommunication systems and internet service, even in remote areas, thus facilitating sharing of reports and getting appropriate medical consultation. We could not explore the problems faced by those patients who do not have access to smart devices. However, even in the absence of internet services, sharing of reports and prescriptions was feasible through SMS, following oral consultation (Table 2).

Ninety percent of patients gave a satisfaction score of 4 (out of 5) or above for their teleconsultation experience, thus suggesting adequate patient satisfaction. The majority of patients (86%) wanted telenephrology to continue beyond the COVID pandemic. This, apart from showing the acceptance of teleservices, indicates that patients may prefer it in certain selected situations. Among 14 patients who wanted only physical consultation, 13 (92.8%) were living in the same city, attending the OPD and returning home on the same day, prior to the COVID pandemic. The benefit of telenephrology was therefore most appreciated by those patients who were traveling longer distances for each visit. An approach involving regular telenephrology follow ups with need-based in-person consultations can significantly reduce the number of visits, cost of travel and stay, in addition to reducing the risk of infection.

One of the concerns of our patients during teleconsultation was the lack of physical connection during the clinic visits which had been the norm till the pandemic. Nearly one-third of the patients feared that lack of in-person clinic visits might compromise their health outcome. One way of overcoming this issue would be by using videoconferencing or video calls, where the patient can see the doctor face-to-face while explaining his/her problems and getting advice. This can also help the physician pick up certain non-verbal cues and address patient issues more effectively. The availability of suitable internet connectivity and smart devices is a prerequisite for this service.

One important observation in this study is that only 4.67% of patients were illiterate. About 85% of patients had studied till 10th grade or above. Also, the majority of patients belonged to the lower middle or upper middle socioeconomic class. This could indicate an underrepresentation of the very poor and illiterate patients who probably do not have access to the internet, mobile phone or are not aware of the telenephrology service. One approach to reach this subset of patients is by widespread dissemination of information regarding telemedicine, explaining how to make an appointment, and sharing investigations over the phone with the help of printed and digital mass media. Another solution could be to set up remote telemedicine clinics staffed with trained nurses or technicians where these patients can consult the nephrologist via telephone or videoconferencing.

The main strength of this study is that it is one of the first studies from India to assess the patient’s attitude and acceptance of telenephrology service, especially at a large public sector hospital. This study was performed at a single center in North India which limits its generalizability to other areas of India. The impact of non-availability of smart phones/internet services could not be assessed. The applicability of results to patients with no support system and the socioeconomically disadvantaged is still unknown. We did not have video telenephrology services for new patients, so patients who had been previously registered and treated by our clinic were included in the study. These patients already had an available nephrology file which included basic patient history, prior clinical details and investigations thus making it convenient for the physicians to provide consults. Nevertheless, this study provides hope that a well-organized telehealth system would ensure continuous follow-up and proper management of patients with chronic diseases in developing countries like India without compromising on patient satisfaction and standard of medical care.

In conclusion, in a country like India made up largely of a rural patient population with limited accessibility to specialist care, telenephrology has a huge potential to provide quality healthcare in view of the reasonably well developed digital infrastructure. Therefore, the integration of telenephrology services to the existing healthcare system is the need of the hour to improve access to care and provide quality service to our patients without compromising outcomes.