Telehealth and Medicine Today <p><strong>Telehealth and Medicine Today (TMT</strong>) is a gold open access international peer reviewed journal examining the value of telehealth and clinical automation, its use and scalable developments, business process guidance, market research and the economic impact of digital health innovations in an evolving virtual health technology sector.</p> Partners in Digital Health en-US Telehealth and Medicine Today 2471-6960 <p>Authors retain copyright of their work, with first publication rights granted to&nbsp; <em>Telehealth and Medicine Today (TMT).</em></p> <p>&nbsp;</p> The Path Forward for Whole-person Virtual Care <p>The COVID-19 pandemic exponentially accelerated adoption of virtual care and heightened consumer expectations, which caused health systems to reimagine their role in virtual care. As a result, adoption of virtual care has empowered health systems to move beyond siloed applications to a comprehensive, whole-person approach that consumers will need across their healthcare journey. </p> <p>In this podcast, Bruce Brandes and Dr. Lyle Berkowitz discuss the current state and future of virtual care and the unique position of health systems to earn their place within the “consumer circle of trust”.</p> Bruce Brandes Lyle Berkowitz Copyright (c) 2021 2021-04-23 2021-04-23 The Effect of a Customized Advocacy Product on Downstream Medical Expenditures and Utilization <p><strong>Background</strong>: The complexity of today’s healthcare system has led to the growth of an emerging healthcare function known as healthcare advocacy. A telephonic healthcare advocate or advisor can play an essential role in care coordination, a better understanding of health benefits, and ease in navigating the healthcare system. A healthcare advocate’s role may be filled by clinical staff (i.e., registered nurses), non-clinical staff, or both, with varying levels of training depending on the intended scope of service.</p> <p><strong>Objective</strong>: With a higher number of employers seeking customized health advocacy programing, this study serves to determine if more favorable healthcare outcomes offset the additional operating costs associated with a more dedicated delivery system. Therefore, this study’s primary objective was to evaluate the impact of patient access to a customized health advocacy program on downstream medical costs and healthcare utilization compared to a control (CON) group without access to this service. The secondary aim was to provide information to employers on whether a higher investment in a more complex customized delivery model provides significant value compared to a less customized program.</p> <p><strong>Methods</strong>: The study treatment (TRT) group included 89,372 individuals with access to a customized advocacy program for employees, while the CON group of 115,465 had access to a non-customized program. Key outcomes included total healthcare expenditures, hospital admissions, emergency room visits, and physician office visits 12 months after the advocacy start date compared to 6 months before the start date. Researchers evaluated the impact the customized advocacy intervention had on expenditures by comparing differences in pre- and post-expenditures between customized health advisor and non-customized health advisor groups after controlling for various demographic, socioeconomic, and health status characteristics. Inverse propensity score weighting helped minimize differences in characteristics between the TRT and CON groups.</p> <p><strong>Results</strong>: With the customized advocacy product, healthcare expenditures increased by only $2.03 per member per month (PMPM) compared with a $26.35 PMPM larger increase for controls with a non-customized product. Also, customized health advisor participants experienced reduced hospital admissions and ER visits compared with the CON group.</p> <p><strong>Conclusions</strong>: Study participants with access to customized healthcare advocacy services experienced significant healthcare cost savings, along with fewer ER visits, and reduced inpatient admissions compared with the CON group. Thus, these findings suggest that healthcare advocacy programs justify the increased delivery cost and can lead to reduced healthcare costs and utilization, along with the potential to improve health outcomes and quality of life.</p> Jessica Navratil-Strawn Stephen Hartley Stephanie MacLeod Andrew Lindsay Copyright (c) 2021 Jessica Navratil-Strawn, Stephen Hartley, Stephanie MacLeod, Andrew Lindsay 2021-04-30 2021-04-30 10.30953/tmt.v6.250 Digitized Maternal Early Warning and Response Telehealth System <p><strong>Introduction</strong>: In this article, we describe a pilot telehealth project for identifying women at risk of developing serious complications early and for instituting timely, appropriate, and up-to-date management even in situations with limited resources and skilled obstetric services. Maternal mortality remains unacceptably high, with less than two-thirds of the signatories to the 2015 Millennium Development Goals achieving the outlined 75% reduction in maternal mortality ratio (MMR) from 1990 to 2015. Looking forward to 2030, the Sustainable Development Goals (SDGs) lay out a target of reducing the MMR in every country to below 70 per 100,000 live births. This will require progress in low-and-middle-income countries at a rate much greater than that seen over the past 15 years. Given that 94% of the global maternal deaths occur in low- and-middle-income countries, a solution to meet the unique challenges of these countries will be necessary to achieve the SDG. The Women’s Obstetrical Neonatal Death and Reduction (WONDER) telehealth system described here offers a potential telehealth solution to reduce mortality and morbidity rates in resource-limited environments by early identification of risk indicators and initiation of care.</p> <p><strong>Materials and methods</strong>: The WONDER system consists of a cloud-based electronic health record with a Clinical Decision Support tool and a color-coded alert system. The Clinical Decision Support tool is based upon Maternal Early Warning Signs and provides real-time assistance to caregivers via relevant national treatment guidelines. This system uses inexpensive computing hardware, displays, and cell-phone technology. This system was tested in a 2-year pilot study in India. A total of 15,184 patients were monitored during labor and the postpartum period.</p> <p><strong>Results</strong>: Within limitations of the study, the incidence of in-hospital eclampsia was reduced by 91.7%, and in 95% of cases, timely treatment was started within an hour of identifying the abnormality in vital signs. Maternal mortality was reduced by 50.1% over local benchmark figures.</p> <p><strong>Conclusions</strong>: The WONDER system identified at-risk patients, directed skilled care to those patients at risk for complications, and helped to institute effective, timely treatment, demonstrating a potential solution for women in resource-limited locations.</p> Narmadha Kuppuswami Suresh Subramanian Karenna J. Groff Radha Rani Ravichandran Copyright (c) 2021 Narmadha Kuppuswami, Suresh Subramanian, Karenna Groff, Radha Rani Ravichandran 2021-04-23 2021-04-23 10.30953/tmt.v6.251 Proceedings of the 16th International Conference of Telemedicine Society of India (TSI) Krishnan Ganapathy Lavanian Dorairaj and Sheila John Copyright (c) 2021 Guest Editor: Krishnan Ganapathy, Associate Editors: Lavanian Dorairaj and Sheila John 2021-04-23 2021-04-23 10.30953/tmt.v6.266 Tele-Mentoring and Monitoring of the National Mental Health Program: A Bird’s-Eye View of Initiatives from India <p><strong><em>Objective</em></strong>: To provide a glimpse of various digital programs and modules that are being implemented across the country by the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India (an institution of national importance under the Ministry of Health and Family Welfare, Government of India; one of its mandates is to develop innovative strategies to improve mental health capacity building as part of the National Mental Health Program, a publicly funded health program to cater to the public health need posed by psychiatric disorders).</p> <p><strong><em>Design</em></strong>: The information is presented in a narrative fashion by organizing the activities into three categories of digital training methods: webinar mode, blended mode and hybrid mode.</p> <p><strong><em>Results</em></strong>: Cadres ranging from lay-counsellors (volunteers in the community), non-specialist health workers to professionals including medical officers are covered with these initiatives. During the period from August 2016 till December 2020, more than 16 million man hours of training is delivered for more than 35,000 participants from across the country.</p> <p><strong><em>Conclusions</em></strong>: These have a tremendous potential to exponentially increase skilled human resources capable of providing quality care to hitherto unserved remote areas of the rural hinterland and ultimately reduce the burgeoning treatment gap. In-depth outcome assessments are the need of the hour.</p> Gopi Gajera Barikar C. Malathesh Lakshmi Nirisha P. Channaveerachari Naveen Kumar Narayana Manjunatha Suchandra H.H. Sujai Ramachandraiah Chethan Basavarajappa Rajendra Gowda K.M. Suresh Bada Math Copyright (c) 2021 Gopi Gajera, Barikar C. Malathesh, Lakshmi Nirisha P., Channaveerachari Naveen Kumar, Narayana Manjunatha, Suchandra H.H., Sujai Ramachandraiah, Chethan Basavarajappa, Rajendra Gowda K.M., Suresh Bada Math 2021-04-23 2021-04-23 10.30953/tmt.v6.262 The AmbuPod Project: Learnings of a Government-Certified, Telemedicine-Enabled, Rural Healthcare Startup in India <p>The Government of India (GoI), during the past 8 years, has been encouraging and supporting start-ups with various schemes, for the purpose of wealth creation, improving economic growth, and employment. There is also a growing support system in India, in the private sector, for funding, mentorship, and techno-commercial support for telemedicine-enabled start-up projects. In practice however, there are many critical decisions that need to be taken and pitfalls to be avoided, for start-ups to achieve success, as envisaged by the GoI.</p> <p><strong><em>Objective</em></strong>: This paper shares the challenges encountered so as to help upcoming healthcare start-up’s navigate this route skilfully, avoiding pitfalls.</p> <p><strong><em>Results</em></strong>: The results of 4 years of work (Jan 2016 to Mar 2020) and the present status are discussed and the learnings drawn from the AmbuPod Project (on-going) summarized.</p> <p><strong><em>Conclusion</em></strong>: Telemedicine supported Rural Healthcare Start-Up projects have a good business potential in India, provided challenges are planned for, addressed, and resolved.</p> Lavanian Dorairaj Copyright (c) 2021 Lavanian Dorairaj 2021-04-23 2021-04-23 10.30953/tmt.v6.259 Artificial Intelligence and Healthcare Regulatory and Legal Concerns <p>We are in a stage of transition as artificial intelligence (AI) is increasingly being used in healthcare across the world. Transitions offer opportunities compounded with difficulties. It is universally accepted that regulations and the law can never keep up with the exponential growth of technology. This paper discusses liability issues when AI is deployed in healthcare. Ever-changing, futuristic, user friendly, uncomplicated regulatory requirements promoting compliance and adherence are needed. Regulators have to understand that software itself could be a software as a medical device (SaMD). Benefits of AI could be delayed if slow, expensive clinical trials are mandated. Regulations should distinguish between diagnostic errors, malfunction of technology, or errors due to initial use of inaccurate/inappropriate data as training data sets. The sharing of responsibility and accountability when implementation of an AI-based recommendation causes clinical problems is not clear. Legislation is necessary to allow apportionment of damages consequent to malfunction of an AI-enabled system. Product liability is ascribed to defective equipment and medical devices. However, Watson, the AI-enabled supercomputer, is treated as a consulting physician and not categorised as a product. In India, algorithms cannot be patented. There are no specific laws enacted to deal with AI in healthcare. DISHA or the Digital Information Security in Healthcare Act when implemented in India would hopefully cover some issues. Ultimately, the law is interpreted contextually and perceptions could be different among patients, clinicians and the legal system. This communication is to create the necessary awareness among all stakeholders.</p> Krishnan Ganapathy Copyright (c) 2021 Krishnan Ganapathy, M.Ch (NEURO) FACS FICS FAMS Ph.D. 2021-04-23 2021-04-23 10.30953/tmt.v6.252 The Mobile Teleophthalmology Unit in Rural and Underserved Areas of South India <p><strong><em>Objective</em></strong>: Our objective was to provide an eye care service to rural and underserved areas in Chennai, Kanchipuram, and Thiruvallur districts of Tamil Nadu, South India.</p> <p><strong><em>Design</em></strong>: We conducted eye camps to provide ophthalmic services to the underserved and rural areas, where people cannot afford to go to a hospital due to lack of accessibility, lack of awareness, or financial constraints.</p> <p><strong><em>Setting</em></strong>: The study was conducted in rural and underserved areas of Thiruvallur, Chennai, and Kanchipuram districts from January 2015 to December 2019.</p> <p><strong><em>Participants</em></strong>: Patients (<em>N</em> = 1,05,827) underwent comprehensive eye examination in eye camps with the state-of-art ophthalmic equipment.</p> <p><strong><em>Main outcome measures</em></strong>: To report on the number of patients examined, number of eye disorders screened, and different types of ocular pathology screened, all clinical findings were recorded and all ocular images were uploaded in the electronic medical records. All patients with ocular diseases underwent teleconsultation with an ophthalmologist at the base hospital with internet connectivity. Video conferencing and teleconsultation were feasible only in areas with good internet connectivity.</p> <p><strong><em>Results</em></strong>: Over the 5-year study period, 1,05,827 patients underwent eye evaluation at 1,061 eye camps. Among these, 48,354 (45.7%) patients were males, 57,473 (54.3%) patients were females, 15,515 patients were emmetropes. The most common cause of avoidable blindness was uncorrected refractive error detected in 66,137 eyes, referable cataract was seen in 13,536 eyes, 2,491 eyes were identified to have retinal diseases, and there were 789 patients with only diabetic retinopathy, thus totaling to 3,280 comprising of all retinal disease. 2424 patients received teleconsultations. For further investigations and treatment, which were provided free of cost, patients were referred to the base hospital in Chennai. There were 6,309 patients who received free spectacles and an additional 31,192 patients received spectacles at a low cost; 13,536 patients had referable cataract and were referred to the base hospital for further evaluation and surgery.</p> <p><strong><em>Conclusions</em></strong>: Teleophthalmology holds great potential to overcome barriers, improve quality, access, and affordability to eye care, and has proven to be an innovative means of taking comprehensive eye care facilities to the doorsteps of rural India.</p> Sheila John Lavanya Allimuthu Ranjitha Kannan Ramesh BabuSekar Martin Manoj Mathiyazahan Padmavathy Appasamy Sangeetha Srinivasan Copyright (c) 2021 Sheila John, Lavanya Allimuthu, Ranjitha Kannan, Ramesh BabuSekar, Martin Manoj Mathiyazahan, Padmavathy Appasamy, Sangeetha Srinivasan 2021-04-23 2021-04-23 10.30953/tmt.v6.257 Identical Telemedicine-Enabled Clinics in Three Different Geographies: Our Learnings <p><strong><em>Background</em></strong>: Scarcity of primary care is felt most in underserved communities. Telemedicine (TM)-enabled clinics bridge the gap in such scenarios. There was a need to understand how the same TM model would work in different settings.</p> <p><strong><em>Aim</em></strong>: The aim was to study outcomes in three identical TM-enabled clinics in different geographies so as to understand how to scale up clinics in future.</p> <p><strong><em>Setting</em></strong>: Three totally different sites were chosen: a rural village with low socioeconomic status, a rurban (rural-urban) prosperous village, and an urban slum. The clinics planned was identical. The process of establishment, training, recruitment and treatment guidelines were the same. Any deviation was noted.</p> <p><strong><em>Methodology</em></strong>: Data were gathered through public health survey, interactions with villagers and local leaders, medical examination of individuals, feedback from patients, and household survey to understand the socioeconomic status of the community.</p> <p><strong><em>Main outcome measures</em></strong>: The article attempted to study how different social, cultural, and economic settings affected the outcome of identical TM clinics.</p> <p><strong><em>Results</em></strong>: TM, though accepted in different settings, was not sufficient to meet the healthcare needs of the community. These needs were related to the social and economic characteristics. Public health initiatives along with TM were most beneficial. In the underserved areas, infrastructure posed challenges to implementing TM, and ‘Last Mile Care Delivery’ was essential to create the full impact of TM.</p> <p><strong><em>Conclusion</em></strong>: TM-enabled clinics along with last mile care delivery are the key to improve healthcare in underserved communities. Further research into customized TM models for different geographies would help in providing the best care.</p> <p><strong><em>Limitations of the study</em></strong>: The study period was 4 months. The study was in one state of India, so the applicability of the findings to other states/countries may vary.</p> Suchitra Mankar Nikhilesh Paradkar Copyright (c) 2021 Suchitra Mankar, Nikhilesh Paradkar 2021-04-23 2021-04-23 10.30953/tmt.v6.253 Nursing Interns’ Perceptions of Telenursing: Implications for Nursing Education <p><strong><em>Background</em></strong>: Telemedicine is a fast-emerging health sector in India. While nurses play an important role in delivering healthcare services through telemedicine, little is known about whether nursing interns are prepared adequately.</p> <p><strong><em>Aim</em></strong>: To evaluate nursing interns’ perceptions of telenursing and to find out their opinion on whether telenursing should be added to the curriculum.</p> <p><strong><em>Methods</em></strong>: This was a cross-sectional descriptive survey carried out among conveniently selected nursing interns (<em>N</em> = 183) from renowned colleges in Bangalore, South India. The data were collected using a self-reported questionnaire.</p> <p><strong><em>Results</em></strong>: In this study, a majority of the participants had smartphones (74.8%), were accessible to the internet (96.7%), and were using the internet for more than 3 h/day (73.3%). While a majority (65.6%) of the participants were able to correctly identify the definition of telenursing, only 33.9% of them rightly answered the definition of telemedicine. Most of the participants indicated that the inclusion of telenursing in undergraduate studies would be useful for future healthcare workers (92.4%), and telenursing can be practiced in all the medical specialties.</p> <p><strong><em>Conclusion</em></strong>: The majority of the nursing interns hold positive perceptions of telenursing and acknowledge its usefulness in nursing practice. However, their knowledge of telenursing is limited. Hence, the findings strongly suggest the need to introduce concepts of telenursing in curricula to prepare future healthcare providers to be able to provide safe and competent care in a highly technical and digital environment.</p> Vijayalakshmi Poreddi Kathyayani Bidadi Veerabhadraiah SaiNikhil Reddy Narayana Manjunatha NaveenKumar Channaveerachari Suresh Bada Math Copyright (c) 2021 Vijayalakshmi Poreddi, Kathyayani Bidadi Veerabhadraiah, SaiNikhil Reddy, Manjunatha Narayana, NaveenKumar Channaveerachari, Suresh BadaMath 2021-04-23 2021-04-23 10.30953/tmt.v6.258 Neurology and Telemedicine: The Way Forward <p><strong><em>Objective</em></strong>: During the coronavirus-2019 (COVID-19) times, we have all learned to appreciate the advantages of communicating with each other on the digital or virtual format. This included both social, commercial and professional settings. This was necessitated through the restrictions on direct physical contact mandated by the pandemic. Through innovations and adaptations, the practice of medicine has also changed with telemedicine, triggered by ‘necessity is the mother of invention’ concept being embraced by both patients and physicians. Neurology, traditionally seen as a complex speciality and the preserve of a couple of thousand practising neurologists in the country, has opened itself up to the telemedicine or tele-neurology format very easily in the anecdotal and a few pilot studies conducted globally and in India.</p> <p><strong><em>Design</em></strong>: Despite the initial misgivings and anticipation of patient reluctance to adopt this technology, the real-world experience has been, to the contrary, where both young and old patients have readily embraced the new medium and cooperated with the neurologists to improve their care, which would otherwise have been severely restricted in the COVID-19 times. The neurologists have also adapted to the new way of working to deliver optimum diagnosis and care plans.</p> <p><strong><em>Outcome measures</em></strong>: There have been technical glitches (in form of internet connectivity, smartphone hardware and software problems and lighting and camera angle and image stabilization issues to name a few), which have been reduced with practice and innovation. Feedback from neurologists, patients, and their carers via regular audits and questionnaires are being circulated, and practice parameters are being improved (IFNR survey- Ref 5). The contribution of national regulatory agencies, such as the Ministry of Health and Family Welfare (MoHFW), and stakeholders, such as the Telemedicine Society of India (TSI), has been phenomenal to facilitate the tele-neurology practice and make it safe for all stakeholders.</p> <p><strong><em>Results</em></strong>: In a country of 1.37 billion population and only 2,500 accredited neurologists, there is a need for tele-neurology to be able to serve patients living in remote areas in mountains and coastal areas, and also in poorly connected areas on the plains. This becomes paramount for patients requiring specialised acute neurological care and to improve access, which now becomes a practical feasibility on the digital format to bring neurology to the doorsteps of the people.</p> <p><strong>Follow-up</strong> care of patients, epidemiological studies of various neurological chronic illnesses and their audit will become realities cutting down on costs and time to access quality neurological care using the digital format for 21st-century India.</p> <p><strong><em>Conclusions</em></strong>: Tele-neurology is no longer a vision, but a reality precipitated by the pandemic, the needs and aspirations of the Indian population, and the technological infrastructure India has achieved in the last 20 years.</p> Partha S. Ray Nirmal Surya Copyright (c) 2021 Partha S. Ray, Nirmal Surya 2021-04-23 2021-04-23 10.30953/tmt.v6.260 Education and Training for Ethical Practice of Telemedicine for Registered Medical Practitioners in India <p>The Telemedicine Practice Guidelines (TPG) released in 2020 provide legal framework for registered medical practitioners (RMPs) to consult with patients deploying Information and Communication Technology. Necessary compliance requirements have also been included. This article analyses the effectiveness of the ‘Train to Practice’ course designed by the Telemedicine Society of India to train doctors in India to follow ethical and safe standards of practice of telemedicine. The online course was taught by a faculty of 18 members, over a period of 6 months using four modules.</p> <p>The course comprised of a pre-course assessment, live lectures, and a post-course assessment to ascertain the level of preparedness and knowledge imparted to the RMPs by way of the course. The article highlights that the RMPs had a preliminary understanding of the concept of telemedicine prior to the course. Post-course assessment indicated improvement in knowledge levels. Pre- and post-course assessments were conducted using multiple choice Yes or No response-based questionnaires.</p> <p>Participating RMPs exhibited a real drive to understand the legalities and operational procedures of the practice of telemedicine as was evidenced by queries posed to the lecturers. While the course was rated generously by all the attendee RMPs, there were also evidences of a lack of seriousness from certain RMPs who did not have to pay for participating in the course. The researchers have also suggested that the presence of a TPG qualification paper online and the swift introduction of TPG aligned courses in medical schools would streamline implementation challenges in the future. The researchers have also recommended the amendment of the TPG and the Medical Council of India (MCI) Code of Ethics Regulations, 2002, to provide better protection to RMPs from possible litigation occurring during telemedicine practice.</p> Sunil Shroff Bagmisikha Puhan Lavanian Dorairaj Mayank Agarwal Manick Rajendran Ravi Modali Suchitra Mankar Permachanahalli Sachidananda Ramkumar Sandeep Patil Copyright (c) 2021 Sunil Shroff, Bagmisikha Puhan, Lavanian Dorairaj, Mayank Agarwal, Manick Rajendran, Ravi Modali, Suchitra Mankar, Permachanahalli Sachidananda Ramkumar, Sandeep Patil 2021-04-23 2021-04-23 10.30953/tmt.v6.254 Telepsychiatry During the COVID Pandemic: Reflection from India <p><strong><em>Introduction</em></strong>: Recent advancements in information technology and access to smartphone have expanded the scope of healthcare delivery services across the globe. Telemedicine is making healthcare affordable and more accessible to the needy in situations like the present pandemic. Although telepsychiatry services were underutilised initially in India due to various barriers, its role in delivering healthcare services, has gained pace since the last few years. During the coronavirus disease (COVID-19) pandemic, India introduced telemedicine practice guidelines (March, 2020), and telepsychiatry operational guidelines (May, 2020), to remove barriers and promote equitable access. In the wake of COVID-19 pandemic various mental health institutes across India relied heavily upon telepsychiatry services to provide care. National Institute of Mental Health and Neuro Sciences, Bangalore being an Institute of National Importance has introduced different modules to provide clinical care to the mentally ill.</p> <p><strong><em>Objectives</em></strong>: In this article, the authors provide an experiential account of various clinical services provided by our institute through telepsychiatry means across India during the COVID-19 pandemic.</p> <p><strong><em>Conclusion</em></strong>: These clinical service modules have tremendous potential to increase the use of technology in providing quality care to the unreached population, bridging the treatment gap for psychiatric disorders globally and developing countries in particular.</p> Harihara Suchandra Dinakaran Damodaran Barikar C. Malathesh Lakshmi Nirisha P. Narayana Manjunatha C Naveen Kumar Gopi Gajera Sujai Ramachandraiah Chethan Basavarajappa Rajendra Gowda K.M. Suresh Bada Math Copyright (c) 2021 Harihara Suchandra, Dinakaran Damodaran, Barikar C. Malathesh, Lakshmi Nirisha P., Narayana Manjunatha, C Naveen Kumar, Gopi Gajera, Sujai Ramachandraiah, Chethan Basavarajappa, Rajendra Gowda K.M., Suresh Bada Math 2021-04-23 2021-04-23 Sixteenth International Conference of Telemedicine Society of India: Experiences and Lessons Learnt for Evolving Transformation at a Global Level Amar Gupta Copyright (c) 2021 Amar Gupta, Editor-in-Chief 2021-04-23 2021-04-23 10.30953/tmt.v6.268 Proceedings of the 16th International Conference of Telemedicine Society of India Krishnan Ganapathy Copyright (c) 2021 Krishnan Ganapathy, M.Ch (NEURO) FACS FICS FAMS Ph.D. 2021-04-23 2021-04-23 10.30953/tmt.v6.256