The onset of the COVID-19 pandemic in India has posed significant challenges in the execution of face-to-face medical consultations. Telemedicine as a healthcare delivery tool has been slow to gain momentum in India due to the absence of concrete guidelines and appropriate frameworks. But in response to the Prime Minister’s announcement of the nationwide lockdown in March 2020, the Ministry of Health and Family Welfare issued the ‘Telemedicine Practice Guidelines’. The purpose of the guidelines is to provide medical professionals practical advice on how to incorporate telemedicine tools for the continued delivery of effective medical care.

The comprehensive guidelines cover various aspects of telemedicine like technological tools that can be used, remote prescription of medicines, and general responsibilities of the registered medical professional. Below are summaries of some of the key guidelines:

Technological tools for telemedicine:

The guidelines detail three primary modes of communication:

• Video - Applications, videos on chat platforms like Skype and Facetime and in telemedicine facilities.

• Audio - Phone calls, applications, Voice over Internet Protocol (VoIP).

• Text-based - Specialized chat-based applications for telemedicine, general text or chat platforms (WhatsApp, Google Hangouts, Facebook Messenger), asynchronous communication (email, fax).

Each mode of communication entails several strengths and limitations, and it is imperative to understand them to ensure the appropriate delivery of a proper diagnosis. The preferred mode of communication for a medical professional would depend on several factors like the complexity of the case, the type of consultation being provided, and IT-related infrastructures available on both the medical professional’s and patient’s sides.

Medical professional’s responsibilities while practicing telemedicine

There are several considerations for the medical professional while transitioning to and practicing telemedicine. Some of them are as follows:

• The medical professional should use their discretion in determining whether a telemedicine consultation would suffice or an in-person consultation is required.

• The standard of care delivered via telemedicine to a patient should not be compromised. The fees charged for a telemedicine consultation should also be the same as for an in-person consultation.

• The patient and medical professional should be able to verify each others’ identities. From the patient’s end, the name, age, address, email ID, and a form of identification is required. From the medical professional’s end, the prominent display of their registration number is needed.

• Explicit consent from the patient is paramount for medical professionals who initiate remote consultations via video, audio, or text messaging. But if a patient initiates a remote consultation, consent is implied.

• The patient’s information (history, examination findings, past records) can be shared with the medical professional through synchronous means (live video chats) or asynchronous means (email or fax).

• With the electronic exchange of patient data, it is necessary for the medical professional to be aware of data protection and privacy laws.

Prescribing medicines via telemedicine

The medical professional may prescribe medicines only when they are satisfied with the information gathered about the patient’s medical condition and if they deem the prescribed medicine to be in the patient’s best interest. The guidelines list four categories of medicines based on their safely and potential for abuse:

• List O - Medicines that can be safely prescribed via any mode of telemedicine consultation. This includes over-the-counter medicines.

• List A - These medicines can be prescribed during a first consult, and can also be re-prescribed or refilled during a follow-up consult.

• List B - These are medicines prescribed during a follow-up consultation in addition to those that have been already prescribed for the same medical condition.

• Prohibited List - These are medicines that strictly cannot be prescribed via any mode of telemedicine consultation due to their high potential of abuse and harm if used improperly.

A medical professional can issue prescriptions upon confirmation of the patient’s age. AI-based and machine-learning-based technology platforms are not authorized to prescribe medicines.

Telemedicine via a caregiver

The guidelines refer to a ‘caregiver’ as a family member or an authorized person who represents the patient. There are a few situations in which the patients may not be present with the caregiver during a telemedicine consultation. The requirement for authorization differs between the two situations:

• If the patient is a minor (16 years or below) or is incapacitated (due to dementia, physical disabilities, etc.), the caregiver is authorized to participate in telemedicine consultations on behalf of the patient.

• For all other patients, formal authorization for the caregiver or documentation verifying the relationship between the patient and caregiver is required for the caregiver to participate in telemedicine consultations in place of the patient.

It should be noted that the guidelines exclude aspects of telemedicine like hardware and software specifications, IT-related infrastructure building and maintenance, and undertaking surgical and invasive procedures remotely. Nevertheless, the current guidelines remedy the earlier lack of a vetted framework on telemedicine for medical professionals to adopt.

• Vikram Thaploo, CEO, Telehealth, Apollo Hospitals Group, India The COVID-19 pandemic has brought on logistical challenges for healthcare delivery given the heightened vulnerability of some populations (like those with noncommunicable diseases) to severe COVID-19 symptoms and the risk of exposure to healthcare workers. Screening patients remotely and the swift adoption of telemedicine tools are now more important than ever. The rollout of the new guidelines has led to a surge in the use of online medical consultations in the country, and many medical professionals have already welcomed the digital model of healthcare delivery. In a 2019 report by the McKinsey Global Institute, India was predicted to save up to $10 billion if 30-40% of consultations were done via telemedicine rather than face-to-face. Telemedicine represents a paradigm shift in the avenue of healthcare delivery, and the new telemedicine guidelines are a move in the right direction towards India embracing digital health technologies.

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