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eAPICON2021 - a-HELLO: API initiated Therapy Specific Recommendations for Teleconsultation

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Dr Mangesh Tiwaskar, Dr Shashank Joshi, Mumbai    05 March 2021

  • Telehealth has three aspects: Monitoring of patients, telemedicine and tele-education.
  • Key therapy areas to be focused – 15 therapy areas distributed across 3 segments
  • First bucket of therapies: Vaccine, Cardiology, Gastroenterology, Diabetes, ENT
  • Second bucket of therapies: Gynecology, Neurology, Pediatrics, Pulmonology, Osteoporosis/Thyroid disorders
  • Third bucket of therapies: Dermatology, Psychiatry, Rheumatoid arthritis/Osteoarthritis, Oncology, Infertility.
  • Medicolegal issues
  • Doctor-patient relationship: The lack of face-to-face contact in some modes of telemedicine is seen as a barrier to adequate development of the doctor-patient relationship; it is essential to maintain the trust of the patient to meet legal requirements
  • Informed consent: Informed consent is an important medicolegal requirement while treating a patient; consent should be obtained for telemedicine interaction, transmission of data, treatment, monitoring and consultation
  • Privacy: The right to privacy has been an integral part of medical ethics since the time of Hippocrates and is supported by various codes including the International Code of Medical Ethics; password security should be maintained to avoid unauthorized access to information; can we guarantee privacy with the use of telemedicine?
  • Rights of patients: Patient has a right to receive one’s medical record in the electronic format to know standards and safety guidelines
  • Reimbursement: Currently, there is no provision for reimbursement from medical insurance in telemedicine practice.
  • Laws applicable in India
  • Some of the laws relating to the medical profession include: The Drugs and Cosmetics Act, 1940, and Drugs and Cosmetics Rules, 1945; Indian Medical Council Act, 1956; Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002; Clinical Establishments (Registration and Regulation) Act, 2010
  • Laws related to ICT include: Information Technology Act, 2000 (IT Act); Information Technology (Reasonable Security Practices and Procedures and Sensitive Personal Data or Information) Rules, 2011; Information Technology (Intermediaries Guidelines) Rules, 2011; Unsolicited Commercial Communications Regulations, 2007; Telecom Commercial Communication Customer Preference Regulations, 2010.
  • HIPAA Guidelines on Telemedicine: Electronic protected health information (ePHI)
  • The channel of communication used for communicating ePHI at distance also has to be HIPAA-compliant
  • You should not use SMS, Skype or email for telemedicine: as copies of communications sent by SMS, Skype or email remain on service providers’ servers, and contain individually identifiable healthcare information
  • Communicating with patients using secure messaging.
  • Challenges and the future
  • Institution of a regulatory authority
  • Standardized format of information to patients and consent form with option to opt in/out of telemedicine
  • Mandatory telemedicine courses for all medical students and refresher courses for medical practitioners and technical staff
  • Responsibility for privacy, confidentiality and security of patient information and treatment
  • Accreditation/licensing of doctors using telemedicine
  • Building confidence of both the patient and distant doctor
  • Clear guidelines for teleconsulting insurance
  • Clear guidelines on issues of telemedicine across national borders
  • Standardization of equipment and teleservices with periodic checks and submission to a regulatory authority
  • Equipment liability, maintenance and safety
  • Telemedicine laws for information storage and access
  • Dedicated staff to manage telemedicine services
  • Establishing telemedicine unit at every hospital
  • Proper communication and documentation
  • Maintenance and regular upgrading of hardware and software.
  • The pandemic has changed our practice. ‘Safety first’ has become the dictum. The change is not difficult; doctors have to adapt and adopt new systems.
  • Need for therapy specific teleconsultation guidelines – 
  • 1:1000 is the WHO globally recommended doctor population ratio. The doctor population ratio in India is 0.62:1000.
  • Impact of pandemic – Ever evolving response to combat the pandemic; minimal access to quality healthcare services; telemedicine is the preferred and most accessible channel.
  • The reliability and quality from digital consultation practices continues to be in question
  • The available guidelines are generic and do not cover indication specific use cases
  • Ambiguity around application and suitability of digital platforms across different therapeutic areas
  • Aims of teleconsultation – To provide cost-effective, faster, quality healthcare services all over India, overcoming geographical barriers; identify disease that can and cannot be diagnosed and treated by teleconsultation; identify disease specific red flags that must not be missed; define key steps for a good quality teleconsultation; frame guidelines to safeguard health and interests of both physician and patient.
  • Pros of teleconsultation
  • Gives access to healthcare services in remote areas and to those with mobility issues such as the elderly
  • It has the power to overcome geographical barriers to provide healthcare services
  • It may provide an opportunity to reduce healthcare spending
  • It can save time for the patient and caregiver
  • With the advent of telemedicine, a medical practitioner or hospital can consult with different specialists, irrespective of their location
  • It helps patients to engage with their healthcare providers more frequently, in a convenient way, which may result in a better doctor-patient relationship
  • The follow-up of patients is likely to be better, which may improve outcomes.
  • Overall, telemedicine has the potential to provide better healthcare services to the masses.
  • Cons of telemedicine
  • Telemedicine requires infrastructure and technical training
  • It may reduce direct interaction of patients with doctors because online interactions are impersonal and to make a complete diagnosis, physical examination needs to be done
  • There is a lack of standardized format to the interaction and the absence of a consent form for either opting for or refusing the service
  • Telemedicine is still not included in the medical curriculum
  • Besides ambiguity regarding responsibilities in case of negligence, there are concerns about privacy, confidentiality, security of patient information and treatment
  • There is no clarity with respect to medicolegal issues arising out of telemedicine
  • Currently, no health insurance policy in India factors in telemedicine.

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