Topic: Telemedicine Indian Context

Speaker: Dr Sunil Srinivasan, Consultant Pediatrician, Trichy, Tamil Nadu, India & 

Dr Monica Vasudev, Allergist & Clinical Immunologist, Fellow of American Academy of Asthma, Allergy and Immunology, Advocate Aurora Health, Wisconsin, USA 

17th September, 2022, Saturday

9.30-10.30am

• Telemedicine has become a necessity due to the Covid pandemic. It is a huge area. It is the delivery of healthcare services by healthcare professionals using information and communication technologies to get information for diagnosis, treatment and prevention of diseases and injuries.
• Telehealth is the delivery and facilitation of health and health-related services by means of telecommunication and digital communication technologies.
• Telemedicine is still useful even though in-person visits have resumed (direct consultations).

• Telemedicine in India began in 2001. Now many hospitals are providing telemedicine services in the country.
• In India, the telemedicine services come under the jurisdiction of the Ministry of Health & Family Welfare and the department of Information technology.
• The health ministry has set up a national telemedicine portal to implement a green field project on e-health including Telemedicine on National Medical College Network (NMCN) for interlinking the Medical Colleges across the country with the purpose of e-Education and National Rural Telemedicine Network for e-Healthcare delivery.
• e-Sanjeevani is the free national telemedicine service provided by the government.
• The health ministry has formulated standards for electronic health records (HER), first released in 2013 and later updated in 2016.
• The telemedicine services in India are just confined to modern medicine, they also cover traditional medicine, the National Rural Ayush Telemedicine Network.
• Various applications of telemedicine are tele-education, tele-conferencing, tele-procutoring, school-based health centers, correctional facilities, mobile health clinics, industries, shipping and transportation.
• Telehealth care is the use of ICTs for preventive and promotive healthcare. It comprises of teleconsultation and tele-follow up.
• Another application of telemedicine is tele-home healthcare where patients can be monitored from a central station with the help of a Computer telephone integrated system for 24-hour monitoring of vitals.
• Telemedicine can also be used in specialties like tele-ophthalmology, tele-psychiatry, tele-cardiology and telesurgery, tele-radiology and tele-endoscopy.
• In August 2020, the Government of India launched its telemedicine service, eSanjeevani as part of its Digital India initiative. It has been used by physicians to diagnose and treat Covid patients in different locations through video conferencing. There are two types of services: Doctor to doctor (eSanjeevani) and patient to doctor (eSanjeevani OPD). This platform was used for non-Covid essential healthcare.
• Benefits of Telemedicine are improved diagnosis and better treatment, continuing education and training, quick and timely follow-up of discharged patients. It also provides access to computerized data of the patients, both off-line and virtually.
• It saves money, time and travel. Its easily accessible and need not be synchronous with the patient’s questions. Doctor can respond when free and not necessarily at the same time. It resolves much of anxiety of the patient.
• Many patients need regular follow-up. This can be easily solved with telemedicine.
• The basic requirements for telemedicine include a WhatsApp account, laptop and a payment gateway. Anydesk access, clinical software and a WhatsApp business account. The consultation can be either prepaid or postpaid. Doctors are allowed to charge for the patient. Ask the patient to send the payment receipt.
• Telemedicine is completely legal according to the National Medical Commission (February 2022). The prescription should be as per guidelines and should contain patient advice and plan of action. Charges can be levied.
• Certain etiquettes need to be followed even for telemedicine. Three calls should be made for any teleconsultation. First call to determine the symptoms. Get permission from the patient for video call. The second call is for visual check, vitals check and response check. In the third call, explain, clarify and then prescribe.
• However, there are disadvantages too. It is difficult to measure pulse, BP and temperature. Palpation and auscultation are not possible. Subtle clinical cues can be missed. There may be logistics problems e.g., internet, electricity etc.
• Ethics are the most important issue associated with telemedicine.
• All sessions must be recorded. Proper terms and conditions including legal conditions should be covered through a simple agreement.
• The pandemic showed us that there was inequity in terms of access to healthcare. Telehealth allows us to address barriers to access to healthcare. 
• The market for telemedicine will continue to grow.
• It has accessibility for primary/ambulatory care (outpatient/referral, on-demand/direct patient access), acute care (tele ICU, surgical/medical support) and post-acute or remote care (transition of care, remote patient monitoring).
• In the postpandemic world, the impact of telehealth is based on specialty. Doctor visits would alternate between in-person and virtual visits. It provides ease to obtain a second or third opinion. The patient can be evaluated by those out of state or in another company. Multiple family members can be communicated with telemedicine.
• Future of telemedicine includes primary care delivery model, potential to reduce the cost of healthcare, improved access to healthcare especially in the underserved communities. But we will need to navigate legislation and the various legalities.
• Monkeypox fatalities have been reported in 10 countries including India, Nigeria, Spain, US and Mexico.
• Neurological complications can occur although they are rare. Altered mental status, loss of bowel and bladder control, upper and lower limb weakness and numbness. Clinicians should be aware of possible neurological complications and potential treatments.
• The site of the body in first contact (skin vs mucosal tissue) may influence the severity of the disease.
• The Covid numbers are slowly improving. “Novid” is someone who has never had Covid. 
• Singapore has quite extensive rules and regulations about telemedicine over the last couple of years. Training was mandatory. During telemedicine, it is important to know exactly where the patient is in order to activate EMS in case the patient collapses during the consultation. The rules also stipulate for collecting payment before the teleconsultation. 
• Internet problems are a limitation of telemedicine. 
• Telemedicine revolutionized care during Covid when doctors were reluctant for in-person consultations.
• There should be regulations to prevent misuse of videos.
• Tele-laboratory is a new concept.
• Doctors should ensure that they are talking to the actual patient and not someone who impersonates the patient. Be fact specific, identify each other and record the session after taking the patient’s consent.
• A credible doctor-patient relationship must be established for teleconsultation.
• Some steps can be missed because of time constraints, which can be dangerous.
• Be careful about cybercrimes.
• Teleconsultation must be followed by a prescription stating what has been discussed, diagnosis, and treatment etc. Documentation is essential. Teleconsultation does not indemnify.

Participants

Member National Medical Associations

Dr Yeh Woei Chong, Singapore, Chair of Council CMAAO

Dr Alvin Yee-Shing Chan, Hong Kong, Treasurer, CMAAO

Dr Mvuyisi Mzukwa, South Africa

Dr Prakash Budhakoti, Nepal

Dr Ravi Naidu, Malaysia

Dr Ashraf Nizami, Pakistan

Dr Akhtar Hussain, South Africa

Dr Salma Kundi, Pakistan

Dr Mulazim Hussain Bukhari, Pakistan

Invitees

Dr Sunil Srinivasan

Dr Monica Vasudev

Dr Abid Karim

Dr EC Ng

Dr Patricia La’Brooy

Dr Pinki Chauhan

Dr Chia Ai Mian

Dr Mubbashir

Dr Lawrence HB Soh

Dr Cheng Ta Ling

Dr Rashid Mahmood

Dr S Sharma, Editor IJCP Group

Moderator

Mr Saurabh Aggarwal