The new Telemedicine Practice Guidelines enabling Registered Medical Practitioners (RMPs) to provide healthcare remotely as per Telemedicine guideline were released by NITI Aayog on 25 March 2020. The guideline aims to address challenges faced in providing health care and access to doctors on account of large geographical distances and limited resources in India. As per WHO, India ranks 184^th out of 191 countries, in terms of percentage of GDP spend on healthcare. While India’s health care sector is one of the largest and fastest-growing in the world, the doctor and patient ratio in India is still not at par with the recommendation of WHO that is one doctor for 1,000 people. The data suggests India has one doctor for every 1,445 Indians. The telemedicine guidelines when viewed in that context would permit doctors to connect with patients via communication technologies benefiting not only urban but also rural population and help to connect with the areas that lack standard healthcare services. Further telemedicine and telehealth services would provide access to the well equipped healthcare experts in case of disasters and pandemic. In other words, telemedicine is well suited for preventing the transmission of infectious diseases reducing the risks to both health care workers and patients preventing the unnecessary and avoidable exposure of the people involved in delivery of healthcare services.

Until coming into effect, the Telemedicine guidelines there was no legislation or guidelines that would regulate the practice of telemedicine, through video, phone, Internet based platforms (web/chat/apps etc). With the popularity of mobile devices and increasing internet penetration, it is a right move by the government to have Telemedicine bridge the gap between low doctor and high patient ratio.

The post highlights key features of the guideline/s:

• The guidelines defines Telemedicine as: “The delivery of health-care services, where distance is a critical factor, by all health-care professionals using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health-care workers, with the aim of advancing the health of individuals and communities.”
• Who can provide the service: The healthcare can be provided by ‘Registered Medical Practitioner’ (RMP) who is enrolled in the State Medical Register or the Indian Medical Register under the Indian Medical Council Act 1956. All registered medical practitioners intending to provide online consultation need to complete a mandatory online course within 3 years of the notification of these guidelines. He/She can provide telemedicine consultation to patients from any part of India.
• The guidelines as of now regulate allopathic medicines.
• The guidelines exclude use of digital technology to conduct surgical or invasive procedures remotely.
• Mode of Communication: Multiple technologies can be used to deliver telemedicine consultation. There are 3 primary modes: Video, Audio, or Text (chat, messaging, email, fax etc.)
• The guidelines also lays out the framework for practicing telemedicine in various mechanism that involves i) Patient and Registered Medical Practitioner ii) Caregiver and Registered Medical Practitioner iii) Health Worker and Registered Medical Practitioner   iv) Registered Medical Practitioner and Registered Medical Practitioner v) Emergency Situations
• Accountability: It entails the same professional accountability as in the traditional in-person consult. Prescribing medications via telemedicine consultation is at the professional discretion of the RMP.
• Patient consent: Patient consent is necessary for any telemedicine consultation. The consent can be Implied or explicit. If, the patient initiates the telemedicine consultation, then the consent is implied while explicit patient consent is needed if a Health worker, RMP or a Caregiver initiates a Telemedicine consultation. 
• Procedure for consulation: Telemedicine consultation should not be anonymous. Both patient and the RMP need to know each other’s identity. An RMP should verify and confirm patient’s identity by name, age, address, email id,  phone number, registered ID or any other identification as may be deemed to be appropriate. The RMP should ensure that there is a mechanism for a patient to verify the credentials and contact details of the RMP. Every RMP shall display the registration number accorded to him/her by the State Medical Council/MCI, on prescriptions, website, electronic communication (WhatsApp/ email etc.) and receipts etc. given to his/her patients. For issuing a prescription, the RMP needs to explicitly ask the age of the patient, and if there is any doubt, seek age proof. Where the patient is a minor, after confirming the age, tele consultation would be allowed only if the minor is consulting along-with an adult whose identity needs to be ascertained. RMP shall provide photo, scan, digital copy of a signed prescription or e-Prescription to the patient via email or any messaging platform.
• Data privacy: Registered Medical Practitioner would be required to fully abide by Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002 and with the relevant provisions of the IT Act, Data protection and privacy laws for protecting patient privacy and confidentiality and regarding the handling and transfer of such personal information regarding the patient. The RMP has to maintain digital trail/ documentation of consultation including log or record of telemedicine interaction (e.g. phone logs, email records, chat/ text record, video interaction logs etc.)., Patient records, reports, documents, images, diagnostics, data etc. (Digital or non-Digital) utilized in the telemedicine consultation should be retained by the RMP. Specifically, in case a prescription is shared with the patient, the RMP is required to maintain the prescription records as required for in-person consultations.
• Misconduct by RMPs:

  The guidelines have provided following as examples of actions that are not permissible and to be treated as misconduct:

  • RMPs insisting on Telemedicine, when the patient is willing to travel to a facility and/or requests an in-person consultation
  • RMPs misusing patient images and data, especially private and sensitive in nature (e.g. RMP uploads an explicit picture of patient on social media etc)
  • RMPs who use telemedicine to prescribe medicines from the specific restricted list
  • RMPs are not permitted to solicit patients for telemedicine through any advertisements or inducements
• What can be prescribed: Not all the medicines can be prescribed through Telemedicine. The categories of medicines that can be prescribed are listed below:  
  • List O: Medic\ines which are safe to be prescribed through any mode of tele-consultation.e.g. Medicines which are used for common conditions and are often available ‘over the counter’ like paracetamol, ORS solutions, cough lozenges etc
  • List A: Medicines which can be prescribed during the first consult which is a video consultation and are being re-prescribed for re-fill, in case of follow-up. These are relatively safe medicines with low potential for abuse.
  • List B: Medicines that can be prescribed to a patient who is undergoing follow-up consultation in addition to those which have been prescribed during in-person consult for the same medical condition. 

There is also a category of prohibited medicines which cannot be prescribed via telemedicine. This includes medicine with high potential of abuse or which can harm the patient.

• Artificial Intelligence based platforms not to act as RMP

Technology platforms based on Artificial Intelligence/Machine Learning are not allowed to counsel the patients or prescribe any medicines to a patient. Only a RMP is entitled to counsel or prescribe and has to directly communicate with the patient in this regard. While new technologies such as Artificial Intelligence, Internet of Things, advanced data science-based decision support systems etc. could assist and support a RMP on patient evaluation, diagnosis or management, the final prescription or counseling has to be directly delivered by the RMP.

To sum up, it would be good to see how the telemedicine practice practically evolves taking into account cultural sensitivities of India that vary from each region. In general if we take United States and Canada as an example where telemedicine has been permitted for quite some time, the reports suggest despite numerous benefits that telemedicine offers, the patients still prefer visiting the doctor for the personal contact. Another important issue is the reimbursement of practitioner charges through health insurance. If insurance schemes in India would not cover telemedicine consultation, the patients in that case would surely follow physical visit to be able to get the reimbursement. As with delivery of any service via internet, the telemedicine will of course not be immune to cyber frauds. Further digitization of highly confidential and sensitive data of patients will bring in privacy issues that medical practitioners may not be attuned to. As the telemedicine becomes popular the solutions would also emerge since much is at stake with healthcare industry in India estimated to be $ 65 billion and growing annually at 15%.