Telemedicine in India

1.1 Introduction

Telemedicine includes the use of communication networks and digital solutions in

providing health services. It allows collaboration between providers and patients
across spatial boundaries, for activities linked to health promotion, prevention,
diagnosis, timely referral, management and follow-up of patients.

Evolution of telemedicine in India

E-health solutions, which include telemedicine, are recognized as cost-effective tools

to increase access to health care and to improve patient outcomes(1). Telemedicine
in India was started with the support of the Indian Space Research Organisation (ISRO)
in 2001 (2). Multiple telemedicine projects have been initiated in different states of the
country in collaboration with Ministry of Electronics and Information Technology
(MEITY) and Ministry of Health and Family Welfare (MoHFW) (3,4).

The National Health Policy-2017 advocated extensive deployment of digital tools for
improving the outreach of the healthcare system (5). Online consultation networks
for telemedicine, including the National Medical College Network (NMCN) and State
telemedicine networks, were established(1). In 2019, the telemedicine guidelines for
Health and Wellness Centres (HWC) of the Ayushman Bharat Scheme were released
to leverage Information Communication Technologies (ICT) to connect the HCW
with the Medical colleges.

Telemedicine guidelines by the Ministry of Health and Family Welfare

MoHFW, Government of India released the ‘Telemedicine Practice Guidelines’ in

March 2020 to give practical inputs to the doctors in realizing the full potential of the
telemedicine for better healthcare delivery in the aftermath of the COVID-19
pandemic (6). The guidelines are focussed on the Registered Medical Practitioner
(RMP) defined as a person who is enrolled in the State Medical Register or the Indian
Medical Register under the Indian Medical Council (IMC) Act 1956.

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The following sections are covered in detail in telemedicine guidelines that is a
component of the Indian Medical Council (Professional conduct, Etiquette and Ethics
Regulations 2002) (IMC Act 2002)

• Definition of telemedicine • Patient information, confidentiality

• Scope of telemedicine and consent
• Types of telemedicine • Drug prescription rules
• Telemedicine technologies • Documentation & medical records
• Duties & responsibilities of Medical
Practitioner

These guidelines shall support increased utilization of telemedicine and will increase
the availability, access and affordability of health care in the long run. Telemedicine
is an important tool to ensure universal health care coverage in India.

1.2 Definitions

Telehealth

The delivery and facilitation of health and health-related services, including medical
care, provider and patient education, health information services, and self-care via
telecommunications and digital communication technologies(6).

Telemedicine

Telemedicine is defined as “the delivery of health care services, where distance is a

critical factor, by all health care professionals using information and communication
technologies for the exchange of valid information for the diagnosis, treatment and
prevention of disease and injuries, research and evaluation, and for the continuing
education of health care providers, all in the interests of advancing the health of
individuals and their communities” (7)(8).

Telemedicine encompasses all systems, modalities and applications involved in the

delivery of health services to substitute for any exchange of information and
communication employing an electronic format. Hence, telemedicine aids in the
electronic exchange of information and communication through -

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• Teleconsultation

Teleconsultation is defined as synchronous or asynchronous consultation using

information and communication technology to overcome geographical and
functional distance (9).
• Telemonitoring

Telemonitoring is described as the use of information and communication

technology to track and communicate patient health problems among
geographically distant people (10).
• Teletriage

The method of identifying individuals into different categories based on their need
for emergency medical attention as opposed to their chance of benefiting from
such care using information and communication technology.

1.3 Types of interventions and modes of communication

There are multiple technologies for the implementation of telemedicine today. The
technology used and the mode of communication used in telemedicine should be
customized to the objectives of the interaction. Commonly, the types of interventions
are differentiated based on the time of communication between the stakeholders.

Synchronous

In synchronous interaction, the stakeholders or the participants of the telemedicine

are interacting with each other dynamically in real-time. The communication is quick,
and it provides an opportunity for the participants to solve queries (if any) in real-time.
For example, video consultation is a synchronous teleconsultation.
Asynchronous

It is also called the “store and forward” way of communication. Here the participants
can interact or reply in their own time frame. There is no real-time interaction between
the stakeholders. It is suitable when the consultation or communication is not urgent.
It is mainly used for forwarding the investigation reports, or for routine follow-up.
Examples include e-mail, text messages, fax.
Remote monitoring

This is also called the remote patient monitoring and refers to the method of health
care delivery that uses the advances in information and technology to monitor

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patients outside the healthcare settings. The patient data is electronically transmitted
to the healthcare provider, who monitors the patient for the maintenance of health
and development of any new disease states.

Mode of communication

The mode of communication chosen should be based on the purpose of the

communication.
• Video
Video consultations are closest to the in-person consultations. The
communication is two ways, interactive and real-time. Patient identification is
straightforward. This mode allows inspecting and getting visual cues from the
patient. It also provides an opportunity to examine patient and demonstrate
certain activities to the patients.

• Audio
Audio consultation is more convenient and readily available compared to the
video consultation. The interaction is dynamic and real-time. The information
provided can be exchanged iteratively between the provider and the receiver.
Audio consultation provides verbal cues but misses non-verbal cues and is not
suitable for conditions that require visual inspection.

• Text-Based
Text-based consultations are convenient and quick. These may be either real-
time when the interaction is simultaneous or delayed, like in ‘store and forward’
systems. These are best for follow-ups and second opinions. The text-based
platforms also help in better transmission of documents, including the test reports
and previous medical records. However, text-based platforms lack both visual
and verbal cues.

1.4 Medical Ethics

Health-related data of patients should be recorded and handled as per Telemedicine

guidelines released as Appendix 5 of the Indian Medical Council (Professional
Conduct, Etiquette and Ethics) Regulation, 2002 (6), that outlines the duties and
responsibilities of a doctor, misconduct rules and ethical aspects of consent, data
privacy and confidentiality.

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1.4.1 Consent

Consent of patient/caregiver holds a vital role in the telemedicine consultation.

Consent needs to ensure that the patient understands the nature and scope of
telemedicine and also the nature and scope of the disease under consideration.

informed consent should also include aspects of teleconsultation. It should explain

• Scope of the consultation

• Expected benefits
• Nature of consultation
• Medical information and records
• Confidentiality
• Risk and limitations of the consultation

The standards of informed consent as is applicable for the in-person consultation are
applicable for the teleconsultation also.

Implied versus Explicit consent

Implied consent is a presumption of approval to do something that is deduced from

the acts of a person, rather than expressly stated. When the patient/ person initiates
a teleconsultation, it is considered to be implied consent. At the same time, explicit
consent is an expressly stated statement of approval. When a teleconsultation is
physician/ doctor initiated, there is a need to take explicit consent.
Consent can be obtained through any one or more of the following modes
depending on the type of consultation, and this should be recorded in the patient’s
records.
• Audio Consent- Verbal
• Video Consent- Through video conferencing
• Digital Consent- As text

1.4.2 Data privacy and confidentiality

• Professional standards for data privacy and confidentiality under IMC Act 1956
and IMC (Professional Conduct, Etiquette and Ethics) Regulations 2002 should
be adhered to while providing telemedicine consultation.
• The teleconsultation is also bound by similar data protection and privacy laws
as applies to an in-person consultation.

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 • A system should be developed for documentation, storage and retrieval of the
medical records. All the documents as applicable for in-person consultation
should also be maintained for teleconsultation.

1.4.3 Standards of care

• The doctors providing telemedicine services shall abide by the same standard
of care as followed in-person consultation.
• The doctors shall ensure that the patients/ family members will receive correct
and timely information on the nature and severity of their illness.

1.5 Preparation

Any organization planning to provide care through telemedicine should assess the
preparedness for the same.

Organizational Readiness

Assessing organizational readiness is a comprehensive task and necessary as many

stakeholders are involved in running an organization.

• Leaders should be proactive and provide direction in adapting to telehealth

services
• The leaders can act as change agents and promote behavioural change of
others in the organization for telemedicine.
• Motivation to learn new skills and explore new ways of care provision will help
in easy implementation of telemedicine.
• The existing operation and administrative protocols of the organization may
need assessment to accommodate telemedicine services.
• While multiple staff of an organization may be involved in care provision, a
nodal person or a group of people from different departments should be
identified who will be accountable for the smooth functioning of telemedicine
services.

Provider Readiness

• Readiness in terms of availability of professionals and ancillary staff, affordability

and operational feasibility of delivering services through telemedicine should
be assessed and strengthened.

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 • Capacity building of both professionals and support staff is necessary based
on the levels of motivation, and challenges identified.

Patient Readiness

• The readiness should be assessed in terms of availability of technology,

affordability, acceptability, user penetration and friendliness of the
telemedicine technologies through in-person interviews, exit services or web-
based patient surveys as may be appropriate.
• Behavioural change for using telemedicine services can be promoted through
counselling, posters, pamphlets and professional guidance.
• Modes of teleconsultation should be customized to the patient’s needs and
comfort.
• Patients might need handholding in terms of understanding the advice and
maintaining electronic health records.