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Frequently Asked Questions [FAQs] on Telemedicine Practice Guidelines

April, 2020

Note: The Telemedicine Practice Guidelines is an integral part of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, popularly known as the Code of Medical Ethics. Hence, the principles enunciated therein are ipso facto applicable to the practice of Telemedicine. FAQs are indicative only , not exhaustive.

FAQs on Telemedicine Practice Guidelines

FromPatients/ Care-seekers’ point of view

1. How can I know whom to contact or how to get in touch with the doctor (Registered Medical Practitioner, RMP) on telemedicine?

Patient can contact any RMP of modern medicine duly registered with MCI/State Medical Councils; and if he/she agrees to provide a telemedicine consult, then it means mutual consent has been given.

2. I am old and unable to physically visit a hospital and I have a nurse taking care of my clinical condition. Can I ask my nurse to consult on my behalf and how can she enable me for a better consultation?

Definitely. Your nurse ( duly trained and registered in Nursing Council ) can consult on your behalf if you record your consent with the RMP for the same during tele-consultation. The RMP can request your Nurse to do routine clinical examination (for which nurse is duly trained) and provide requisite information, and then RMP can provide health care advice, counselling and prescribe appropriate medications.

3. In case of an emergency, can I call any RMP for an immediate advice?

Yes, you may call any RMP for an advice for a medical emergency, but you cannot insist for an advice if the RMP chooses not to reply or give any specific advice.

4. How would teleconsultation be useful in an emergency?

In case alternative care is not immediately feasible, tele-consultation might be the only way to provide timely care. In such situations, RMPs may provide consultation to their best judgement. Such services might be limited to first aid, life-saving measure, counselling and advice on referral. However, telemedicine should be avoided for emergency care to the possible extent specially when alternative in-person care is available.

5. Would a RMP be entitled for fee for his/her consultation through telemedicine also?

As per the guidelines, an RMP is authorized to charge a fee for a consultation and provide a receipt for the same.

6. Can a RMP refuse or discontinue tele-consultation at any point of time?

The guidelines allow a RMP to refuse or discontinue a teleconsultation, with due notice to the patient , during any time of the consultation process. Similar liberty has also been provided to the patients.

7. Are the prescriptions provided via teleconsultation legally valid and how do I ensure that the RMP is qualified for the prescription?

It is mandated in the guidelines that for all teleconsultations, the RMP should identify him/herself and also mention/ display his/her MCI/State Medical Council registration number. It is also mandatory that the RMP issues prescription as per the specified format, which should have his/her digital signature and the Registration number. The Registration of the RMP can always be counter checked, if desired on the websites of relevant Medical Councils.

8. How do we know that our privacy is not breached by teleconsultation?

The Guidelines have laid down strict norms for the RMPs not to breach the privacy of the patients in any form. However, the RMP cannot be held responsible if there is a reasonable evidence to believe that patient’s privacy and confidentiality has been compromised by a technology breach or by a person other than RMP.

9. If I am on a follow-up care for a Chronic condition (say Diabetes), for how long can I continue to request for refill for my medications to my RMP?

The Guidelines define follow-up consultation for a maximum period of 6 months. After this period, an in-person consultation is mandatory.

10. We are a group of Technology Platform providers for enabling teleconsultations on behalf of patients with RMPs. How does the guideline enable us?

Section 5 of the Tele medicine Guidelines have laid down specific guidelines for the same and may please be referred to.

From RMP/ Care-givers’ point of view

1. Who are entitled to provide telemedicine consultation?

As on date all Registered Medical Practitioners (RMP) under IMC Act, 1956 can provide telemedicine consultations but only after they qualify the prerequisites.

2. What are the prerequisites to be for doing a telemedicine consultation?

The MCI is in process of developing an online telemedicine course for ensuring uniformity. Once the course is developed, it will be mandatory for all RMPs to undertake this course within three years of its notification. Thereafter, it will be compulsory for all RMPs who wish to tele-consult to have undergone such a course. As on date, all RMPs can tele-consult, provided they follow the Telemedicine Practice Guidelines notified under IMC Act, 1956.

3. Can a Health Worker and Care givers do teleconsultation for a patient?

Yes a health worker such as Auxiliary Nurse Mid-wife (ANM)/Nurse etc. can do tele-consultation for a given patient. The guidelines mention the framework for such a scenario.

4. In case I feel the patient requires a physical examination, how do I ensure that?

The RMP has the right to pause his/her tele-consultation and recommend an in-patient consultation. Besides, if during the teleconsultation it appears that a physical examination is mandatory but not feasible on the mode being used for the consultation, the tele-consultation should be aborted and the patient referred for an in-person review.

5. Do I need to keep screenshots and records to safeguard myself?

Yes. It is specified in guidelines. It is incumbent on the RMP to maintain the following records/ documents for the period, as prescribed from time to time. These include Log or record of Telemedicine interaction (e.g. Phone logs, email records, chat/ text record, video interaction logs etc.). The RMP should retain patient records, reports, documents, images, diagnostics, data (Digital or non-Digital) etc. utilized in the telemedicine consultation. 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.

6. Recently, I have heard in legal disputes that judgement has been given that doctors are not supposed to communicate on WhatsApp. What is the status after these guidelines?

With the notification of Telemedicine Practice Guidelines under the IMC Act, 1956 RMPs under IMC Act, 1956 are now empowered and legally protected to provide teleconsultation by any mode, for various settings, as specified in the document.

7. What are the legal effects of inadequate management as perceived by a patient?

The Telemedicine Guidelines comprehensively provides various settings under which different modes of teleconsultation can be undertaken and also enunciates steps to be undertaken to prevent any miscommunication between the patient and RMP. Besides, it also mentions steps to be taken to ensure documentation and thereby avoid legal issues. If despite these measures, the patient still perceives inadequate management, which can also happen in an in-person consultation, the legal issues need to be dealt in a similar way.

8. What happens if a doctor does not want or wishes not to attend to a request made by phone or WhatsApp?

The Telemedicine Guidelines mention that a RMP has the liberty not to attend a teleconsultation request made by a patient.

9. What if a patient calls at an odd time like midnight when the RMP is not on duty?

The RMP can choose either to attend the call or not. The RMP can also choose not to provide consultation to the patient (if it does not suit the RMP) during on duty hours also.

10.In trauma and in acute emergency, if the RMP asks for immediate referral to a hospital and a patient insists for tele-management, what to do?

The doctor should record his/her statement about the advice given regarding referral for in-person consult (as specified in the guide lines) and referral. In case the patient insists, the best possible care that can be given on tele-consult in the form of advice, counselling, first-aid measures to enable immediate relief should be provided. In case the consultation is through a Health Worker of another RMP, advice on medications, as specified in the guidelines can be given.

11. In case of problems with internet connectivity, the resultant telephonic consult may be of poor quality. What should be done in this context?

If the issue of connectivity is in the beginning of the consult, the RMP may choose not to proceed with the consultation, citing the reasons. If the issue of poor connectivity happens during the course of the communication, the same can be recorded and kept as a proof.

12. Will the prescription sent online as an image or scan be honoured by the local chemist?

Yes, the following are specified in the guidelines: If the RMP has prescribed medicines, RMP shall issue a prescription as per the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations and shall not contravene the provisions of the Drugs and Cosmetics Act and Rules. A sample format is suggested in Annexure 2 of the document. RMP shall provide photo, scan, digital copy of a signed prescription or e-Prescription to the patient via email or any messaging platform. In case the RMP is transmitting the prescription directly to a pharmacy, he/ she must ensure explicit consent of the patient that entitles him/her to get the medicines dispensed from any pharmacy of his/ her choice

13. Do I need a print out of the prescription?

No, an e-prescription as specified in the guidelines will be sufficient. However, it should comply with the guidelines as mentioned.

14. For that matter if some investigations are needed and doctor asks for them through tele communication, will the Pathology Lab/Imaging Centre etc. honour it?

Yes, the labs or centres etc. will honour it. The Telemedicine guidelines clearly mention that counselling a patient may also involve ordering new investigations, if deemed necessary by the RMP.

15. How to tackle issue of payment of fees to an RMP, as a patient may be reluctant to pay as physical examination is not possible?

For the purpose of fees in telemedicine consultation, the guidelines specify that Telemedicine consultations should be treated the same way as in-person consultations from a fee perspective and an RMP may charge an appropriate fee for the Telemedicine consultation provided. The very fact that the tele-consultation has been initiated, it means that both patient and doctor have mutually consented for the same. These are specified in the flowcharts accompanying the Guidelines.

16. The RMP may advise beyond his jurisdiction, for which he may not have specialization. How to take care of this issue?

Once a tele-consultation has been initiated on a mutual consent between a patient and a consulting RMP, then the RMP can advise on the health issues to the best of his knowledge. All RMPs can practice modern medicine and are also aware of the jurisdiction of their specialization.

17. Can schedule H class of Drugs be prescribed by tele-consultation? Which classes of drugs have been enabled by the guidelines for teleprescription?

The drug prescription in Telemedicine guidelines is based on the clinical scenario, judgement of the RMP and the mode of consultation, as specified in the framework. Hence, specific nomenclatures such as Schedule H etc. classes of drugs have been avoided. The classification of list of drugs provided in the document is based on practical clinical pathways. A prohibited list of drugs is also given and this is specified as to include Schedule X of Drug and Cosmetic Act and Narcotic, Psychotropic substances. As such these lists of drugs mentioned in guidelines can be amended from time to time based on directions of the MCI and MoHFW.

18. Can I prescribe antibiotics on tele-consultation?

Antibiotics can be prescribed by the RMP, if he/she is strongly convinced about the same based on the type and mode of tele-consultation. As such, all tele-consultations mandate a clear documentation of provisional diagnosis and reasons for prescription of particular drug. This is as well applicable for antibiotics. As in all scenarios, the RMP will be responsible for his/her prescriptions.

19. Can I prescribe injectable medications on tele-consultation?

Prescriptions for injectable medicines can only be given if the consultation is between an RMP with another RMP. In certain circumstances, it may be prescribed to a Health Worker for administration to a given patient. In such a scenario, the RMP must be confident of the setting of the facility and the technical expertise of the Health Worker. The exceptions to these would be prescribing some follow-up medications which are available only as injections such as Insulin, Low Molecular Weight Heparin, Vaccines etc.

20. I run a busy OPD and cannot attend to many patients at the same time. Can I record a tele-consultation through my allied healthcare professional on video and then, prescribe medications off-line to the patient ?

No, this is absolutely not allowed in the guidelines. The very premise of tele-consultation through a Health worker (as per the guidelines) dictates that the RMP, Health worker and the patient introduce themselves to each other and give mutual consent for the tele-consultation. The role of Health worker is just to facilitate the process of tele-consultation to enable RMP to take informed decisions during this process. These are possible only on a live consultation. It would be highly unethical for an offline consultation through a health worker.

21. We are a group of RMPs who would like to start a ‘Telemedicine Clinic’ to care for the needy patients who would approach us. How do the guidelines help us do that? patient ?

Foremost, you have to decide the appropriateness of tele-medicine consult and its mode for a given scenario, as specified in the guidelines. You will have to record all tele-consultations and would be responsible for all consultations provided by telemedicine.
Broadly, the following are the services your group could provide:

. Health education
.Guide patients for an appropriate in-patient consult. If it’s a follow-up consult for a patient whom you have seen, can prescribe for medications for optimizing that particular medical condition to the patient or care-giver
. If it’s a new clinical condition which can be reasonably diagnosed on a video-call (such as Dermatological lesions etc), then you can prescribe medications to the patient or care-giver
. If you are a group of specialists, then, can advise other RMPs appropriately . If you have a Health Worker on the field with the patient, then you can prescribe medications based on the Health Workers’ inputsprovided these are as per norms of the guidelines.
. In case of emergency clinical conditions, provide advice for immediate relief, first-aid and guide/ facilitate appropriately for an immediate in-patient consult.

21. Could you try to expand on the list of conditions by examples, which you can advise on Video-call consultation? patient ?

Video consultation give an added advantage of visual perception (provided it is of reasonable good quality) which is crucial for many clinical conditions. For instance, a RMP can take suitable teleconsultation pathways for conditions such as:
. Pallor and Koilonychia: Prescribe Iron tablets on first-consultation and advice further investigations
. Jaundice/ Cyanosis: Advice for urgent referral for in-patient consultation
. Trauma: Can assist in Tele-triaging through a Health Worker

. Respiratory distress: Assess work of breathing and advice another RMP/ Health Worker for appropriate intervention
. Rheumatic conditions: Can assess range of motion of joints through a health worker and can modify medications during a follow-up consultation
.Tele-radiology, Tele-ophthalmology, Tele-pathology can be leveraged for discussion between two RMPs.

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