Telemedicine has always been legal in India. However, it is only recently, did we witness the introduction and implementation of a legal framework outlining the contours within which a health professional may engage in a telemedicine consult over means of information and communications technology. Earlier in March this year, Covid-19 crisis offered the fillip which was necessary to bring to the fore the Telemedicine Practice Guidelines1 (TPG), which eased the burden and reliance on the healthcare infrastructure in the country in these tumultuous times.
The TPG recognized, accommodated, and provided for:
- Online consultations: physician to patient; physician to caregiver; physician to health worker; and physician to specialist where recognized and codified in law.
- Delivery of healthcare services over means of ICT across state and union territories' lines, for a fee!
- Patient management, including prescription of medicines on the basis of appropriate or provisional diagnosis of the patient by the treating physician.
Amongst other things, for which the TPG provided necessary handholding, the three factors discussed hereinabove brought in the necessary societal acceptance of telemedicine, reinforced the faith of the physicians to be able to increase their outreach to the patients, and also presented the patient with an opportunity to better access, and continuity of care.
Scope. At the outset the scope has been restricted to the Registered Medical Practitioners (RMPs) under the Indian Medical Council Act, 1956 only, and lays down the norms and standards that must be adhered to by the RMPs for effective consultation with patients via telemedicine. There are no express or implied limitations on the mode / medium of technology. Any and all technology capable of communication by way of audio, voice, text and digital data exchange, visual have been scoped in the present Guidelines.
Exclusions. The document defers to the information technology laws, and the conflict of laws principles, in abstaining from any guidance or handholding being provided in the following matters:
- Specifications for hardware or software, infrastructure building and maintenance.
- Data management systems involved, standards and interoperability.
- Use of digital technology to conduct surgical or invasive procedures remotely.
- Other aspects of telehealth such as research and evaluation and continuing education of health-care workers.
- Practice outside India.
Patient continues to be the focus of these guidelines, and so, the RMP has been burdened with the necessary task of exercising their professional judgment in ascertaining whether a consult via means of telemedicine is sufficient or not. The basic elements for initiating a telemedicine consult are: (i) context; (ii) identification of RMP and patient; (iii) mode of communication; (iv) consent; (v) type of consultation; (vi) patient evaluation; and, (vii) patient management.
As boundaries between health, life and disease blurs, medical advice is needed at home, office and also in the community, and at the fast pace of the internet service itself. Increased access to affordable and anytime healthcare, will lead to efficiency in care delivery as well as the reimbursements and financial transactions revolving around it. With a law in place, and with the opportunity that Covid-19 pandemic has presented, the practice of telemedicine has become widespread. The outlook of the individuals is gradually shifting from illness to wellness, and it has also become more apparent to the patients that lifestyle physicians are better approachable and available via telemedicine.
With the notification of the TPG, the Insurance Regulatory and Development Authority of India (IRDAI) also advised the insurers to allow telemedicine wherever consultation with a medical practitioner is allowed in terms and conditions of policy contract. This further emboldens the practice and allows for commercial, remunerative models, service offerings be built around this.
It is important to note that the TPG does not erode the existing laws, norms, and expects that the additional safety latches that it provides for, are also factored into the delivery of healthcare services from over the internet. Telemedicine is not a substitute to conventional modes of care delivery, but it certainly augments the disparity in outreach, and the disparity in levels of access warranted by virtue of one's presence in a larger city/ town.
Moreover, the National Digital Health Mission (NDHM) has laid down the foundation for digitizing healthcare in India. The vision leads to creation of unique health IDs which would be used to facilitate interoperability amongst the existing heterogenous systems to a great extent. The NHDM follows the earlier issued National Digital Health Blueprint, and the guiding principles laid down there are being replicated. The implementation of NDHM is expected to significantly improve the efficiency, effectiveness, and transparency of health service delivery overall. Patients will be able to securely store and access their medical records (such as prescriptions, diagnostic reports, and discharge summaries), and share them with health care providers to ensure appropriate treatment and follow-up. There is also a dedicated intent to integrate this online movement with the e-pharmacies, which would further boost the growth of the sector and allow for recognition to be rendered to the scattered provisioning of services by online platforms.
In a welcome move, and in the absence of a comprehensive data privacy legislation, the NDHM was quick to release a draft data policy, to invite comments from stakeholders on health data management. This has yielded in discussions taking place at an industry level and has also led to stakeholders voluntarily bolstering their own internal processes, to ensure data privacy and security measures are commensurate with the industry standards. Much similar to the finance sector, which has stringent measures for data management and handling, the healthcare sector is also witnessing a cultural revolution, in respect of adoption and implementation of global technical and organizational standards/ measures in the Indian context.
Conclusion. Telemedicine is here to stay and bridge the gaps that were created by a discordant heterogenous healthcare infrastructure. This also allows the physicians to leverage the affordability and efficiency of online systems to promote healthcare. This law comes at a time, where people are heavily reliant on accessing services remotely, and where tele-triage has become the new normal. The TPG, along with the NDHM, will bring about a paradigm shift in how patients perceive healthcare relationships, care delivery, and continuity of care. As the NDHM also provides for regulatory sandboxes, it is evident that the intent is to observe, learn and re-create, while ensuring patient's safety, security of the systems and the information. In this world with new norms being set for almost everything, telehealth is not just the new norm, but also the way forward. In a growing and diverse economy like India, the demography deserves affordable, accessible, and efficient healthcare. Fortunately, with enough impetus from the government across all levels, the seemingly fledgling healthcare infrastructure of the country, has proved its mantle in catering to the healthcare requirements of the people in these distressed times. With the introduction of personal health records and a central repository, this would make it simpler for the State to realize its goals of universal health coverage and realize its commitments to the sustainable development goals.
1 Appendix 5 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics Regulation, 2002]. Notified on May 14, 2020.
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