This document outlines guidelines for telemedicine in India. It discusses the need for telemedicine, different modes of communication, guidelines issued by the Ministry of Health and Family Welfare, the framework and technology platforms for telemedicine. It also discusses success stories, challenges, and scenarios where telemedicine can be used, such as between patients and doctors, caregivers and doctors, health workers and doctors, and doctors consulting each other. The document provides detailed guidelines on the practice of telemedicine in India.

1. Presenter – Dr. Prateek Goyal
Moderator – Dr. Jugal Kishore

2.  Introduction
 Need of Telemedicine
 Different modes of communication
 Guidelines for Telemedicine in India
 Framework for Telemedicine
 Guidelines for Technology Platforms
 Success Stories of telemedicine
 Challenges for Telemedicine

3. “Telemedicine is the use of technology to deliver medical services
to the point of need”.
-Dr. Jay H. Sanders
President and CEO of The Global Telemedicine Group
Professor of Medicine at Johns Hopkins School of Medicine
Dr. Jay H. Sanders
(Father of Telemedicine)

4.  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 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.
- World Health Organization
- (Same definition has been adopted by MOHFW)

5. 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.
In general, telemedicine is used to denote clinical service
delivered by a Registered medical practitioner while
Telehealth is a broader term which is using technology for
health and health related services including telemedicine.

6. A ‘Registered Medical Practitioner’ is defined as a person who is
enrolled in the State Medical Register or the Indian Medical
Register under the IMC Act 1956.

7. Telemedicine is not a new
concept. Actually, it began
around 100 years back. With
Health being delivered via
radio to the people seeking it.
But it has become more
popular by the advent of
better technologies and has
come to lime light in recent
times.

8. In India, the story of Telemedicine began for real in the year 2001
when the Indian Space Research Organisation (ISRO) began a pilot
project, linking the Apollo Hospital in Chennai with the Apollo Rural
Hospital at Aragonda Village in Andhra Pradesh.
In the year 2005, MoHFW constituted Indian Task Force for
Telemedicine.
In the year 2006, School of Telemedicine & Biomedical Informatics
(STBI) was set up at SGPGIMS, Lucknow by Govt. of U.P
In the year 2010, SGPGIMS was made National Resource Centre for
Telemedicine by MoHFW.
On March 25th,2020, Guidelines for practicing Telemedicine released
by MOHFW

9. Regional Resource Centres (RRC) have been set up from time to
time. As of now, there are 8 RRCs.
1. National Resource Centre at SGPGIMS, Lucknow (Central RRC)
2. RRC at PGIMER Chandigarh is for (Northern States)
3. RRC at KEM, Mumbai is for (Western States)
4. RRC at JIPMER Pondicherry (Southern states)
5. RRC at NEIGRHIMS at Shillong (North Eastern states)
6. RRC at BHU, Varanasi (Eastern states)
7. RRC at SCTIMST, Thiruvananthpuram (2nd RRC for Southern
states)
8. RRC at AIIMS Delhi for Central/other states

10. In India, till recently, there were no legislations or guidelines on
the practice of telemedicine, through either video, phone or
Internet based platforms (web/chat/apps etc). So, there has
been a concern on the practice of telemedicine.
But now, an online program will be developed MOHFW. All
registered medical practitioners intending to provide online
consultation will have to complete the online course within 3
years of its notification & in the interim period, the principles
mentioned in the guidelines release by MOHFW need to be
followed.

11.  AIIMS New Delhi inaugurated its Telemedicine services on
28th March, & started services from 30th March.
 On 8th July AIIMS started tele-consultation guidance for State
doctors on COVID-19 clinical management. Ten hospitals, nine
from Mumbai (Maharashtra) and one from Goa, were
included for the sessions that started on 8th July.

13. As in the words of Dr. Suresh Bada Math (Head of Telemedicine
Department, NIMHANS), We have successfully used technology to
reach Mars……

14. But we have failed to reach them….

15. But telemedicine has picked up pace just recently, amidst the COVID-
19 crisis. So another major reason we need telemedicine is to prevent
the healthcare staff and the patients from infecting each other.

16.  It provides access to services that may not be otherwise
available locally.
 The access is usually faster.
 Provides timely access in emergency situations for first-
aid/initial management.
 Patients don’t need to wait in queues.
 Saving of cost and effort, especially for people living in remote
areas, as they need not travel long distances. It also reduces
inconvenience to family members.

17.  Particularly in situations of Disasters and Pandemics (like
COVID-19), a telemedicine consultation can be conducted
without exposing patients/Healthcare staff to infection.
 Patient gets the opportunity to consult a doctor he wishes to,
even if the doctor is physically located on a distant location.
Also, a doctor gets the opportunity to provide consultation to
his/her friends/family who are at a distant location.
 Doctor can focus all his attention on one case at a time.
 Chances of disagreement are there, but chances of physical
assault are Nil.

19. RMP may use any mode of communication for carrying out
technology-based patient consultation. Basically It can be of 3
types :
1. Text Based (Messaging, Whatsapp chat)
2. Audio based (Telephone call, Mobile call)
3. Video based (Skype, Whatsapp video call, Zoom)
All technologies have their own strengths & limitations

20. Strengths:
1. Convenient and quick
2. Suitable for follow-ups, second opinions.
3. No separate infrastructure required
4. Can be real time
Limitations:
1. Text-based interactions misses all, the physical touch, the
visual cues and the verbal cues .
2. Difficult to establish rapport with the patient.
3. Difficult to be sure of identity of the doctor or the patient.
4. Not suitable for conditions that require a visual inspection
(e.g. skin, eye or tongue examination)

21. Strengths:
1. Convenient and fast
2. Unlimited reach. Most have an access to phone.
3. Suitable for urgent cases.
4. No separate infrastructure required.
5. Real-time interaction.
Limitations:
1. Not easy to be sure of identity of the doctor or the patient.
2. Not suitable for conditions that require a visual inspection
(e.g. skin, eye or tongue examination)

22. Strengths:
1. Closest to an in person-consult, real time interaction
2. Patient identification is easier
3. RMP can see the patient and discuss with the caregiver
4. Visual cues can be perceived
5. Inspection of patient can be carried out.
Limitations:
1. Is dependent on high quality internet connection at both
ends, else will lead to a sub optimal exchange of information
2. There is a possibility of abuse/ misuse of personal data and
images. Ensuring privacy of patients in video consults is
extremely important, but security may be breached by
Hackers.

24.  The guidelines are not valid for consultation outside the
jurisdiction of India.
 The professional judgment of a Registered Medical
Practitioner is to be the guiding principle for all telemedicine
consultations.
 These guidelines are to encourage Medical Practitioners to
practice telemedicine correctly.

25. 1. Context
2. Identification of RMP and Patient
3. Mode of Communication
4. Consent
5. Type of Consultation
6. Patient Evaluation
7. Patient Management

26. 1. An RMP is well positioned to decide whether a technology-
based consultation is sufficient or an in-person review is
needed.
2. An RMP should consider the mode/technologies available
and their adequacy for a diagnosis before choosing to
proceed with any health education or counseling or
medication.

27. 1. Telemedicine consultation should not be anonymous: both
patient and the RMP need to know each other’s identity.
2. 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.
3. For issuing a prescription, the RMP needs to explicitly ask the
age of the patient, and if there is any doubt, seek age proof.
4. An RMP should begin the consultation by informing the
patient about his/her name and qualifications. She/he shall
display the registration number accorded to him/her by the
State Medical Council/MCI, on prescriptions, website &
electronic communication.

28. 1. Primarily there are 3 modes: Video, Audio or Text, which
have been discussed.
2. There may be situations where the RMP needs to visually
examine the patient and make a diagnosis. In such a case,
the RMP could recommend a video consultation. Considering
the situation, using his/her best judgment, an RMP may
decide the best technology to use to diagnose and treat.

29. 1. If the patient initiates the telemedicine consultation, then the
consent is implied.
2. An Explicit patient consent is needed if a Health worker, RMP
or a Caregiver initiates a Telemedicine consultation. An
Explicit consent can be recorded in any form. Patient can send
an email, text or audio/video message. Patient can state
his/her intent on phone/video to the RMP. The RMP must
record this in his patient records.

30. There are two types of patient consultations, First consult
and the Follow-up consult.
First Consult means:
1. The patient is consulting with the RMP for the first time; or
2. The patient has consulted with the RMP earlier, but more
than 6 months have lapsed since the previous consultation;
or
3. The patient has consulted with the RMP earlier, but for a
different health condition

31. Follow-Up Consult(s) means
The patient is consulting with the same RMP within 6 months of
his/her previous in-person consultation and this is for
continuation of care of the same health condition.
However, it will not be considered a follow up if:
1. There are new symptoms that are not in the spectrum of the
same health condition; and/or
2. RMP does not recall the context of previous treatment and
advice

32. 1. An RMP would use his/her professional discretion to gather
the type and extent of patient information (history
findings/Investigation reports/past records etc.) required to
be able to exercise proper clinical judgement.
2. This information may be shared in real time or shared later
via email/text, as per the nature of such information. For
example, an RMP may advise some laboratory or/and
radiological tests to the patient. In such an instance, the
consult may be considered paused and can be resumed at the
rescheduled time.

33. If the condition can be appropriately managed via telemedicine,
based on the type of consultation, then the RMP may proceed
with a professional judgement to:
1. Provide Health Education
2. Provide Counseling
3. Prescribe Medicines
Prescribing Medicines without an appropriate diagnosis or
provisional diagnosis will amount to a professional misconduct
The categories of medicines that can be prescribed are divided in
lists.

34. List O: It comprises those medicines which are safe to be
prescribed through any mode of tele-consultation.
In essence they comprise of medicines which are used for
common conditions and are often available ‘over the counter’.
1. Antipyretics: Paracetamol
2. Cough Supplements: Lozenges
3. Cough/ Common-cold medications (such as combinations of
Guaifensen, Ambroxol, Bromhexene, Dextromethorphan)
4. ORS Packets , Syrup Zinc
5. Supplements: Iron & Folic Acid tablets, Vitamin D, Calcium
supplements

35. List A: These medications are those which can be prescribed
during the first consult (video consultation only) or in the case of
follow up consult, if they are just being refilled. Examples :
1. Ointments/Lotion for skin ailments: Ointments Clotrimazole,
Mupirocin, Calamine Lotion, Benzyl Benzoate Lotion etc
2. Local Ophthalmological drops such as: Ciprofloxacillin for
Conjunctivitis, etc
3. Local Ear Drops such as: Clotrimazole ear drops
Follow-up medications for chronic illnesses for ‘re-fill’ :
1. Hypertension: Enalapril, Atenolol etc
2. Diabetes: Metformin, Glibenclamide etc
3. Asthma: Salmetrol inhaler etc

36. List B: It is a list of medication which RMP can prescribe in 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.
That is, medications prescribed as ‘Add-on’ to ongoing
medications such as for Addition of Sitagliptin to Metformin for
management of Diabetes.
Also, The BoG in supression of MCI may modify the drug lists
from time to time. Recently, Phenobarbitone, Clonazepam &
clobazam have been added to List A on 11th April, 2020.

37. Prohibited List: These medicine have a high potential of abuse and
could harm the patient or the society at large if used improperly.
So these drugs can not be prescribed over telemedicine
consultation.
Medicines listed in Schedule X of Drug and Cosmetic Act and Rules
or any Narcotic and Psychotropic substance listed in the Narcotic
Drugs and Psychotropic Substances, Act, 1985 are included in this
list.
Examples :- Amphetamines, Methaphetamine, Methylphenidate,
methylphenobarbital, Morphine etc

38. RMP shall provide photo, scan, digital copy of a signed
prescription or e-Prescription to the patient via email or any
messaging platform .
Prescribing Medicines without an appropriate
diagnosis/provisional diagnosis, without the name, qualification
and registration number of the RMP will amount to a professional
misconduct.

40. 1. Registered Medical Practitioner has 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.
2. Registered Medical Practitioners will not be held responsible
for breach of confidentiality 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 .
3. RMPs should not insist on Telemedicine, when the patient is
willing to travel to a hospital and/or requests an in-person
consultation.
4. RMPs are not permitted to solicit patients for telemedicine
through any advertisements or inducements.

41. Telemedicine consultations should be treated the same way as in-
person consultations from a fee perspective. RMP may charge an
appropriate fee for the Telemedicine consultation provided.
An RMP should also give a receipt/invoice for the fee charged for
providing telemedicine-based consultation.

43. There are 5 possible scenarios for telemedicine :
1. Patient to Registered Medical Practitioner
2. Caregiver to Registered Medical Practitioner
3. Health Worker to Registered Medical Practitioner
4. Registered Medical Practitioner to Registered Medical
Practitioner
5. Emergency Situations
The professional judgement of a Registered Medical Practitioner
should be the guiding principle for all scenarios.
Both the patient and the RMP can choose to discontinue with the
consultation at any time .

44. In this case, the patient initiates telemedicine consultation and
thereby consent is implied.
A proper process must be followed to ensure maximum benefit
to the patient.
Two scenarios are possible :- Either it’s a first consult or follow up
consult.

47. “Caregiver” could be a family member, or any person authorized
by the patient to represent the patient.
There could be two possible settings:
1. Patient is present with the Caregiver during the consultation.
2. Patient is not present with the Caregiver. This may be the case
in the following:
• Patient is incapacitated.
• Caregiver has a formal authorization or a verified document
establishing his relationship with the patient and/or has been
verified by the patient in a previous in-person consult (explicit
consult).
In all of the above, the consult shall proceed as in the case of
RMP and the patient

48. “Health worker” could be a Nurse, Allied Health Professional,
Mid-Level Health Practitioner, ANM or any other health worker
designated by an appropriate authority.
This setting will also include health camps, home visits, mobile
medical units or any community-based interaction.
The premise of this consultation is that a patient has been seen
by the Health worker & in the judgment of the health worker, a
tele-consultation with a RMP is required.

50. 1. Registered Medical Practitioner might use telemedicine
services to consult with another RMP or a specialist for a
patient under his/her care. Such consultations can be
initiated by a RMP on his/her professional judgement.
2. The RMP asking for another RMP’s advice remains the
treating RMP and shall be responsible for treatment and
other recommendations given to the patient.
Examples:
Tele-radiology - use of technology to send radiographic images
(CT, MRI, Ultrasound) from one location to another.
Tele-pathology - use of technology to transfer image data
between distant locations.

51. In all telemedicine consultations, as per the judgment of the RMP, if
it is an emergency situation, the goal and objective should be to
provide in-person care at the soonest.
The RMP, based on his/ her professional discretion may
1. Advise first aid
2. Counseling
3. Facilitate referral
In all cases of emergency, the patient mustbe advised for an in-
person interaction with a Registered Medical Practitioner at the
earliest.

53. This specifically covers those technology platforms which work
across a network of Registered medical practitioners and enable
patients to consult with RMPs through the platform.
1) They shall ensure that the patients are consulting with
Registered medical practitioners duly registered with National
Medical Councils or respective State Medical Council
2) They shall conduct their work-up before listing any RMP on its
online portal. Platform must provide the name, qualification,
registration number & contact details of every RMP listed on the
platform.

54. 3) Technology platforms based on Artificial Intelligence/Machine
Learning are not allowed to counsel the patients or prescribe any
medicines to a patient.
4) They must ensure that there is a proper mechanism in place to
address any queries or grievances that the patient may have .
5) In case any specific technology platform is found in violation,
BoG, in supression of MCI may designate the technology platform
as blacklisted, and no RMP may then use that platform to provide
telemedicine consultation.

56. In 2001 the Indian Space Research Organisation (ISRO) began a
pilot project, linking the Apollo Hospital in Chennai with the
Apollo Rural Hospital at Aragonda Village in Andhra Pradesh.
Since then, things came a long way. With the rapid penetration of
smartphones and the widespread availability of internet services
everywhere, At present, Apollo TeleHealth runs about 700
healthcare centres in Public-Private-Partnership mode across
India majorly spread across Andhra Pradesh, Himachal Pradesh,
Uttar Pradesh and Jharkhand, touching more than 11.4 million
lives. From 1 to 700 in just 20 years.

57. State Telemedicine Network (STN) initiatives is working with
the vision to provide Telemedicine Services to the remote
areas by upgrading existing Government Healthcare Facilities
(DH, SDH, PHC and CHC) in States.
1. PHC Fatehgarh in Arain block of Ajmer District has been
connected to JLN Medical College in Rajasthan
2. CHC Panisagar in Panisagar block of North Triputra District
has been connected to Agartala Govt. Medical College & GBP
Hospital of Tripura
3. PHC Vadacheepurupalli in Parwada block of
Vishakhapatnam Distt. Has been connected to King George
Medical College & Hospital in Andhra Pradesh State.
Based on inputs and outcomes of Pilot projects, National
Telemedicine Network is being scaled–up all over country.

58. New Telemedicine centres were set up at pilgrimage sites too
which are visited by a large number of devotees bringing
benefit to thousands. Currently the active sites are:
1. Kashi Vishwanath Temple, Varanasi, Uttar Pradesh
2. Maa Vindhyavasini Mandir, Vindhyachal Dham, Mirzapur
(UP)
3. Sheshnag, Amarnath Pilgrimage (J&K)
4. Pampa Hospital, Ayyappa Temple at Sabrimala in Kerala.

59. Telemedicine also has been successful where large populations
occasionally/periodically gather at a point of time & the provision
of medical care becomes the need of the hour. For example, the
Government of Uttar Pradesh practices telemedicine during
Maha Kumbhamelas.
Chellaiyan VG, Nirupama A Y, Taneja N. Telemedicine in India: Where do we stand?. J Family Med Prim Care 2019;8:1872-6
AIIMS has also started a National Teleconsultation Centre. You
can reach CoNTeC (COVID-19 teleconsultation Centre) at
9115444155

60. AIIMS has also started an online dashboard for patients who have
already visited AIIMS at least once. Patients can register for tele
consultation using the Unique Identification Number provided on
the OPD slip

61. Various Indigenous Softwares have been developed for
providing Telemedicine Consultations, accelerating the spread
and acceptance of Telemedicine:
1. Mercury
2. Sanjeevani
3. e-Sushrat
4. Tejas
5. e-Dhanwanthari

63. 1. Many elderly RMPs may not feel comfortable with the
technology. They may not understand how to use the
technology.
2. Not everyone has an access to Internet connection. Not
everyone has an access to smartphone. Also, video
consultations require high speed connections. Ensuring that
can be a problem.
3. With Literacy rate of India being just 74%, and many less then
that knowing English, for many, text based conversation is not
possible.
4. Proper infrastructure may not be available at distant sites so
that a good telemedicine consultation can take place.

64. 5. Maintaining of Records of consultations given online may be
cumbersome and appear difficult.
6. There are concerns about data safety and privacy of
patients. Images, videos may fall into wrong hands following
a breech of safety.
7. No repercussions on the patient if he/she releases the
RMP’s video.
8. The place of complaint if conflict arises is not mentioned in
guidelines.
9. Bringing Telemedicine consultations under the umbrella of
Health Insurance is a challenge.
10.Online Platforms advertise doctors and provide ratings for
doctors. Guidelines have not touched that issue.

65. All in all, Telemedicine is a great tool to answer the scarcity of
doctors, specialists, to avoid unnecessary contact, to save
patient time and cost etc. Its advantages are tremendous. But
there are some challenges too. If these challenges are tackled
properly, and professional ethics are maintained, Telemedicine
can change the way we practice Medicine, for the greater good.

66. Resources:
1. Telemedicine Practice guidelines by MoHFW
2. American Telemedicine Association
3. Evolution of Telemedicine in India: Brief Summary by MoHFW
4. E- Governance & Telemeidicne by MoHFW
5. User Guide for Doctors for eOPD by MoHFW
6. World Health Organisation
7. FAQ by MOHFW

68. Coming Next
News presentation by Dr. Suraj P. Singh
Journal Club presentation by Dr. Anirudh Saxena
24/07/2020, Friday, 2:30 PM