From A Doctors persepctive

1. Telemedicine
Present status, Indian Guidelines and Future prospects
Dr.Rammohan.K.P

2. • We go online to-----
• Shop to your hearts content
• Bank and do your transactions
• Order your food and dine lavishly
• Chat with your friends and exchange
pleasentaries and greetings
• You even date online
• Why not go online and have your doctor
consultations also on the net?

3. Defenitions
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.’
TELEMEDICINE
• “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.”
Telehealth is a broad term that
includes all health services provided
using telecommunications
technology, telemedicine refers
specifically to clinical services

5. A doctor's diagnosis "by radio" -on the cover of the
February, 1925 issue of Science and Invention
magazine
Dr. Hugo Gernsback, called the “teledactyl.”
The imagined tool would use spindly robot fingers and radio technology to
examine a patient from afar

7. NASA

9. Telemedicine in India

10. Pandemic Effect:
Telemedicine Is Now a 'Must-Have' Service
• "No longer are remote health services
viewed as 'nice to have' – they are now a
must-have care delivery option,“
• Innovations – like digital and telehealth
solutions – designed to meet patient needs
will likely become embedded into the health
care delivery system.

11. Explosion in telehealth market due to
COVID-19
The telehealth market in the US
seven-fold growth by 2025,
five-year compound annual growth
rate (CAGR) of 38.2%.
In 2020, the telehealth market is
likely to experience a tsunami of
growth, resulting in a year-over-
year increase of 64.3%.

12. “With over 687 million internet users and 629
million mobile users as of January 2020, India
is the second-largest online market in the
world”.

14. Store and Forward(Asynchronous)
Telemedicine
• Gathering of data from the
patient which is then sent
through a secure e-mail or
messaging service to a
cloud-based platform
• The data is analyzed and a
diagnosis and treatment
plan are sent back to the
patient or provider.
• Commonly used platforms
inclde E-mails, Chat
platforms like Whats up
and Telegram
Particularly popular for
diagnoses and treatment with
certain specialties like
dermatology, ophthalmology,
radiology and pathology.

15. Benefits to store-and-forward
technology
• Enables patients to access specialty care without having to
travel to the specialist;
• Reduces wait times for specialty consults and improves
the workload for specialists
• The specialist is able to review cases when it’s convenient
for him/her;
• Enables primary care providers and specialists to work
together on cases regardless of location

16. Remote patient monitoring

17. Examples of remote patient
monitoring technology
• Glucose meters for patients with diabetes.
• Heart rate or blood pressure monitors.
• Continuous surveillance monitors.
• At-home tests that can keep substance abuse
patients accountable for and on track with
their goals.
• Caloric intake or diet logging programs.

19. (Synchronous)
It is popular for primary care, urgent care, follow-up visits,
and the management of medications and chronic illness.

20. Common programs used for Real-time
Telemedicine
• Video calling programs of
Whatsup, Skype, Facetime
etc.
• Conference applications like
Zoom, Google meet and
Microsoft Teams.
• Dedicated telemedicine
Platforms

21. What is a Telemedicine Health
Platform?
• A mode for healthcare professionals to evaluate,
treat and diagnose patients from their location
on telecommunication medium.
• In US only HIPAA complaint programs can be used
for realtime teleconsultation but in India there is
no legislation forbidding any type of technology.
• Health Insurance Portability and Accountability
Act (HIPAA) is a US law with security provisions to
safeguard medical information.

23. • 10 Best Telemedicine
Companies in US
• Teladoc
• MeMD
• iCliniq
• Amwell
• MDlive
• Doctor on Demand
• LiveHealth Online
• Virtuwell
• PlushCare
• HealthTap
• Takeaway
Most pure-play
telemedicine
companies are
privately held or only
trade over the counter.
The one exception is
Teladoc Health (TDOC)

24. Comparative analysis among telemedicine companies in India
Company Name Country Ranking Total Visitors Services
Practo 255
47.48
Million
- Medical delivery
- Wellness and fitness
centres
- Diagnostic centres
1 mg 466
26.18
Million
- E-pharmacy
- Online consultation
- Lab tests
Lybrate 534
25.18
Million
- Health
communication
delivery platform
- Health wiki
Medlife 1,174
2.54
Million
- Online consultation
- E- health records & E
prescription
- Health products
- E-pharmacy
Portea Medica 7076
7.3
Million
- Healing at home
- Medical equipment
- Counselling
- Lab tests

25. Virtues of using a Dedicated
Telemedicine program
• Schedules appointment for patients once he
visits the site.
• Directly sends a link to patients mail or
whatsup through which they can log in.
• They can keep the log of consultations and
records which is important from medicolegal
aspect.
• Collects payment in advance and reimburses
to Doctor.

27. Telemedicine society of India
• Healthcare for All, Anytime, Anywhere
• Spearheading and facilitating the
Telemedicine movement in India TM
Telemedicine Society of India (TSI) Kerala Chapter Formed
December 16, 2019 at Amrita Institute of Medical Sciences
(AIMS), Kochi.

28. Health Ministry's 'E-Sanjeevani' Telemedicine
Service Records 2 Lakh Tele-Consultations
19 August 2020
• E Sanjeevani platform has enabled two
types of telemedicine services. These are:
• Doctor-to-Doctor (eSanjeevani) and
• Patient-to-Doctor (eSanjeevani OPD) Tele-
consultations.
• E-Sanjeevani has been implemented so
far by 23 states and other states are in the
process of rolling it out.

29. Telemedicine-Legislations in India
• Prior to 2020, there were few
concerns regarding the practice of
telemedicine which were largely
due to lack of guidelines and
ambiguity that accordingly existed
• 2018 judgement of Deepa Sanjeev
Pawaskar and Anr. v. State of
Maharashtra had an adverse impact
on Telemedicine Practice in India

30. • On March 25, 2020, the Board of
Governors (“BoG”) entasked by the
Health Ministry to regulate practice
and practitioners of modern
medicine
• They published an amendment to
the Indian Medical Council
(Professional Conduct, Etiquette
and Ethics) Regulations,
2002 (“Code of Conduct”) that gave
statutory support and basis for the
practice of telemedicine in India

32. REGISTERED MEDICAL PRACTITIONER
(RMP)
• A person who is enrolled in the State
Medical Register or the Indian Medical
Register under the Indian Medical Council
Act 1956.’
• A RMP is entitled to provide telemedicine
consultation to patients from any part of
India
• shall uphold the same professional and
ethical norms and standards as applicable
to traditional in-person care, within the
intrinsic limitations of telemedicine
• RMPs intending to provide online
consultation need to complete a mandatory
online course within 3 years of its
notification.

33. Platforms that can be used
• May use any telemedicine tool suitable for carrying
out technology-based patient consultation;
• Video (Telemedicine facility, Apps, Video on chat
platforms, Skype/Face time etc.)
• Audio (Phone, VOIP, Apps etc.)
• Text Based:
• Telemedicine chat based applications ( telemedicine
smartphone Apps etc.
• General messaging/ text/ chat platforms (WhatsApp,
Google Hangouts, Facebook Messenger etc.)
• Asynchronous (email/ Fax etc.)

34. Strengths and limitations of various
modes

37. • The professional judgment of a Registered Medical
Practitioner should be the guiding principle for all
telemedicine consultations

38. TELEMEDICINE SHOULD BE APPROPRIATE AND
SUFFICIENT AS PER CONTEXT
• RMP should exercise their
professional judgment to decide
whether a telemedicine
consultation is appropriate in a
given situation or an in-person
consultation is needed.
• They should consider the
mode/technologies available and
their adequacy for a diagnosis
before choosing to proceed with
any health education or
counseling or medication.

39. Identification of The RMP and The
PATIENT is required .
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.
An RMP should begin the consultation by informing the patient
about his/her name and qualifications. Every RMP shall
display the registration number.

40. PATIENT CONSENT
• If, the patient initiates the
telemedicine consultation, then
the consent is implied
• 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. The RMP
must record this in his patient
records.

41. TYPES OF CONSULTATION:
FIRST CONSULT/ FOLLOW-UP CONSULT
First Consult means
The patient is consulting with the
RMP for the first time; or
The patient has consulted with the
RMP earlier, but more than 6
months have lapsed since the
previous consultation; or
The patient has consulted with the
RMP earlier, but for a different
health condition
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

42. Continue/Discontinue Teleconsultation
If a physical examination is critical information for
consultation, RMP should not proceed until a physical
examination can be arranged through an in-person
consult
The RMP can choose not to proceed with the
consultation at any time. At any step, the RMP may
refer or request for an in-person consultation
At any stage, the patient has the right to choose to
discontinue the teleconsultation

44. Patient Managment:
Health education,Councelling & Medications
Provide
Health
Education as
appropriate
in the case;
Provide
Counseling
related to
specific
clinical
condition;
Prescribe
Medicines

45. In an Emergency situation
• If RMP identifies an emergency
condition necessitating urgent care,
• Advise first aid
• Counseling
• Facilitate referral.
• The goal and objective should be to
provide in-person care at the soonest.

46. Prescribing Medicines
• Prescribing medications, via
telemedicine consultation is
at the professional
discretion of the RMP.
• Prescribing Medicines
without an appropriate
diagnosis/provisional
diagnosis will amount to a
professional misconduct.

47. Specific Restrictions
The categories of medicines that can be prescribed via tele-consultation will
be as notified in consultation with the Central Government from time to time.
List O:
It will comprise
those medicines
which are safe to
be prescribed
through any
mode of tele-
consultation
List A:
These
medications are
those 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.
List B:
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.
Prohibited List:
Medicines listed
in Schedule X or
any Narcotic and
Psychotropic
substance

49. Issue a Prescription and Transmit
• RMP shall issue a prescription as
per the Indian Medical Council
Regulations
• 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

51. Maintain DIGITAL TRAIL/
DOCUMENTATION of consultation
• Maintain the following records/ documents for the period as
prescribed from time to time
• Log or record of Telemedicine interaction (e.g. Phone logs,
email records, chat/ text record, video interaction logs etc.)
• 2.Patient records, reports, documents, images, diagnostics,
data etc. (Digital or non-Digital)
• 3.RMP is required to maintain the prescription records as
required for in-person consultations

52. Fee for Telemedicine Consultation
• 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.

53. Duties and responsibilites of a RMP in
general
• Principles of medical ethics, including professional norms for
protecting patient privacy and confidentiality as per IMC Act
and relevant provisions of the IT Act, Data protection and
privacy laws shall be binding and must be upheld and
practiced.
• 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.
• The RMPs should ensure that reasonable degree of care
undertaken during hiring such services.

54. Misconduct
All actions that willfully compromise patient care or privacy and
confidentiality, or violate any prevailing law.
• 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,
• 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
• Penalties: As per IMC Act, ethics and other prevailing laws

55. Enforcement of the Telemedicine
Guidelines
Any violation of the Telemedicine Guidelines will be looked at as a ‘misconduct’ at hands
of the concerned doctor under the Code of Conduct.
A patient, who suffers due to misconduct, has the right to complain to the respective State
Medical Council with whom the doctor is registered about the misconduct.
If the doctor is found guilty of the misconduct, he or she may be reprimanded, or his/her
registration may be suspended or cancelled.

56. Guidelines for Technology Platforms
enabling Telemedicine
• Obligated to
ensure that the
consumers are
consulting with
Registered
medical
practitioners
only;
• Conduct due
diligence before
listing any RMP
on its online
portal
• 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
• Al, Internet of
Things 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

57. • Technology Platform must ensure that there is
a proper mechanism in place to address any
queries or grievances that the end-customer
may have
• In case any specific technology platform is
found in violation, BoG, MCI may designate
the technology platform as blacklisted, and
no RMP may then use that platform to
provide telemedicine

59. Comments on the Guidelines
Positive aspects

63. Setting Up a Telemedicine Program in
Your Practice
Get started with a
modest
commitment that
does not have to
disrupt your
practice.
Once established,
you can build on
your initial services
and create more
sophisticated
offerings.
Decide how you will
use telemedicine.
--same-day
appointments,
after-hours care, or
visits determined
by the doctor?

64. Setting Up Your Space

65. Presenting Yourself
Even if working from home, dress as you do when you see
patients in the office.
Be punctual for tele-appointments. Many platforms allow you to
set up a notification system that lets patients know when you're
ready, and lets you know when patients are ready.
Because telemedicine interactions are more limited than in-person
ones, be attuned to visual cues from the patient
Maintain eye contact with patients. Rather than looking at the
image of patient on the screen, look into the camera lens

66. The Content of the Visit
Confirm the patient's identity, take a history, and assess the
patient's appearance.
• will have to rely more on what patients
are telling you than in an in-person
visit.
You may have to direct
the patient to perform
a self-examination
Patients should understand the amount that will be charged,
what they will have to pay, and the procedures for payment.

67. Advanced Use
Setting up an office
for patients to visit, so
that the doctor can
conduct a more
extensive
examination.
This arrangement
requires building a
telemedicine cart at
the patient's end, and
designating a nurse or
other clinician—the
telepresenter—to
help the patient with
the physical
examination.
The telemedicine cart
might consist of a pan-
tilt-zoom video
camera and mobile
medical devices, such
as a digital
stethoscope, an
ophthalmologic scope,
and various other
scopes, depending on
the case

68. • Professions that were considered to be
immune to any change, including Medicine,
are now facing unprecedented variations in
how they are practiced.
• Three main pillars of Clinical diagnosis -
History, Physical examination, Investigations
• Rapid advancement in technology of
investigations has led to a proportional
decline in the utility of the physical exam.,
But History taking has stood its ground

69. Why, then, are we still doing physical
exams?
• The act of the physical exam is
tied in with the identity of a
physician.
• There is a certain comfort in the
physician’s touch where a
patient develops a kindred
regard for the physician.
• Medical schools devote entire
curricula to training and
reinforcing bedside manner for
healthcare professionals, but
“webside manner” is an entirely
different skill.

70. Speciality usage of Telemedicine
• 1. Dermatology: 76 percent
• 2. Psychiatry: 54 percent
• 3. Infectious disease: 46 percent
• 4. Pain management: 37 percent
• 5. Neurology: 36 percent
• 6. Cardiology: 34 percent
• 7. Rheumatology: 32 percent
• 8. Gastroenterology: 24 percent
• 9. Sports medicine: 18 percent
• 10. Oncology: 17 percent

73. Tele-dermatology

74. Tele-Mental
Health

75. Economics of Telemedicine

78. Indian market

79. Some Multidimensional Unintended
Consequences of Telehealth Utilization
• Overconfidence in Technology
• Rigidity of the Technology
• Dependence on the Technology Provider
• Dematerialization and Depersonalization of
Relationships and Interactions
• Changing Dynamics and Hierarchical
Relationships
• Strategic Repositioning of Organizations
• Technology and Data: Ownership and Use

80. Future of Telemedicine
• Telemedicine can provide a
compelling alternative to
conventional acute, chronic and
preventive care, and can improve
clinical outcomes
• The future of telemedicine will
depend on:
• (1) human factors, (2) economics and
(3) technology
• The growth and integration of ICT
into health-care delivery holds great
potential for patients, providers and
payers in health systems of the
future.

81. • (I) Technology Platforms: Privacy And Data Security Concerns
•
(Ii) Digital Health Ecosystem: Issues In Collection And Storage Of Medical
Records
• (Iii) Identification Of Potential Legal And Ethical Concerns
• (Iv) Broadband Connectivity: Infrastructural Challenge In A Resource
Constrained Environment

82. will telemedicine be the
NEW NORMAL?
• “The actualisation of the medium during the
pandemic was really promising

84. What it means to “Davinci”
• We are a group that has one thing in
common!
• Abundance of experience and
clinical wisdom acquired of many
years of clinical practice.
• Many of us are at fag end of our
clinical career.
• The hazards of negotiating the
busy traffic, being on time at
workplace and some cognitive
slow down may be driving many
to a semi retired attitude.

85. What if we can
give some of our
advice based on
our years of
acquired clinical
experience,
sitting in the
solitude of our
homes?
I am sure that
that there will
be abundance of
“takers”
considering the
multitude of
clientele you
have built over
many years
We can have a
“Davinci
telemedicine”
platform where
we can offer
consultations to
existing if not
new patients.