Author: wpadmin

To promote Telemedicine, a hybrid program, themed “Telemedicine – the Untapped Potential” was organized by the Telemedicine Society of India (TSI) – TN Chapter, at The Tamil Nadu Dr. M.G.R. Medical University in Guindy, Chennai on November 19, 2021. This event was supported by TeleOphthalmology Society of India (TOSI) and Tamil Nadu Ophthalmic Association (TNOA).

The online conference commenced with Dr. K. Selvakumar introducing the event and welcoming everyone. This was followed by brief lectures on History and Definition of Telemedicine by Prof. Dr. K Ganapathy; Modes of Communication, Bandwidth by Dr. S Dheeraj Krishnaa; and Mobile Health by Dr. Sheila John.

Next, Dr. Sunil Shroff walked the audience through Telemedicine Practice and Guidelines from Government of India in detail, to help them easily understand the subject, and a lecture on Producing a “Wow” effect – Using Telemedicine by Prof. Dr. K Ganapathy followed.

The guest of honour for the occasion was Dr. J Radhakrishnan IAS – Health Secretary of Tamil Nadu. The formal welcome address was delivered by Dr. Sunil Shroff, President – TSI TN Chapter and Dr. Sudha Seshayyan – Vice Chancellor, The Tamil Nadu Dr. M.G.R. Medical University delivered the inaugural address. Dr. J Radhakrishnan IAS spoke in brief about the future of Telemedicine and highlighted its effectiveness during the pandemic. Special addresses by Dr. Mohan Rajan and Padmashri Dr. S Natarajan were followed by vote of thanks by Dr T Senthil.

After a short break, Dr. Ikramullah moderated a Panel Discussion on Specialty Practice in Telemedicine, featuring the following TSI members as speakers:

• Dr. Senthil
• Dr. Sheila John
• Dr. Vidya Ramkumar
• Dr. Lovelena Munawar and
• Dr. Kim R

Dr. Sunil Shroff briefed about the courses in Telemedicine that are going to be offered in the near future. Dr. Masood Ikram chaired a session on How to Set up Telemedicine in your Practice.
Dr. Natarajan presented his key note address on “Teleophthalmology for Blind-Free Tamil Nadu 2025.” A second panel discussion on Promoting Telemedicine in Tamil Nadu was moderated by Dr. Natarajan and the speakers were:

• Dr. Kim R
• Dr. Ganapathy
• Dr. Prabhu Rajagopal and
• Dr. Selva Kumar

The final segment featured participant discussions and the concluding remarks were delivered by Mr. D. Satheesh Kumar.

Documentation for Teleconsultations

Anay Shukla
Founding Partner, Arogya Legal – Health Laws Specialist Law Firm
Eshika Phadke
Associate, Arogya Legal – Health Laws Specialist Law Firm

The legal significance of well-maintained medical records cannot be emphasized enough. Especially for telemedicine where the jurisprudence is still in its primitive stages, it is of utmost important for doctors to maintain detailed records of their teleconsultations.

The Telemedicine Practice Guidelines 2020 specify the minimum information that must be documented in a patient’s telemedicine records. In this article, we outline the mandatory information that should be recorded, as well as additional best practices to ensure maximum legal protection.

Patient’s Location
It is advisable to record where the patient is located at the time of consultation. In the event that the patient is situated in a place where the doctor is not licensed to practice, he/she should refrain from continuing with the consultation, and should advice the patient to seek medical advice from a licensed professional. If the patient is a regular patient of the doctor who is temporarily located outside of the area where the doctor is licensed, the doctor may, if he deems necessary, proceed with the consultation, and should note down the peculiarity of the situation in the patient’s records.

Patients Consent
Explicit consent must be sought from the patient if the consultation is being initiated by anyone other than the patient (such as a relative, friend, another doctor or a health worker). The doctor may elect to have the patient state his/her consent during the consultation or send their consent via email, text message or an audio/video recording.

If the patient is a minor or mentally incapacitated, a guardian or caregiver may consent on their behalf. The identity of such person should be ascertained and recorded along with the consent.

If the doctor wishes to record the sessions, explicit written consent must be sought from the patient for recording and storing the session.

Patient information
If the doctor requests any identity or age proof in the course of the consultation, details of the same should be noted. The doctor must maintain records of the patient’s case history, doctor’s notes, investigation reports, images, etc that they rely upon to arrive at a diagnosis or treatment plan.

If the patient shares information about pulse, blood oxygenation, blood pressure, blood sugar, etc which they/their caregivers have recorded, it is advisable to record what device was used for measuring the levels.

Logs
The doctor should record how the consultation was carried out, and maintain the logs of the same for future reference.

During the course of the consultation, if the doctor deems that it is necessary to change to another mode of consultation (from text/audio to video or in-person), the reasons for same should be recorded. If the patient refuses, the doctor should be sure to capture the same in their records.

Prescriptions
The doctor may either issue a signed paper-prescription and share a photograph or scanned copy of the same, or issue an e-prescription. A recommended format has been annexed to the Telemedicine Practice Guidelines. The doctor must maintain copies of all prescriptions that are issued as he/she would for in-person consultations.

Comprehensive Records
Note that if the teleconsultation is taking place across various mediums (for example, the initial discussion over voice call, prescription for pathology tests issued over text message, results shared via email, etc), the doctor should ensure that copies of all communications and records are stored in a common folder, along with any records from in-person consultations, so that the records for the patient are complete and easily accessible.

The background to the Telemedicine Practice Guidelines 2020 specifies that one of the key advantages to telemedicine is a higher likelihood of maintenance of records and written documentation. Thus, while it may seem cumbersome to maintain detailed records of telemedicine consultations, the law expects meticulous documentation.

History of Teleophthalmology at Sankara Nethralaya

Dr. Sheila John
Head of Teleophthalmology and E-Learning Department,
Sankara Nethralaya, Chennai.

Teleophthalmology holds great potential to improve the quality, access, and affordability in health care. For patients, it can reduce the need for travel and provide the access to a super-specialist. Ophthalmology lends itself easily to telemedicine as it is a largely image based diagnosis. The rapid progress achieved in the field of Telecommunications renders Teleophthalmology easily feasible.

HOW IT BEGAN -2002
A pilot project was started by Sankara Nethralaya, Chennai, linking two of its eye care centers that were separated by a distance of 3 km. A junior ophthalmologist at the distant center examined about 100 patients, and has their medical information transferred to the Sankara Nethralaya main hospital by LAN over a fiber optic cable. After looking at the images, a senior ophthalmologist at Sankara Nethralaya diagnosed and discussed the treatment modalities with the junior consultant.

The next step, which was accomplished in 2002, was to link Sankara Nethralaya Eye Hospital, Chennai, with Sankara Nethralaya Eye Hospital at Bangalore. The Bangalore branch located 400 km away from Chennai is headed by a vitreo-retinal consultant. Patients who required secondary consultations were subjected to routine examinations and their images were captured and sent to Sankara Nethralaya, Chennai.

A unique teleophthalmology project was started in villages within a 100 km radius of Chennai with a mobile bus offering primary eye care. It was inaugurated by the former President of India, Dr. APJ Abdul Kalam, in 2003. The key to the project was a mobile bus, designed by a team from Sankara Nethralaya with assistance from the Indian Space Research organization.

The Mobile teleophthalmology unit has expanded its services all over India.

Rural Mobile Teleophthalmology units in five States of India.

Central Hub- Procedure
The selected patients have their slit lamp anterior segment, diffuse illumination, slit photos, and usually their non-mydriatic fundus photos taken inside the bus. Patients who subsequently have findings in the fundus are dilated and photographs are taken again. Patients who have squint or other extra ocular problems are also photographed with a digital still camera capable of taking external photographs with zoom capability. Telecommunication between rural camp and Sankara Nethralaya, Chennai is achieved by satellite connection through VSAT, which has a bandwidth of 384 Kb/ps. Now presently we are using internet connectivity with bandwidth of 512 kb/ps to 1Mpbs.

The senior ophthalmologist at Sankara Nethralaya, Chennai examines the images received and comes to a provisional diagnosis. An anterior segment video may be requested in special situations. Demonstration of extra procedures like eye movements may also be requested. The ophthalmologist maintains electronic medical records of all the patients, segregates interesting cases, maintains a file for discussion with peers or seniors, and is involved in the training of fellow ophthalmologists, paramedical ophthalmic assistants, and nursing staff in rural and semi urban areas. During the course of the teleconsultation, the ophthalmologist counsels the patient about familial eye diseases, preventive aspects and eye care.

Expert Opinion and Tele-Continuing Medical Education
Sankara Nethralaya has worked with other hospitals to spread the concept of Teleophthalmology for second opinion for diagnosis of sick patients , this includes the Southern Railways Eye Hospital, Perambur, G P Pant Hospital, Andaman & Nicobar Island , Shri Ganpati Nethralaya, Jalna, Maharashtra, Sri Sankaradeva Nethralaya, Guwahati , Assam and SN, Kolkatta. We are also connected to many institutions through the online mode for -Continuing Medical Education.

Dr. S. S. Badrinath, Chairman of Sankara Nethralaya was the first president of the Telemedicine Society of India.

Presently, the rural mobile teleophthalmology units at Tamilnadu and Kolkata are functioning and have examined more than more six lakh patients. Other units have been transferred to other ophthalmologists in the respective states to implement the program. Due to Covid19 and social distancing, tele counselling and teleconsultations have been implemented for paying patients from April 2020 till date and more than 10,000 patients have benefitted.

Informed Consent for Telemedicine

Anay Shukla
Founding Partner, Arogya Legal – Health Laws Specialist Law Firm
Eshika Phadke
Associate, Arogya Legal – Health Laws Specialist Law Firm

The developments in the field of information technology have resulted in geographic borders becoming increasingly redundant. Within the healthcare system, this has had a marked impact on the access that patients have to medical care since it is becoming increasingly common for doctors to consult a patient remotely. The Telemedicine Practice Guidelines have re-affirmed that inter-state teleconsultations within India are lawful and permitted.

However, the liberty to practice across country lines is not without limitation; international consultations are still restricted by geographic boundaries. The Telemedicine Practice Guidelines, 2020 explicitly excludes consultations outside the jurisdiction of India.

What amounts to practise of medicine? Would telemedicine be included?
Practising medicine involves any or all of the following: diagnosing, treating, operating or prescribing medicines or other remedies for any ailment, disease, injury, pain, deformity, or physical condition. Irrespective of whether such activity takes place in person or remotely through a teleconsultation, it would amount to the practise of medicine.

What is eligible to practise medicine?
To be eligible to practice medicine (including offering teleconsultations) in India, a doctor must be registered with the National Medical Commission (erstwhile Medical Council of India) or a State Medical Council.

Similarly, it is safe to assume that the other countries may have laws which restrict who can practice medicine in those countries.

Whose location is relevant for determining the license requirements?
A frequently asked question is whether the doctor is required to be licensed in the jurisdiction where he/she is physically located, or where the patient is located. However, the issue is quite nuanced, and there is no clear cut answer.

It is important to understand that the laws that regulate medical professionals and services typically envisage a scenario where both parties are located in the same room. While some countries, including India, have come up with guidelines that specifically address remote consultations, these guidelines are still in tune with the parent laws for medical professionals and services, and do not have the power to confer the right to a medical practitioner who is not duly licensed in that region to practise medicine. Thus, while the Telemedicine Practice Guidelines endorse a doctor’s right to practise pan-India irrespective of which state medical council they are registered with, it does not give them the authority to practise in a territory where the regulator has no jurisdiction whatsoever. In the Indian context, if a patient was aggrieved and wanted to complain against a doctor, he/she would still be able to approach the medical council of the state where the doctor is registered. However, if the doctor was registered with an authority in another country, the patient would not be able to approach the NMC/state medical council to seek relief. The patient would be rendered helpless. Thus, the law may be interpreted in a way to support the patient, and take a position that the doctor who offers teleconsultation should be licensed to practice medicine in the place where the patient is located.

Are cross border second opinions permitted?
A doctor or patient may, in the course of a consultation or treatment plan, deem that it would be advisable to seek a second opinion from a specialist located overseas. It is important to note that, in such cases, the consultation takes place between two doctors (and not between a doctor and a patient located in different jurisdictions). The doctor who has been approached for a second opinion discusses the case with the treating doctor, and provides his/her inputs to the treating doctor. It is up to the treating doctor to evaluate all the information and provide suitable advice to the patient. The doctor who is providing the second opinion is not practising medicine per se, and is thus not bound by the borders imposed by his/her license.

17th Annual International Conference (TELEMEDICON2021) of Telemedicine Society of India

The 17th Annual International Conference (TELEMEDCICON2021) of Telemedicine Society of India to be held on 12th-14th November, 2021. The theme of the conference is – ‘Tele-health Trends in the 21st Century.’ This issue of the newsletter carries the program for your perusal. Due to COVID the number of participants who would be physically attending are limited, however it is expected that like the last year there will be an overwhelming response. The sessions for free papers and posters are still open. Do make your submission to make the meeting a success.

Click here to Register for TELEMEDICON2021

SCIENTIFIC PROGRAM

Click here to view the latest Scientific Program

Ms. Saranya Gupta
Mentor: Manvee Bansal / Abhimanyu Rathore
Pathways World School, Aravali (IB)

Telemedicine has recently emerged and gained popularity as a new hope to remove the bottlenecks in the healthcare seeking. While telehealth technology and its use are not new, widespread adoption among patients, especially in rural areas, beyond simple telephone correspondence has been relatively slow. Many professional medical societies endorse telehealth services and provide guidance for medical practice in this evolving landscape.

One such example are the incessant advocacy efforts of the Telemedicine Society of India (TSI) that have paid off with the approval of Telemedicine Practice Guidelines by Ministry of Health and Family Welfare, Government of India in March 2020. TSI, now with an enhanced vitality is determined to reduce Urban-rural healthcare disparity.

My detailed research has looked at the problem that exists in rural India and why people residing there are hesitant to adapt to telehealth as a prime medium to acquire healthcare services. Thereafter, it goes into further detail of how this can be destigmatised through solutions like overcoming the language barrier, hiring ambassadors for spreading awareness, and regularly updating the content on the company website.

Lastly, it also includes a state-wise analysis of the 11 states that TSI principally targets, which discusses the problem that a certain state faces and a recommended solution for that problem. For example, people in Maharashtra have concerns about the privacy guidelines around the uptake of telemedicine and to resolve this problem, a recommendation was to revise the guidelines to address the weaknesses and to establish an ongoing system of evaluation to permit future improvements in the guidelines to make them increasingly comprehensive.

The recommendations for adaptation of telehealth in rural areas include –

 1.  proper training of doctors and other healthcare professionals to deliver the telemedicine technology effectively, including vastly improved Internet services;

 2. A much higher level of public-private partnerships related to telemedicine activities;

 3. Developing more cohesive privacy policies and guidelines for TSI to ensure that patients feel secure and integrate telemedicine with the existing health system;

 4. An efficient management structure for monitoring quality standards of telemedicine practice in the country;

 5. Efforts should be made to educate public about telemedicine and its   related benefits.

This kind of research was necessary because of the growing relevance of telehealth services in today’s rapidly revolutionising, technology-dependent world. It is also prominent in the situation of the pandemic in which we are living in today, given the requirement to stay at home and reduce physical contact. In terms of focusing on rural areas of India as a prime target audience for this research, there was a crying need for habitants of these areas to accept newer approaches as the world progresses.

To obtain a full copy of my research, please write a mail to my mentors – aks1953@hotmail.com