Tag: TeleHealth Newsletter

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

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

Eshika Phadke
Associate, Arogya Legal – Health Laws Specialist Law Firm

The Telemedicine Practice Guidelines specify that consent may be implied when a patient initiates a teleconsultation; however, there are certain situations wherein a doctor is legally required to obtain consent from the patient.

Consultation not initiated by the patient
If someone other than the patient – including their family member, a healthcare professional, another doctor, or even the doctor who is consulting the patient themselves – initiates the consultation, explicit consent must be taken from the patient.

If a healthcare professional seeks a medical consultation for a patient through telemedicine, both the healthcare professional and the consulting doctor would need to obtain explicit consent from the patient. The healthcare professional would be required to counsel the patient on the risks and limitations of telemedicine, and the doctor would be required to seek the patient’s consent to proceed with the consultation.

No capacity to consent
If the patient is a minor or does not have the mental capacity to legally provide consent, the person’s caregiver is authorised to consult with a doctor and take decisions on their behalf. However, the doctor must first confirm that the person is the patient’s caregiver by asking to see either a formal authorisation to that effect, or a government-issued document that establishes the person’s relationship with the patient. This would not be required if the doctor has previously treated the patient in-person, and is aware of their relationship with the caregiver. For the sake of documentation in such cases, the doctor ought to record that they have treated the patient in-person prior to the teleconsultation, and may even request that the caregiver confirm the same through a text message or email.

Recording
If the doctor will be recording the consultation, they ought to inform the patient and seek their consent for the same. This is especially vital for specialists like psychiatrists, venereologists, gynaecologists, etc, who discuss highly sensitive and personal information and may receive private visuals from the patients.

Refusal to comply
If the doctor is of the impression that the patient ought to go for an in-person consultation for their condition but the patient refuse, the doctor should inform them of the risks and consequnces of not seeking in-person treatment. If the patient still refuses, the doctor should require the patient to send a statement that they were informed of the risks and elected to proceed with the teleconsultation against medical advice in writing or as a voice note, and the doctor should preserve the consent with the records that he/she maintains for the consultation.

Transmitting Prescription to Pharmacy
If the doctor issues a prescription post a teleconsultation and the patient wishes that the prescription be sent directly to a pharmacy of their choosing, the doctor must obtain explicit consent from the patient prior to doing so, since without consent, the act of transmitting a patient’s prescription to a pharmacy would constitute a breach of confidentiality.

Support groups
If the doctor starts virtual support groups for patients suffering from or people affected by a disease/condition where they will be sharing information and/or allowing the group members to provide emotional support to one another, the doctor must seek explicit consent from a patient/person before adding them to the group, since the patient’s identity would be revealed to other members of the group, and confidentiality would thus be compromised.

Limitations of Telemedicine
It is advisable that doctor’s refrain from tending to spontaneous teleconsultations unless it is an emergency; they should put in place a process whereby the patient takes an appointment. Along with the appointment confirmation, the doctor should send a brief statement outlining the risks and limitations of teleconsultation, and informing the patient that by proceeding with the consultation, they are providing their consent.

How to record consent
For the teleconsultation itself, the consent will be implied if a patient proceeds to initiate the consultation after being informed of the risks involved.

For situations where explicit consent is required or advisable, the doctor may ask the patient to record it in any form – they could send an email, text, audio note, video recording stating that they are providing their consent for telemedicine (and any other context that may be required). The doctor must always record the fact of receipt of consent in his notes which should be preserved with the patient’s records.

Source:
Telemedicine Practice Guidelines

Prof. K. Ganapathy
Former Secretary and Past President Neurological Society of India, Telemedicine Society of India & Indian Society for Stereotactic & Functional Neurosurgery | Hon Distinguished Professor The TamilNadu Dr. MGR Medical University | Member Roster of experts Digital Health WHO | Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services | URL: https://kganapathy.in |  EMail: drganapathy@apollohospitals.com

Chronicle of events

• Sep 16th 1996 – The compiler of this chronicle delivered an Institute Lecture @ IIT Kanpur at 8pm. . Prof K. Srivathasan then HoD EE introduced him to the word Telemedicine and persuaded him to jointly prepare a project report from 10.30pm to 4am immediately after the lecture !!!.
• Nov 1996 – Made a formal proposal along with Prof Srivathsan to Dr P C Reddy, Chairman Apollo Hospitals to do a pilot project @ Apollo Hospital Nellore . Prof Srivathsan and I even chose the room in Nellore !! However it did not fructify . We were too far ahead of the times!
• April 1998 – Dr Reddy asked the author if he was still interested in Telemedicine. Ms Sangita Reddy had persuaded ISRO to use a VSAT for Telemedicine purposes @ the new secondary level hospital in the village of Aragonda ( near Chitoor) the birth place of Dr Reddy.
• March 24th 2000 – The world’s first Teleconsultation from a village hospital thro amn ISRO enabled VSAT was commissioned by the then US president Bill Clinton from Hyderabad in the presence of the then Chief Minister Sri Chandrababu Naidu
• In 2001 – Apollo Telemedicine Networking Foundation was formally established as a not for profit Section 25 company. Spoke in the first intercontinental live multipoint telemedicine symposium on June 19 2001. Bill Gates was also a speaker . Initiated teleconferences with, Japan, USA, Saudi Arabia and Hong Kong.
• Feb 15 2002 – Apollo SHAR Telemedicine project commissioned by Chairman ISRO . ISRO convinced that Telemedicine was doable and took it up as a major initiative.
• April 2002 – Addressed 600 principals of Engineering Colleges @ Anna University on Telemedicine. Subsequently started Telemedicine units in 5 Engineering colleges !!
• May 2002 – Assisted ATnKK Area in Southern Command. Indian Army to set up Telemedicine units
• 2003 – First formal University accredited 4 week certificate course on Telehealth technology was started with Anna University. Featured in Govt of India Documentary India 2.0
• 2004-05 – Clinically validated Telemedicine enabled peripheral medical devices for IITM start up REMEDI
• 2005 – VSAT enabled Hospital on Wheels commissioned at Madurai . Became first Treasurer and Joint Secretary of TSI with Reg No 001 ATNF also became first institutional member of TSI
• 2006 onwards – Evangelisation on mission mode ! Talks given all over India and overseas creating awareness . Large number of VIP’s and VVIP’s visited the Dept to see Telemedicine in action . ATNF became a member of the Standards Committee on Telemedicine, the National Task Force on Telemedicine, the Working Group on Telemedicine of the Planning Commission, and the SARC Committee.
• August 2007 – Assisted Ericsson in demonstrating wireless transmission of heart sounds etc thro 3G for the first time in South Asia
• Nov 2007 – International Conference on Telemedicine at Chennai 350 attended including 35 from overseas
• 2009 – MEA Govt. of India initiated the Pan Africa e-Network project for teleconsultations ATNF was part of the steering Committee and an active participant
• 2010 – Commenced “Transforming Health Care with IT” international conference held annually till 2019
• 2010 – Creation of Apollo Telehealth Services Pvt Ltd with a full time CEO and support staff
• 2011 – eHome Visits initiated in Chennai won Best Post Poster award Washington DC
• 2012 – 527 patients in 13 different specialities were connected simultaneously to six tertiary Apollo hospitals, from a Hospital on Wheels @ a mega health camp in Ajmer 11th /12th February. A world record then.
• 2014 – Patient empowerment in rural India – project with MS Swaminathan Research Foundation promoting eHealth Literacy thro internet enabled Village Resource Centers > 26,000 from 13 villages have attended
• 2015 onwards International Educational Activities with various Management Schools including London School of Economics, Harvard , Columbia etc , Chosen as case study to illustrate Global Best Practices by Columbia University
• eICU’s 20 smaller ICU’s connected to Apollo Hospitals Hyderabad 1200 plus teleICU consults in subspecialities given.
• Public Private Partnerships a) Himachal Pradesh . Four Telemedicine Centres in the Himalayas and the world’s first 24/7 Tele emergency Services . About 30,000 teleconsults already provided . b) >1.2 million teleconsultations provided under the Mukhyamantri Arogya Kendram (e-UPHC)- project covering 182 Centres from October 2016.c) Jharkhand Digital Dispensaries programme In first 15 months 328,648 patients attended d) Uttar Pradesh Telemedicine programme in the first one year 141,793 patients visited 114 Government Community Health Centres e) Uttar Pradesh Teleradiology PPP program has 127 teleradiology centres in rural UP with 400 images reported daily with turn around time < f 4 hours f) Tele Opthalmology Through 115 existing Community Health Centres / Vision Centres in 13 districts,5 million patients screened in 2 years. Thro Mukhyamantri e-Eye Kendram or MeEK project 405,000 fundus examinations were done remotely by 30 Opthalmologists from Chennai.
• 2019 Only medical paper presented @ International Conference on Human Spaceflight Programme organised by ISRO.
• 2021 Since inception over 400 papers have been presented in various regional, national and international meetings held in India and 105 held overseas . Over 180 articles have been published on Telehealth besides 45 in peer-reviewed journals and 12 chapters in textbooks. Several national and international awards have been received.