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On March 25, 2020, the Board of Governors (“BoG”) entasked by the Health
Ministry to regulate practice and practitioners of modern medicine, 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.
“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”
India does not have a great doctor to patient ratio. This, coupled with the fact that
India is a huge country and that the density of doctors is far higher in cities than in
rural areas where the bulk of India’s population resides, is the reason why
teleconsultation has great demand and potential in India.
Unfortunately, there were hardly any standards for doctors to follow and patients to
expect during a teleconsultation. For example, Indian patients sometimes felt short-
changed when a doctor was not clear or audible, or the doctor refused to issue a
prescription or did not provide a report of the consultation after the consultation
ended. Some patients feared whether the person on the other end was, in fact, a
doctor or not. A few worried about their privacy, as electronic communications
over mobile application or email, can leave a trail.
Doctor can choose the medium of teleconsultation: A doctor may use any medium
for patient consultation, e.g. telephone, mobile or landline phones, chat platforms
like WhatsApp, Facebook Messenger etc., other mobile apps or internet-based
digital platforms for telemedicine or data transmission systems like Skype/ email/
fax etc. However, before proceeding with the teleconsultation, the doctor should
exercise professional judgement to decide whether the teleconsultation is, in fact,
appropriate and in the interest of the patient. If the answer is yes, then the doctor
should evaluate which medium would be preferred for the teleconsultation. For
example, a complaint of appendicitis may require a physical examination and
teleconsultation may not be preferred. On the other hand, some common
complaints may not require physical examination or even consultation in real-time.
For example, a complaint of headache or fever may not always require the doctor
to examine the patient physically or audio-visually through a mobile or computer
application. However, in certain cases, for example, on presentation of allergy or
inflammation (e.g. Conjunctivitis), the doctor may choose to examine the patient
in-person or through an audio-visual teleconsultation. Thus, the decision to
examine the patient physically or remotely i.e. through teleconsultation, and the
medium of teleconsultation, is to be taken by the doctor himself or herself on case
to case basis.
No fixed Format for issuing a prescription: There is no fixed format for issuing a
prescription in a teleconsultation. The Telemedicine Guidelines has recommended
a format, but following it is not mandatory. However, the doctor must provide
photo/scan /digital copy of a signed prescription or e-Prescription to the patient via
email or any messaging platform. Please note that a doctor can transfer the
prescription to a pharmacy only if he/ she has the explicit consent of the patient.
Invoice for fees: Doctors can charge appropriate fees for teleconsultation. A receipt
or invoice should be given to the patient against the fees.
Doctor should not continue with teleconsultation if it not appropriate: the doctor is
not satisfied with the information provided by the patient to provide specific
treatment, i.e. prescription or health advice, then he/she should provide limited
consultation as appropriate and refer the patient for an in-person consultation.
Doctor should not deny emergency teleconsultation, but limit it for immediate
assistance or first aid: Emergency teleconsultation should not be provided
remotely except when it is the only way to provide timely care.Even then, such
emergency teleconsultation should be limited to first aid, life-saving measures,
counselling and advice on referral. Every emergency teleconsultation must end
with an advise to the patient or his/her carer for in-person interaction with a Doctor
at the earliest.
If the teleconsultation with the patient does not take place over video, then the
concerned doctor cannot prescribe drugs to the patient other than common over-
the-counter (“O.T.C.”) medications such as paracetamol, O.R.S. solutions, cough
lozenges etc. Such patient also cannot be prescribed medication for which
diagnosis is possible only by video consultation such as antifungal medications for
Tinea Cruris, Ciprofloxacillin eye drops for Conjunctivitis etc. The doctor may,
however, prescribe ‘add-on’ medication to such patient to optimize the existing
treatment through drugs if such existing treatment was prescribed in an in-person
consultation less than six months ago. Please note that there is no bar in prescribing
emergency medications, even if they are not O.T.C. medicines, as and when
notified by the government, through any form of teleconsultation, whether video or
not.
If the patient is examined through video, then the doctor may prescribe
medications other than O.T.C. medicines described in List A of Appendix 5 of
Code of Conduct. Some examples of such medicines are:
The doctor may also prescribe a ‘refill’ of medication already prescribed during an
in-person consultation for chronic illnesses (hypertension, diabetes, asthma etc.) or
an ‘add-on’ medication to optimize the existing treatment (like in the case of non-
video consultation).
Please note, however, that no doctor is permitted to prescribe habit forming drugs
(i.e. drugs in Schedule X of Drugs and Cosmetics Rules, 1945) or narcotic or
psychotropic drug (i.e. drugs regulated by Narcotic Drugs and Psychotropic
Substances Act, 1985) through any medium of teleconsultation.
In 2018, a judgement of High Court of Bombay caused panic amongst doctors who
offered teleconsultation. In that case, two gynaecologists were denied anticipatory
bail on the grounds that, prima facie, they were criminally negligent towards their
patient who unfortunately died while under their care. The material facts of the
case are that the deceased patient had presented herself with a complaint of fever
and severe vomiting. She was admitted to the nursing home of the accused doctors
by the hospital staff without examination, as the doctors were out of town. One of
the doctors started treatment for the patient telephonically, by instructing the on
duty nurse. Unfortunately, the patient died. The Court held that the patient died
because, amongst other things, she was prescribed treatment over telephone
without appropriate diagnosis, and found such practice to be an act of criminal
negligence. The application of the doctors for bail in anticipation of arrest was
rejected. However, the doctors were successful in receiving the bail in appeal and
were not arrested.
Therefore, the above judgement of Bombay High Court does not interfere with the
Telemedicine Guidelines at all. In fact, it supports it. The Telemedicine Guidelines
require doctors who provide teleconsultation to start patient treatment only if the
doctor is satisfied that he/ she has gathered adequate and relevant information
about the patient’s medical condition and prescription of medicines which are in
the best interest of the patient. Else, the doctor should not prescribe medication to
the patient. If the doctor prescribes patient in violation of the Telemedicine
Guidelines, he/she risks losing his/her registration with respective State Medical
Council i.e. the license to practice medicine on grounds of professional
misconduct.
Conclusion
The notification of the Telemedicine Guidelines marks the dawn of a new era in
the practice of modern medicine. The law has finally caught up with the reality and
necessity of modern times.
At the same time, they protect patient interest by mandating doctors to identify
themselves before consultations, disclose their registration number, offer the same
standard of care to patients as during in-person consultation and limit medicines
that can be prescribed through a teleconsultation.
Indians will now be able to enjoy access to quality healthcare remotely, and
doctors will be able to extend their services to many more needy patients.