Telemedicine has been around for years but is receiving a lot of attention recently. It allows health care professionals to evaluate, diagnose and treat patients remotely using technology, exactly what the healthcare fraternity requires during the ongoing pandemic crisis. The Medical Council of India along with The NITI Aayog released updated guidelines for telemedicine in India on 25^th March 2020. It is a welcome move as the legislation and guidelines around online consultation were not very clear earlier. This article simplifies the intricacies of these highly dynamic and well-timed guidelines that are bound to revolutionize healthcare delivery in India.

In order to follow the most sought-after precaution of this global pandemic, social distancing, you can now start practicing telemedicine for the patients through four basic modes of communication

1. Text-based or chat: It is asynchronous since there is a time lag between the responses from both ends i.e. doctor & patients. It includes SMS, WhatsApp chat, e-mail, and other messaging platforms.
2. Audio-based: such as phone call or WhatsApp audio call. This is synchronous and provides more cues to the doctor as compared to the passive messaging or chat mode.
3. Video-based: such as WhatsApp video call and Skype call. This is way more advantageous as compared to audio-only as a doctor can carry out visual inspection of the patient’s condition and gets stronger cues.
4. Many platforms provide an amalgamation of two or more of the above-mentioned consultation modes. Typically, these are included in specialized Android/ iOS apps on smartphones and some browser-based apps too.

Now that you are well versed in the modes of telemedicine, let us look at some key guidelines that you must keep in mind while providing online consultations.

Step 1: When a patient approaches you

The first and foremost point that you should keep in mind when a patient approaches you for online consultation is to evaluate the overall well-being of the patient. If the patient seems under the influence of alcohol or drugs, is not in the right mental state, or requires emergency attention then do not begin telemedicine and ask the patient to seek in-person consultation.

Another important step is taking explicit consent for telemedicine using a simple text such as “I consent and understand the limitations of telemedicine”. Further, it is advisable that you record the demographic details and/or an ID number such as Aadhar or PAN. This becomes important if you must identify the patient for follow-up consultations or any medico-legal issue. Do not forget to take the details of the accompanying parents and/or guardians in the case of minor patients.

Also, make sure that the patient is in proper surroundings such as no background noise and adequate lighting so that you can listen and see the patient properly and do optimum diagnosis and treatment. If necessary, you can ask the caregiver to join the discussion (only if the patient is comfortable). Similarly, you can ask the caregiver to leave the consultation at any time, on any of the telemedicine platforms, if you need to consult the patient in private.

Step 2: Understanding medical history and performing diagnosis in Telemedicine

It is advisable to record the entire medical history in telemedicine to avoid any medical liabilities in the future. It is advisable to write the medical history in Rx itself, as it will be easier for you to store and it can be easily shared with the patient too. Otherwise, write it in your medical notes and make sure to keep it safe with you for future reference.

Note: You can discontinue the consultation if the patient does not give proper medical history. Politely ask them for more information and if they do not comply or are not able to answer then ask them to visit you or any other medical practitioner in-person.

During the diagnosis, it is preferred that you make use of other cues (beyond what the patient is saying), focus on their tone, expressions or any other uneasiness. As mentioned earlier, make sure that the patient is in proper surroundings such as no background noise, adequate lighting, so you can listen and see, and deliver successful diagnosis and treatment.

Step 3: Writing Prescription in Telemedicine

While writing a prescription in Telemedicine write the word “Telemedicine” or “Teleconsultation” at the top of prescription. This will set the right expectations for all the stakeholders including patient, referred physician (if any), radiologists, etc. while safeguarding you on the legal front.

Considering the ongoing crisis, the authorities have put some limitations on the kind of medicines that can be prescribed to the patients via telemedicine. This list is expected to be updated over the next few months and years. It is important to know what can and cannot be prescribed using telemedicine:

• List O: Medicines that are used for common conditions and are often available ‘over the counter’ or OTC. You can prescribe drugs from this list via any mode of telemedicine i.e. phone, video or chat. The list includes medicines that could be deemed necessary during public health emergencies.
• List A: The scope of prescription for drugs under List A is limited to only video calls for the first consultation, but they can be re-prescribed or re-filled over any mode (audio, video or chat) for follow-up consultations.
• List B: The doctor can prescribe medicines from List B only in case of follow-up consultations and not during the patient’s first online visit.
• Prohibited List: You cannot prescribe drugs that have a high potential for abuse via telemedicine. This includes drugs under List X and narcotic drugs.

Related article: Frequently Asked Questions (FAQs) about OPDlift: For Doctors who wish to practice telemedicine on a compliant platform.

Reference: List of Schedule H drugs by the ministry of Health & family welfare, GoI