<p>A disturbing aspect of the lockdown since March 2020 has been the limited access of non-COVID-19 patients to doctors and hospitals. Many private and small hospitals closed temporarily until a better understanding of pandemic protocols and safety precautions emerged. Patients with chronic illnesses needing follow-up, or dialysis, patients on chemotherapy, those with mental illness and others with lifestyle disorders had nowhere to turn to, their condition worsening as they waited. Even when hospitals reopened, many patients stayed away, fearing they may be at higher risk of infection. This distress of patients, as the health system struggled to cope with the virus outbreak, could have been mitigated to some extent if patients were able to have audio and video consultations and share test results, receive counselling, reassurance or follow-up prescriptions.</p>.<p>In a timely move, the Ministry of Health and Family Welfare issued a notification on March 25 on telemedicine guidelines. Through the Board of Governors (MCI), this notification amended the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002, adding consultation by telemedicine to Chapter 3, and the guidelines as Appendix 5 of the regulations. This is a welcome step as hospitals struggle to cope with physical distancing and concerns about the contagion during COVID-19. It allows hospitals and doctors to continue to serve patients in the safety of their homes and reduces overcrowding of hospitals already stretched by the pandemic.</p>.<p>Even beyond the pandemic, telemedicine is likely to remain a useful option for patients, for follow-up and non-emergency consultations. Once the technology platforms are readied for online video streaming, linked to hospital information systems, electronic medical records and payment gateways, the hospital or clinic will have an outreach capability that can complement other services. Storage and retrieval of data will be critical for success of e-consultations. Data security would need robust solutions that can resist hacking and data loss; a step that would generate trust in all stakeholders.</p>.<p>Clearly not all patients can be treated through telemedicine and this discernment ultimately rests with the doctor. If the patient needs physical examination or hospital admission, this has to be clearly explained, and the e-consult terminated. Liability for any mismanagement or negligence will be the same as with face-to-face consultations. For this reason, it is recommended that e-consultations should be limited initially to follow-up consults, geriatric care, and chronic diseases. First-time e-consultations may help to triage patients who are uncertain if they should ‘see’ a doctor. Telemedicine can also be used in emergencies for advice on immediate measures before the patient is brought to the hospital.</p>.<p>The modalities and protocol to be adopted for e-consultations are described in some detail in the guideline but may change based on real-time experience. The choice of this option will be left to the patient and appointments would be made online, with consent recorded for every session. The duration of each consultation could vary, and prescribed tests and medications will be signed and scanned to the patient. The guideline places restrictions on drugs that can be prescribed online for safety reasons; schedule drugs with toxic side effects may only be prescribed on visit to the physician.</p>.<p>Online physician consultation has hitherto been on offer by some private hospitals and doctor apps, but it remained a grey area of practice. Some ethical concerns may persist, even as patients get familiar with the process and doctors build capacity to treat online. Medical training will need to include this aspect of care communication. The guidelines suggest the same consultation fees for online consultations, as patients benefit from not having to take leave or travel. This will have to be tested against the experience of patients, comfort with technology, and satisfaction levels. Entrenched perceptions of patients and their expectations of doctor-patient interaction may affect adoption levels, at least initially. In-built feedback forms would enable evaluation of the platform and ease of the process, facilitating continuous improvement. Hospitals may need to allot specific timings for these consults, adjusting the physician’s workload to prevent compromise of other clinical duties. Given the access to technology across the population, it is fair to expect that only a fraction of patients stand to benefit from e-consults. This systemic inequality excludes a majority of patients, many of whom will continue to incur debt in order to access health services.</p>.<p>In India, teleconsultation holds out the promise of healthcare access to rural underserved areas. ASHA workers can consult with medical experts in health centres and provide interim care before patients reach the hospital. More importantly, it can take health awareness and preventive care to every person with phone connectivity and Internet. There is hope for inclusion of the traditionally marginalized, the elderly, disabled, Dalits and women, served last in the hierarchy of health needs. In this way, telemedicine can serve both ends of the spectrum of demand, at the cutting edge of biotech innovations, as well as primary health needs, bridging the healthcare gap in this country</p>.<p><span class="italic"><em>(The writer is part of division of Health and Humanities, St Johns Research Institute) </em></span></p>
<p>A disturbing aspect of the lockdown since March 2020 has been the limited access of non-COVID-19 patients to doctors and hospitals. Many private and small hospitals closed temporarily until a better understanding of pandemic protocols and safety precautions emerged. Patients with chronic illnesses needing follow-up, or dialysis, patients on chemotherapy, those with mental illness and others with lifestyle disorders had nowhere to turn to, their condition worsening as they waited. Even when hospitals reopened, many patients stayed away, fearing they may be at higher risk of infection. This distress of patients, as the health system struggled to cope with the virus outbreak, could have been mitigated to some extent if patients were able to have audio and video consultations and share test results, receive counselling, reassurance or follow-up prescriptions.</p>.<p>In a timely move, the Ministry of Health and Family Welfare issued a notification on March 25 on telemedicine guidelines. Through the Board of Governors (MCI), this notification amended the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002, adding consultation by telemedicine to Chapter 3, and the guidelines as Appendix 5 of the regulations. This is a welcome step as hospitals struggle to cope with physical distancing and concerns about the contagion during COVID-19. It allows hospitals and doctors to continue to serve patients in the safety of their homes and reduces overcrowding of hospitals already stretched by the pandemic.</p>.<p>Even beyond the pandemic, telemedicine is likely to remain a useful option for patients, for follow-up and non-emergency consultations. Once the technology platforms are readied for online video streaming, linked to hospital information systems, electronic medical records and payment gateways, the hospital or clinic will have an outreach capability that can complement other services. Storage and retrieval of data will be critical for success of e-consultations. Data security would need robust solutions that can resist hacking and data loss; a step that would generate trust in all stakeholders.</p>.<p>Clearly not all patients can be treated through telemedicine and this discernment ultimately rests with the doctor. If the patient needs physical examination or hospital admission, this has to be clearly explained, and the e-consult terminated. Liability for any mismanagement or negligence will be the same as with face-to-face consultations. For this reason, it is recommended that e-consultations should be limited initially to follow-up consults, geriatric care, and chronic diseases. First-time e-consultations may help to triage patients who are uncertain if they should ‘see’ a doctor. Telemedicine can also be used in emergencies for advice on immediate measures before the patient is brought to the hospital.</p>.<p>The modalities and protocol to be adopted for e-consultations are described in some detail in the guideline but may change based on real-time experience. The choice of this option will be left to the patient and appointments would be made online, with consent recorded for every session. The duration of each consultation could vary, and prescribed tests and medications will be signed and scanned to the patient. The guideline places restrictions on drugs that can be prescribed online for safety reasons; schedule drugs with toxic side effects may only be prescribed on visit to the physician.</p>.<p>Online physician consultation has hitherto been on offer by some private hospitals and doctor apps, but it remained a grey area of practice. Some ethical concerns may persist, even as patients get familiar with the process and doctors build capacity to treat online. Medical training will need to include this aspect of care communication. The guidelines suggest the same consultation fees for online consultations, as patients benefit from not having to take leave or travel. This will have to be tested against the experience of patients, comfort with technology, and satisfaction levels. Entrenched perceptions of patients and their expectations of doctor-patient interaction may affect adoption levels, at least initially. In-built feedback forms would enable evaluation of the platform and ease of the process, facilitating continuous improvement. Hospitals may need to allot specific timings for these consults, adjusting the physician’s workload to prevent compromise of other clinical duties. Given the access to technology across the population, it is fair to expect that only a fraction of patients stand to benefit from e-consults. This systemic inequality excludes a majority of patients, many of whom will continue to incur debt in order to access health services.</p>.<p>In India, teleconsultation holds out the promise of healthcare access to rural underserved areas. ASHA workers can consult with medical experts in health centres and provide interim care before patients reach the hospital. More importantly, it can take health awareness and preventive care to every person with phone connectivity and Internet. There is hope for inclusion of the traditionally marginalized, the elderly, disabled, Dalits and women, served last in the hierarchy of health needs. In this way, telemedicine can serve both ends of the spectrum of demand, at the cutting edge of biotech innovations, as well as primary health needs, bridging the healthcare gap in this country</p>.<p><span class="italic"><em>(The writer is part of division of Health and Humanities, St Johns Research Institute) </em></span></p>