MOHFW India Telemedicine Guidelines Summary

Modes of Telemedicine

Telemedicine includes all channels of communication with the patient that leverage Information

Technology platforms, including: 

  • Video (Telemedicine facility, Apps, Video on chat platforms, Skype/Face time etc.)

  •  Audio (Phone, VOIP, Apps etc.)

  •  Text Based:

    • Telemedicine chat based applications (specialized telemedicine smartphone Apps, Websites,other internet-based systems etc.)

    • General messaging/ text/ chat platforms (WhatsApp, Google Hangouts, Facebook Messenger etc.)

    • Asynchronous (email/ Fax etc.)

Prescription by RMP 

If the condition can be appropriately managed via telemedicine, based on the type of consultation, then the RMP may proceed with a professional judgement to:

 

  • Provide Health Education as appropriate in the case; and/or

  • Provide Counseling related to specific clinical condition; and/or

  • Prescribe Medicines: 

    • If the RMP has prescribed medicines, RMP shall issue a prescription as per the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations and shall not contravene the provisions of the Drugs and Cosmetics Act and Rules.

    • RMP shall provide photo, scan, digital copy of a signed prescription or e-Prescription to the patient via email or any messaging platform

List O

 

Medicines which are used for common conditions and are often available ‘over the

counter’. For instance, these medicines would include, paracetamol, ORS solutions, cough lozenges etc. Medicines that may be deemed necessary during public health emergencies.

 

 Common over-the counter medications such as

  • Antipyretics: Paracetamol

  • Cough Supplements: Lozenges,

  • Cough/ Common-cold medications (such as combinations of Acetylcysteine, Ammonium

  • Chloride, Guaifensen, Ambroxol, Bromhexene, Dextromethorphan)

  • ORS Packets

  • Syrup Zinc

  • Supplements: Iron & Folic Acid tablets, Vitamin D, Calcium supplements etc.

 

Medications notified by Government of India in case from time to time on an Emergency basis

  • Such as Chloroquine for Malaria control for a specific endemic region, when notified by Government

 

List A
 

This would be an inclusion list, containing relatively safe medicines with low potential for

abuse Is a list of medication which RMP can prescribe in a patient who is undergoing

follow-up consult, as a refill.

 

First Consult Medications (Diagnosis done on video mode of consultation) such as

  • Ointments/Lotion for skin ailments: Ointments Clotrimazole, Mupirocin, Calamine Lotion,

  • Benzyl Benzoate Lotion etc

  • Local Ophthalmological drops such as: Ciprofloxacillin for Conjunctivitis, etc

  • Local Ear Drops such as: Clotrimazole ear drops, drops for ear wax etc..

  • Follow-up consult for above medications

 

Follow-up medications for chronic illnesses for ‘re-fill’ (on any mode of consultation) such as medications for: 

  • Hypertension: Enalapril, Atenolol etc

  • Diabetes: Metformin, Glibenclamide etc

  • Asthma: Salmetrol inhaler etc

 

List B

 

Is a list of medication which RMP can prescribe in a patient who is undergoing follow-up

consultation in addition to those which have been prescribed during in-person consult for the same medical condition.

 

On follow-up, medications prescribed as ‘Add-on’ to ongoing chronic medications to optimize management such as for hypertension: Eg, add-on of Thiazide diuretic with Atenolol

  • Diabetes: Addition of Sitagliptin to Metformin etc. 

Prohibited List: 

 

An RMP providing consultation via telemedicine cannot prescribe medicines in

this list. These medicine have a high potential of abuse and could harm the patient or the

society at large if used improperly

 

  • Medicines listed in Schedule X of Drug and Cosmetic Act and Rules or any Narcotic and Psychotropic substance listed in the Narcotic Drugs and Psychotropic Substances, Act, 1985

  • The following are the Schedule X drugs mentioned in the Drugs and Cosmetics Rules 1945:

  • Amobarbital, Amphetamine, Barbital, Cyclobarbital, Dexamphetamine, Ethchlorvynol, Glutethimide, Meprobamate, Methamphetamine, Methylphenidate, Methylphenobarbital,Pentobarbital, Phencyclidine, Phenmetrazine, Secobarbital. Ketamine Any stereoisometric form of the substance specified in this Schedule, any salt of the substance and preparation containing such substances are also covered by this Schedule. Also, preparations containing the above substances are also covered by this Schedule

Urgency or emergency usage guidelines

In all telemedicine consultations, as per the judgment of the RMP, if it is an emergency situation, the goal and objective should be to provide in-person care at the soonest. However critical steps could be life-saving and guidance and counseling could be critical. For example, in cases involving trauma,right advice and guidance around maintaining the neck position might protect the spine in somecases. The guidelines are designed to provide a balanced approach in such conditions. The RMP,based on his/ her professional discretion may: 

  • Advise first aid

  • Counseling

  • Facilitate referral


 

Telemedicine services should however be avoided for emergency care when alternative in-person care is available, and telemedicine consultation should be limited to first aid, life-saving measure, counseling and advice on referral. In all cases of emergency, the patient must be advised for an in-person interaction with an RMP at the earliest.

Patient Consent

Patient consent is necessary for any telemedicine consultation. The consent can be Implied or explicit depending on the following situations:

  • If, the patient initiates the telemedicine consultation, then the consent is implied

  • An Explicit patient consent is needed if:

    • A Health worker, RMP or a Caregiver initiates a Telemedicine consultation.

 

An Explicit consent can be recorded in any form. Patients can send an email, text or audio/video message. Patient can state his/her intent on phone/video to the RMP (e.g.“Yes, I consent to avail consultation via telemedicine” or any such communication in simple words). The RMP must record this in his patient records.


Patient Consent (by RMP): RMP should confirm the patient’s consent to continue the consultation

Types of Consults

First Consult means

  • The patient is consulting with the RMP for the first time; or

  • The patient has consulted with the RMP earlier, but more than 6 months have lapsed since the previous consultation; or

  •  The patient has consulted with the RMP earlier, but for a different health condition

    First Consultation Process


 

Follow-Up Consult(s) means

  • The patient is consulting with the same RMP within 6 months of his/her previous inperson consultation and this is for continuation of care of the same health condition.However, it will not be considered a follow up if:

    •  There are new symptoms that are not in the spectrum of the same health condition; and/or

    • RMP does not recall the context of previous treatment and advice



    • Followup Consultation process

Tele-Consultation Process

Start of a Telemedicine Consultation for First Consult

 

  • Telemedicine consultation should be initiated by the patient and thereby consent is implied


  • 1. The telemedicine consultation is initiated by the patient (For example, a patient may do an audio or video call with a RMP or send an email or text with a health query) o RMP accepts to undertake the consultation

    2. Patient identification and consent o RMP should confirm patient identity to his/her satisfaction by asking patient’s name, age, address, email ID, phone number or any other identification that may be reasonable 


    3. Quick assessment:

    The patient’s condition needs to be quickly assessed by the RMP based on available inputs and RMP uses his professional discretion if emergency care is needed, to decide if emergency care is needed.

    If the condition of the patient merits emergency intervention, then advice for first aid/ immediate relief is provided and guidance is provided for referral, as appropriate. If the condition does not merit an emergency intervention, the following steps are undertaken:

    4. Exchange of Information for Patient Evaluation

    The RMP may ask the patient to provide relevant information (complaints, information about any other consults for the same problem, available investigation and medication details, if any). The patient shall be responsible for accuracy of information shared by him/her with the RMP.

    If the RMP feels that the information provided at this stage is inadequate, then he/she shall request for additional information from the patient. This information may be shared in real time or shared later via email/text, as per the nature of such information.

    The consultation may be resumed at a rescheduled time after receipt of the additional information (this may include some laboratory or radiological tests). In the meantime, the RMP may provide health advice as appropriate.

    If the RMP is satisfied that he/she has adequate patient information for offering a professional opinion, then he/she shall exercise one’s professional judgment for its suitability for management via telemedicine.
    If the situation is NOT appropriate for further telemedicine consultation, then the RMP should provide Health advice/ Education as appropriate; and/or refer for in-person consultation.

    5. Patient Management If the condition can be appropriately managed via telemedicine, then the RMP may take a professional judgement to either: o Provide Health Education as appropriate in the case; and/or

    Provide Counseling related to specific clinical condition, including advice related to new investigations that need to be carried out before next consult; and/or

    Provide specific treatment by prescribing medicines as in List O (which are over the counter drugs or others as notified). Additional medicines (as per List A) can also be prescribed if the ongoing tele-consultation is on video. 

 

Follow-up Consult: Patient to Registered Medical Practitioner

 

Tele-Consultation Process The flow of the process is summarized:

1. Start of a Telemedicine Consultation for Follow Up

Patient may initiate a follow up consult with a RMP for continuation of his/her ongoing treatment or for a new complaint or complication arising during the course of the ongoing treatment using any mode of communication.
For e.g., the patient may do an audio or video call with a RMP or send him/her an email or text message with a specific health query

RMP accepts to undertake the consultation 2. Patient identification and consent

RMP should be reasonably convinced that he/she is communicating with the known patient, for e.g. if the patient is communicating with RMP through the registered phone number or registered email id

If there is any doubt RMP can request the patient to reinitiate the conversation from a registered phone number or email id or should confirm patient identity to his/her satisfaction by asking patient’s name, age, address, email ID or phone number. Patient initiates the Telemedicine consultation and thereby consent is implied

3. Quick Assessment for Emergency Condition

If the patient presents with a complaint which the RMP identifies as an emergency condition necessitating urgent care, the RMP would then advice for first aid to provide immediate relief and guide for referral of the patient, as deemed necessary.

4. In case of routine follow-up consultation, the following would be undertaken:

If the RMP has access to previous records of the patient, he/ she may proceed with continuation of care.

RMP shall apply his/her professional discretion for type of consultation based on the adequacy of patient information (history/examination findings/Investigation reports/past records).
If the RMP needs additional information, he/ she should seek the information before proceeding and resume tele-consultation for later point in time.

5. Patient Management

If RMP is satisfied that he/she has access to adequate patient information and if the condition can be appropriately managed by tele-consultation, he/she would go ahead with the tele-management of the patient.

If the follow-up is for continuation of care, then the RMP may take a professional judgement to either:

 Provide health education as appropriate in the case; or o Provide counseling related to specific clinical condition including advice related to new investigations that need to be carried out before next consult;  And/or Prescribe Medications.

The medications could be either of the below:  If the follow up is for continuation of care for the same medical condition, the RMP would re-prescribe original set of medications for a refill (List A of medications, which has been previously prescribed for the patient).

f the RMP considers addition of a new drug, as an ‘add-on’ medication to optimize the underlying medical condition, then the RMP can prescribe medications listed under List B.

If the follow-up consult is for a new minor ailment necessitating only ‘over the counter’ medications or those notified for this purpose, medications under List O can be prescribed.

If the follow-up consult reveals new symptom pertaining to a different spectrum of disease, then the RMP would proceed with the condition as enunciated in the scenario for a first-time consultation

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