TELEMEDICINE

Nizam’s Institute of Medical Sciences

1
What is Telemedicine ?
• It is the term given to remote health care delivery and consultation given to
patient at a distance .

• A tool that makes healthcare more accessible, cost-effective, and that

increases patient engagement.

• Telemedicine allows health care professionals to evaluate, diagnose and treat

patients at a distance using telecommunications technology.
Telemedicine History
• Telemedicine is not a new practice.

• The concept of telemedicine is dated back to the 19th century! What began

as a few hospitals wanting to reach patients in remote locations became an

integrative system across the care continuum.

• The history of telemedicine will unveil how we got to where we are today.
 1876 1924 s’1950
• Alexander • [Link] • Medical personal
Graham Bell:
Gernsback: start doing
• Patents the experiments with
• envisions the
telephone and close- circuit
“tele dactyl”: a
launches the television.
tool with robotic
beginnings of our
fingers.
telecommunicati
on field.
 s’1960 s’1970 1989-1999

• Nasa takes on • The late 70’s brought a

• The first time a
telemedicine. golden age of
• Which is patient was
telemedicine research
successfully
researched ways to and expansion.
defibrillated by
provide HealthCare • The federal government
telephone.(1989)
to astronauts and funded a range of • ATA is created as a
improve telemedicine program
telecommunication non-profit
to improve healthcare
s technology. organization.(1993)
access in the rural
• Medicare gets in the
areas.
telemedicine game.
(1999)
 In the 20th century :
• Video chat programs and apps like skype take-off.(2000)
• ARRA helps stimulate the telemedicine sector.(2009)
• Healthcare goes mobile.(2015).

Todays telemedicine:
• Most people have access to basic telemedicine devices like mobile phones and computers.
• Improved accessibility, individuals in rural areas and busy urban areas can connect with a
provider with ease.
• Home-use medical devices make it possible for caregivers to monitor everything from vitals
to glucose levels. Physicians can gather essential medical information and make a diagnosis
without patients stepping foot in a doctors office.
Telemedicine Benefits
Benefits to Patients:
 Access to specialized health care services to under-served rural, semi-
urban and remote areas,
 Access to expertise of Medical Specialists to a larger population without
physical referral,
 Reduced visits to specialty hospitals for long term follow-up care for the
aged and terminally ill patients.
Benefits to Physicians:
 Improved diagnosis and better treatment management
 Access to computerized, comprehensive data (text, voice, images etc.) of
patients – offline as well as real time
 Quick and timely follow-up of patients discharged after palliative care
 Continuing education or training through video conferencing periodically
Hospital and Insurance Benefits:
 Significant reduction in unnecessary visits & hospitalization for
specialized care at tertiary hospitals
 Earlier discharge of patients leading to shorter length of stay in
hospitals
 Increase in the scope of services without creating physical
infrastructure in remote hospitals
 What is
Teleconsultation?
• Teleconsultation, sometimes referred to as remote consultation or

telehealth, refers to interactions that happen between a clinician and

a patient for the purpose of providing diagnostic or therapeutic advice

through electronic means.

Tele-consultation
Purposes
• The goal of teleconsultation is to omit geographical and functional
distance between two or more geographically separated health care
providers.
• No transportation time or costs.

• No need to take time off of work.

• Eliminate child or elder care issues.

• On-demand options.

• Access to Specialists.

• Less Chance of Catching a New Illness.

• Less Time in the Waiting Room.

• Better Health.
 WHO Definition of Telemedicine
World Health Organization defines telemedicine as
“The delivery of health-care services, where distance is a critical
factor, by all health-care professionals using information and
communications technologies for the exchange of valid information
for diagnosis, treatment and prevention of disease and injuries,
research and evaluation, and the continuing education of health-
care workers, with the aim of advancing the health of individuals
and communities.”
 Definition of Telehealth

• NEJM Catalyst defines telehealth as “The delivery and facilitation of health

and health-related services including medical care, provider and patient
education, health information services, and self- care via
telecommunications and digital communication technologies.”

• In general, telemedicine is used to denote clinical service delivered by a

Registered medical practitioner while telehealth is a broader term of use of
technology for health and health related services including telemedicine.
Definition of Registered Medical Practitioner
(RMP)
• For the purpose of this document a ‘Registered Medical Practitioner’
is defined as a person who is enrolled in the State Medical Register or
the Indian Medical Register under the IMC Act 1956.
• Board of Governors in Supersession of Medical Council of India in
partnership with NITI Aayog has prepared guidelines regarding
teleconsultation in India in 2020.
 Background
Telemedicine: An Enabler of Healthcare Access and Affordability
• Benefits of Telemedicine
• Increases timely access to appropriate interventions
• Provides cost and effort savings, especially for rural patients
• Reduces inconvenience and impact on family and caregivers
• Plays an important role in non-urgent cases and continuous monitoring
• Ensures maintenance of records and documentation
• Provides patient and health worker safety
• Prevents transmission of infectious diseases
• Provides rapid access to medical practitioners during disasters and pandemics
• The government is committed to providing equal access to quality care
to all and digital health is a critical enabler for the overall
transformation of the health system.
• Hence, mainstreaming telemedicine in health systems will minimize
inequity and barriers to access.
• India’s digital health policy advocates use of digital tools for improving
the efficiency and outcome of the healthcare system and lays
significant focus on the use of telemedicine services, especially in the
Health and Wellness Centers at the grassroots level wherein a mid-
level provider/health worker can connect the patients to the doctors
through technology platforms in providing timely and best possible care
Telemedicine applications can be classified into four basic types,
according to the mode of communication, timing of the information
transmitted, the purpose of the consultation and the interaction
between the individuals involved—be it RMP-to-patient / caregiver, or
RMP to RMP.
1. According to the Mode of Communication
• 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.)
2. According to timing of information transmitted

Asynchronous exchange of relevant

Real time Video/audio/text interaction information
Transmission of summary of patient
complaints and supplementary data
Video/audio/text for exchange of relevant including images, lab reports and/or
information for diagnosis, medication and radiological investigations between
health education and counseling stakeholders. Such data can be
forwarded to different parties at any
point of time and thereafter
accessed
per convenience/need
3. According to the purpose of the consultation
For Non-Emergency consult:

First consult with any RMP for Follow-up consult with the
diagnosis/treatment/health same RMP
education/ counseling
Patients may use this service
Patients may consult with an for follow up consultation on
RMP for diagnosis and treatment his ongoing treatment with
of her condition or for health the same RMP who
education and counseling prescribed the treatment in
an earlier in-person consult.
• Emergency consult for immediate assistance or first aid etc.

• In case alternative care is not present, tele-consultation might be the only

way to provide timely care. In such situations, RMPs may provide consultation
to their best judgement. 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.
4. According to the individuals involved
RMP to RMP Health worker to RMP

RMP may use telemedicine services to A Health Worker can facilitate a

discuss with other RMPs issues of care consultation session for a patient
of one or more patients, or to with an RMP. In doing so, the former
disseminate knowledge can help take history, examine the
patient and convey the findings. They
can also explain/reinforce the advice
given by the RMP to the patient.

Patient to RMP Caregiver to RMP

Telemedicine services may connect
Telemedicine services may connect Care givers to an RMP, under certain
patients to an RMP conditions as detailed in Framework
(Section 4)
Technology Used & Mode of
Communications
• Multiple technologies can be used to deliver telemedicine
consultation.
• There are 3 primary modes: Video, Audio, or Text (chat, messaging,
email, fax etc.)
• Each one of these technology systems has their respective strengths,
weaknesses and contexts, in which, they may be appropriate or
inadequate to deliver a proper diagnosis
 Strengths & Limitations of various modes
Mode Strengths Limitations
VIDEO:  Closest to an in person-consult, real  Is dependent on high quality internet
Telemedicine time interaction connection at both ends, else will lead
facility,  Patient identification is easier to a sub optimal exchange of
Apps,  RMP can see the patient and information
Video on chat discuss with the caregiver  Since there is a possibility of abuse/
 Visual cues can be perceived misuse, ensuring privacy of patients in
platforms, Inspection of patient can be
Facetime etc.  video consults is extremely important
carried out
 Convenient and fast  Non-verbal cues may be missed
AUDIO:  Unlimited reach
Phone,  Suitable for urgent cases  Not suitable for conditions that
VOIP,  Noseparate infrastructure required require a visual inspection (e.g. skin,
Apps etc.  Privacy ensured eye or tongue examination), or
 Real-time interaction. physical touch
 Patient identification needs to be
clearer, greater chance of imposters
representing the real patient
 Strengths & Limitations of various modes
Mode Strengths Limitations
TEXT BASED: Convenient and quick  Besides the visual and physical touch,
 text-based interactions also miss the
Specialized Chat based  Documentation & Identification
Telemedicine may be an integral feature of the verbal cues
Smartphone Apps, SMS, platform  Difficult to establish rapport with the
Websites, messaging  Suitable for urgent cases, or patient.
follow-ups, second opinions
systems e.g. WhatsApp, provided RMP has enough context  Cannot be sure of identity of the doctor
Google Hangouts, FB from other sources
 No separateinfrastructure or the patient
Messenger required
 Can be real time
ASYNCHRONO US: • Convenient and easy to document • Not a real time interaction, so just one-
Email Fax, • No specific app or download way context is available, relying solely on
recordings etc requirement the articulation by the patient
• Images, data, reports readily • Patient identification is document based
shared only and difficult to confirm
• No separate infrastructure required • Non-verbal cues are missed
• More useful when accompanied • There may be delays because the Doctor
with test reports and follow up and may not see the mail immediately
second opinions
 Guidelines for Telemedicine in India
The professional judgment of a Registered Medical Practitioner should be the
guiding principle for all telemedicine consultations: An RMP is well positioned to
decide whether a technology-based consultation is sufficient or an in-person review
is needed.

Practitioner shall exercise proper discretion and not compromise on the quality of
care. Seven elements need to be considered before beginning any telemedicine
consultation
Seven Elements to be considered before any telemedicine consultation

1 Context
2 Identification of RMP and Patient
3 Mode of Communication
4 Consent
5 Type of Consultation
6 Patient Evaluation
7 Patient Management
Guidelines for Technology Platforms enabling Telemedicine

• Technology platforms (mobile apps, websites etc.) providing telemedicine

services to consumers shall be obligated to ensure that the consumers are
consulting with Registered medical practitioners duly registered with
national medical councils or respective state medical council and comply
with relevant provisions
• Technology Platforms shall conduct their due diligence before listing any
RMP on its online portal. Platform must provide the name, qualification and
registration number, contact details of every RMP listed on the platform
• In the event some non-compliance is noted, the technology platform shall
be required to report the same to BoG, in supersession to MCI who may
take appropriate action
Guidelines for Technology Platforms enabling Telemedicine

• Technology platforms based on Artificial Intelligence/Machine

Learning are not allowed to counsel the patients or prescribe any
medicines to a patient. Only a RMP is entitled to counsel or prescribe
and has to directly communicate with the patient in this regard.
• While new technologies such as Artificial Intelligence, Internet of
Things, advanced data science-based decision support systems etc.
could assist and support a RMP on patient evaluation, diagnosis or
management, the final prescription or counseling has to be directly
delivered by the RMP
Guidelines for Technology Platforms enabling Telemedicine

• Technology Platform must ensure that there is a proper mechanism in

place to address any queries or grievances that the end-customer may
have

• In case any specific technology platform is found in violation, BoG,

MCI may designate the technology platform as blacklisted, and no
RMP may then use that platform to provide telemedicine