A Review of Telemedicine Practice Guidelines for COVID-19 and Global Emergencies

Abstract

The coronavirus pandemic has changed the palliative care and clinical medicine narrative to reduce exposure, maintain social distancing, and mitigate in-person consultation risks. Telemedicine during such times has emerged as a critical technology to bring medical care to patients while attempting to reduce the virus transmission. The telemedicine practice remains highly unregulated, raising concerns about its implementation. In this article, we review the worldwide scenario of policy instruments on telemedicine and also discuss the recently published telemedicine guidelines in India in detail. The methodology adopted included data collection from primary sources—key expert interviews—and secondary sources—systematic literature review. It was observed that even though countries have included telemedicine in their national health strategy, its adoption and dissemination remain a challenge. There is a need for exhaustive telemedicine practice guidelines focusing on key parameters for convenient, accessible, and cost-effective care to patients.

   What Do We Already Know About This Topic?

Telemedicine guidelines have been under consideration in many countries since the past few years. With the COVID-19 pandemic, there has been a need for adoption of telemedicine guidelines for a reliable telemedicine practice.

   How Does Your Research Contribute to the Field?

This work presents a landscape for understanding the global scenario and status with respect to the telemedicine guidelines.

   What Are Your Research’s Implications Towards Theory, Practice, or Policy?

Research implications (1) towards policy includes formation of telemedicine guidelines and referring to India as a use-case for the same and (2) towards theory and practice is addressing the existing gap of telemedicine policies at different stages around the globe.

Introduction

Coronavirus (COVID-19) not only brings radical uncertainties in social, economic, and political paradigms but also redefines the contours of public policy and administration. Policy design and instruments can make an enduring contribution to disaster management in emergencies, pandemics, etc.

One such area adopted by the health systems throughout the world in response to COVID-19 has been the practice of telemedicine. Telemedicine can enhance quality of care, provide psychological support, improve compliance, and help patients save time and money. ¹ The literature suggests that telemedicine can also enhance learning skills, case handling strategies, and help in providing different medical services. ² Telehealth models have also inculcated physical examinations for less extensive areas. ³

Therefore, telemedicine has been a useful tool to deliver healthcare even in less accessible and low-income countries, especially during COVID-19. Telemedicine allows managing cost, convenience, and ready accessibility of medical information. ⁴ Telemedicine use has been increasing during the COVID-19 pandemic, being a tool that reaches patients’ home. ⁴ The importance of telemedicine amongst other uses during COVID-19 is reducing risk of cross-contamination due to close contact.

However, the policy instruments around telemedicine, promoting usage and discussing practice nuances, remain limited across the globe. The determinants influencing the adoption of telemedicine are infrastructural (IT technologies and data privacy), institutional (compliances, licensing, and funding) and human resources (training and ethical considerations). ⁵ This article focuses on the institutional determinants, more specifically, the policy instruments for effective implementation of practice of telemedicine. For telemedicine to be effective and more so during COVID-19 and such similar future events, there is a need to integrate telemedicine into health services along with formalized policy instruments. The article also outlines the status of country-wise telemedicine policy instruments and discusses in detail the recent telemedicine guidelines in India.

Telemedicine Policy Instruments: Global Presence

The practice of telemedicine remains unexplored, amongst other reasons, due to lack of clarity in regard of the stakeholders (for example, medical councils and medical practitioners), scope of services covered in telehealth, and other inclusion and exclusion criteria. Telemedicine policy instruments, for the purpose of this article, shall mean the guidelines, policies, order, acts, rules, or regulations enabling the adoption of practice of telemedicine. A few countries have published guidelines on different aspects of telemedicine, its usage, and services. Figure 1 shows the worldwide status of presence of telemedicine guidelines. The methodology adopted to sketch the map with details of presence of telemedicine guidelines includes data collection from primary and secondary sources. Key expert interviews were conducted over a period of 4 months to include the current positioning of various countries in regard to the telemedicine guidelines. The key experts belonged to both the industry and academia from across the world. Further, readings and the literature suggested by the key experts were also referred to have an exhaustive status of the country-wide telemedicine. Additionally, a systematic literature review was conducted with inclusion criteria to refine the search (see Table 1).

Figure 1.

Worldwide status of telemedicine policy instruments.

Table 1.

Inclusion Criteria for Systematic Literature Review.

S. No	Criteria	Details
1	Keywords	Telemedicine, telehealth, countries, and guidelines
2	Boolean operators	“and”, “&”, and “OR”
3	Databases	EBSCO, EMERALD, Google Scholar, JSTOR, PUBMED
4	Language	English

Australia has telemedicine guidelines including the Medical Board of Australia Guidelines for technology-based patient consultations and the Australian College of Rural and Remote Medicine Telehealth Guidelines. ⁶ Canadian provinces also have published telemedicine bylaws and policies. ⁷ In the United Kingdom, the roadmap for digital healthcare services includes details of telemedicine services, online consultations, remote monitoring along with guides and standard operating procedures for the same. ⁸

The states in the United States have very actively adopted telehealth and more so during COVID-19. The states have issued various telehealth guidelines for providing medically necessary services that can be appropriately delivered through telecommunication services. For example, in Alabama, to practice telemedicine, the practitioner must hold the Alabama medical license. The Government of Arizona issued an Executive Order (EO 2020-15) in order to expand telemedicine coverage for all services that would be covered for an in-person consultation. California warrants the need of obtaining verbal or written consent from the patient before the use of telehealth services. The telehealth flexibilities in California extend till end of 2022 via signing of Assembly Bill No. 133. ⁹ The states have been modifying telehealth response depending on the COVID-19 situation.

Austria has acknowledged the need for policy on telemedicine and drafted a framework modeled on technological architecture needed for telemonitoring. ¹⁰ In Mexico, a telehealth service catalogue serves as a reference tool that acts as a unifying criterion allowing the decision-makers in telehealth to communicate in same terms. ¹¹ Israel’s first published circular was in 2012, which has been regularly updated, for example, the recent 2017 amendment on remote medical consultation for patients with acute morbidity. ¹² Norway established a national center for telemedicine in 1994 called the Norweigan Centre for eHealth Research and a knowledge base for a policy on eHealth. ¹³ Centro Nacional de Telessúade in Portugal provides a toolkit for implementation of teleconsultation and telehealth factsheets replicate good practices of telehealth services in the country. ¹⁴

While a few countries have exhaustively adopted telemedicine guidelines and few are in process of the same, there remains a majority of the countries with less or no developed telemedicine guidelines.

Telemedicine in India

The practice of telemedicine in India, like in many countries, is still in its infancy stage, and with transmission dynamics of COVID-19, the relevance of telemedicine has become recognized. The Ministry of Health and Family Welfare, India, further emphasized this matter by publishing telemedicine guidelines toward streamlining the practice. ¹⁵ These long-pending guidelines serve as a crucial policy instrument for healthcare accessibility during such emergency times. The literature recognizes India’s telemedicine policy instruments as an important step in providing healthcare services during COVID-19. ¹⁶ The article studies India as a case study since these guidelines are exhaustive and provide a roadmap for regularization of teleconsultation services. ¹⁷

The guidelines define important terms like telemedicine, telehealth, and registered medical practitioner and provide a framework for telemedicine. The guidelines are meant for the registered medical practitioners under the Indian Medical Council Act, 1956 (now known as National Medical Commission Act). Telemedicine application can be classified into 4 types, based on—(a) mode of communication—video, audio, and text-based; (b) timing of the information transmitted—real-time consultation and asynchronous exchange of information; (c) purpose of the consultation—first consultation and follow-up consultation; and (d) interaction between the individuals involved—patients, caregiver, registered medical practitioner, and health workers.

Seven pre-requisite elements of telemedicine consultation as per the Indian telemedicine guidelines are:

• (1) Context—The registered medical practitioner will decide as per the guidelines and his/her experience as to whether the case is fit for online consultation or mandates in-person consultation.

• (2) Identification of registered medical practitioner and patient—It is important to establish the identity of both the registered medical practitioner as well as the patient. The medical practitioner has to seek all information related to the patient’s identity and similarly disclose his/her credentials.

• (3) Mode of communication—The guidelines prescribe and categorizes 3 major tools of consultation—audio, video, and texts. According to the type, purpose, and frequency of consultation, the modes can be selected. The guidelines also elaborate the characteristics and limitations of each mode.

• (4) Consent—Patient consent (implied or explicit) is an important aspect of telemedicine and the guidelines also takes the same into account.

• (5) Type of consultation—The consultations are divided into 2 categories—(a) first consultation and (b) follow-up consultation. The guidelines also define the scope and ambit for the same.

• (6) Patient evaluation—The registered medical practitioner has to get all necessary information from the patient to evaluate the patient’s condition. Though the guidelines give an indicative framework of the kind of information to be sought from the patient, the burden is on the medical practitioner to get the relevant information from the patient.

• (7) Patient management—The registered medical practitioner, depending on the patient’s condition, can provide health education, counseling, and/or medicines. The medicines can only be provided from Lists O, A, and B of the guidelines, and no drug can be prescribed from the Prohibited List of the guidelines. Also, while issuing prescriptions, the medical practitioner will be governed by other rules related to medicines and medicinal conduct.^18,19

The guidelines also consider the medical ethics, data privacy, and confidentiality aspect. The registered medical practitioner is required to uphold the same professional and ethical norms as applicable to in-person care, within the intrinsic limitations of telemedicine. Additionally, it also states that the registered medical practitioner, before practicing telemedicine, will have to undertake an online course for the same. However, if there is reasonable evidence to believe that the patient’s confidentiality and privacy have been compromised due to a technology breach, the registered medical practitioner will not be held liable.

Furthermore, these guidelines also provide recommendations to be followed by the technology platforms that enable such telemedicine services. These recommendations include due diligence by the technology platforms and blacklisting in case of any violation.

Discussion and Implications

Telemedicine and telehealth services can aid in medical challenges being posed in times of pandemics like that of COVID-19. And for the practice of telemedicine to be adopted, the related policy instruments’ vacuum should be addressed to promote broader and safe telemedicine adoption. This article sketches a coverage map highlighting the countries where there remains a vacuum in the practice of telemedicine. Additionally, the recent telemedicine guidelines in India can be used as an example for countries to adopt a permanent solution for adoption of telemedicine.

The main limitation of this article is aligned to the use of secondary data. Primary data was not employed to validate all the factors. Also, by defining the inclusion–exclusion criteria, the article may have inevitably left some salient studies on the research objective. Future work can help in expanding the study based on primary data.

Conclusion

The guidelines provide a framework for the practice of telemedicine in India, covering existing ambiguity relating to liability, consent, confidentiality, and negligence, much needed to be addressed during COVID-19 times. In addition to this, the guidelines mention exclusions and emergency circumstances where such telemedicine consultation would not be applicable.

Some of the key observations relating to these guidelines that further need to be looked into are:

• (a) The definition of the term “telemedicine” needs more elaboration and setting of clear ambit of “timely access” which becomes an important factor in emergencies.

• (b) For exhaustiveness, there is a need to elaborate on the scope of due diligence required by the technology platforms before listing the registered medical practitioner.

• (c) Lastly, the guidelines provide a wide scope for exercising discretion by the registered medical practitioners without detailing the standards/measures to be considered while exercising the discretion.

Telemedicine can play an essential role during global challenges impacting the health systems. However, the literature suggests that new practices like telemedicine are still not optimally used due to reasons such as (a) resistance to change, (b) lack of efficient infrastructure, and (c) absence of regulatory bodies and policy instruments governing the same. ⁶

Therefore, even though countries have included telemedicine in their national health strategy, its adoption and dissemination remain a challenge. There is a need for exhaustive telemedicine practice guidelines focusing on key parameters for convenient, accessible, and cost-effective care to patients.

ORCID iD

Surabhi Gupta https://orcid.org/0000-0001-8739-1486