In countries like the USA, each
state allows doctors to not only practice but also provide reimbursement for
such practice. One common area where this is regularly practiced is for refill
prescription for a medication used for chronic illnesses like blood pressure or
‘Online medical consults in India is attracting attention for wrong
reasons. The current guidelines allow doctors to advice treatment or
prescribe medication only after physically seeing a patient. This makes
the telephonic or online consultation illegal
In August last year, the Indian
Medical Association (IMA) had asked for precise guidelines regarding the matter
of telephonic medication and online consultations from the Medical Council of
India (MCI), as it considered the practice as unlawful and unethical.
There are four primary methods of telehealth consultation
video consults, store-and-forward type of consult through email, remote-patient
monitoring and mobile health consults.
In May this year, the Karnataka
Medical Council (KMC) had urged doctors to avoid participating in online
declaring that it openly contradicts the regulatory body's
"Such consultations are
detrimental to both patients as well as the doctor and may lead to many
complications, which is nothing but playing with the life of a patient"
said H. Veerabhadrappa, President
of the council. He further added that the Karnataka Medical Council could even
go to the extent of initiating action (including cancellation of registration)
against doctors who take up online consultations.
The KMC's verdict came out
following a complaint filed by the Bangalore Dermatological Society
(BDS) on an advertisement printed in a newspaper by a technological health
services company that invited doctors to join as their online consultants.
P. Jagadish, Secretary of
Bangalore Dermatological Society said, "At the same time, it is detrimental
for patients, too, as online consultation may end up with a wrong diagnosis.
They can also develop complications as many medicines may have side effects."
on April 13, 2019, Bombay High Court has declared that telephonic medical
consultation cannot be criminalized.
The Bombay High Court's judgment on Ratnagiri based doctor couple - Deepa and Sanjeev Pawaskar resulted
in them getting booked under Section 304 (culpable homicide not amounting to
murder) of the Code of Criminal Procedure after a woman died within a few days
of being discharged from their hospital. Apparently, prescription of medication was prescribed over the
phone to a woman who had given birth a few days previously and she died. The
court even rejected the anticipatory bail of the doctor couple and observed
that prescribing medicines to patients without diagnosis amounted to culpable
The Bombay High
Court order resulted in the Indian Medical
Association (IMA) sending out warnings to doctors
over online consults and prescribing over phone, a fairly common habit in
India. Dr Piyush Jain, President of the East Delhi chapter of IMA which happens to be the largest chapter of the IMA with 9643
members, held an internal meeting with its members and issued the the
following statement, "In the meeting we decided to come up with warnings for
patients and doctors asking them to refrain from offering consultation over
phone or WhatsApp. For this purpose, we created two posters - one stating that
patients will be arrested for consulting doctors and the other warning
doctors. These posters were then sent out to members of the East Delhi chapter
asking them for their opinion."
Dr. Ravi Wankhedkar, the national president of IMA at that time, said that all doctors in
Maharashtra had been told to refrain from offering consultation without first
having physically diagnosed
the patient. He promised to create an official guideline for the medical
fraternity across the country on this subject.
"The matter being sub-judice we
cannot issue official guidelines. For now we have conveyed the same to doctors
via word of mouth but will put it in the rules once the case is closed,"
"The practice of offering
consultations on text or call without diagnosing the patient is not right. It
is highly risky to prescribe medicines based on how the patients or their
family members describe symptoms,"
said the secretary of IMA Dr. Sanghavi.
Six months have passed since this
episode but IMA has still to release its guidelines. The Medical Council of
India has the regulatory authority; however it has been in a state of flux and
paralysis for the last few years and now there is a new body in its place.
The Prime Minister has been keen
to make India digital and the Government of India has always supported telemedicine through
Indian Space Research Organization by lending out its satellites free of
cost for over a decade now. Many big groups like Apollo healthcare practice
telemedicine consults in thousands every day. Some state governments like
Andhra Pradesh have encouraged the use of tele-ophthalmolgy for the prevention
of blindness by installing fundus cameras in their primary health centers.
India has advanced in adopting digital
health despite the lack of regulation by the government. The Indian healthcare
ecosystem, however, is very complex; consider the following shocking facts and
- A 2016 WHO report on the
health workforce in India stated that 57.3percent of those practicing allopathic medicine were
not qualified. Which indirectly meant they were likely to be quacks.(1✔)
- Another report a bit old by WHO in 2001 said that barely 20percent of
those who practiced medicine in rural India had any medical qualification
and many were only educated up to Class 12.
- Many quacks also have regularly performed surgery. The most
common example is for the treatment of anal canal diseases such as piles
and fistulas or for setting fractures. One can find their advertisements
in every city and town or watch their hoardings or advertisement on the
walls if one travels into a city by train. Quacks have also in fact gone
on to perform transplant surgery - who can forget the infamous case of
Dr. Amit Kumar of Gurgaon. He had performed kidney transplants for many
years until he was nabbed in Kathmandu in 2008 and locked up.(2✔)
- An estimated 1,500 quack doctors were booked in the state of
Tamil Nadu, however, most escaped or got a bail. Dr K. Kolandaisamy,
Director of public health in Chennai said "They get bail or pay fine
and restart practice." IMA believes quackery is endemic in India and
in Tamil Nadu alone 50,000 quacks are functioning. Thomas Prabhakaran, deputy superintendent of
police said, "These
quacks know most families, charge less and give high dose drugs that give them quick relief," "So people prefer them." In his words, "It is the
trust we are not able to break."
- According to another WHO report, 35percent of the world's spurious
drugs are produced in India. The spurious drugs market in India is
worth nearly Rs 4000 crores. This accounts for 20percent of the domestic
pharmaceutical business in India. USA has put India in 301-watch threat
list (The Special 301 Report is prepared annually by the Office of the United
States Trade Representative. It identifies trade barriers to United States
companies and products due to the intellectual property laws in other
- Seeking advice on sexual health in India using online platforms
is not uncommon. Dr Shyam Mithia, neuropsychiatrist and sexologist in
Mumbai said, "Today, as many as 70% of all sexual dysfunction patients
go to quacks who don't have a medical degree."
- No health insurance policy factors in
digital health or online consultations or telemedicine in India.
This background makes digital
health highly prone to Medico-legal and ethical
challenges including issues related to lack of professional credentials,
possible spurt in spurious medication sales, not maintaining the standard of
care, breach in confidentiality of patients, and the possibility of
profession in India is currently regulated by the Indian Medical Council Act,
1956, the Indian Medical Council (Professional Conduct, Etiquette and Ethics)
Regulations, 2002, Drugs and Cosmetics Act, 1940, and Drugs and Cosmetics
Rules, 1945 and the Clinical Establishments (Registration and Regulation)
Act, 2010 ('Clinical Establishments Act').
The job of creating a regulatory framework with this backdrop
of healthcare in India makes the job doubly difficult and maybe one reason why
there has been undue delay in formulating any regulation or guidelines. The question
that crops up is how does one neutralize these factors and move forward to
offer a digital health policy that is safe for the citizens of India.
The laws related to Information Communication
Technology include the Information Technology Act, 2000 (IT Act), the
Information Technology (Reasonable Security Practices and Procedures and
Sensitive Personal Data or Information) Rules, 2011, the Information Technology
(Intermediaries Guidelines) Rules, 2011, Unsolicited Commercial Communications
Regulations, 2007 and Telecom Commercial Communication Customer Preference
Regulations, 2010 ('TCCP Regulations').
In none of these laws is
telemedicine or digital health included or mentioned. Indirect references to
data security will be applied. Consent too is missing.
Dr. Ravi Wankhedkar, Immediate Past President of the IMA said in a
statement, "Online consultations, online prescriptions and telemedicine are
all topics which have posed ethical dilemmas. But at the same time, advancing
technology can be harnessed for augmenting healthcare in remote areas. The MCI
must come out with clear-cut guidelines on these important issues."
Most often there is knee jerk
reaction when something goes wrong in medical practice by both the patients and
the police and there is a rise in the criminal
prosecution of doctors.
prosecution is possible before the criminal courts on the grounds such as the
commission of offenses under any criminal statute and the most common charges
faced by doctors are causing death by negligence (Section 304-A of the Indian
Penal Code [IPC]), endangering life or personal safety of others (Section 336
of the IPC), causing hurt by an act endangering life or personal safety of
others (Section 337 of the IPC) and causing grievous hurt by an act endangering
the life or personal safety of others (Section 338 of the IPC). Punishment
generally includes imprisonment as well as fine under the relevant sections as
has sadly happened to the doctor couple from Ratnagiri.
Digital Health in European
Union (EU) Countries
Action Plan was adopted by EU in 2004, to support the application of ICTs in
the health sector, which was followed by the eHealth Action Plan for 2012-20.(4✔
The EU has issued different data protection
directives and data protection regulations to popularize the use of
Health and Telemedicine in United States of America
In the United States, different states have
allowed the practice of telemedicine and digital health. In the progressive
state of California, the Telemedicine Development Act of 1996 actually
prohibits face-to-face visits if the service can be provided through
an important part of the regulation. The Telehealth Advancement Act, 2012,
includes a number of telemedicine services including the reimbursement
In Washington DC, too there is a provision for reimbursement
of services rendered through telemedicine under the Telemedicine Reimbursement
Act of 2013.
in South Africa
South Africa clearly limits the practice of
telemedicine consultation by stating - "It should be given only in those
situations where face-to-face consultation is not possible because of a
As for the present, as medical
consults in India have no legal standing, there is a high possibility of
accusations and finding negligence by a legal forum and the doctors need to
take cognizance of this fact before offering their services to this form of
In all this doom and gloom, the Managing Editor of Medindia also spoke
to Dr. Ganpathy, a senior neuro-surgeon who has been an evangelist for
telemedicine in India for 20 years on his views and he seemed very positive
about the future of telehealth in India (watch the video interview). References :
- The Health Workforce In India - (https://www.who.int/hrh/resources/16058health_workforce_India.pdf)
- Gurgaon kidney scandal - (https://en.wikipedia.org/wiki/Gurgaon_kidney_scandal)
- The Spurious Drug Menance & Remedy - (http://medind.nic.in/haa/t06/i1/haat07i1p29.pdf)
- Telemedicine: The legal framework (or the lack of it) in Europe - (https://www.ncbi.nlm.nih.gov/pubmed/27579146)