The onset of Covid-19 has accelerated the adoption of telemedicine by consumers in India. Reports indicate that the popular Indian healthcare application Practo has witnessed a steep 500% increase in demand for video consultations. Further, telemedicine has been recently formalised by the passage of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) (Amendment) Regulations, 2020 containing the Telemedicine Practice guidelines.
Given that the practice of telemedicine was previously operating in a grey zone, the regulations are a welcome move. They have provided regulatory clarity to both registered medical practitioners (RMPs) and technology platforms in the healthcare space. The immediate cause for the boost in telemedicine is attributable to the pandemic. However, telemedicine itself is not a novel phenomenon. In this post, I discuss the manner in which telemedicine can be made a sustainable enabler for accessible and affordable healthcare in India.
Key implications of regulations
Flowing from a recognition of the benefits of telemedicine for India, the regulations have broadly set out norms for RMPs to adhere to while consulting patients through telemedicine. Such consultation may be carried out through the modes of video, audio, or text. Three key components of the guidelines deserve mention below.
First, the guidelines emphasise the need to establish the identity of both the patient and the RMP. In other words, a telemedicine consultation cannot be anonymous. A patient must establish her identity by submitting her name, age, residential address, e-mail address and phone number. In fact, in order to issue a prescription, the RMP is required to know the age of the patient. A patient should also be able to verify the credentials and identity of an RMP.
Second, the guidelines have acknowledged the significance of patient consent for a telemedicine consultation. Depending on the context, consent may either be assumed to be implied or required to be shown in an explicit form. For instance, if a telemedicine consultation is initiated by a patient herself, the consent will be implied. Explicit consent is required where the consultation is initiated by an RMP, health worker or care giver.
Third, the guidelines bring health technology platforms within the regulatory fold. These platforms are henceforth obligated to ensure the credibility of RMPs listed on their platforms. Moreover, the guidelines state that artificial intelligence and machine learning may only play a limited and supporting role for RMPs in evaluating, diagnosing or managing patients. They cannot substitute the final judgment of the RMP in counselling or prescribing medicines to a patient. In other words, the end point delivery of medical advice must be done by the RMP herself. The guidelines have also underlined the need for technology platforms to put in place robust grievance redressal mechanisms for patients.
Sensitivity of health data
Telemedicine has brought new life into a market of established players—resulting in a disruption in the medical hegemony. In order to ensure its sustainability in enabling accessible and affordable healthcare in India, the following concerns must be addressed.
The practice of telemedicine is heavily dependent on access to personal data of patients. RMPs would be unable to discharge their medical obligations effectively without obtaining the requisite information about a particular patient, including personal data to establish her identity and assess her health condition. Moreover, it is likely that the surge in telemedicine could encourage the use of connected health trackers and Internet-of-Things devices to aid doctors in observing patients’ health. This will mean a further upsurge in the collection of health data.
Health data is considered to be sensitive personal data (under the Information Technology (Reasonable Security Practices and Procedures and Sensitive Personal Data or Information) Rules, 2011 and the Personal Data Protection Bill, 2019) due to their highly revealing nature and potential to cause aggravated harm. However, the convenience of telemedicine has meant that health data about individuals are being shared on personal devices, chat and e-mail. This could expose such data to privacy and security breaches potentially causing significant harm to individuals.
In this regard, the guidelines prove to be inadequate. While consent is accounted for, the guidelines do not elaborate on how one can ensure that the consent obtained is free, informed, specific, clear and capable of being withdrawn. As such, the guidelines have relegated consent to merely another box to be checked and may also fall short of the standard contained in the Personal Data Protection Bill, 2019. Moreover, apart from consent, the guidelines do not address other privacy or security issues, instead conceding to applicable legislation. This is surprising considering the sensitivity of the data within the remit of the guidelines.
On a related note, the pandemic has witnessed a drastic rise in the incidence of cyber-attacks. Data security in telemedicine is an area that deserves priority attention. Adherence to stringent data security standards by RMPs and health technology entities to keep health data of patients secure would enhance consumer trust. In this regard, the implementation of privacy by design measures would be helpful.
In addition to the privacy and security concerns discussed above, leveraging telemedicine as a force for good would require further enablers.
It is worth noting that the success of digital solutions to health are predicated upon the robustness of the internet infrastructure they ride upon. Thus, the benefits of democratisation can only be achieved if a decent quality of internet is available to everyone. Availability of good quality internet, along with a high rate of internet penetration, would open up healthcare access for semi-urban and rural populations, the poor and vulnerable groups. Looking at countries like Australia and Finland, which have legally enshrined minimum broadband speeds, may serve as useful examples.
Further, it is likely that telemedicine may attract more regulation in the future. It is essential for policymakers to craft enabling regulation to lend coherence to its practice, and streamline its delivery to patients.
While technological solutions to healthcare lead to increased competition and innovation, the significance of a robust primary healthcare paradigm cannot be overlooked. It remains necessary for the Indian government to bolster public expenditure on healthcare infrastructure in order to expand public health capacities. Telemedicine solutions could then suitably perform a supporting role by permitting greater access.
Sohini Banerjee is a Research Fellow at Shardul Amarchand Mangaldas & Co, India.