VETERINARY TELEMEDICINE IN INDIA: A NEW HORIZON FOR TRANSFORMING ANIMAL HEALTHCARE

VETERINARY TELEMEDICINE IN INDIA: A NEW HORIZON FOR TRANSFORMING ANIMAL HEALTHCARE

Telemedicine, telehealth, and virtual care are recent buzzwords in veterinary medicine, despite veterinarians practicing it for years. The American Veterinary Medical Association (AVMA) defines telehealth as ‘the overarching term that encompasses all uses of technology geared to remotely deliver health information or education’. It defines telemedicine as ‘the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status’. It also defines mobile health or mHealth as ‘a subcategory of telehealth that employs mobile devices,’ including wearables and mobile applications (AVMA Practice Advisory Panel, 2017).

The Royal College of Veterinary Surgeons (RCVS) (2018) states ‘telemedicine is the use of electronic communication and information technologies to provide clinical healthcare remotely’. It further states ‘telemedicine extends to the provision of veterinary services by video link, text, instant messaging or telephone, or by any other remote means,’ (RCVS, 2018). Veterinary Telehealth is a rapidly growing sector of Veterinary Medicine.

Another definition to understand is the veterinarian-client-patient relationship (VCPR). The AVMA (2019) defines it as: The veterinarian-client-patient relationship is the basis for veterinary care.

To establish such a relationship the following conditions must be satisfied:

1. The licensed veterinarian has assumed the responsibility for making medical judgments regarding the health of the patient(s) and the need for medical therapy and has instructed the client on a course of therapy appropriate to the circumstance;

2. There is sufficient knowledge of the patient(s) by the veterinarian to initiate at least a general or preliminary diagnosis of the medical condition(s) of the patient(s);

3. The client has agreed to follow the licensed veterinarian’s recommendations;

4. The licensed veterinarian is readily available for follow-up evaluation or has arranged for:

1. Emergency or urgent care coverage, or;

2. Continuing care and treatment has been designated by the veterinarian with the prior relationship to a licensed veterinarian who has access to the patient’s medical records and/or who can provide reasonable and appropriate medical care.

5. The veterinarian provides oversight of treatment;

6. Such a relationship can exist only when the veterinarian has performed a timely physical examination of the patient(s) or is personally acquainted with the keeping and care of the patient(s) by virtue of medically appropriate and timely visits to the operation where the patient(s) is(are) kept, or both;

7. Patient records are maintained. The RCVS does not have a written definition of VCPR, however they provide information in their Code of Professional Conduct (RCVS, n.d. [Accessed 6 October 2020]): 2.29 Specific advice provided remotely, for example via phone or video-link with or without additional physiological data (commonly referred to as telemedicine or telehealth), should only be given to the extent appropriate without a physical examination of the animal. The more specific the advice, the more likely it is that the animal’s owner should be advised to consult a veterinary surgeon in person for a physical examination. In this scenario, the animal owner should be asked to provide the veterinary surgeon carrying out the physical examination with a copy of any advice given remotely.  Veterinary surgeons should ensure as far as possible that the provision of specific advice provided remotely does not compromise welfare, since the animal has not been examined and there is no ability to monitor the animal. The Federation of Veterinarians of Europe (FVE) does not have a specific definition of telemedicine or of the VCPR. They do recommend in the European Veterinary Code of Conduct with regards to the utilisation of digital technology (Federation of Veterinarians of Europe, 2019): ‘Veterinarians should utilise digital and emerging technologies to enhance their provision of services as long as they can use these technologies competently, and hold up-to-date knowledge of the animal(s), of the owner and/or of the farm(s)/farmer(s).’ Telemedicine has also picked up in veterinary practice and many private entrepreneurs have jumped into it as service providers. The prominent name in the field of telemedicine in veterinary practice all over the world is VDIC from USA. Kansas State University has officially sanctioned a project on “Proactive herd health management for disease prevention” and five professors are working on the project to deliver the goods to the end users. The goal of this project is to research and develop the technological and sociological infrastructure to support intelligent, mobile medical monitoring devices that continuously assess the health of cattle in concentrated and distributed herds. These monitoring systems will improve the ability of the animal sciences industry to react to and predict disease onset and its epidemiological spread, whether from natural or terrorist events. Trend analysis, information storage, and health prediction lessons learned from this effort will have immediate application to distributed medical systems targeted at assessing and predicting human state of health and the spread of disease in human populations.

In the Indian context, asynchronous telemedicine involving sending of case details and images/lab reports via e-mail to experts for a second opinion is gaining ground. Real-time telemedicine involving text/video chats with the experts has also become more feasible with the availability of broadband internet connections in rural areas also. Standardized systems need to be developed for the transmission of data like case history, ECG, ultrasound, radiograph, laboratory test reports etc. in order to minimize errors due to mis-communication. Creation of a website where field vets can upload their case details in a standard format and experts from Veterinary Colleges or anywhere across the globe can give their opinion would go a long way towards disseminating information on complicated cases and ensuring best possible veterinary care. Data collected on such a website over a period of time, including interventions carried out and the resultant effect, would help in evaluation of various therapeutic strategies and serve as a guideline for future reference.

Veterinary telemedicine is a technology whose time has come and we must adopt it with open arms in order to ensure that two-way flow of information is facilitated between field veterinarians and subject experts, thus resulting in an enriching experience for both.

Telemedicine is a rapidly developing application of clinical medicine wherein medical information is transferred via telephone, the Internet or other networks for the purpose of consulting, and sometimes remote medical procedures or examinations. Telemedicine may be as simple as two health professionals discussing a case over the telephone, or as complex as using satellite technology and video-conferencing equipment to conduct a real-time consultation between medical specialists in two different countries. Telemedicine generally refers to the use of communications and information technologies for the delivery of clinical care.

Care at a distance (also called in absentia care), is an old practice which was often conducted via post; there has been a long and successful history of in absentia health care, which, thanks to modern communication technology, has metamorphosed into what we now know as modern telemedicine.

The terms e-health and tele-health are at times wrongly interchanged with telemedicine. Like the terms “medicine” and “health care”, telemedicine often refers only to the provision of clinical services while the term tele-health can refer to clinical and non-clinical services such as medical education, administration, and research. The term e-health is often, particularly in the UK and Europe, used as an umbrella term that includes tele-health, electronic medical records, and other components of health IT.

Types of Telemedicine

Telemedicine is practiced on the basis of two concepts: Synchronous and Asynchronous.

• Synchronous or Real-time telemedicine: This could be as simple as a telephone call or as complex as robotic surgery. It requires the presence of both parties at the same time and a communication link between them that allows a real-time interaction to take place. Video-conferencing equipment is one of the most common forms of technologies used in synchronous telemedicine. There are also peripheral devices which can be attached to computers or the video-conferencing equipment which can aid in an interactive examination. For instance, a tele-otoscope allows a remote physician to ‘see’ inside a patient’s ear; a tele-stethoscope allows the consulting remote physician to hear the patient’s heartbeat. Video conferencing has been successfully inducted as a mode of distance learning for veterinary students as well as practicing veterinarians at the College of Veterinary Medicine, University of Tennessee (USA).
• Asynchronous or Store-and-forward telemedicine  involves acquiring medical data (like medical images, bio-signals etc) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline. It does not require the presence of both parties at the same time. A properly structured Medical Record preferably in electronic form should be a component of this transfer. Laboratory diagnosis by radiologists or pathologists extensively depends on this method.

Telemedicine is most beneficial for populations living in isolated communities and remote regions and is currently being applied in virtually all medical domains. Specialties that use telemedicine often use a “tele-” prefix; for example, telemedicine as applied by radiologists is called tele-radiology. Similarly telemedicine as applied by cardiologists is termed as tele-cardiology etc. Telemedicine is also useful as a communication tool between a general practitioner and a specialist available at a remote location.

The first interactive Telemedicine system, operating over standard telephone lines, for remotely diagnosing and treating patients in cardiac arrest (defibrillation) was developed and marketed by MedPhone Corporation in 1989. A year later, the company introduced a mobile cellular version, the MDPhone. Twelve hospitals in the U.S. served as receiving and treatment centers.

Monitoring a patient at home using known devices like blood pressure monitors and transferring the information to a caregiver is a fast growing emerging service. These remote monitoring solutions have a focus on current high morbidity chronic diseases and are mainly deployed for the First World. In developing countries a new way of practicing telemedicine is emerging better known as Primary Remote Diagnostic Visits whereby a doctor uses devices to remotely examine and treat a patient. This new technology and principle of practicing medicine holds big promises to solving major health care delivery problems.

Tele-Radiology

Tele-radiology is the ability to send radiographic images (x-rays) from one location to another. For this process to be implemented, three essential components are required, an image sending station, a transmission network, and a receiving / image review station. The most typical implementation is two computers connected via Internet. The computer at the receiving end will need to have a high-quality display screen that has been tested and cleared for clinical purposes. Sometimes the receiving computer will have a printer so that images can be printed for convenience. The tele-radiology process begins at the image sending station. The radiographic image and a modem or other connections are required for this first step. The image is scanned and then sent via the network connection to the receiving computer.

The field of telemedicine is growing rapidly. With advances in technology, there is better accessibility and affordability of tools of telemedicine. Telemedicine was started to manage patients in remote locations with limited access to healthcare services. However, it is becoming a tool for convenience in healthcare. For patients who do not want to waste their time in the waiting room of the doctor’s clinic, telemedicine can provide an alternative solution. In certain situations such as stroke, it cannot replace the time-critical initiation of therapy to the patient at a distant location; though, it is helpful in the recognition of stroke.

 

NB-Consultation through Telemedicine by the Registered Medical Practitioner under the Indian Medical Council Act, 1956 shall be permissible in accordance with the Telemedicine Practice Guidelines contained in Appendix 5 (of Code of Conduct).

A registered medical practitioner under Indian Medical Council Act, 1956 is a person who is enrolled in the State Medical Register or the Indian Medical Register under the Indian Medical Council Act, 1956 (or National Medical Commission Act, 2019 as and when it comes into full force and replaces the Indian Medical Council Act, 1956). Every practising doctor in India today is required by law to be enrolled in the State Medical Register or Indian Medical Register before the start of his or her medical practice. Therefore, the amendment does not add any new requirement of registration for doctors who want to practice telemedicine and provide teleconsultation to his or her patients.

ON THE SAME PATTERN , IN OUR COUNTRY TOO, WE NEED AMENDEMENT IN VETERINARIAN’S CODE OF CONDUCT GUIDELINES REGARDING VETERINARY TELEMEDICINE.

Telemedicine is defined under the Telemedicine Guidelines as:

“The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”

What does the amendment mean for Doctors?

Telemedicine consultation (or “teleconsultation”) has been offered by doctors in India since the year 2000. However, in the absence of statutory basis and support, it was not clear whether it was legal or not. In fact, there have been news reports that State Medical Councils had banned the practice of teleconsultation. For example, the Karnataka State Medical Council had reportedly warned doctors in the State of Karnataka against offering online consultations and threatened them with dire consequences if they did (including cancellation of registration). Despite such reports, the practice of telemedicine and teleconsultation flourished, and several major companies currently provide online teleconsultation services for a fee in India.

Now, doctors who are providing teleconsultation independently or through such companies can rest assured that such practice is lawful as long as it is done in compliance with Telemedicine Guidelines. Doctors can also provide teleconsultations to patients from any part of India.

In fact, the Telemedicine Guidelines specifically permit Doctors to provide teleconsultation for prescribing medicines, providing counselling (e.g. food restrictions, do’s and don’t’s for a patient on anticancer drugs, proper use of a hearing aid etc.) and imparting health education (e.g. advice on contagious infections, immunizations, exercises, hygiene practices, mosquito control etc.).

What does the amendment mean for patients?

India does not have a great doctor to patient ratio. This, coupled with the fact that India is a huge country and that the density of doctors is far higher in cities than in rural areas where the bulk of India’s population resides, is the reason why teleconsultation has great demand and potential in India.

Unfortunately, there were hardly any standards for doctors to follow and patients to expect during a teleconsultation. For example, Indian patients sometimes felt short-changed when a doctor was not clear or audible, or the doctor refused to issue a prescription or did not provide a report of the consultation after the consultation ended. Some patients feared whether the person on the other end was, in fact, a doctor or not. A few worried about their privacy, as electronic communications over mobile application or email, can leave a trail.

Indian patients now will be able to hold doctors accountable to provide teleconsultation as per the Telemedicine Guidelines, which provide a clear set of do’s and don’ts for doctors. A violation of the Telemedicine Guidelines will give patients avenue to complain against the doctor before appropriate State Medical Council for ‘misconduct’.

 What is the difference between Telemedicine and Telehealth?

The terminology of telehealth and telemedicine have been frequently used interchangeably, however, definitions vary in what is actually covered. Both serve to depict healthcare that is provided virtually and without physical contact with a healthcare provider. A patient explains his or her complaints virtually, often by video conferencing, and the healthcare provider will give a recommendation or diagnosis.

Telemedicine is treated as a clinical application of technology, while telehealth encompasses a broader, consumer-facing approach. As opposed to something strictly clinical, this could simply be a collection of methods to reach a health outcome. With the expansion of telehealth, we have seen health service disciplines from counseling to physical therapy to clinical medicine. Telehealth tends to put more emphasis on wellness and care management versus clinical diagnoses.

 

What is Telemedicine and Virtual Consultation?

Telemedicine means ‘healing from a distance’. WHO has adopted the following description of telemedicine: ‘The delivery of health care services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities’.

A virtual consultation is a process of getting a medical opinion without visiting the specialist in person, which is the only difference from a traditional medical consultation.Virtual consultations also allow a physician to start a chat session with another physician to consult various electronic medical records.

To provide quality healthcare services all over India is the main purpose of telemedicine and virtual consultation. This includes facilitating access to healthcare to both privileged and underprivileged populations, providing faster, cheaper and better communication for treatment, follow-up by experts and to store records. It helps remove geographical barriers to healthcare, especially by reaching distant areas poorly connected by any means of transport.

Pros

In most situations, telemedicine is beneficial. It gives access to healthcare services in remote areas and to those with mobility issues such as the elderly. Therefore, it has the power to overcome geographical barriers to provide healthcare services. It may provide an opportunity to reduce healthcare spending and save time for the patient and caregiver. With the advent of telemedicine, a medical practitioner or hospital can consult with different specialists, irrespective of their location. Telemedicine helps patients to engage with their healthcare providers more frequently, in a convenient way, which may result in a better doctor–patient relationship. The follow-up of patients is likely to be better, which may improve outcomes. Overall, telemedicine has the potential to provide better healthcare services to the masses.

Cons

Telemedicine has some downsides because of its virtual nature. It requires infrastructure and technical training. It may reduce direct interaction of patients with doctors because online interactions are impersonal and, to make a complete diagnosis, physical examination needs to be done. There is a lack of a standardized format to the interaction and the absence of a consent form for either opting for or refusing the service. Telemedicine is still not included in the medical curriculum. Besides ambiguity regarding responsibilities in case of negligence, there are concerns about privacy, confidentiality, security of patient information and treatment. There is no clarity with respect to medicolegal issues arising out of telemedicine. Currently, no health insurance policy in India factors in telemedicine.

Need of initiative of telemedicine in veterinary practice:

The veterinary and animal husbandry are highly specialized area involving management and health care of varied species of animals, disease diagnosis, treatment and prevention of the diseases, quality assessment of meat and food including milk and milk products, quarantine procedures, animal welfare, feed formulation and testing, dissemination of technologies, besides teaching, training, innovation, generation and transfer of knowledge or technologies for end users as well as for administrators. The role of veterinarians has, thus, become versatile as a clinician, educator, researcher, extension educator, research administrator, consultant, policy maker and advisor demanding much more workforce in scarcity of time as well as resources. In India there are approximately 9527 veterinary hospitals/polyclinics, 20,897 veterinary dispensaries, 24482 veterinary aid centers and 67,048 artificial insemination centers offering quality veterinary services. But there is a huge gap, the requirement of 67,000 veterinarians is fulfilled only by the available 34,500 veterinarians. Against the requirement of 7500 veterinary and animal science specialists for teaching and research, only 3050 are available to manage universities and colleges (Planning commission working body report, 2014). Shortage of work force and inadequacy of veterinary infrastructure arouses the need of telemedicine as future of animal health care services in India. The NITI Aayog will soon launch a pilot project to provide telemedicine services for livestock health and safety in the wake of growing concerns over outbreak of lumpy skin disease (LSD) leading to death of cattle in several states.

Technology of telemedicine:

Telemedicine is a confluence of communication technology, information technology, biomedical engineering and medical science. Technology ranges from the basic telephone service to broadband internet that allows physicians, nurses and other allied health professionals to provide healthcare at a remote locations (Breen and Matusitz, 2007). Three things are necessary to achieve communication: a sender, receiver and a medium which will transmits information from a sender to a receiver. The telemedicine system consists of customized hardware and software at both the patient and specialist doctor ends, with some of the diagnostic equipments like ECG, X-ray, microscope/camera etc., provided at the patient end. Communication is made through a Very Small Aperture Terminal (VSAT) system and controlled by the network hub station of Indian Space Research Organization (ISRO) (Wootton, 2001). Through a telemedicine system, medical images and other information relative to the patients could be sent to the specialist doctors, either after imaging or on a real time basis through the satellite link in the form of digital data packets. These packets are received at the specialist centre, the images and other information is reconstructed so that the specialist doctor can study the data, perform diagnosis, interact with the patient, and suggest the appropriate treatment during a video conference with the patient end. Telemedicine facility thus enables the specialist doctor and the patient separated by thousands of kilometers to see each other, talk with each other, assessing the physical and psychological state of the patient and to suggest appropriate treatment. In this way, the systematic application of Information and Communication Technology (ICT) to the practice of health care rapidly expands the outreach of the health care system.

Types of telemedicine:

Asynchronous telemedicine (Store and Forward) involves acquiring medical data (like medical images, biosignals etc.) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline not requiring the presence of both parties at the same time. Cases requiring specialist opinion viz. dermatology, radiology and pathology are accessible to asynchronous telemedicine (Bedi, 2003). In the Indian context, asynchronous telemedicine involving sending of case details and images/lab reports via e-mail to experts for a second opinion (like human medicine) is gaining a ground.

Remote Monitoring

(Tele home care) allows the remote observation and care of a patient using various technological devices. Patient status can be reviewed and alarms can be set from the hospital nurse’s station, depending on the specific home health device. Real Time Telemedicine (Interactive or Synchronous telemedicine) could be as simple as a telephone call or as complex as robotic surgery requiring the presence of both parties at the same time and a communications link between them that allows a real time interaction to take place demanding video conferencing equipment as one of the most common and important technology. There are also peripheral devices, which can be attached to computers or the video conferencing equipment aiding in an interactive examination. For example, a tele-otoscope allows a remote physician to ‘see’ inside a patient’s ear; a tele-stethoscope allows the consulting remote physician to hear the patient’s heartbeat. Almost all specialties of medicine have been found to be conducive to real time consultation including psychiatry, internal medicine, cardiology and gynaecology and obstetrics (Dasgupta and Deb 2008).

 Potential scope under telemedicine

1.Teledermatology: Images of skin lesions/skin parasites transferred electronically for proper diagnosis of skin infections/diseases.

2. Teleophthalmology: It includes remote screening of cases of cataract, glaucoma and diabetic retinopathy.

3. Telecardiology: Important to remotely diagnose, treat and manage cardiac diseases through echocardiograms, angiograms and, blood pressure monitoring.

4. Telepathology: It refers to process of diagnostic pathology performed on digital images viewed on a display screen rather than by conventional light microscopy with glass slides.

A Telepathology image sent through electronic mail provides acceptable efficacy and a quicker turnaround time than post and can be applied to veterinary diagnostic cytology (Maiolino et al., 2006).

5.Teleradiology: Teleradiology is considered as a paradigm for other applications owing to long history of use. Patient’s radiographic/pathologic images and consultative texts are electronically transmitted from one medical location to another.

6. Telesurgery: A particular advantage of this type of work is that the surgeon can perform many more operations of a similar type and with lesser fatigue.

Economics of telemedicine:

Economic considerations are a crucial element in the planning and execution of a telemedicine programme. Economic evaluation is a set of formal analytical techniques that provide systematic information about costs: benefit ratio of alternative options, and can thereby assist in priority setting (Drummond and Sculpher, 2005; Sculpher and Price 2003; Sassi et al., 1997; Drummond et al., 2005). Economic analyses can take more than one economic perspective, but the Panel on Cost Effectiveness in Health and Medicine recommends that collective perspective should be considered always (Gold et al., 1996). Diversity in telemedicine applications, lack of standardized methodology, randomized control trials (RCTs) and, long term evaluation studies and absence of quality data are few commonly encountered limitations seen in telemedicine economic analyses disabling to fully evaluate and authenticate economic impact of telemedicine (Bashshur et al., 2005; Whitten et al., 2002; Reardon, 2005; Jennett et al., 2003; Ruckdaschel et al., 2006). Most of studies investigating cost effectiveness of telemedicine found that benefits are evaluated in terms of cost savings with no assessment done in terms of changes in the benefits for the patients (Whitten et al., 2002; Hailey et al., 2002). There is wide variation in reports on economic analysis of telemedicine. No reports are available for economic analysis of veterinary telemedicine. Many studies suggested that telemedicine seemed to be cost effective for examples: 91% of the studies showed telehomecare to be cost effective by reducing visit to hospitals, improving patient compliance, satisfaction and quality of living (Rojas and Gagnon 2008), telemedicine was found to be cost effective in management of chronic diseases (Gaikwad and Warren 2009), telemonitoring proved to be rewarding in heart failure patients by reducing travel time, hospital admissions and constant monitoring of such critical condition (Seto, 2008), home telehealth for chronic conditions was found to be cost saving (Tran et al., 2008). While other reports did not showed good evidence about cost effectiveness viz., the cost effectiveness of telehomecare for older people and people suffering from chronic conditions is uncertain (Barlow et al., 2007), lack of consistent results regarding costs of synchronous telehealth in primary care is a limiting factor (Deshpande et al., 2008), little evidence is there for the economic viability respiratory monitoring at home (Jaana et al., 2009) and also cost effectiveness in diabetes care through the use of information technology is undetermined (Jackson et al., 2006).

Applications and validity of veterinary telemedicine:

Telemedicine is a technology that allows a veterinarian to digitalize radiographic, ultrasound and microscopic images and send them via fax or the internet to a veterinary specialist for interpretation providing service without leaving their veterinary dispensary/hospital. Veterinary cardiologists, radiologists, dentists, ophthalmologists, dermatologists, surgeons, and internal medicine specialists are now accessible by telemedicine. While tele-electrocardiography has been around since the 1980s, teleultrasonography, teleradiology and telecytology appears to be the most commonly practiced and viable forms of veterinary telemedicine (Papageorges and Hebert 2001; Papageorges and Tilley 2001; Papageorges et al., 2001; Hebert et al., 2001). Veterinary teleradiology was first commercially introduced in the early 1990s with limited success because of slow internet speeds and large file sizes but currently the practice of teleradiology in veterinary medicine is widespread due to the easy availability of high speed broadband internet connections, image compression softwares, economically priced Picture Archiving and Communication System (PACS) and Digital Imaging and Communications in medicine (DICOM) software (Poteet, 2008). Cysts, obstructions, congenital heart disease, heart murmurs and abscesses are list of conditions that can be diagnosed with ultrasound via telemedicine (Gater, 2008). Validity of remote consultation for treatment of canine separation anxiety using two types of behavioral services offered by Tufts Cummings School of Veterinary Medicine (TCSVM) was compared: (a) “PetFax,” a distant conference service in which dog owners and a certified applied animal behaviorist correspond with each other via fax or email and (b) in person clinic talk, requiring owners to bring their dogs to the animal behavior clinic at TCSVM. Study stated that remote consultation was a valid way for behavioral professionals to instruct behavior modification advice to owners regarding canine separation anxiety (Cottam et al., 2008). In another study on prototype telemonitoring system that utilizes wearable technology, it has been reported that it provides continuous animal health data (Smith et al., 2006). A research “proactive herd health management for disease prevention” conducted by Kansas State University to develop the technological and sociological infrastructure to support intelligence, mobile medical monitoring devices which continuously assess the health of cattle in concentrated and distributed herds was proved to be effective. A light reflectance sensor connected to a pulse oximeter circuit to acquire red and infrared photo plethysmographic data from the ear of the cow is utilized (Patil, 2009). Obtaining heart rate by way of a single lead electrocardiographic hardware encased in a waterproofed polyvinylchloride pipe based bolus was used with a wearable cattle health monitoring system (Warren et al., 2008).

Telemedicine Guidelines – Salient features

Doctor can choose the medium of teleconsultation: A doctor may use any medium for patient consultation, e.g. telephone, mobile or landline phones, chat platforms like WhatsApp, Facebook Messenger etc., other mobile apps or internet-based digital platforms for telemedicine or data transmission systems like Skype/ email/ fax etc. However, before proceeding with the teleconsultation, the doctor should exercise professional judgement to decide whether the teleconsultation is, in fact, appropriate and in the interest of the patient. If the answer is yes, then the doctor should evaluate which medium would be preferred for the teleconsultation. For example, a complaint of appendicitis may require a physical examination and teleconsultation may not be preferred. On the other hand, some common complaints may not require physical examination or even consultation in real-time. For example, a complaint of headache or fever may not always require the doctor to examine the patient physically or audio-visually through a mobile or computer application. However, in certain cases, for example, on presentation of allergy or inflammation (e.g. Conjunctivitis), the doctor may choose to examine the patient in-person or through an audio-visual teleconsultation. Thus, the decision to examine the patient physically or remotely i.e. through teleconsultation, and the medium of teleconsultation, is to be taken by the doctor himself or herself on case to case basis.

Doctor has to maintain the same standard of care during teleconsultation as during in-person consultation: The Telemedicine Guidelines require doctors to maintain the same standard of care towards a patient during a teleconsultation as they would during an in-person consultation. In other words, the fact that the teleconsultation took place over a mobile app or email or telephone cannot be taken as a defence by a doctor against an allegation of medical negligence. Every doctor is expected to know the limitation of teleconsultation and advise or prescribe accordingly.

Patient is responsible for the accuracy of information: During the course of teleconsultation, if the doctor inquires for relevant information from the patient, then the patient is supposed to disclose the right information. The Telemedicine Guidelines have clarified that is the patient who will be responsible for accuracy for the information shared with the doctor, and not the doctor. However, since the standard of care is as high in the case of teleconsultation as in-person consultation, the doctor must make all efforts to gather sufficient medical information about the patient’s condition before deciding on a diagnosis or a treatment. If a patient provides any contradictory information, or if the doctor is not convinced with the information at hand to make a professional decision, he may ask patient to provide such documents or undertake such tests as he/she may feel proper in his/her professional judgement without fear of liability.

Caregiver is deemed to be authorized on behalf of minor or incapacitated patients: If the age of the patient is 16 years or less, or if the patient is incapacitated (due to mental conditions like dementia or physical disability due to an accident), then the caregiver is deemed to be authorized to consult on behalf of the patient. The Telemedicine Guidelines clarify that in such cases, the teleconsultation can take place with the caregiver without the presence of the patient.

No fixed Format for issuing a prescription: There is no fixed format for issuing a prescription in a teleconsultation. The Telemedicine Guidelines has recommended a format, but following it is not mandatory. However, the doctor must provide photo/scan /digital copy of a signed prescription or e-Prescription to the patient via email or any messaging platform. Please note that a doctor can transfer the prescription to a pharmacy only if he/ she has the explicit consent of the patient.

Invoice for fees: Doctors can charge appropriate fees for teleconsultation. A receipt or invoice should be given to the patient against the fees.

Do’s and Don’t’s for Doctors

Patient identification is mandatory during first consultation: If the teleconsultation is, in fact, the first consultation of the patient with the doctor, then doctor should confirm the patient’s identity to his/her satisfaction by asking patient’s name or age or address or email I.D. or phone number or any other identification that may be reasonable.

Patient identity confirmation is not mandatory during follow-up consultation, but may be carried out on need basis: It is not mandatory to identify the patient during a follow-up teleconsultation with a known patient, especially if the doctor is communicating through the registered user id, email id or phone number. However, in case of doubt, the doctor should confirm patient identity as during the first consultation.

Caregiver identity and authorization should be checked: If the patient is not a minor or is not incapacitated, then a caregiver cannot consult on behalf of the patient unless he or she has a formal authorization such as a signed authority letter by the patient or his/her legal representatives (family members) or, where the caregiver is a family member himself or herself, if he or she has a document that verifies his or her relationship with the patient such as a government identity proof. The caregiver’s identity and authorization should be checked by the doctor before offering teleconsultation. In the case of minors, the identity of the caregiver should be confirmed.

Doctor should identify himself/herself to the patient before start of every teleconsultation: A doctor should begin any teleconsultation by informing the patient about his/her name and qualification. This may be uncomfortable to be done every time, especially to a known patient. However, this is the requirement of Telemedicine Guidelines at present.

Doctor should display his/her registration number at every touch-point with patient: A doctor who provides teleconsultation is required to display his/her registration number provided by respective State Medical Council on his/her prescription, website, electronic communications (WhatsApp/Message/Email etc.) and fee receipts given to his/her patients.

Doctor should not continue with teleconsultation if it not appropriate: the doctor is not satisfied with the information provided by the patient to provide specific treatment, i.e. prescription or health advice, then he/she should provide limited consultation as appropriate and refer the patient for an in-person consultation.

Doctor should maintain patient records of teleconsultation: For in-person O.P.D. consultations in India, the doctors, in general, do not maintain patient records. Appropriate patient history, observations and findings are recorded on the prescription and it is handed over to the patient. However, for teleconsultation, it is mandatory for doctors to prepare, maintain and preserve the patient’s records (e.g. case history, investigation reports, images, etc.), copy of prescription issued and proof of teleconsultation (e.g. phone call history, email records, chat/ text record, video interaction logs etc.). While no time period is prescribed for how long such records are required to be preserved, it is generally recommended to maintain these records for three years.

Patient’s personal data should not be disclosed or transferred without written consent of the patient: Since teleconsultation happens on an electronic medium, the Indian law that protects personal information, including medical and health-related information of patients, squarely applies to doctors who provide teleconsultation and receive such information from patients. This is in addition to the ethical obligation to protect patient privacy that is recognized in the Code of Conduct. The most important thing to note here is that Doctors who provide teleconsultation should not disclose or transfer any information that may identify the patient without the prior written consent of the patient.

Doctor should not deny emergency teleconsultation, but limit it for immediate assistance or first aid: Emergency teleconsultation should not be provided remotely except when it is the only way to provide timely care.Even then, such emergency teleconsultation should be limited to first aid, life-saving measures, counselling and advice on referral. Every emergency teleconsultation must end with an advise to the patient or his/her carer for in-person interaction with a Doctor at the earliest.

Limitation on prescribing medicines to patients: This is, perhaps, the most significant limitation imposed by Telemedicine Guidelines on the practice of telemedicine in India. Going forward, doctors will not be able to prescribe medicines over teleconsultation freely.

In order to prevent abuse, the Telemedicine Guidelines require every doctor to “prescribe medicines via telemedicine ONLY when (the doctor) is satisfied that he/ she has gathered adequate and relevant information about the patient’s medical condition and prescribed medicines are in the best interest of the patient.” Prescribing Medicines without an appropriate diagnosis/provisional diagnosis will amount to professional misconduct.

Before issuing a prescription through teleconsultation, every doctor is supposed to inquire about the age of the patient. If there is any doubt about the age of the patient, then the doctor should seek age proof. If the patient turns out to be a minor, then further teleconsultation should be done and prescription should be issued only in the presence of an adult, whose identity should also be ascertained by the doctor.

If the teleconsultation with the patient does not take place over video, then the concerned doctor cannot prescribe drugs to the patient other than common over-the-counter (“O.T.C.”) medications such as paracetamol, O.R.S. solutions, cough lozenges etc. Such patient also cannot be prescribed medication for which diagnosis is possible only by video consultation such as antifungal medications for Tinea Cruris, Ciprofloxacillin eye drops for Conjunctivitis etc. The doctor may, however, prescribe ‘add-on’ medication to such patient to optimize the existing treatment through drugs if such existing treatment was prescribed in an in-person consultation less than six months ago. Please note that there is no bar in prescribing emergency medications, even if they are not O.T.C. medicines, as and when notified by the government, through any form of teleconsultation, whether video or not.

A list of common O.T.C. medications that can be prescribed without video teleconsultation is described in List O, Appendix 5 of the Code of Conduct. A list of ‘add-on’ medications to optimize existing treatment is described in List B, Appendix 5 of the Code of Conduct. For the purpose of this list, emergency medications would be included in the list of O.T.C. medications, i.e. List O.

If the patient is examined through video, then the doctor may prescribe medications other than O.T.C. medicines described in List A of Appendix 5 of Code of Conduct. Some examples of such medicines are:

• 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.

The doctor may also prescribe a ‘refill’ of medication already prescribed during an in-person consultation for chronic illnesses (hypertension, diabetes, asthma etc.) or an ‘add-on’ medication to optimize the existing treatment (like in the case of non-video consultation).

Please note, however, that no doctor is permitted to prescribe habit forming drugs (i.e. drugs in Schedule X of Drugs and Cosmetics Rules, 1945) or narcotic or psychotropic drug (i.e. drugs regulated by Narcotic Drugs and Psychotropic Substances Act, 1985) through any medium of teleconsultation.

Mandatory training in telemedicine

At some point of time in future, the Board of Governors in supersession of Medical Council or National Medical Commission would introduce training programs in telemedicine. It will be mandatory to participate in those training programs for all doctors who intend to offer teleconsultations to patients. However, until those training programs are developed, there is no restriction in terms of prior training or qualification for registered doctors to engage in teleconsultation.

Do Telemedicine Practice Guidelines apply to doctors who are practising Indian medicine?

The Telemedicine Guidelines do not apply to practitioners of Ayurveda, Yoga, Homeopathy, Unani or Siddha.

What happens to the Telemedicine Guidelines when the National Medical Commission is set-up?

The Board of Governors in supersession of Medical Council of India will soon make way for the National Medical Commission. However, this transition will not impact the Telemedicine Guidelines and the practice of telemedicine in India. The National Medical Commission Act, 2019 has a savings clause, which will allow the Code of Conduct and Telemedicine Guidelines to survive and remain enforceable until new regulations are made.

Enforcement of the Telemedicine Guidelines

The Telemedicine Guidelines have been published in form of an amendment to the Code of Conduct. Therefore, any violation of the Telemedicine Guidelines will be looked at as a ‘misconduct’ at hands of the concerned doctor under the Code of Conduct. A patient, who suffers due to misconduct, has the right to complain to the respective State Medical Council with whom the doctor is registered about the misconduct. If the doctor is found guilty of the misconduct, he or she may be reprimanded, or his/her registration may be suspended or cancelled. A suspension or cancellation of registration would effectively stop the doctor from carrying on his/her medical practice.

Advantages of Telemedicine

Telemedicine is advantageous to the patients, health care professionals, and society in many different ways. Telemedicine facilitate timely access to locally unavailable services enabling delivery of health care benefits to patients suffering from serious conditions or diseases (Matusitz and Breen, 2007; Matusitz and Breen, 2007). It speeds up the medical research and innovations by allowing health care professionals to share their findings from any location (Cermack, 2006; Pazmino et al., 2004). It spares burden and cost of unnecessary travel of the patients (Robinson et al., 2003) thus limiting patient exposure to infections by eliminating or limiting the need of visit to a hospital for health care services. To the society telemedicine benefits through critical care monitoring when it is not possible to transfer the animals and by providing veterinarian expertise to livestock at remote locations. Most importantly medical records are digitalized enabling universal and, permanent availability at any time of age allowing continuity in treatment and reducing the incidence of adverse events or medication errors (Leape and Berwick, 2005). Telemedicine allows local communication between scientists, researchers, field veterinarians and, private practioners allowing update with recent advancements in veterinary science at any time and learning vice-versa. Telemedicine could also be able to be used to overcome shortages of veterinarians in some areas, deliver education and facilitate research (Robinson et al., 2003). Mobile internet applications are also helpful in telemedicine and gaining popularity making it possible that minor health problems can be solved at a distance also. Many professional groups are created on social networking sites like facebook where veterinarians are sharing and discussing their technical knowledge adding some dimensions to primitive type of telemedicine.

During the testing times of COVID-19 one of the greatest advantage of telemedicine in India is that it eliminated the in person visit to a health care facility, hence greatly reducing the chances of contracting of contracting any new disease or COVID-19 itself. By eliminating the risk of exposure, the chances of spreading the disease ourselves is also eliminated specially in case of COVID-19 which is highly transmissible. It also saves time, money and energy by cutting down the time of travel, travel expenses and tiredness of long journey which would otherwise have been unavoidable. The daily hustle bustle of modern-day life, responsibilities and prior commitments, work overload have all made it very difficult to find adequate amount of time to devote for our healthcare visits especially if the visits are to be frequent. Telemedicine provides options of selecting the desired time slots according to one’s convenience. People living in places that do not have easy access to super speciality hospitals can have the best health care advices and treatments possible through telemedicine. The primary health care provider can help connect a patient to a specialist. When it comes to health anyone would choose the best over the closest. When one can have appointments as easily as one wants to and whenever in need, it in return helps in better health management, medication regulation, better health related lifestyle choices and better care of chronic illnesses. Telemedicine not only helps in making life easy it is also convenient and less time consuming.

Drawbacks of Telemedicine

It is not always possible to form a diagnosis or prescribe treatment without hands on approach. Many a times different tests like imaging tests, serological examinations require the patient to be physically present. The patients’ health records are confidential. Maintaining privacy of data and its secure storage is a major concern involved in telehealth. The security and privacy of the patient-clinician relationship, its intimacy and confidentiality, are in question in the telehealth delivery system. Though insurance companies have started to cover expenses of telemedicine, telemedicine is still a new concept and many of the expenses may not have been included under insurance coverage which may lead to more expenses.

Challenges and the Future

There is much hope for the future of telemedicine. With rapid advances in technology, telemedicine will become easier and more widely accepted in coming years. For successful integration of telemedicine with the existing health structure, we need to develop policies and guidelines. The future directions and challenges could be:

1. Institution of a regulatory authority
2. Standardized format of information to patients and consent form with option to opt in/out of telemedicine
3. Mandatory telemedicine courses for all medical students and refresher courses for medical practitioners and technical staff
4. Responsibility for privacy, confidentiality and security of patient information and treatment
5. Accreditation/licensing of doctors using telemedicine
6. Building confidence of both the patient and distant doctor
7. Clear guidelines for teleconsulting insurance
8. Clear guidelines on issues of telemedicine across national borders
9. Standardization of equipment and teleservices with periodic checks and submission to a regulatory authority
10. Equipment liability, maintenance and safety
11. Telemedicine laws for information storage and access
12. Dedicated staff to manage telemedicine services
13. Establishing telemedicine unit at every hospital
14. Proper communication and documentation
15. Maintenance and regular upgrading of the hardware and software

 

There is an urgent need to clarify medicolegal issues pertaining to the use of telemedicine through legislation so that doctors can use these services without reservation. There is also a need for an open platform for connectivity to use telemedicine, which means that telemedicine facility should be available easily in a secure manner to maintain confidentiality and privacy in the doctor- patient relationship. The use of smartphone-based applications should be developed to avail healthcare services so that a patient can contact a doctor without the need to go for a consultation physically.

Veterinary Telehealth Market Size is projected to reach USD 510.49 Million by 2030, growing at a CAGR of 17.69%: Straits Research

The global market for veterinary telehealth was valued at USD 117.85 million in 2021, and it is anticipated to reach USD 510.49 million by 2030 at a CAGR of 17.69%. North America dominated the market.

Medical professionals and anyone receiving medical support can communicate with health information, education, or treatment remotely. To improve a patient’s clinical health status, telehealth offers the transmission of technology from one location to another. Patients who are not in the same place as the healthcare professional can be monitored thanks to the technology. The use of telehealth by veterinarians is a result of ongoing technical improvements.

The practice of veterinary care (advice, diagnosis, and treatment), which takes place remotely using telecommunication between a veterinarian and an animal owner, is referred to as telehealth. In other words, telehealth is a tool used in veterinary medicine, and it entails the electronic transmission of medical data on a patient’s clinical health status. Telehealth is a supplement to conventional veterinary medical practice, not a replacement. All legal prerequisites, including informed permission, must be met before an animal doctor can diagnose and treat an individual via telehealth.

 

The Rising Cases of Zoonotic Infections and Chronic Diseases among Animals
The enormous preference for veterinary telemedicine services is partly influenced by the rising occurrence of zoonotic illnesses and chronic animal diseases. Approximately 1 million illnesses and millions of deaths are attributed to zoonotic diseases each year, as well as 60 percent of all new infections, according to WHO data from 2021. As a result, the infection surge is pressuring farm and pet owners to use telehealth services to monitor and improve their animals’ health. Additionally, the extensive use of veterinary telehealth services is being prompted by the rising incidence of diseases that affect the animal population, such as chronic kidney disease and diabetes. Therefore, the above causes play a part in the growing demand for veterinary telemedicine services.

Increasing Pet Owners Globally
The popularity of pet owners’ telehealth services is growing, partly due to the rise in pet ownership worldwide. About 85 million American families own pets, according to the American Pet Products Association’s (APPA) 2019-2020 National Pet Owners Survey. Additionally, due to a growing preference for companionship, roughly one in three Americans adopted a pet during the COVID-19 epidemic, according to the Insurance Research Council’s October 2020 study. Additionally, 3.2 million households in the UK have adopted a pet since the start of the COVID-19 epidemic, according to statistics from the Pet Food Manufacturers Association (PFMA) 2021. Pet owners choose virtual care since it eliminates the burden of travelling, waiting, and spending time and money on their dogs. As a result, the need for veterinary telehealth services is growing as pet ownership increases globally.

Growth Opportunities for the Global Veterinary Telehealth Market

• Market Players And Their Strategies

Many businesses emphasise organic growth initiatives, including new launches, product approvals, patents, and events. Acquisitions, partnerships & collaborations were examples of inorganic growth tactics observed in the market. These actions have enabled market participants to increase their clientele and revenue. With the growing demand for Veterinary telehealth in the global market, market participants from the veterinary telehealth market are projected to benefit from lucrative growth prospects in the future.

Regional Analysis of the Global Market for Veterinary Telehealth
The global market for veterinary telehealth is segmented into North America, Europe, Asia-Pacific, Latin America and the Middle East & Africa. North America dominated the market.
The United States currently holds the largest proportion of the North American market, a position it is certain to keep. This is due to high healthcare costs, influential market participants, technological improvements, and rising disposable income. The region’s demand for companionship and lifestyle has prompted Americans to opt for pet insurance, fuelling the use of veterinary telehealth services.

North American Pet Health Insurance Association (NAPHIA): US gross written premiums of USD 1.99 billion in 2020, up 27.5% from USD 1.56 billion in 2019. The rise in cattle consumption also boosts the demand for veterinary telehealth services. 93 million cattle and calves will be in the US by 2021, according to the USDA’s National Agricultural Statistics Service. The veterinary telehealth market in North America is expected to increase significantly over the projected period.

 

Key Highlights

• The global market for veterinary telehealth was valued at USD 117.85 million in 2021, and it is anticipated to reach USD 510.49 million by 2030 at a CAGR of 17.69%.
• The global market for veterinary telehealth is segmented into four parts based on animal type, service type, application and region. Further, based on animal type, the market is segmented into livestock and companion. The livestock segment is sub-segmented into poultry, pigs, cattle, and others. The companion segment is further segmented into canine, feline, equine, and others. The livestock segment dominated the market.
• The market is segmented into telemonitoring, telemedicine, teleconsulting, and service type. The teleconsulting segment dominated the market.
• The market is segmented into x-ray and picture archiving and communication system (PACS) advice, computed tomography (CT) reporting, radiographic reporting, magnetic resonance imaging (MRI) reporting and others based on application.
• The global market for veterinary telehealth is segmented into North America, Europe, Asia-Pacific, Latin America and the Middle East & Africa. North America dominated the market.

 

Some of the Key Players Contributing Majorly To the Global Veterinary Telehealth Market Are

• Agora.io
• Animation
• Linkyvet
• Oncura Partners
• TeleVet
• Vetchat
• VetCT.
• Vetoclock
• WellHaven Pet Health
• PawSquad
• Petro Connect
• Airvet
• Babel Bark Inc.
• Pet Desk
• TeleTails
• Vester Inc.
• Whiskers Worldwide LLC
• FirstVet
• Petriage Inc.
• Activ4Pets
• Guardian vets
• Petzam
• VitusVet
• Virtuwoof LLC
• Paw Squad

Conclusion

In India, where access to affordable healthcare service is an issue, telemedicine will provide immense benefit to the public. Telemedicine allows for a new form of doctor–patient interaction, which needs mutual trust and acceptance.

Although WHO has given importance to telemedicine, there is no legislation in India concerning telemedicine and virtual consultation. Hence, it is governed by a combination of the practice of medicine and information technology with their associated rules, regulations or laws. Specific laws governing the practice of ‘tele-medicine’ are needed to have clarity on legal issues and resolution of technical issues. Regular assessment of quality standards in health-related telecommunication is required. Telemedicine shall continue developing and be used in a multitude of settings by more health-care doctors and patients, and these standards of practice will be a crucial driver within this evolution. To protect the rights of all persons and guarantee that variations in literacy, linguistic, geographical region, physical and mental capacity, age, and gender do not lead to the alienation of treatment, telemedicine must be administered fairly and to the highest standards of ethics. Telemedicine, on the other hand, cannot solve every problem and cannot substitute in-person consultations. The relevance of telemedicine in healthcare delivery and how it will be adopted in the future has been highlighted by this catastrophe. In India, the benefits of investing in telemedicine are numerous, and its usage might make healthcare more affordable and fairer in the long term. As a corollary, policymakers and healthcare professionals should be aware of the benefits of giving treatment via virtual mode in this digitalized environment, and should stimulate the rapid formulation of regulations and standards on the topic to assist the efficient use of telemedicine. The use of visual aids and video conferencing can assist more in smoothening the process of diagnosis. With the upcoming uncertainties telemedicine has proved to be a game changer. If any future pandemic follows we are now technologically and strategically more equipped. Not only during pandemic but in day to day life it is now becoming easier to consult a specialist without compromising time, schedule and comfort. Telemedicine has a bright future in India.

The notification of the Telemedicine Guidelines marks the dawn of a new era in the practice of modern medicine. The law has finally caught up with the reality and necessity of modern times.The Telemedicine Guidelines enable doctors to confidently provide teleconsultation via any medium (such as email, phone call, message, fax, WhatsApp, other mobile and computer applications such as Skype, Google Hangouts etc.) to the patients.

At the same time, they protect patient interest by mandating doctors to identify themselves before consultations, disclose their registration number, offer the same standard of care to patients as during in-person consultation and limit medicines that can be prescribed through a teleconsultation.Indians will now be able to enjoy access to quality healthcare remotely, and doctors will be able to extend their services to many more needy patients.

Compiled & Edited by- Team, LITD