However, along with all its potential for bridging the geographical gap and enhancing the availability of medical expertise in the remote rural regions, telemedicine does have some serious ethical, legal and safety issues as discussed below.
1. Problems Related to Distance (on line) Consultation:
During normal consultation, the patient chooses the consultant or the hospital of his choice and after confirming the credentials and competence of the consultant, has a face to face consultation. In telemedicine, however, he has no way of checking the genuineness of the doctor prior to consultation and gets the consultation from a person never seen, heard or known before. Further, the consultation depends on the quality of internet communication. Corruption of communication at any stage may compromise the integrity of information.
2. Informed Consent:
Informed consent of the patient/attendant is required for treatment through telemedicine. They will have to be fully informed about, besides the disease process, the credentials and role of the Telemedicine Specialist being consulted (never seen, heard or known before), the role of local physician in-charge and the system of functioning of telemedicine.
The consent would be required even for allowing people for the video sessions.
3. Licensing/Credentialling of Consultants:
A system of licensing by the State Medical Council will have to be put in place for practice of telemedicine to protect the patients from being duped by fake doctors with fake degrees. Since, the patient or the local staff at the Tele Consulting Center (TCC) may have no knowledge about the Tele Specialist Consultant (on the other end) and his/her level of actual qualifications, training and experience, regulations must stipulate the eligibility criteria to ensure the professional competence of consultants at Tele Specialty Centers. Equally important would be a system of screening of the primary physicians at the TCCs as they have a crucial role in the entire process.
4. Licensing of Tele Medical Centers:
With so many fake/under qualified doctors and ill equipped treatment centers around, it will be imperative to install a system of licensing the Telemedicine Centers—both the users (TCC) as well as providers (TSC) of service. Licensing for TSC should be strictly specialty wise and not blanket licensing for all specialties.
In teleconsultation/treatment, there are chances of damages to the patient due to wrong advice by the telespecialist, faulty execution by the local doctor, corruption of data transmitted, or misinterpretation of messages due to communication barriers such as language, dialect, level of knowledge. This can be important specially, in cases of interstate, inter region or international consultations. Accountability for the same must be clarified in the form of a legal contract between the TCC seeking the consultancy and the TSC providing it.
6. Confidentiality of Information:
In telemedicine, all the health information about the patient, along with personal identification details, is transmitted online. As of now there are hardly any checks in place to restrict the access to and prevent the private information from becoming public by accident or design. There should be legislation for implementing stringent measures to ensure confidentiality of information (such as HIPAA in USA) as well as for fixing the accountability of TCC/TSC for any violation thereof.
7. Security Issues:
Security of information is a vital issue.
What if a mischief monger or a criminal hacker gains entry and alters, by design or accident, the critical lab reports or the name or dosage of the drug prescribed. A system of access control and authentication of users through digital signatures should be mandatory.
8. Unique Digital Identifiers:
For security of patient related information and prevention of unauthorized access, digital identifiers for Telemedicine Specialist Centers (TSC), Consulting centers (TCC), the Tele-Medicine Consultants as well as patients, will be a crucial requirement.
The identifiers for consultants should incorporate the name, the MCI registration number, the telemedicine specialty licensed for, the professional qualifications, the hospital/Tele Specialty Centre to which attached, the PAN number and the states/countries in which permitted to practice.
9. Medical records:
In many countries (including India) electronic records are not legally admissible in the courts of law. Telemedicine records being mostly electronic, the legislation must incorporate provisions about their admissibility as evidence.
System of Grievance Redressal and Disciplinary Authority:
There should be a procedure for redressal of patients’ grievances which should specify the disciplinary authority as well as its disciplinary powers for action against the errant consultants. Current system of grievance redressal by the IMC/State Medical Councils has not been effective. The system must be made effective so as to inspire the confidence of the user public.
11. Penal Provisions:
Telemedicine is likely to be exploited by unqualified/inexperienced professionals as well as quacks to make a quick buck, especially since it is practiced through internet and without any personal knowledge, acquaintance or doctor-patient relationship. The legislation must have an effective mechanism for fixing the responsibility and stringent penal provisions to act as deterrent for the crimes related to telemedicine practice.
Question of Jurisdiction of Licenses and Legal Liability of the Practitioners for Medical Negligence in other Areas/States:
The situation needs to be understood in the right perspective because internet has enabled the telemedicine provider to provide services, anywhere in the world, just sitting at one place.
13. Reimbursement of Bills:
The records being mostly electronic, a satisfactory system of reimbursement of bills will have to be worked out.