Healy Nurse’s Guidelines for Telemedicine

CONTENT

 

Introduction

Background

Purpose

Chapter 1: Telemedicine: Definitions and Applications

Definition

Scope

Telemedicine Application

Using telemedicine according to the purpose of the consultation

Chapter 2: Technology Used & Mode of Communications

Strengths and Limitations of Various Modes of Communication

Chapter 3: Healy Nurse’s Guidelines for Telemedicine

Telemedicine Should Be Appropriate and Sufficient

Identification of the Registered Medical practitioner and the Patient is Required

Mode of Telemedicine

Patient Consent

Exchange of Information for Patient Evaluation

Types of Consultation: FIRST Consult/ Follow-up Consult

Patient Management: Health Education, Counseling & Medication

Duties and Responsibilities of an RMP in General

Chapter 4: Framework for Telemedicine

Consultation Between Patient and Registered Medical Practitioner

Consultation Between Patient and RMP Through a Caregiver

Chapter 5: Guidelines on the Use of Our Technology Platforms

Flow Charts

Annexures

 

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Introduction to Telemedicine

Providing telehealth/medicine differs from hospital-based consultations. The following information describes how our Partner Doctors and other Registered Medical Practitioners should work together with our Nurses and Patients to provide home and community-based services to patients. This document is a guide/manual for how Healy Nurse’s Telehealth.

 

Background

Telemedicine: An Enabler of Healthcare Access and Affordability.

There are several benefits of telemedicine. It increases timely access to interventions, including faster access and access to services that may not otherwise be available.

In Nigeria, providing in-person healthcare is challenging, particularly given the large geographical distances and limited resources. One of the major advantages of telemedicine is cost saving and effort, especially for rural patients, as they need not travel long distances to get consultation and treatment. In this type of scenario, telemedicine can provide an optimal solution for not just providing timely and faster access. It would also reduce the financial costs associated with travel. It also reduces the inconvenience/impact on family and caregivers and social factors. Telemedicine can play an important role where there is no need for the patient to see the RMP (or other medical professional) in person, e.g., for routine check-ups or continuous monitoring. Telemedicine can reduce the burden on secondary hospitals.

 

With telemedicine, there is a higher likelihood of maintenance of records and documentation, hence minimizing the likelihood of missing out on advice from the doctor or other health care staff. Conversely, the doctor has an exact document of the advice provided via teleconsultation. Written documentation increases the legal protection of both parties. Telemedicine provides patient safety, as well as health workers’ safety, especially in situations where there is a risk of contagious infections. We can use several technologies in telemedicine, which can help patients adhere better to their medication regimens and manage their diseases better. Telemedicine can also enable the availability of vital parameters of the patient available to the physician with the help of medical devices such as blood pressure, blood glucose, etc. management.

Disasters and pandemics pose unique challenges to providing health care. Though telemedicine will not solve them all, it is well suited for scenarios in which medical practitioners can evaluate and manage patients. We can conduct a telemedicine visit without exposing staff to viruses/infections during the times of such outbreaks. Telemedicine practice can prevent the transmission of infectious diseases, reducing the risks to both health care workers and patients. Using telemedicine, we can avoid unnecessary exposure of the people involved in the delivery of healthcare and screening of patients remotely. It can provide rapid access to medical practitioners who may not be immediately available in person. In addition, it makes available extra working hands to provide physical care at the respective health institutions. Thus, health systems that are invested in telemedicine are positioned to ensure that patients with issues such as Covid-19 can receive the care they need.

We have committed to providing equal access and quality care to all, and digital health is a critical enabler for the overall transformation of our service delivery. Hence, mainstreaming telemedicine in delivery processes will minimize inequity and barriers to access. Healy Nurse’s digital health care policy advocates the use of digital tools for improving the efficiency and outcome of our consultations and treatments.

Telemedicine will enable Healy Nurse to continue to grow, and these guidelines will be a key enabler to fostering that growth.

 

Purpose

These guidelines give practical advice to doctors and other RMPs. These guidelines will assist the medical practitioner in pursuing a sound course of action to provide effective and safe medical care founded on current information, available resources, and patient needs to ensure the RMPs and patient safety.

 

These telemedicine guidelines will help realize the full potential of these advancements in technology for health care delivery. It provides norms and protocols relating to physician-patient relationship; issues of liability and negligence; evaluation, management and treatment; informed consent; continuity of care; referrals for emergency services; medical records; privacy and security of the patient records and exchange of information; prescribing; and reimbursement; health education and counselling.

These guidelines will provide information on various aspects of telemedicine, including information on technology platforms and tools available to medical practitioners and how to integrate these technologies to provide health care delivery. It also spells out how to use technology and transmission of voice, data, images and information with other clinical standards, protocols, policies and procedures for the provision of care. Where clinically appropriate, telemedicine is a safe, effective and valuable modality to support patient care.

Like any other technology, we can abuse the technology used for telemedicine services. It has some risks, drawbacks and limitations; however, we can mitigate it through training, and enforcement of standards, protocols, and guidelines.

We should use these guidelines with the other national clinical standards, protocols, policies and procedures.

 

 

 

 

1. Telemedicine: Definitions and Applications

 

DEFINITIONS

 Definition of Telemedicine

World Health Organization defines telemedicine as:

“The delivery of health-care services, where distance is a critical factor, by all health-care professionals using information and communications technologies for the exchange of valid information for the diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health-care workers, to advance the health of individuals and communities.”

 

Definition of Telehealth

NEJM Catalyst defines telehealth as:

“The delivery and facilitation of health and health-related services including medical care, provider and patient education, health information services, and self-care via telecommunications and digital communication technologies.”

In general, telemedicine is used to denote clinical service delivered by a registered medical practitioner, while telehealth is a broader term of use of technology for health and health-related services, including telemedicine.

 

Definition of Registered Medical Practitioner (RMP)

The Law Insider defines a registered medical practitioner as:

“Registered medical practitioner means a person qualified by a degree in western medicine and duly licensed or registered with the relevant medical board or council to practice medicine and surgery in the geographical area of his/her practice, and who in rendering such services is practicing within his/her licensing and training.”

 

SCOPE

Within the broad paradigm of telemedicine, we have published these guidelines for Healy Nurse Services and its partner registered medical practitioners, especially medical doctors, and are for privileged access only. These guidelines serve as an aid and tool to enable our RMPs to leverage Telemedicine to enhance healthcare service and access to all our patients.

 

In summary, we developed these guidelines for our RMPs. Also:

• The guidelines cover norms and standards of the RMP to consult patients via telemedicine
• Telemedicine includes all channels of communication with the patient that leverage Information
• Technology platforms, including Voice, Audio, Text & Digital Data exchange

 

EXCLUSIONS:

The guidelines specifically explicitly exclude:

• Specifications for hardware or software, infrastructure building & maintenance
• Data management systems involved; standards and interoperability
• Use of digital technology to conduct surgical or invasive procedures remotely
• Other aspects of telehealth, such as research and evaluation and continuing education of healthcare workers
• Does not provide for consultations outside the jurisdiction of Healy Nurse

 

TELEMEDICINE APPLICATIONS

Tools for Telemedicine

1. RMP may use any telemedicine tool suitable for carrying out technology-based patient consultation e.g., telephone, video, devices connected over LAN, WAN, Internet, mobile or landline phones, Chat Platforms like WhatsApp, Facebook Messenger etc., or Mobile App or internet-based digital platforms for telemedicine or data transmission systems like Skype/ email/ fax etc. Irrespective of the tool of communication used, the core principles of telemedicine practice remain the same.

2. We classified telemedicine applications into four basic types, according to the mode of communication, the timing of the information transmitted, the purpose of the consultation and the interaction between the individuals involved—be it RMP-to-patient / caregiver, or RMP to RMP.

According to the Mode of Communication

• Video (Telemedicine facility, Apps, Video on chat platforms, Skype/Face time etc.)
• Audio (Phone, VOIP, Apps etc.)
• Text-Based:
• Telemedicine chat-based applications (specialized telemedicine smartphone apps, websites, other internet-based systems, etc.)
• General messaging/ text/ chat platforms (WhatsApp, Google Hangouts, Facebook Messenger, etc.)
• Asynchronous (email/ Fax etc.)

 

According to the timing of information transmitted

 Real-time Video/audio/text interaction

• Video/audio/text for exchange of relevant information for diagnosis, medication and health education and counselling.

Asynchronous exchange of relevant information

• Transmission of summary of patient complaints and supplementary data, including images, lab reports and/or radiological investigations between stakeholders. Such data can be forwarded to different parties at any point in time and thereafter accessed per convenience/need.

Using telemedicine according to the purpose of the consultation

For Non-Emergency consult:

 

First consult with any RMP for diagnosis/treatment/health education/ counseling

•  Patients may consult with an RMP for diagnosis and treatment of their condition or health education and counselling

Follow-up consult with the same RMP

• Patients may use this service for follow-up consultation on their ongoing treatment with the same RMP who prescribed the treatment in an earlier in-person consultation.

 Emergency consult for immediate help or first aid, etc.

•  When alternative care is not present, teleconsultation might be the only way to provide timely care. In such situations, RMPs may provide consultation to their best judgement. Telemedicine services should, however, be avoided for emergency care when alternative in-person care is available, and telemedicine consultation should be limited to first aid, life-saving measures, counselling and advice on referral.
• In all cases of emergency, RMP must advise the patient for an in-person interaction immediately.

 

According to the individuals involved,

 

Patient to RMP

• Telemedicine services may connect patients to an RMP

RMP to RMP

• RMP may use telemedicine services to discuss with other RMPs issues of care of one or more patients or to disseminate knowledge

Caregiver to RMP

• Telemedicine services may connect Caregivers to an RMP, under certain conditions as detailed in the Framework

Health worker to RMP

• A Health Worker can facilitate a consultation session for a patient with an RMP. In doing so, the former can help take the history, examine the patient and convey the findings. They can also explain/reinforce the advice given by the RMP to the patient.

 

 

 

 

 

2. Technology Used & Mode of Communications

 

RMPs can use multiple technologies to deliver telemedicine consultations. There are 3 primary modes: video, audio, or text (chat, messaging, email, fax, etc.) Each one of these technology systems has its respective strengths, weaknesses and contexts, in which they may be appropriate or inadequate to deliver a proper diagnosis.

 

It is therefore important to understand the strengths, benefits and limitations of different technologies. Broadly, though telemedicine consultation provides safety to the RMP from contagious conditions, it cannot replace physical examination that may require palpation, percussion or auscultation; that requires physical touch and feel. Newer technologies may improve this drawback.

 

STRENGTHS AND LIMITATIONS OF VARIOUS MODES OF COMMUNICATION

 

Mode	Strengths	Limitations
VIDEO: Telemedicine facility, Apps, Video on chat platforms, Facetime, etc.	Closest to an in-person-consult, real-time interaction Patient identification is easier RMP can see the patient and discuss with the caregiver RMP can perceive visual cues RMP can carry out inspection of the patient out	Depends on a high-quality internet connection at both ends, else will lead to a sub-optimal exchange of information Since there is a possibility of abuse/ misuse, ensuring the privacy of patients in video consults
AUDIO: Phone, VOIP, Apps etc.	Convenient and fast Unlimited reach Suitable for urgent cases Requires no separate infrastructure Privacy ensured Real-time interaction.	Non-verbal cues may be missed Not suitable for conditions that require a visual inspection (e.g. skin, eye or tongue examination), or physical touch Patient identification needs to be clearer, and a greater chance of imposters representing the actual patient
TEXT BASED: Specialized Chat based Telemedicine Smartphone Apps, SMS, Websites, messaging systems e.g., WhatsApp, Google Hangouts, FB Messenger	Convenient and quick Documentation & Identification may be an integral feature of the platform Suitable for urgent cases, or follow-ups, second opinions provided RMP has enough context from other sources No separate infrastructure required Can be real-time	Besides the visual and physical touch, text-based interactions also miss the verbal cue Difficult to establish rapport with the patient Cannot be sure of the identity of the doctor or the patient
ASYNCHRONOUS: Email Fax, recordings etc.	Convenient and easy to document No specific app or download requirement Images, data, and reports are readily shared No separate infrastructure required More useful when accompanied by test reports and follow-up and second opinions	Not a real-time interaction, so just a one-way context is available, relying solely on the articulation of the patient Patient identification is document based only and difficult to confirm Non-verbal cues are missed There may be delays because the Doctor may not see the mail immediately

 

 

 

 

 

3. Healy Nurse’s Guidelines for Telemedicine

 

The judgment of a Registered Medical Practitioner should be the guiding principle for all telemedicine consultations: An RMP is positioned to decide whether a technology-based consultation is sufficient or an in-person review is needed. The practitioner shall exercise proper discretion and not compromise on the quality of care. Seven elements need to be considered before beginning any telemedicine consultation (see panel)

 

Seven Elements to be Considered before any Telemedicine Consultation
1	Context
2	Identification of RMP and Patient
3	Mode of Communication
4	Consent
5	Type of Consultation
6	Patient Evaluation
7	Patient Management

 

 

TELEMEDICINE SHOULD BE APPROPRIATE AND SUFFICIENT IN PER CONTEXT

Registered Medical Practitioners should exercise their judgment to decide whether a telemedicine consultation is appropriate in a situation or if an in-person consultation is needed in the patient’s interest. They should consider the mode/technologies available and their adequacy for a diagnosis before choosing to proceed with any health education or counselling or medication. They should be reasonably comfortable that telemedicine is in the patient’s interest after taking a holistic view of the situation.

The complexity of the Patient’s health condition

Every patient/case/medical condition may be different. For example, a new patient may present with a simple complaint such as a headache, while a known patient with diabetes may consult for a follow-up with emergencies such as Diabetic Ketoacidosis. The RMP shall uphold the same standard of care as in an in-person consultation but within the intrinsic limits of telemedicine.

 

IDENTIFICATION OF THE REGISTERED MEDICAL PRACTITIONER AND THE PATIENT IS REQUIRED

Telemedicine consultation is should not be anonymous: both patient and the RMP need to know each other’s identity.

An RMP should verify and confirm the patient’s identity by name, age, address, email ID, phone number, registered ID or any other identification, as may be deemed to be appropriate. The RMP should ensure that there is a mechanism for a patient to verify the credentials and contact details of the RMP.

For issuing a prescription, the RMP needs to ask explicitly the age of the patient, and if there is any doubt, seek age proof. Where the patient is a minor, after confirming the age, teleconsultation would be allowed only if the minor is consulting along with an adult whose identity needs to be found out.

An RMP should begin the consultation by informing the patient about his/her name and qualifications.

Every RMP shall display the registration number accorded to him/her by the State Medical Council/MCI, on prescriptions, website, electronic communication (WhatsApp/ email etc.) and receipts etc. given to his/her patients.

 

MODE OF TELEMEDICINE

RMPS can use multiple technologies to deliver telemedicine consultations. All these technology systems have their respective strengths, weaknesses and contexts in which they may be appropriate or inadequate to deliver proper care.

Primarily there are 3 modes: Video, Audio or Text (chat, images, messaging, email, fax etc.). Their strengths, limitations and appropriateness as detailed in Section 2 need to be considered by the RMP.

There may be situations where to reach a diagnosis and understand the context better; a real-time consultation may be preferable over an asynchronous exchange of information. Similarly, there would be conditions where an RMP could require hearing the patient speak, therefore, the RMP may prefer a voice interaction to an email or text for a diagnosis. There are also situations where the RMP needs a visual examination of the patient to make a diagnosis. In such a case, the RMP could recommend a video consultation. Considering the situation, using his/her best judgment, an RMP may decide the best technology to use to diagnose and treat.

 

PATIENT CONSENT

Patient consent is necessary for any telemedicine consultation. The consent can be implied or explicit depending on the following situations:

• If the patient starts the telemedicine consultation, then consent is implied.

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Implied Consent: In an in-person consultation, it is assumed the patient has consented to the consult by his/her actions. When the patient walks into an OPD, the consent for the consultation is taken as implied. Like an in-person consultation, for most teleconsultations consent can be assumed to be implied because the patient has started the consultation.

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• RMP needs explicit patient consent if:

A Health worker, RMP or a Caregiver starts a Telemedicine consultation.

• RMP can record explicit consent in any form. The patient can email, text, or audio/video messages. The patient can state his/her intent on phone/video to the RMP (e.g., “Yes, I consent to avail consultation via telemedicine” or any such communication in simple words). In his/her patient records, the RMP must record this.

 

EXCHANGE OF INFORMATION FOR PATIENT EVALUATION

RMPs must make all efforts to gather sufficient medical information about the patient’s condition before making any judgment.

Patient’s Information

• An RMP would use his/her professional discretion to gather the type and extent of patient information (history/examination findings/Investigation reports/past records etc.) required to be able to exercise proper clinical judgement.
• This information can be supplemented through conversation with a healthcare worker/provider and by any information supported by technology-based tools.
• If the RMP feels that the information received is inadequate, then he/she can request additional information from the patient. This information may be shared in real-time or shared later via email/text, as per the nature of such information. For example, an RMP may advise some laboratory or/and radiological tests to the patient. In such instances, the consult may be considered paused and can be resumed at the rescheduled time. An RMP may provide health education as appropriate at any time.
• Telemedicine has its own set of limitations for adequate examination. If a physical examination is a critical information for consultation, RMP should not proceed until a physical examination can be arranged through an in-person consult. Wherever necessary, depending on the professional judgement of the RMP, he/she shall recommend:

– Video consultation

– Examination by another RMP/ Health Worker;

– In-person consultation

• The information required may vary from one RMP to another based on his/her professional experience and discretion and for different medical conditions based on the defined clinical standards and standard treatment guidelines.

• RMP shall maintain all patient records including case history, investigation reports, images, etc.

TYPES OF CONSULTATION: FIRST CONSULT/ FOLLOW-UP CONSULT

There are two types of patient consultations: first consult and the follow-up consult.

An RMP may have only a limited understanding of the patient seeking teleconsultation for the first time when there has been no prior in-person consultation. However, if the first consult is via video, RMP can make a much better judgment and hence can provide much better advice, including additional medicines, if shown.

If the RMP has earlier seen the patient in person, then it is possible to be more comprehensive in managing the patient.

First Consult means

• The patient is consulting with the RMP for the first time; or
• The patient has consulted with the RMP earlier, but over 6 months have elapsed since the previous consultation; or
• The patient has consulted with the RMP earlier, but for a different health condition

 

Follow-Up Consult(s) means

• The patient is consulting with the same RMP within 6 months of his/her previous in-person consultation, and this is for a continuation of care for the same health condition. However,

RMP will not consider it a follow-up if:

• There are new symptoms that are not in the spectrum of the same health condition; and/or
• RMP does not recall the context of previous treatment and advice

 

PATIENT MANAGEMENT: HEALTH EDUCATION, COUNSELING & MEDICATION

If RMP can appropriately manage the condition via telemedicine, based on the type of consultation, then the RMP may proceed with a professional judgement to:

• Provide Health Education as appropriate in the case; and/or
• Provide Counseling related to specific clinical conditions; and/or
• Prescribe medicines

Health Education: An RMP may impart health promotion and disease prevention messages. These include diet, physical activity, cessation of smoking, contagious infections and so on. Likewise, he/ she may advise on immunizations, exercises, hygiene practices, mosquito control, etc.

Counselling: This is specific advice given to patients and it may, for instance, include food restrictions, do’s and don’ts for a patient on anticancer drugs, proper use of a hearing aid, home physiotherapy, etc. to mitigate the underlying condition. This may also include advice for new investigations that need to be carried out before the next consult.

Prescribing Medicines

Prescribing medications via telemedicine consultation is at the professional discretion of the RMP. It entails the same professional accountability as in the traditional in-person consult. If a medical condition requires a particular protocol to diagnose and prescribe, as with an in-person consult, then the same prevailing principle will apply to a telemedicine consult.

RMP may prescribe medicines via telemedicine ONLY when RMP is satisfied that he/ she has gathered adequate and relevant information about the patient’s medical condition and that prescribed medicines are in the best interest of the patient.

Prescribing Medicines without an appropriate diagnosis/provisional diagnosis will amount to professional misconduct.

 Specific Restrictions

There are certain limitations on prescribing medicines on consultation via telemedicine, depending on the type of consultation and mode of consultation. The categories of medicines that can be prescribed via teleconsultation will be as notified in consultation with the Nigerian Government through its agencies from time to time. RMP can prescribe the categories of medicines:

• List O: It will comprise those medicines which are safe to be prescribed through any mode of teleconsultation. They would comprise

– Medicines which are used for common conditions and are often available ‘over the counter’. For instance, these medicines would include paracetamol, ORS solutions, cough lozenges, etc.

– Medicines that may be deemed necessary during public health emergencies.

• List A: These medications are those which can be prescribed during the first consult, which is a video consultation and is being re-prescribed for re-fill, in case of follow-up.

– This would be an inclusion list containing relatively safe medicines with a low potential for abuse. It includes medications which RMP can prescribe to a patient who is undergoing a follow-up consult, as a refill.

• List B: This is a list of medications which RMP can prescribe to a patient who is undergoing follow-up consultation besides those which have been prescribed during in-person consultation for the same medical condition.

– Prohibited List: An RMP providing consultation via telemedicine cannot prescribe medicines on this list. These medicines have a high potential for abuse and could harm the patient or society at large if abused.

 

Issue a Prescription and Transmit

• If the RMP has prescribed medicines, RMP shall issue a prescription as per the Nigerian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations and shall not contravene the provisions of the Food and Drugs Act and Rules. We have provided a sample format in Annexure 2
• RMP shall provide a photo, scan, or digital copy of a signed prescription or e-Prescription to the patient via email or any messaging platform
• In case the RMP is transmitting the prescription directly to a pharmacy, he/ she must ensure explicit consent of the patient that entitles him/her to get the medicines dispensed from any pharmacy of his/ her choice

 

Table: Matrix of the permissible drug lists based on the type and mode of consultation

List Group	Mode of Consultation [Video/Audio/Text]	Nature of Consultation [First-consultation/ Follow-up]	List of Medicines
O	Any	Any	List O
A	Video	First Consultation Follow-up, for the continuation of medications	List A
B	Any	Follow-up	List B
Prohibited	Not to be prescribed	Not to be prescribed	Schedule X of Drug and Cosmetic Act and Rules or any Narcotic and Psychotropic substance listed in the Narcotic Drugs and Psychotropic Substances
1. This list included commonly used ‘over-the-counter’ medications such as Paracetamol, Oral Rehydration Solution (ORS) packets, Antacids, etc. This list also includes medicines that may be deemed necessary during emergencies and would be notified from time to time. 2. This list includes usually prescribed medications for which diagnosis is possible only by video consultation such as antifungal medications for Tinea Cruris, Ciprofloxacillin eye drops for Conjunctivitis, etc. and re-fill medications for chronic diseases such as diabetes, hypertension, asthma, etc. 3. This list includes ‘add-on’ medications which are used to optimize an existing condition. For instance, if the patient is already on Atenolol for hypertension and the blood pressure is not controlled, an ACE inhibitor such as Enalapril. 4. For instance, Anti-Cancer drugs; Narcotics such as Morphine, Codeine, etc.

DUTIES AND RESPONSIBILITIES OF A RMP IN GENERAL

MEDICAL ETHICS, DATA PRIVACY & CONFIDENTIALITY

• Principles of medical ethics, including professional norms for protecting patient privacy and confidentiality, as per NMA and NMCN Acts, shall be binding and must be upheld and practiced.
• Registered Medical Practitioners would be required to abide by their Nigerian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, and with the relevant provisions of the NCC Act, Data protection and privacy laws or any applicable rules notified from time to time for protecting patient privacy and confidentiality and regarding the handling and transfer of such personal information regarding the patient. This shall be binding and must be upheld and practiced.
• A technology breach will not hold registered Medical Practitioners responsible for a breach of confidentiality if there is reasonable evidence to believe that patient’s privacy and confidentiality have been compromised or by a person other than RMP. The RMPs should ensure that reasonable care is undertaken during hiring such services.

 

Misconduct

We specifically noted that besides all general requirements under the NMA and NMCN Acts for professional conduct, ethics etc., while using telemedicine, all actions that willfully compromise patient care or privacy and confidentiality, or violate any prevailing law are explicitly not permissible.

Some examples of actions that are not permissible:

• RMPs insisting on Telemedicine, when the patient is willing to travel to a facility and/or requests an in-person consultation
• RMPs misusing patient images and data, especially private and sensitive (e.g., RMP uploads an explicit picture of a patient on social media etc.)
• RMPs who use telemedicine to prescribe medicines from the specific restricted list
• RMPs may not solicit patients for telemedicine through any advertisements or inducements

 

Penalties: As per the Nigerian Medical and Association (NMA), Nursing and Midwifery Council of Nigeria (NMCN) Acts, ethics and other prevailing laws.

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It is the responsibility of the RMP to be cognizant of the current data protection and privacy laws. RMP shall not breach the patient’s confidentiality akin to an in-person consultation. For example: If the RMP is planning to create a virtual support group for disseminating health education for patients suffering from a particular disease condition then he/she shall be wary of the patient’s willingness and not violate the patient’s privacy and confidentiality by adding them to the group without their consent.

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MAINTAIN DIGITAL TRAIL/ DOCUMENTATION OF CONSULTATION

It is incumbent on RMP to maintain the following records/ documents for the period as prescribed from time to time:

• Log or record telemedicine interaction (e.g., phone logs, email records, chat/ text records, video interaction logs etc.)
• The RMP should keep patient records, reports, documents, images, diagnostics, data, etc
• Specifically, in case a prescription is shared with the patient, the RMP is required to maintain the prescription records as required for in-person consultations.

 

Fee for Telemedicine Consultation

• Telemedicine consultations should be treated the same way as in-person consultations from a fee perspective: Healy Nurse charges patients an appropriate fee for telemedicine consultations provided by RMPs. And Patients must pay all fees to Healy Nurse. Healy Nurse will reimburse RMPs for all their teleconsultations provided on the Healy Nurse’s platform.
• Healy Nurse will also give a receipt/invoice for the fee charged for providing telemedicine-based consultation.

 

 

4. Framework for Telemedicine

This section lays out the framework for practicing telemedicine in 5 scenarios:

1. Patient to Registered Medical Practitioner.
2. Caregiver to Registered Medical Practitioner.
3. Health Worker to Registered Medical Practitioner.
4. Registered Medical Practitioner to Registered Medical Practitioner.
5. Emergency Situations.

 

Essential Principles:

– The professional judgement of a Registered Medical Practitioner should be the guiding principle: an RMP is well positioned to decide whether a technology-based consultation is sufficient, or an in-person review is needed. The practitioner shall exercise proper discretion and not compromise on the quality of care.

– Same principles apply irrespective of the mode (video, audio, text) used for a telemedicine consultation. However, patient management and treatment can be different depending on the mode of communication used.

– RMP should exercise his/her professional discretion regarding the mode of communication depending on the type of medical condition. If a case requires a video consultation for examination, RMP should explicitly ask for it.

– The RMP can choose not to proceed with the consultation at any time. At any step, the RMP may refer or request an in-person consultation.

– At any stage, the patient may choose to discontinue the teleconsultation.

 

CONSULTATION BETWEEN PATIENT AND REGISTERED MEDICAL PRACTITIONER

 

Specifically, this section details the key elements of the process of teleconsultation to be used in the First consults and Follow-up consults when a patient consults with an RMP.

In these 2 situations, the patient starts telemedicine consultation and, consent is implied.

First Consult: Patient to Registered Medical Practitioner

First Consult means

1. The patient is consulting with the RMP for the first time;
2. The patient has consulted with the RMP earlier, but over 6 months have elapsed since the previous consultation; or
3. The patient has consulted with the RMP earlier, but for a different health condition

 

Tele-Consultation Process

The flow of the process is summarized in Figure 1 and the steps are detailed below.

1. Start a Telemedicine Consultation for First Consult

• The patient starts the telemedicine consultation (For example, a patient may do an audio or video call with an RMP or email or text with a health query)
• RMP accepts to undertake the consultation

 

2. Patient identification and consent

• RMP should confirm the patient’s identity to his/her satisfaction by asking patient’s name, age, address, email ID, phone number or any other identification that may be reasonable
• Telemedicine consultation should be started by the patient and consent is implied

 

3. Quick assessment

• The patient’s condition needs to be quickly assessed by the RMP based on available inputs and RMP uses his professional discretion to decide if emergency care is needed
• If the condition of the patient merits emergency intervention, then advice for first aid/ immediate relief is provided and guidance is provided for referral, as appropriate

If the condition does not merit an emergency intervention, the following steps are undertaken:

 

4. Exchange of Information for Patient Evaluation

• The RMP may ask the patient to provide relevant information (complaints, information about any other consults for the same problem, available investigation and medication details, if any). The patient shall be responsible for the accuracy of information shared by him/her with the RMP
• If the RMP feels that the information provided at this stage is inadequate, then he/she shall request additional information from the patient. This information may be shared in real-time or shared later via email/text, as per the nature of such information. They may resume the consultation at a rescheduled time after receipt of the additional information (this may include some laboratory or radiological tests). In the meantime, the RMP may provide health advice as appropriate
• If the RMP is satisfied that he/she has adequate patient information for offering a professional opinion, then he/she shall exercise one’s judgment for its suitability for management via telemedicine
• If the situation is NOT appropriate for further telemedicine consultation, then the RMP should provide health advice/ education as appropriate; and/or refer to an in-person consultation

 

5. Patient Management

If the condition can be appropriately managed via telemedicine, then the RMP may take a professional judgement to either:

– Provide Health Education as appropriate in the case; and/or

– Provide Counseling related to a specific clinical condition, including advice related to new investigations that need to be carried out before the next consult; and/or

– Provide specific treatment by prescribing medicines as in List O (which are over-the-counter drugs or others as notified). Additional medicines (as per List A) can also be prescribed if the ongoing teleconsultation is on video

 

Follow-up Consult: Patient to Registered Medical Practitioner

 In a follow-up consultation, since the RMP-patient interaction has already taken place for the specific medical condition under follow-up, there is already an understanding of the context, with the availability of previous records. This allows a more definitive and secure interaction between the RMP and the patient.

 

Follow-Up Consult means

The patient is consulting with the RMP within 6 months of his/her previous in-person, and this consultation is for a continuation of care for the same health condition. Follow-up can be found in situations of a chronic disease or a treatment (e.g. renewal or change in medications) when a face-to-face consultation is unnecessary. Examples of such chronic diseases are asthma, diabetes, hypertension and epilepsy, etc.

 

Tele-Consultation Process

 

We summarize the flow of the process in Figure 2 and we detail the steps below.

1. Start a Telemedicine Consultation for Follow Up

• The patient may start a follow-up consult with an RMP for the continuation of his/her ongoing treatment or if a new complaint or complication arises during the course of the ongoing treatment using any mode of communication, e.g., the patient may do an audio or video call with an RMP or send him/her an email or text message with a specific health query
• RMP accepts to undertake the consultation

 

2. Patient identification and consent

• RMP should be reasonably convinced that he/she is communicating with the known patient, e.g., if the patient is communicating with RMP through the registered phone number or registered email id
• If there is any doubt RMP can request the patient to re-start the conversation from a registered phone number or email id or should confirm the patient’s identity to his/her satisfaction by asking for the patient’s name, age, address, email ID or phone number. [Details in section 3.2]
• The patient starts the Telemedicine consultation and consent is implied

 

3. Quick Assessment for Emergency Condition

• If the patient presents with a complaint that the RMP identifies as an emergency condition causing urgent care, the RMP would then advise first aid to provide immediate relief and guide for referral of the patient, as deemed necessary

 

4. In the case of routine follow-up consultation, the following would be undertaken

• If the RMP has access to previous records of the patient, he/ she may proceed with the continuation of care
• RMP shall apply his/her professional discretion for the type of consultation based on the adequacy of patient information (history/examination findings/Investigation reports/past records)
• If the RMP needs additional information, he/ she should seek the information before proceeding and resume teleconsultation for a later point in time

 

5. Patient Management

• If RMP is satisfied that he/she has access to adequate patient information and if teleconsultation can appropriately manage the condition, he/she would go ahead with the tele-management of the patient
• If the follow-up is for a continuation of care, then the RMP may take a professional judgement to either:
• Provide health education with counselling related to the specific clinical condition, including advice related to new investigations that need to be carried out before the next consult;
• And/or Prescribe Medications. The medications could be one of the following below:
• If the follow-up is for a continuation of care for the same medical condition, the RMP would re-prescribe an original set of medications for a refill (List A of medications, which has been previously prescribed for the patient)
• If the RMP considers the addition of a new drug, as an ‘add-on’ medication to optimize the underlying medical condition, then the RMP can prescribe medications listed under List B
• If the follow-up consult is for a new minor ailment causing only ‘over-the-counter’ medications or those notified for this purpose, an RMP can prescribe medications under List O
• If the follow-up consult reveals new symptoms in a different spectrum of disease, then the RMP would proceed with the condition as enunciated in the scenario for a first-time consultation

 

CONSULTATION BETWEEN PATIENT AND RMP THROUGH A CAREGIVER

For these guidelines, a “Caregiver” could be a family member, or any person allowed by the patient to represent the patient.

There could be two possible settings:

1. The patient is present with the Caregiver during the consultation.
2. The patient is not present with the Caregiver. This may be the case in:

2a. Patient is a minor (aged 16 or less) or the patient is incapacitated, for example, in medical conditions like dementia or physical disability, etc. An RMP will deem the caregiver to be allowed to consult on behalf of the patient.

2b. Caregiver has a formal authorization, or the patient has verified a verified document establishing his relationship with the patient and/or in a previous in-person consult (explicit consult).

In all the above, the consult shall proceed as with RMP and the patient (first or follow-up consult, vide 4.1)

 

 

 

5. Guidelines on the Use of Our Technology Platforms

This specifically covers our technology platforms which RMPs use to conduct telemedicine for our patients.

• Healy Nurse (using registered mobile apps, websites etc.) providing telemedicine services to consumers shall be obligated to ensure that the consumers are consulting with registered medical practitioners duly registered with national medical councils or respective state medical councils and comply with relevant provisions
• Healy Nurse shall conduct their due diligence before listing any RMP on its online portal. The platform must provide the name, qualification and registration number, and contact details of every RMP listed on the platform
• In the event some non-compliance is noted, Healy Nurse shall suspend or dismiss the erring RMP
• Healy Nurse does not allow Artificial Intelligence/Machine Learning to counsel its patients or prescribe any medicines to a patient. Only an RMP may counsel or prescribe and have to address this with the patient in this regard. While new technologies such as Artificial Intelligence, Internet of Things (IoT), advanced data science-based decision support systems etc. could assist and support an RMP on patient evaluation, diagnosis or management, the final prescription or counselling has to be directly delivered by the RMP
• Healy Nurse must ensure that there is a proper mechanism in place to address any queries or grievances that the end customer may have
• In case the Nigerian government through its supervising agencies, i.e., NCC, NMA, NMCN, etc., finds Healy Nurse in violation, we may be blacklisted and no RMP may then use that platform to provide telemedicine

 

 

 

Annexure 1

 

MEDICINE LISTS

List O

• Common over-the-counter medications such as
  • Antipyretics: Paracetamol
  • Cough Supplements: Lozenges,
  • Cough/ Common-cold medications (such as combinations of Acetylcysteine, Ammonium Chloride, Guaifenesin, Ambroxol, Bromhexine, Dextromethorphan)
  • ORS Packets
  • Syrup Zinc
  • Supplements: Iron & Folic Acid tablets, Vitamin D, Calcium supplements
  • Etc
• Medications are notified by the Nigerian Government in the case from time to time on an Emergency basis
  • Such as Chloroquine for Malaria control for a specific endemic region, when notified by the Government

 

List A

• First Consult Medications (Diagnosis done on video mode of consultation) such as
  • 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 for ear wax etc.
  • Follow-up consults for the above medications
• Follow-up medications for chronic illnesses for ‘re-fill’ (on any mode of consultation) such as medications for
  • Hypertension: Enalapril, Atenolol etc.
  • Diabetes: Metformin, Glibenclamide etc
  • Asthma: Salmetrol inhaler etc
  • Etc

 

List B

• On follow-up, medications prescribed as ‘Add-on’ to ongoing chronic medications to optimize management such as for hypertension: e.g., add-on of Thiazide diuretic with Atenolol
  • Diabetes: Addition of Sitagliptin to Metformin
  • Etc