Homoeopathic Practitioners (Professional Conduct, Etiquette and Code of Ethics) Regulations, 1982

Homoeopathy Central Council Act, 1973

Last Updated 28th November, 2020 [act3238]

In exercise of the powers conferred by clause (I) of section 33 read with section 24 of the Homoeopathy Central Council Act, 1973 (59 of 1973), the Central Council of Homoeopathy, with the previous sanction of the Central Government, hereby makes the following regulations, namely : -

1. These regulations may be called the Homoeopathic Practitioners (Professional Conduct, Etiquette and Code of Ethics) Regulations, 1982.

I. Declaration and Oath

2. (a) At the time of registration, each applicant shall submit the following declaration and oath read and signed by him to the Registrar concerned attested by the Registrar himself or by a registered practitioner of Homoeopathy : -

(1) I solemnly pledge myself to consecrate my life to the service of humanity.

(2) Even under threat, I will not use my medical knowledge contrary to the laws of humanity

(3) I will maintain the utmost respect for human life.

(4) I will not permit considerations of religion, nationality, race, political beliefs or social standing to intervene between my duty and my patient.

(5) I will practise my profession with conscience and dignity in accordance with the principles of Homoeopathy and/or in accordance with the principles of biochemic system of medicine (tissue remedies)

(6) The health of my patient shall be my first consideration.

(7) I will respect the secrets which are confided to me.

(8) I will give to my teachers the respect and gratitude which is their due.

(9) I will maintain by all means in my power the honour and noble traditions of medical profession

(10) My colleagues will be my brothers and sisters

(11) I make these promises solemnly, freely and upon my honour

(b) Hahnemannian Oath "On my honour I swear that I shall practise the teachings of Homoeopathy, perform my duty, render justice to my patients and help the sick whosoever comes to me for treatment. May the teachings of master Hahnemann inspire me and may I have the strength for fulfilment of my mission."

II General Principles

3. Character of Medical Practitioner. - The primary object of the medical profession is to render service to humanity with full respect for the dignity of man; financial reward is a subordinate consideration. Whosoever chooses this profession assumes the obligation to conduct himself in accordance with its ideals. A practitioner of Homoeopathy shall be an upright man, instructed in the art of healing. He shall keep himself pure in character and be diligent in caring for the sick. He shall be modest, sober, patient and prompt and do his duty without anxiety, and shall be pious and conduct himself with propriety in his profession and in all the actions of his life.

4. Standards of Character and Morals. - The medical profession expects from its members the highest level of character and morals, and every practitioner of Homoeopathy owes to the profession and to the public alike a duty to attain such a level. It shall be incumbent on a practitioner of Homoeopathy to be temperate in all matters, for the practice of medicine requires unremitting exercise of a clear and vigorous mind.

5. Practitioner's Responsibility. - A practitioner of Homoeopathy shall merit the confidence of patients entrusted to his care, rendering to each full measure of service and devotion. The honoured ideals of the medical profession imply that the responsibilities of a practitioner of Homoeopathy extend not only to individuals but also to the entire society.

5A. (i) A registered medical practitioner shall maintain a Register of Medical Certificates containing the details of the medical certificates issued by him which shall be in the manner specified in Appendix-1.

(ii) While issuing medical certificate referred to in sub-regulation (1), he shall enter the identification mark of the patient and keep a copy of the same.

(iii) The medical practitioner shall obtain the signature or thumb mark of the patient and record at least one identification mark and address of the patient on the medical certificate.

[5B. A practitioner of Homoeopathy shall provide the prescription to a patient or authorized attendant or legal authority within the period of 72 hours as requested or required by such person.]

6. Advertising. - (1) Solicitation of patients directly or indirectly by a practitioner of Homoeopathy either personally or by advertisement in the newspapers, by placards or by the distribution of circular cards or handbills is unethical. A practitioner of Homoeopathy shall not make use of, or permit others to make use of, him or his name as a subject of any form or manner of advertising or publicity through lay channels which shall be of such a character as to invite attention to him or to his professional position or skill or as would ordinarily result in his self-aggrandisement provided that a practitioner of Homoeopathy is permitted formal announcement in press about the following matters, namely :-

(i) the starting of his practice;

(ii) change of the type of practice;

(iii) change of address;

(iv) temporary absence from duty;.

(v) resumption of practice

(vi) succeeding to anothers practice.

(2) He shall further not advertise himself directly or indirectly through price lists or publicity materials of manufacturing firms or traders with whom he may be connected in any capacity, nor shall he publish cases, operations or letters of thanks from patients in non-professional newspapers or journals provided it shall be permissible for him to publish his name in connection with a prospectus or a director's or a technical expert's report

7. Payment of Professional Service. - (1) A practitioner of Homoeopathy engaged in the practice of medicine shall limit the sources of his income to fees received from professional activities for services rendered to the patient. Remuneration received for such services shall be in the form and amount specifically announced to the patient at the time the service is rendered; in all other cases he shall deem it a point of honour to adhere to the compensation for professional services prevailing in the community in which he practices.

(2) Fees are reducible at the discretion of the practitioner of Homoeopathy and he shall always recognize poverty as presenting valid claims for gratuitous services;

(3) It shall be unethical to enter into a contract of "no cure no payment";

8. Rebates and Commission. - A practitioner of Homoeopathy shall not give, solicit or receive, nor shall he offer to give, solicit or receive, any gift, gratuity, commission or bonus in consideration for the referring, recommending or procuring of any patient for medical, surgical or other treatment nor shall he receive any commission or other benefit from a professional colleague, trader of appliances, dentist or an occulist or from laboratory or diagnostic centres.

III. Duties of Homoeopathic Practitioners to Their Patients

9. Obligations to the Sick. - Though a practitioner of Homoeopathy is not bound to treat each and every one asking for his services except in emergencies, he shall, for the sake of humanity and the noble traditions of the profession, not only be ever ready to respond to the calls of the sick and the injured, but shall be mindful of the high character of his mission and the responsibility he incurs in the discharge of his professional duties.

10. Patient not be Neglected. - (1) A practitioner of Homoeopathy is free to choose whom he will serve provided he shall respond to any request for his assistance in an emergency or whenever temperate public opinion expects the service.

(2) Once having undertaken a case, a practitioner of Homoeopathy shall not neglect the patient nor shall he withdraw from the case without giving notice to the patient, his relatives or his responsible friends sufficiently long in advance of his withdrawal to allow them time to secure another practitioner.

11. (a) The following shall be valid reasons for his withdrawal : -

(1) where he finds another practitioner in attendance;

(2) where remedies other than those prescribed by him are being used;

(3) where his remedies and instructions are refused;

(4) where he is convinced that illness is an imposture and that he is being made a party to a false pretence;

(5) where the patient persists in the use of opium, alcohol, chloral or similar intoxicating drugs against medical advice;

(6) where complete information concerning the facts and circumstances of the case are not supplied by the patient or his relatives.

(b) The discovery that the malady is incurable is no excuse to discontinue attendance so long as the patient desired his services.

12. Acts of Negligence. - (1) No practitioner of Homoeopathy shall wilfully commit an act of negligence that may deprive his patient of necessary medical care.

(2) A practitioner of Homoeopathy is expected to render that diligence and skill in services as would be expected of another practitioner of Homoeopathy with similar qualifications, experience and attainments.

(3) His acts of commission or omission shall not be judged by any non-Homoeopathic standards of professional service expected of him but by those standards as are expected from a Homoeopath of his training, standing and experience.

(4) A practitioner of Homoeopathy shall use any drug prepared according to Homoeopathic principles and adopt other necessary measures as required.

12A. Physician to obey law and regulation. - A physician, -

(a) shall not act contrary to the laws regulating the practice of Homoeopathy;

(b) shall not assist others to disobey the law regulating the practice of Homoeopathy;

(d) shall comply with the provisions of the Drugs and Cosmetics Act, 1940 (23 of 1940), Drugs and Cosmetics Rules, 1945; the Pharmacy Act, 1948 (8 of 1948); the Narcotic Drugs and Psychotropic Substances Act 1985 (61 of 1985); the Medical Termination of Pregnancy Act, 1971 (34 of 1971), the Transplantation of Human Organ Act, 1994 (42 of 1994); the Persons with Disabilities (Equal Opportunity and Full Participation) Act, 1995 (1 of 1996) and Biomedical Waste (Management and Handling) Rules, 1998 and such other related Acts, Rules, of the Central Government or the State Government or the Local Administrative bodies relating to protection and promotion of public health.

13. Behaviour Towards Patients. - The demeanour of a practitioner of Homoeopathy towards his patients shall always be courteous, sympathetic, friendly and helpful. Every patient shall be treated with attention and consideration.

14. Visits. - A practitioner of Homoeopathy shall endeavour to add to the comfort of the sick by making his visits at the hour indicated to the patients.

15. Prognosis. - (1) The practitioner of Homoeopathy shall neither exaggerate nor minimize the gravity of a patient's condition. He shall ensure that the patient, his relatives or responsible friends have such knowledge of the patient's condition as will serve the best interest of the patient and his family.

(2) In cases of dangerous manifestations, he shall not fail to give timely notice to the family or friends of the patient and also to the patient when necessary.

16. Patience, Delicacy & Secrecy. - Patience and delicacy shall characterize the attitude of a practitioner of Homoeopathy. Confidences concerning individual or domestic life entrusted by patients to a practitioner and defects in the disposition or character of patients observed during the medical attendance shall not be revealed by him to anyone unless their revelation is required by the laws of the State.

IV Duties of Practitioners to the Profession

17. Upholding honour of Profession. - A practitioner of Homoeopathy shall, at all times, uphold the dignity and honour of this profession.

18. Membership of Medical Society. - For the advancement of his profession a practitioner of Homoeopathy may affiliate himself with Medical Societies and contribute his time, energy and means to their progress so that they may better represent and promote the ideals of the profession.

19. Exposure of Unethical Conduct. - A practitioner of Homoeopathy shall expose, without fear or favour, the incompetent, corrupt, dishonest or unethical conduct on the part of any member of the profession.

20. Association with Unregistered Persons. - A practitioner [*omitted] shall not associate himself professionally with any body or society of unregistered practitioners of Homoeopathy.

21. Appointment of Substitutes. - Whenever a practitioner of Homoeopathy requests another to attend to his patients during his temporary absence from practice, professional courtesy requires the acceptance of such appointment by the latter, if it is consistent with his other duties. The practitioner of Homoeopathy acting under such an appointment shall give the utmost consideration to the interests and reputation of the absent practitioner. He shall not charge either the patient or the absent practitioner of Homoeopathy for his services, except in the case of a special arrangement between them.

All such patients shall be restored to the care of the absent practitioner of Homoeopathy upon his return.

22. Charges for service to Practitioners of Homoeopathy. - (1) There is no rule that a practitioner of Homoeopathy shall not charge another practitioner of Homoeopathy for his services, but a practitioner of Homoeopathy shall consider it a pleasure and privilege to render gratuitous service to his professional brother and his dependents, if they are in his vicinity or to a medical student.

(2) When a practitioner of Homoeopathy is called from a distance to attend or advise another practitioner of Homoeopathy or his dependents reimbursement shall be made for travelling and other incidental expenses.

23. (1) The practitioner of Homoeopathy called in an emergency to visit a patient under the care of another practitioner of Homoeopathy shall, when the emergency is over, retire in favour of the latter; but he shall be entitled to charge the patient for his services.

(2) When a practitioner of Homoeopathy is consulted at his own residence, it is not necessary for him to enquire of the patient if he is under the care of another practitioner of Homoeopathy

(3) When a consulting practitioner of Homoeopathy sees a patient at the request of another practitioner of Homoeopathy, it shall be his duty to write a letter stating his opinion of the case with the mode of treatment he thinks is required to be adopted.

24. Engagement for an Obstetrics Case. - (1) If a practitioner of Homoeopathy is engaged to attend to a woman during her confinement, he shall do so. Refusal to do so on an excuse of any other engagement shall not be considered ethical except when he is already engaged on a similar or other serious case.

(2) When a practitioner of Homoeopathy who has been engaged to attend on an obstetrics case is absent and another is sent for and delivery is accomplished, the acting practitioner of Homoeopathy shall be entitled to his professional fees; provided he shall secure the patients consent to withdraw on the arrival of the practitioner of Homoeopathy already engaged.

25. When it becomes the duty of a practitioner of Homoeopathy occupying an official position to see and report upon an illness or injury, he shall communicate to the practitioner of Homoeopathy in attendance so as to give him an option of being present. The medical officer shall avoid remarks upon the diagnosis or the treatment that has been adopted.

V. Duties of Practitioners in Consultation

26. Consultation shall be Encouraged. - In cases of serious illness, especially in doubtful or difficult conditions the practitioner of Homoeopathy shall request consultation. He shall also do so in perplexing illness, in therapeutic abortions, in the treatment of a woman who had procured criminal abortion, in suspected cases of poisoning, or when desired by the patient or his representative.

27. Punctuality in Consultation. - Utmost punctuality shall be observed by a practitioner of Homoeopathy in meeting for consultation. If the consultant practitioner of Homoeopathy does not arrive within a reasonable time such as a quarter of an hour after the appointed time, the first practitioner of Homoeopathy shall be at liberty to see the patient alone provided he shall leave his conclusion in writing in a closed envelope.

28. Patient referred to another Physician. - When a patient is referred to another practitioner of Homoeopathy by the attending practitioner of Homoeopathy, a statement of the case shall be given to the latter practitioner of Homoeopathy. The latter practitioner of Homoeopathy shall communicate his opinion in writing in a closed cover direct to the attending practitioner of Homoeopathy.

29. Consultation for Patients Benefit. - In every consultation, the benefit to the patient shall be of first importance. All practitioners of Homoeopathy interested in the case shall be candid with a member of the patient's family or responsible friends.

[29A. Consultation by Telemedicine. - (1) The Consultation through Telemedicine to the registered Homoeopathic Practitioners shall be permissible in accordance with the Telemedicine Practice Guidelines contained in Appendix 3.

(2) Telemedicine Practice Guidelines shall be followed by the registered Homoeopathic Practitioners to enhance health services to the public at large.]

30. Conduct in Consultation. - (1) In consultations, there shall be no place for insincerity, rivalry or envy. All due respect shall be shown to the practitioner of Homoeopathy in charge of case and no statement or remarks shall be made which would impair the confidence reposed in him by the patient. For this purpose, no discussion shall be carried on in the presence of the patient or his representatives.

(2) All statements of the case to the patient or his representatives shall take place in the presence of all the practitioners consulting, except as otherwise agreed; the announcement of the opinion to the patient or his relations or friends shall rest with the attending practitioner of Homoeopathy.

(3) Differences of opinion shall not be divulged unnecessarily; provided when there is an irreconcilable difference of opinion, the circumstances shall be frankly and impartially explained to the patient or his friends.

(4) It shall be open to them to seek further advice if they so desire.

31. Cessation of Consultation. - Attendance of the consulting practitioner of Homoeopathy shall cease when the consultation is concluded, unless another appointment is arranged by the attending practitioner of Homoeopathy.

32. Treatment after Consultation. - (1) No decision shall restrain the attending practitioner of Homoeopathy from making such subsequent variations in the treatment as any unexpected change may require; provided at the next consultation, reasons for variation are stated.

(2) The same privilege, with its obligations, belongs to the consultant when sent for in an emergency during the absence of the attending practitioner of Homoeopathy. The attending practitioner of Homoeopathy may prescribe at any time for the patient, but the consultant, only in case of emergency.

33. Consultant not to take charge of the case. - (1) When a practitioner of Homoeopathy has been called as a Consultant none but the rarest and most exceptional circumstances shall justify the consultant taking charge of the case.

(2) He must not do so merely on the solicitation of the patient or his friends.

34. Bar against Consulting Non-registered Practitioner. - No practitioner of Homoeopathy shall have consultation with any practitioner of Homoeopathy who is not registered.

VI. Duties of Practitioners to the Public

35. Practitioners as Citizens. - Practitioners of Homoeopathy as good citizens, possessed of special training, shall advise concerning the health of the community wherein they dwell. They shall play their part in enforcing the laws of the community and in sustaining the institutions that advance the interest of humanity. They shall cooperate with the authorities in the observance and enforcement of sanitary laws and regulations and shall observe the provisions of all laws relating to Drugs, Poisons and Pharmacy made for the protection and promotion of public health.

36. Public Health. - Practitioners of Homoeopathy engaged in public health work, shall enlighten the public concerning quarantine regulations and measures for the prevention of epidemic and communicable disease. At all times the practitioners shall notify the constituted public health authorities of every case of communicable disease under their care, in accordance with the laws, rules and regulations of the health authorities. When an epidemic prevails, the practitioner of Homoeopathy shall continue his labours without regard to the risk to his own health.

37. Dispensing. - A practitioner of Homoeopathy has a right to prepare and dispense his own prescription.

VII. Professional Misconduct

38. (1) The following acts of commission or omission by a practitioner shall constitute professional misconduct and he shall be liable for disciplinary action, namely:-

(a) if the practitioner contravenes any of the provisions of these regulations;

(b) if the practitioner fails to display the registration number accorded to him by the State Homoeopathic Council or Board or the Central Council of Homoeopathy, as the case may be, in his clinic;

(d) if commits the offence of adultery or misbehaves with a patient, or maintaining an improper association with a patient;

(e) if convicted by a court of law for offences involving moral turpitude;

(f) if signs or gives under his name and authority any certificate, report or document of kindred character which is untrue, misleading or improper;

(g) if contravenes the provisions of law relating to the Drugs and Cosmetics Act, 1940 (23 of 1940) and the rules made thereunder;

(h) if sells a drug or poison prohibited by the Drugs and Cosmetics Act,1940 (23 of 1940).

(i) if performs or encourages un-qualified person to perform abortion or any operation;

(j) if issues certificates in Homoeopathy to unqualified or non-medical persons:

Provided that nothing contained in these regulations shall prevent or restrict the proper training and instruction of legitimate employees of doctors, midwives, dispensers, attendants or skilled mechanical and technical assistants under the personal supervision of practitioners of Homoeopathy.

(k) if affixes a signboard in the shop of a chemist or in a place where he does not reside or work;

(l) if discloses the secrets of a patient that have been learnt in the exercise of profession, except in a court of law under order of the presiding judge;

(m) if contravenes the guidelines issued by the concerned Council :

Provided that nothing contained in these regulations shall apply if he conducts the Clinical Drug Trials or other Research involving patients or Volunteers as per the guidelines of Council constituted for Homeopathy by the Central Government or State Government:

Provided further that in all cases regard shall be had to the ethical consideration.

(n) if publishes photographs or case-reports of patients in any medical or other journal:

Provided nothing contained in these regulations shall apply if the same is published with the consent of the patient or without disclosing his identity.

(o) if exhibits in public the scale of fees:

Provided that nothing contained in these regulations shall apply if he displays the same in the physician's consulting or waiting room;

(p) if he uses touts or agents for procuring patients;

(q) if he claims to be a specialist without possessing a special qualification in the branch concerned;

(r) if he contravenes the provisions of sub-regulation (4) of regulation 12;

(s) if he advertises or notifies the name of the institution or clinic in which no facility is offered, names of the diseases not treated;

(t) if he publishes the names or photographs of doctor running or attending the clinic or institution in the advertisement;

(u) if he affixes a sign board unusually large in size and having on it anything other than the name of the practitioner and his qualification with the name of the awarding authority;

(v) if he refuses to treat the patients on the grounds of religion or caste:

Provided that nothing contained in these regulations shall apply if he writes for laying in the press under Provided that nothing contained in these regulations shall apply if he writes for laying in the press under his own name in matters of public health, hygiene or occasionally delivers a public lecture, gives talks on television or radio relating to health or hygiene without suggesting specific treatment or prescription;

(w) if he issues any certificate referred to in Appendix- 2 which is false, untrue, misleading or improper, his name shall be removed from the Register of Homoeopathic Practitioners.

39. Disciplinary Action. - (1) If a homoeopathic practitioner commits any act of misconduct, the State Board may,-

(a) take such disciplinary action as it thinks fit;

(b) remove his name from the Register of State Homoeopathic practitioners permanently or for specified period if convicted of any offence:

Provided that no action under this sub-regulation shall be taken without giving the practitioner a reasonable opportunity of being heard: Provided further that no complaint of misconduct under this regulation shall be maintained unless the complaint has been made to the State Board or State Council in the form of an affidavit on a non-judicial stamp paper of rupees one hundred, duly attested by a Notary Public or Oath Commissioner.

(2) The State Board shall forward its decision referred to in sub-regulation (1) to the Central Council.

(3) The aggrieved homoeopathic practitioner may prefer an appeal to the Central Council against the decision of the State Board and the Central Council may decide the case after giving the practitioner and the State Board an opportunity of being heard.

(4) The Council may direct the State Board to restore the name of the practitioner in the State Register after the expiry of the period for which the name of the practitioner was removed.

(5) The Council may restrain the practitioner from practicing homoeopathy during the pendency of the complaint.

(6) While deciding the complaint of professional incompetency, the Central Council shall take the opinion of peer group of practitioners as specified by the Central Council of Homoeopathy.

(7) No complaint against a practitioner for misconduct shall be allowed unless it is made within a period of six months from the date of the alleged misconduct.]

*APPENDIX-I

[See regulation 5A (1)]

Form of Certificate Recommended for Leave or Extension or Communication of Leave and for Fitness

Signature of patient Or thumb impression__________________________________________

To be filled in by the applicant in the presence of the Government Medical Attendant, or Medical Practitioner.

Identification marks:-

1. ____________________________

2. ____________________________

I, Dr. _______________________________________after careful examination of the case hereby certify that ______________whose signature is given above is suffering from _______________________and I consider that a period of absence from duty of ________ with effect from ________________________is absolutely necessary for the restoration of his or her health.

I, Dr. _________________________after careful examination of the case certify hereby that ___________________on restoration of health is now fit to join service.

Signature of Medical Attendant.

Place________________
Date_________________

Registration No.______________

(Central Council of Homoeopathy/State Council of Homoeopathy)

Note. - The nature and probable duration of the illness should also be specified. This certificate must be accompanied by a brief resume of the case giving the nature of the illness, its symptoms, causes and duration.

*APPENDIX -2

[See regulation 38(w)]

List Of Certificates to be Issued by Doctors for the Purpose of Various Acts or Administrative Requirements.

1. Certificates of birth or death or disposal of the dead under various Central Acts or State Acts;

2. Certificates of lunacy and mental illness under the Mental Health Act, 1987 (14 of 1987) and the rules made thereunder.

3. Certificates under the Education Acts.

4. Certificates under the Public Health Acts and the orders made thereunder.

5. Certificates under the Acts and orders relating to the notification of infectious diseases.

6. Certificates under the Employee's State Insurance Act, 1948 (34 of 1948).

7. Certificates in connection with sick benefit insurance and friendly societies.

8. Certificates for procuring or issuing of passports.

9. Certificates of illness for seeking exemption from attending Court of Justice, in public services, in public offices or in ordinary employment.

10. Certificates in connection with matters under the control of Department of Pensions.

11. Certificates for procuring driving license.

Telemedicine Practice Guidelines

(see regulation 29A)

Telemedicine - '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.'

Telehealth - '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.'

Registered Homoeopathy Practitioner

'A Registered Homoeopathy Practitioner [RHP] is a person who is enrolled in the State Register of Homoeopathy or the Central Register of Homoeopathy under the Homoeopathy Central Council Act 1973.' [HCC Act, 1973] S.O. No. 76 The Gazette of India: Extraordinary [Part II-SEC. 1] dated 28th December, 1973.

Background. - Homoeopathy being a wholistic system of medicine has been benefiting people for their health problems. Telemedicine can help to increase the availability of homoeopathy to the level where health care is difficult to reach. Telemedicine can play a particularly important role in cases where there is no need for the patient to physically see the RHP (or other medical professional), e.g. for regular, routine check-ups or continuous monitoring. Homoeopathy Telemedicine / Teleconsultation will enhance primary health care immensely.

India's digital health policy advocates use of digital tools for improving the efficiency and outcome of Healthcare system and lays significant focus on the use of telemedicine services especially in the Health and Wellness centres at the grass root level wherein a mid-level health care provider / health worker can connect the patient to the doctor through Technology platforms for providing timely and best possible care.

In spite of this policy till now there is no legislation or guidelines for Homoeopathic practitioners on the practice of telemedicine through video, phone and internet based platforms (webchat, apps etc). Lack of clear guidelines has created significant ambiguity for registered medical professionals of the Homoeopathic systems raising doubts on the practice of telemedicine. The 2018 judgment of the Honourable High Court of Bombay has created uncertainty about the place and legitimacy of telemedicine as an appropriate Framework does not exist.

In India the practice of Homoeopathic medicine is mainly governed by concerned State Acts along with The Homoeopathy Central Council Act 1973, the Homoeopathic Practitioners (Professional Conduct, Etiquette and Code of Ethics) Regulations 1982; Drugs & Cosmetics Act 1940 & rules 1945; and Clinical Establishment (Registration and Regulation) Act, 2010. Information technology is governed by IT Act 2000, and the information technology (reasonable security practices and procedure and sensitive personal data or information) rules 2011. Gaps in legislation and the uncertainty of rules force a risk for both the doctors and their patients.

It is the need of the hour to bridge the gaps in legislation and the uncertainty of rules. These guidelines will serve as a step forward to be treated as professional norms that need to be followed by RHPs to enable them to regulate the practice of telemedicine.

Purpose

• The purpose of these guidelines is to enable Homoeopathic practitioners to use telemedicine tools. This will be done by providing information as well as training which will be updated from time to time in the coming years. Telemedicine will continue to grow and be adopted by more health care practitioners and patients in a wide variety of forms.

• These guidelines will give practical advice to registered homoeopathic practitioners regarding telemedicine to encourage them to consider the use of telemedicine as a part of their normal practice as well as in disasters and pandemics which pose unique challenges to provide Healthcare.

• Practice of Telemedicine can prevent transmission of infectious diseases reducing the risk to both doctors and patients by avoiding social contact. These guidelines will provide norms and protocols relating to doctor patient relationship issues of liability and negligence, evaluation, management and treatment, informed consent, continuity of care, referral for emergency services, medical records, privacy and security of patient records and exchange of information, describing and reimbursement, health education and counseling.

• Telemedicine will not only encourage social distancing in special situations of epidemics and pandemics but talking to doctors will also allay their anxiety in the situation of complete lockdown

Advantage of Telemedicine

• Telemedicine provides patient's safety as well as doctor's & health worker's safety, especially in situations where there is a risk of contagious infections. A telemedicine visit can be conducted without exposing staff to viruses/infections at the time of such outbreaks.

• Telemedicine provides rapid access to medical practitioners who may not be available in person.

• Telemedicine will not only encourage social distancing in special situations of epidemics and pandemics but talking to doctors will also allay their anxiety in the situation of complete lockdown.

• With telemedicine there is higher likelihood of maintenance of records and documentation. Written documentation increases legal protection of doctors as well as patients.

• Telemedicine, when effectively used, reduces the burden on secondary health care system.

• Telemedicine is useful for regular routine checkup on continuous monitoring and minimizes gaps in timely follow ups.

Important. - It is to be noted that unlike other technologies, the technology used for telemedicine has some risks, drawbacks & limitations, which can be mitigated through appropriate training, enforcement of standards, protocols & Guidelines from time to time. These guidelines should be used in conjunction with the other national clinical standards, protocols, policies and procedures.

1. Telemedicine: Definitions and Applications

1.1 Definitions.

1.1.1 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 diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health-care workers, with the aim of advancing the health of individuals and communities."

1.1.2 Definition of Telehealth NEJM Catalyst defines tele-health 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 Homoeopathy practitioner while telehealth is a broader term of use of technology for health and health related services including telemedicine.

1.1.3 Definition of Registered Homoeopathy Practitioner (RHP) For the purpose of this document a Registered Homoeopathic Practitioner (RHP) is defined as a person who possess any of the medical qualifications in homoeopathy included in the 2nd or 3rd Schedule of the Homoeopathy Central Council Act 1973 and enrolled in the State Register of Homoeopathy or the Central Register of Homoeopathy under the Act.

1.2 Scope Within the broad paradigm of telemedicine, these guidelines will be published under the HCC Act and are for privileged access only. These guidelines are designed to serve as an aid and tool to enable RHPs to effectively leverage Telemedicine to enhance healthcare service and access to all

• The guidelines are meant for RHPs under the HCC Act 1973

• The guidelines cover norms and standards of the RHP 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 the following:

• Specifications for hardware or software, infrastructure building & maintenance

• Data management systems involved; standards and interoperability

• Other aspects of telehealth such as research and evaluation and continuing education of health-care workers

• Does not provide for consultations outside the jurisdiction of India

1.3 Registered Homoeopathy Practitioners are Entitled to Practice Telemedicine: all of them Will Take an Online Course on Practice of Telemedicine.

1.3.1 A Registered Homoeopathy Practitioner is entitled to provide telemedicine consultation to patients from any part of India

1.3.2 RHPs using telemedicine shall uphold the same professional and ethical norms and standards as applicable to traditional in-person care, within the intrinsic limitations of telemedicine

1.3.3 To enable all those RHPs who would want to practice telemedicine get familiar with these Guidelines as well as with the process and limitations of telemedicine practice:

• An online program will be developed and made available by the Board of Governors in supersession of Central Council of Homoeopathy.

• All registered Homoeopathy practitioners intending to provide online consultation need to complete a mandatory online course within 3 years of its notification.

• In the interim period, the principles mentioned in these guidelines need to be followed.

• Thereafter, undergoing and qualifying such a course, as prescribed, will be essential prior to practice of telemedicine.

1.4 Telemedicine Applications.

1.4.1 Tools for Telemedicine RHP 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.

1.4.2 Telemedicine applications can be classified into four basic types, according to the mode of communication, timing of the information transmitted, the purpose of the consultation and the interaction between the individuals involved-be it RHP-to-patient / caregiver, or RHP to RHP.

1.4.2.1 According to the Mode of Communication

• Video (Telemedicine facility, Apps, Video on chat platforms, Skype/Facetime etc.)

• Audio (Phone, VOIP, Apps etc.)

• Text Based:

o Telemedicine chat based applications (specialized telemedicine smartphone Apps, Websites, other internet-based systems etc.)

o General messaging/ text/ chat platforms (WhatsApp, Google Hangouts, Facebook Messenger etc.)

o Asynchronous (email/ Fax etc.)

1.4.2.2 According to timing of information transmitted

Real time Video/audio/text interaction	Real time Video/audio/text interaction
Video/audio/text for exchange of relevant information for diagnosis, medication and health education and counseling	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 of time and thereafter accessed per convenience/need

1.4.2.3 According to the purpose of the consultation

For Non-Emergency consult:

First consult with any RHP for diagnosis/treatment/health education/counseling	Follow-up consult with the same RHP
Patients may consult with an RHP for diagnosis and treatment of her condition or for health education and counseling	Patients may use this service for follow up consultation on his ongoing treatment with the same RHP who prescribed the treatment in an earlier in-person consult.

Emergency consult for immediate assistance or first aid etc.

• In case alternative care is not present, tele-consultation might be the only way to provide timely care. In such situations, RHPs 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 measure, counseling and advice on referral.

• In all cases of emergency, the patient must be advised for an in-person interaction with an RHP at the earliest.

1.4.2.4 According to the individuals involved

Patient to RHP	Caregiver to RHP
Telemedicine services may connect patients to an RHP	Telemedicine services may connect Care givers to an RHP, under certain conditions as detailed in Framework (Section 4)

RHP to RHP/RMP	Health workers to RHP
RHP may use telemedicine services to discuss with other RHP/Registered Medical Practitioners (from other systems of medicine) issues of care of one or more patients, or to disseminate knowledge	[Health Workers] can facilitate a consultation session for a patient with a RHP. In doing so, the former can help take history, examine the patient and convey the findings. They can also explain/reinforce the advice given by the Registered Homoeopathic Practitioners to the patient.

2. Technology Used & Mode Of Communications

Multiple technologies can be used to deliver telemedicine consultation. There are 3 primary modes: Video, Audio, or Text (chat, messaging, email, fax etc.) Each one of these technology systems has their 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 as well as limitations of different technologies. Broadly, though telemedicine consultation provides safety to the RHP 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

• Registered Homoeopathic Practitioners can see the patient and discuss with the caregiver

• Visual cues can be perceived

• Inspection of patient can be carried out

• Is dependent on 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 privacy of patients in video consults is extremely important

AUDIO:

Phone, VOIP, Apps etc.

• Convenient and fast

• Unlimited reach

• Suitable for urgent cases

• No separate infrastructure required

• 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, facial gestures or movements), or physical touch

• Patient identification needs to be clearer, greater chance of imposters representing the real 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 RHP 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 cues

• Difficult to establish rapport with the patient.

• Cannot be sure of 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, reports readily shared

• No separate infrastructure required

• More useful when accompanied with test reports and follow up and second opinions

• Not a real time interaction, so just one-way context is available, relying solely on the articulation by 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. Guidelines For Telemedicine In India

The professional judgment of a RHP should be the guiding principle for all telemedicine consultations. A Registered Homoeopathic Practitioner is well positioned to decide whether a technology-based consultation is sufficient or an in-person review is needed. 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 RHP and Patient
3	Mode of Communication
4	Consent
5	Type of Consultation
6	Patient Evaluation
7	Patient Management

3.1 Telemedicine Should be Appropriate and Sufficient as per Context

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

3.1.2 Complexity Of 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 headache while a known patient of Diabetes may consult for a follow-up with emergencies such as Diabetic Ketoacidosis. The RHP shall uphold the same standard of care as in an in-person consultation but within the intrinsic limits of telemedicine.

3.2 Identification Of The Registered Homoeopathic Practitioner And The Patient Is Required

3.2.1 Telemedicine consultation should not be anonymous: both patient and the RHP need to know each other's identity.

3.2.2 A RHP should verify and confirm 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 RHP should ensure that there is a mechanism for a patient to verify the credentials and contact details of the RHP.

3.2.3 For issuing a prescription, the RHP needs to explicitly ask the age of the patient, and if there is any doubt, seek age proof. Where the patient is a minor, after confirming the age, tele-consultation would be allowed only if the minor is consulting along-with an adult whose identity needs to be ascertained.

3.2.4 ARHP should begin the consultation by informing the patient about his/her name and qualifications.

3.2.5 Every RHP shall display the registration number accorded to him/her by the State Register of Homoeopathy/Central Register of Homoeopathy, on prescriptions, website, electronic communication (WhatsApp/email etc.) and receipts etc. given to his/her patients.

3.3 Mode of Telemedicine

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

3.3.2 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 RHP.

3.3.3 There may be situations where in order to reach a diagnosis and to understand the context better; a realtime consultation may be preferable over an asynchronous exchange of information. Similarly, there would be conditions where a RHP could require hearing the patients peak, therefore, a voice interaction may be preferred than an email or text for a diagnosis. There are also situations where the RHP needs to visually examine the patient and make a diagnosis. In such a case, the RHP could recommend a video consultation. Considering the situation, using his/her best judgment, a RHP may decide the best technology to use to diagnose and treat.

3.4 Patient's Consent. - Patient's consent is necessary for any telemedicine consultation. The consent can be Implied or explicit depending on the following situations:

3.4.1 If, the patient initiates the telemedicine consultation, then the consent is [implied.]

3.4.2 An Explicit patient consent is needed if:

A Health worker, RHP or a Caregiver initiates a Telemedicine consultation.

3.4.3 An Explicit consent can be recorded in any form. Patient can send an email, text or audio/video message. Patient can state his/her intent on phone/video to the RHP (e.g. "Yes, I consent to avail consultation via telemedicine" or any such communication in simple words). The RHP must record this in his/her patient records.

3.5 Exchange Of Information For Patient Evaluation

RHPs must make all efforts to gather sufficient medical information about the patient's condition before making any professional judgment.

3.5.1 Patient's Information

- A RHP 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 judgment.

- This information can be supplemented through conversation with a healthcare worker/provider and by any information supported by technology-based tools.

- If the RHP feels that the information received is inadequate, then he/she can request for additional information from the patient. This information may be shared in real time or shared after via email/text, as per the nature of such information. For example, a RHP 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. A RHP may provide health education as appropriate at anytime.

- Telemedicine has its own set of limitations for adequate examination. If a physical examination is critical for consultation, RHP should not proceed until a physical examination can be arranged through an in-person consult. Wherever necessary, depending on professional judgement of the Registered Homoeopathic Practitioner, he/she shall recommend:

- Video consultation

- Examination by another RHP / Health Worker;

- In-person consultation

The information required may vary from one RHP 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.

- RHP shall maintain all patient records including case history, investigation reports, images, etc. as appropriate.

3.6 Types of Consultation: First Consult/follow-Up Consult

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

An RHP may have only a limited understanding of the patient seeking tele consultation for the first time, when there has been no prior in-person consultation. However, if the first consult happens to be via video, Registered Homoeopathic Practitioner can make a much better judgment and hence can provide much better advice including additional medicines, if indicated.

On the other hand, if a patient has been seen in-person earlier by the -RHP, then it is possible to be more comprehensive in managing the patient.

3.6.1 First Consult means

• The patient is consulting with the RHP for the first time; or

• The patient has consulted with the RHP earlier, but more than 6 months have lapsed since the previous consultation; or

• The patient has consulted with the RHP earlier, but for a different health condition

3.6.2 Follow-Up Consult(s) means

• The patient is consulting with the same RHP within 6 months of his/her previous in- person consultation and this is for continuation of care of the same health condition. However, it will not be considered a follow up if:

• There are new symptoms that are not in the spectrum of the same health condition; and/or

• RHP does not recall the context of previous treatment and advice

3.7 Patient Management: Health Education, Counseling and Medication

3.7.1 If the condition can be appropriately managed via telemedicine, based on the type of consultation, then the RHP may proceed with a professional judgment to:

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

• Provide Counseling related to specific clinical condition; and/or

• Prescribe Medicines

3.7.2 Health Education: An RHP may impart health promotion and disease prevention messages. These could be related to diet, physical activity, cessation of smoking, contagious infections and so on. Likewise, he/ she may give advice on immunizations, exercises, hygiene practices, mosquito control etc.

3.7.3 Counseling: This is specific advice given to patients and it may, for instance, include food restrictions, individual specific regimen, dos and don'ts with homoeopathic medication, etc to mitigate the underlying condition. This may also include advice for new investigations that need to be carried out before the next consult.

3.7.4 Prescribing Medicines Prescribing medications, via telemedicine consultation is at the professional discretion of the Registered Homoeopathic Practitioner. 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 in a case of in-person consult then same prevailing principle will be applicable to a telemedicine consult.

Manufacturing and right to prescribe medicine are governed by State acts, hence varies from state to state. RHP should always keep in mind this variation in State Act while prescribing the medicines, even though these guidelines allow him to practice telemedicine all over India.

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

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

3.7.4.1 Specific Restrictions: Practitioner of Homoeopathy shall refer to the provisions of 12A.

There are certain limitations on prescribing medicines on consult via telemedicine depending upon the type of consultation and mode of consultation.

Prohibited Medicines: An RHP providing consultation via telemedicine cannot prescribe medicines in this category. These medicines have a high potential of abuse and could harm the patient or the society at large if used improperly. All homoeopathic medicines containing Poisonous Substances in crude doses including any Narcotic and Psychotropic substances listed in the Narcotic Drugs and Psychotropic Substances, Act, 1985 are not allowed to prescribe through telemedicine.

3.7.4.2 Issue a Prescription and Transmit

• If the Registered Homoeopathic Practitioner has prescribed medicines, Registered Homoeopathic Practitioner shall issue a prescription as per the Homoeopathic Practitioners (Professional Conduct, Etiquette and Code of Ethics) Regulations 1982 and shall not contravene the provisions of the Drugs and Cosmetics Act and Rules. A sample format is suggested in Annexure.

• Registered Homoeopathic Practitioner shall provide photo, scan, digital copy of a signed prescription or e- Prescription to the patient via email or any messaging platform.

• In case the Registered Homoeopathic Practitioner 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.

3.8 Duties and Responsibilities of A Rhp Ingeneral

3.8.1 Medical Ethics, Data Privacy & [Confidentiaility]

3.8.1.1 Principles of medical ethics, including professional norms for protecting patient privacy and confidentiality as per HCC Act shall be binding and must be upheld and practiced.

3.8.1.2 Registered Homoeopathic Practitioner would be required to fully abide by the Homoeopathic Practitioners (Professional Conduct, Etiquette and Code of Ethics) Regulations 1982 and with the relevant provisions of the IT 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.

3.8.1.3 Registered Homoeopathic Practitioner will not be held responsible for breach of confidentiality if there is a reasonable evidence to believe that patient's privacy and confidentiality has been compromised by a technology breach or by a person other than Registered Homoeopathic Practitioner. The Registered Homoeopathic Practitioner should ensure that reasonable degree of care undertaken during hiring such services.

3.8.1.4 Misconduct It is specifically noted that in addition to all general requirements under the HCC Act 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:

• Registered Homoeopathic Practitioners insisting on Telemedicine, when the patient is willing to travel to a facility and/or requests an in-person consultation

• Registered Homoeopathic Practitioners misusing patient images and data, especially private and sensitive in nature (e.g. Registered Homoeopathic Practitioner uploads an explicit picture of patient on social media etc.)

• Registered Homoeopathic Practitioners who use telemedicine to prescribe homoeopathic medicines in such potencies which are not safe as per Homoeopathic Pharmacopoeia of India.

• Registered Homoeopathic Practitioners are not permitted to solicit patients for telemedicine through any advertisements or inducements.

3.8.1.5 Penalties: As per HCC Act, ethics and other prevailing laws.

3.8.2 Maintain Digital Trial/ Documentation of consultation It is incumbent on Registered Homoeopathic Practitioner to maintain the following records/ documents for the period as prescribed from time to time:

3.8.2.1 Log or record of Telemedicine interaction (e.g. Phone logs, email records, chat/ text record, video interaction logs etc.).

3.8.2.2 Patient records, reports, documents, images, diagnostics, data etc. (Digital or non-Digital) utilized in the telemedicine consultation should be retained by the Registered Homoeopathic Practitioner.

3.8.2.3 Specifically, in case a prescription is shared with the patient, the Registered Homoeopathic Practitioner is required to maintain the prescription records as required for in-person consultations.

3.8.3 Fee for Telemedicine consultation

3.8.3.1 Telemedicine consultations should be treated the same way as in-person consultations from a fee perspective: RHP may charge an appropriate fee for the Telemedicine consultation provided.

3.8.3.2 A RHP should 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 Homoeopathic Practitioner

2. Caregiver to Registered Homoeopathic Practitioner

3. Health Worker to Registered Homoeopathic Practitioner

4. Registered Homoeopathic Practitioner to Registered Homoeopathic Practitioner

5. Emergency Situations

Essential Principles:

- The professional judgment of a RHP should be the guiding principle: an RHP is well positioned to decide whether a technology-based consultation is sufficient, or an in-person review is needed. 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, the patient management and treatment can be different depending on the mode of communication used.

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

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

- At any stage, the patient has the right to choose to discontinue the tele-consultation.

4.1 Consultation Between Patient and Registered Homoeopathic Practitioner Specifically, this section details with the key elements of the process of tele-consultation to be used in the First consults and Follow up consults when a patient consults with an RHP.

In these 2 situations, the patient initiates telemedicine consultation and thereby consent is implied

4.1.1 First Consult: Patient to Registered Homoeopathic Practitioner

4.1.1.1 First Consult means

1. The patient is consulting with the RHP for the first time; or

2. The patient has consulted with the RHP earlier, but more than 6 months have lapsed since the previous consultation; or

3. The patient has consulted with the RHP earlier, but for a different health condition.

4.1.1.2 Tele-Consultation Process The flow of the process is summarized in the Figure 1 at Annexure and the steps are detailed below.

1. Start of a Telemedicine Consultation for First Consult

• The telemedicine consultation is initiated by the patient (For example, a patient may given audio or video call with a RHP or send an email or text with a health query)

• RHP accepts to undertake the consultation

2. Patient identification and consent

• RHP should confirm 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 initiated by the patient and thereby consent is implied

3. Quick assessment:

• The patient's condition needs to be quickly assessed by the RHP based on available inputs and RHP 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 RHP 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 accuracy of information shared by him/her with the RHP.

• If the RHP feels that the information provided at this stage is inadequate, then he/she shall request for 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. The consultation may be resumed at a rescheduled time after receipt of the additional information (this may include some laboratory or radiological tests). In the meantime, the RHP may provide health advice as appropriate.

• If the RHP is satisfied that he/she has adequate patient information for offering a professional opinion, then he/she shall exercise one's professional judgment for its suitability for management via telemedicine.

• If the situation is NOT appropriate for further telemedicine consultation, then the RHP should provide Health advice/Education as appropriate; and/or refer for in-person consultation.

5. Patient Management If the condition can be appropriately managed via telemedicine, then the RHP may take a professional judgment to either:

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

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

• Provide specific treatment by prescribing medicines considering the case totality.

4.1.2 Follow-up Consult: Patient to Registered Homoeopathic Practitioner In a follow-up consultation, since the RHP -patient interaction has already taken place for the specific medical condition under follow-up, there is already an understanding of the context, with availability of previous records. This allows a more definitive and secure interaction between the RHP and the patient.

4.1.2.1 Follow-Up Consult means The patient is consulting with the Registered Homoeopathic Practitioner within 6 months of his/her previous inperson, and this consultation is for continuation of care of the same health condition. Follow-up can be in situations of a chronic disease or a treatment (e.g. renewal or change in medications) when a face-to-face consultation is not necessary. Examples of such chronic diseases are: asthma, diabetes, hypertension and epilepsy etc.

4.1.2.2 Tele-Consultation Process The flow of the process is summarized in Figure 2 at Annexure and the steps are detailed below:

1. Start of a Telemedicine Consultation for Follow-Up

• Patient may initiate a follow up consult with a RHP for continuation of his/her ongoing treatment or for a new complaint or complication arising during the course of the ongoing treatment using any mode of communication. For e.g., the patient may give an audio or video call with a RHP or send him/her an email or text message with a specific health query.

• RHP accepts to undertake the consultation

2. Patient identification and consent

• RHP should be reasonably convinced that he/she is communicating with the known patient, for e.g. if the patient is communicating with RHP through the registered phone number or registered email Id

• If there is any doubt RHP can request the patient to reinitiate the conversation from a registered phone number or email id or should confirm patient identity to his/her satisfaction by asking patient's name, age, address, email ID or phone number. [Details in the section 3.2]

• Patient initiates the Telemedicine consultation and thereby consent is implied

3. Quick Assessment for Emergency Condition

• If the patient presents with a complaint which the RHP identifies as an emergency condition necessitating urgent care, the RHP would then advice for first aid to provide immediate relief and guide for referral of the patient, as deemed necessary.

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

• If the RHP has access to previous records of the patient, he/ she may proceed with continuation of care.

• RHP shall apply his/her professional discretion for type of consultation based on the adequacy of patient information (case history/examination/ findings/Investigation reports/past records etc.).

• If the RHP needs additional information, he/ she should seek the information before proceeding and resume teleconsultation for later point in time.

5. Patient Management

• If a RHP is satisfied that he/she has access to adequate patient information and if the condition can be appropriately managed by tele-consultation, he/she would go ahead with the tele-management of the patient.

• If the follow-up is for continuation of care, then the RHP may take a professional judgment to either :

o provide health education as appropriate in the case;

o provide counseling related to specific clinical condition including advice related to new investigations that need to be carried out before next consult;

o And/or prescribe medications. The Medications could be either of the below:

• If the follow up is for continuation of care for the same medical condition, the RHP would prescribe medicine according to the laws of Homoeopathy.

• If the follow-up consult reveals new symptom pertaining to a different spectrum of disease, then the RHP would proceed with the condition as enunciated in the scenario for a first-time consultation (4.1.1).

4.2 Consultation Between Patient and Rhp Through A Caregiver

4.2.1 For the purpose of these guidelines "Caregiver" could be a family member, or any person authorized by the patient to represent the patient.

4.2.2 There could be two possible settings:

1. Patient is present with the Caregiver during the consultation.

2. Patient is not present with the Caregiver. This may be the case in the following:

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. The caregiver is deemed to be authorized to consult on behalf of the patient.

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

In all of the above, the consult shall proceed as in the case of Registered Homoeopathic Practitioner and the patient

(first or follow up consult, vide 4.1)

4.3 Consultation Between Health Worker and Rhp For the purpose of these guidelines, "Health worker" could be a Nurse, Allied Health Professional, Mid- Level Health Practitioner, ANM or any other health worker designated by an appropriate authority

Proposed Set up

• This subsection will cover interaction between a Health Worker seeking consultation for a patient in a public or private health facility.

• In a public health facility, the mid-level health practitioner at a Sub-center or Health and Wellness center can initiate and coordinate the telemedicine consultation for the patient with a RHP at a higher center at district or State or National level. Health and Wellness centers are an integral part of comprehensive primary healthcare.

• This setting will also include health camps, home visits, mobile medical units or any community-based interaction.

Tele-Consultation Process The flow of the process is summarized in Figure 3 at Annexure and the steps are detailed below:

1. Start of a Telemedicine Consultation through a Health Worker/Registered Homoeopathic Practitioner

• The premise of this consultation is that a patient has been seen by the Health worker

• In the judgment of the health worker, a tele-consultation with a RHP is required

• Health Worker should obtain the patient's informed consent

• Health worker should explain the potential uses and limitations of a telemedicine consultation

• He/she should also confirm patient identity by asking patient's name, age, address, email ID, phone number or any other identification that may be reasonable

• Health Worker initiates and facilitates the telemedicine consultation.

2. Patient Identification (by RHP)

• RHP should confirm patient identity to his/her satisfaction by asking patient's name, age, address, email ID, phone number or any other identification that may be reasonable

• RHP should also make their identity known to the patient

3. Patient Consent (by RHP):

• RHP should confirm the patient's consent to continue the consultation

4. In case of Emergency

• The Health Worker would urgently communicate about the underlying medical condition of the patient to the RHP.

• If based on information provided, if the RHP identifies it as an emergency condition necessitating urgent care, he/she should advice for first aid to be provided by the Health Worker for immediate relief and guide for referral of the patient, as deemed necessary.

In case, the condition is not an emergency, the following steps would be taken:

5. Exchange of Information for Patient Evaluation (by RHP)

• The Health Worker must give a detailed explanation of the health problems to the Registered Homoeopathic Practitioner which can be supplemented by additional information by the patient, if required.

• The Registered Homoeopathic Practitioner shall apply his/her professional discretion for type and extent of patient information (history/examination findings/Investigation reports/past records) required to be able to exercise proper clinical judgment.

• If the Registered Homoeopathic Practitioner feels that the information provided is inadequate, then he/she shall request for additional information. This information may be shared in real time or shared later via email/text, as per the nature of such information. For e.g., Registered Homoeopathic Practitioner may advice some laboratory or/and radiological tests for the patient. For such instances, the consult may be considered paused and can be resumed at the rescheduled time. Registered Homoeopathic Practitioner may provide health education as appropriate at anytime.

6. Patient Management

• Once the RHP is satisfied that the available patient information is adequate and that the case is appropriate for management via telemedicine, then he/she would proceed with the management. Health worker should document the same in his/her records.

• The Registered Homoeopathic Practitioner may take a professional judgment to either:

o Provide health education as appropriate in the case,

o Provide counseling related to specific clinical condition including advice related to new investigations that need to be carried out before next consult;

o And/or prescribe medications.

Role of Health Worker In all cases of emergency, the Health Worker must seek measures for immediate relief and first-aid from the Registered Homoeopathic Practitioner who is being tele-consulted. Health worker must provide immediate relief/first aid as advised by the Registered Homoeopathic Practitioner and facilitate the referral of the patient for appropriate care. The Health Worker must ensure that patient is advised for an in-person interaction with a Registered Homoeopathic Practitioner, at the earliest.

For patients who can be suitably managed via telemedicine, the Health Worker plays a vital role of

o Reinforcing the health education and counseling provided by the RHP

o Providing the medicine prescribed by the RHP and Providing patient counseling on his/her treatment.

4.4 Registered Homoeopathic Practitioner To Another Rhp/specialist

• Registered Homoeopathic Practitioner might use telemedicine services to consult with another RHP or a Registered Medical specialist for a patient under his/her care. Such consultations can be initiated by a RHP on his/her professional judgment.

• The RHP asking for another RHP's advice remains the treating RHP and shall be responsible for treatment and other recommendations given to the patient except for those recommended by Registered medical specialist from other discipline of medicine.

• It is acknowledged that many medical specialties like radiology, pathology, ophthalmology, cardiology, dermatology etc. may be at advanced stages of adoption of technology for exchange of information or some may be at early stage. Guidelines support and encourage interaction between Registered Homoeopathic Practitioners/ specialists using information technology for diagnosis, management and prevention of disease.

o Tele-radiology is the ability to send radiographic images (x-rays, CT, MRI, PET/CT, SPECT/CT, MG, Ultrasound) from one location to another.

o Tele-pathology is the use of technology to transfer image-rich pathology data between distant locations for the purposes of diagnosis, education, and research.

o Tele-ophthalmology provides eye specialists access to patients in remote areas, ophthalmic disease screening, diagnosis and monitoring.

4.5 Emergency Situations In all telemedicine consultations, as per the judgment of the RHP, if it is an emergency, the goal and objective should be to provide in-person care at the earliest. However critical steps could be life-saving and guidance and counseling could be critical. For example, in cases involving trauma, right advice and guidance around maintaining the neck position might protect the spine in some cases. The guidelines are designed to provide a balanced approach in such conditions. The Registered Homoeopathic Practitioner, based on his/ her professional discretion may

• Advise first aid

• Counseling

• Facilitate referral

In all cases of emergency, the patient MUST be advised for an in-person interaction with a Registered Medical Practitioner in a Health Care Facility having emergency treatment services.

5. Guidelines for Technology Platforms Enabling Telemedicine This specifically covers those technology platforms which work across a network of Registered Homoeopathic Practitioners and enable patients to consult with RHPs through the platform.

5.1 Technology platforms (mobile apps, websites etc.) providing telemedicine services to consumers shall be obligated to ensure that the consumers are consulting with RHP duly registered with Central Register of Homoeopathy or respective state homoeopathic board/council and comply with relevant provisions.

5.2 Technology Platforms shall conduct their due diligence before listing any RHP on its online portal. Platform must provide the name, qualification and registration number, contact details of every RHP listed on the platform.

5.3 In the event some non-compliance is noted, the technology platform shall be required to report the same to Central Council of Homoeopathy who may take appropriate action.

5.4 Technology platforms based on Artificial Intelligence/Machine Learning are not allowed to counsel the patients or prescribe any medicines to a patient. Only a RHP is entitled to counsel or prescribe and has to directly communicate with the patient in this regard. While new technologies such as Artificial Intelligence, Internet of Things, advanced data science-based decision support systems etc. could assist and support a RHP on patient evaluation, diagnosis or management, the final prescription or counseling has to be directly delivered by the RHP.

5.5 Technology Platform must ensure that there is a proper mechanism in place to address any queries or grievances that the end-customer may have.

5.6 In case any specific technology platform is found in violation, CCH may designate the technology platform as blacklisted, and no Registered Homoeopathic Practitioner may then use that platform to provide telemedicine.

6. Special Responsibilities Of Central Council Of Homoeopathy (CCH)

6.1 Any of the drug-lists for Telemedicine Practice Guidelines can be issued/modified by the CCH/Govt. of India from time to time, as and when required.

6.2 The Central Council of Homoeopathy may issue necessary directions or advisories or clarifications in regard to these Guidelines, as required.

6.3 The Telemedicine Practice Guidelines can be amended from time to time in larger public interest with the prior approval of Central Government [Ministry of AYUSH, Government of India].

Figure 1 Flowchart for teleconsultation for first consult

Figure 1 Flowchart for teleconsultation on follow-up consult

Health worker (HW)& Registered Homoeopathic Practitioner

Figure 3: Flowchart for teleconsultation on Health worker (HW) & Registered Homoeopathic Practitioner (RHP)

Sample Prescription Format

REGISTERED HOMOEOPATHIC PRACTITIONER'S NAME

QUALIFICATION

REGISTRATION NUMBER

ADDRESS

CONTACT DETAILS (PHONE AND E-MAIL ID)

PATIENT ID:


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