Telemedicine technology plays a crucial role in addressing healthcare challenges, particularly in countries like India, by mitigating physician shortages, reducing patient burden and costs, and aiding in disease prevention. The term telemedicine, meaning “healing at a distance,” was coined in 1970 [1]. It encompasses the use of electronic, communication, and information technologies to deliver healthcare services remotely. To regulate telemedicine practice, the Government of India released telemedicine guidelines on March 25, 2020, during the Covid-19 pandemic [2]. The National Medical Commission (NMC) added the Telemedicine Practice Guidelines as Appendix-5 to the Professional Conduct (Etiquette and Ethics) Regulation 2002 of the erstwhile Medical Council of India (MCI) [3]. Additionally, on June 11, 2020, the Insurance Regulatory and Development Authority of India (IRDAI) recognised teleconsultation services for insurance claims [4], which led to a surge in telemedicine consultations and the proliferation of various apps and service providers.
Telemedicine has proven to be invaluable during natural disasters and in remote areas. It reduces patient costs, time, and effort, leading to widespread acceptance of teleconsultation as an alternative to in-person consultations. Additionally, patients do not need to be physically present, reducing hospital burden, preventing the transmission of infectious diseases, and enabling easy digital record-keeping accessible, anytime and anywhere.
Indian Telemedicine Guidelines have significant gaps, such as the absence of specific data protection laws, the lack of a mandatory grievance officer as per the IT Act [5], unclear jurisdiction for professional misconduct, and the need for national or interstate registration of Registered Medical Practitioners (RMPs), as RMPs can consult patients from any location within India. Furthermore, the guidelines do not address the issuance of medical certificates via teleconsultation or their validity.
Medical certificates are essential for medico-legal and administrative purposes. Issuing false certificates is a serious offence, equivalent to giving false evidence in court, under Section 234 of the Bhartiya Nyaya Sanhita (formerly, Section 197 IPC) [6], and punishable by up to seven years of imprisonment. Standard medical practice requires thorough physical examinations and appropriate investigations before issuing certificates for fitness, sickness, or disability. Teleconsultation does not permit in-person recording of patient vitals by RMPs, making it unreliable for certificate issuance.
The Telemedicine Practice Guidelines allow and have been effective for outpatient department (OPD) consultations and patient follow-ups; but restrict teleconsultations in emergencies, complex surgeries, and invasive procedures. These guidelines do not provide directions on issuing medical certificates following virtual examinations.
The legalisation of telemedicine has led to a surge in startups offering digital apps that promise various services, including teleconsultation, medication dispensing, and diagnostic tests, often with incentives like discounts and cashback. It is challenging for laypeople to distinguish between legitimate teleconsultation apps with qualified RMPs and fraudulent apps that scam users. Recently, some startups have advertised issuing medical certificates via teleconsultation, aggressively marketing dubious products online, promising certificates within minutes from RMPs based on simple questionnaires. These platforms falsely claim that their certificates are valid under the telemedicine guidelines issued by the NMC/MCI.
Medical certificates are often used for medico-legal or administrative purposes. The online certificates issued, based solely on patient-provided answers, lack a mechanism to verify the patient’s claims, allowing individuals to feign illness to obtain false certificates. The responsibility for issuing false certificates, which is legally punishable, rests on the RMP. Feigned illnesses for personal gain can negatively impact the country’s economic growth due to sickness absenteeism and loss of productivity.
A review of international telemedicine guidelines, such as those issued by medical boards in the United States,[7], Australia [8], New Zealand [9], and the Standing Committee of European Doctors [10], advises that teleconsultation services should only be practised when in-person consultation is not feasible and should be used for OPD and follow-up purposes only. The Singapore Medical Council’s teleconsultation guidelines specifically state that medical certificates must be issued only after a thorough clinical assessment of the patient, including history taking and physical examination [11].
The unprecedented Covid-19 pandemic led to an exponential rise in teleconsultation. To ensure patient safety and uphold ethical standards, the Government of India, in consultation with the National Medical Commission, released the Telemedicine Practice Guidelines 2020 to regulate the exponential growth of teleconsultation. Some entities exploit loopholes in these guidelines, scamming vulnerable individuals and placing RMPs at risk by issuing certificates without physical examinations, based solely on patient-reported history. Clear guidelines on issuing certificates following teleconsultation are necessary. The authors believe that certificates should only be issued after thorough physical examination and not merely on online claims of illness or submission of supporting medical reports by the patient.
Conflict of Interest and funding: None of the authors has received any financial or non-financial support from any agency or organisation.
Dipen Dabhi (itsdipendabhi@gmail.com, https://orcid.org/0009-0008-6275-1017), Assistant Professor, Department of Forensic Medicine and Toxicology, AIIMS Bilaspur, Himachal Pradesh 174037, INDIA; Yatiraj Singi (corresponding author — drsingiyatiraj@gmail.com), Associate Professor, Department of Forensic Medicine and Toxicology, AIIMS Bilaspur, Himachal Pradesh 174037, INDIA; Nirmal Nagar (nagarnirmal4@gmail.com), Senior Resident, Department of Forensic Medicine and Toxicology, AIIMS Bilaspur, Himachal Pradesh 174037, INDIA.