Why telemedicine needs an urgent fix

The next morning, Ramchandani noticed several missed calls on her phone. Minutes later, she got another call from the same number. The person identified himself as a doctor from Medlife. Without preamble, he began to ask her about the patient’s case history.

He then insisted that Ramchandani’s father consult with one of Medlife’s doctors. Ramchandani declined, saying that they had already seen their family doctor, whose prescription she had put up. She couldn’t understand why Medlife was suddenly insisting on a consultation—she had been ordering the tablets for a year, sometimes without a prescription.

The Medlife doctor gave her an ultimatum: unless she agreed to a consultation, the company would cancel the order. Ramchandani told him to do that. Twenty minutes later, she got another call from a different doctor at Medlife. This doctor, too, pried into her father’s case history and insisted on a consultation. When Ramchandani declined, the doctor admonished her: “But what if the patient suffers from kidney failure?"

Finally, the doctor relented and told her that the medicines would be delivered.

What the two Medlife doctors did isn’t illegal, although they were in contravention of the new Telemedicine Practice Guidelines that require doctors to state their qualifications (the guidelines hadn’t yet been notified into law).

But their unprompted grilling of a caregiver, aggressive sales pitch and attempted cross-selling of a service that the customer didn’t need reflect the guiding practices of a growth-obsessed internet platform rather than a healthcare service provider that is expected to prioritise patient interest.

Medlife contests this interpretation and told Mint that it conducts stringent verification checks before signing up doctors and trains them extensively on delivering the best patient care via teleconsultation. All such calls are recorded, and samples are audited every week by qualified doctors, Medlife said. Based on the audits and customer feedback, the company assigns quality scores to every doctor and periodically de-lists 5% of its doctors who “fall short on the quality parameters".

In the offline world, healthcare is strictly regulated; doctors are subject to the amended Indian Medical Council Act and the Clinical Establishments Act (CEA); hospitals and diagnostic labs to the CEA; pharmacies to the Drugs and Cosmetics Rules; apart from dozens of other laws, including various state policies and the umbrella consumer protection regulations.

Platforms like Medlife, Practo, Pharmeasy, Netmeds and 1MG offer all kinds of healthcare services and yet, by claiming that they are merely technology service providers, evade health regulatory oversight. These firms are currently subject to the Information Technology Act, and the telemedicine guidelines, which focus on registered medical practitioners. The guidelines have little to say about online platforms, despite the fact that digital healthcare is already a big business that is accelerating because of the pandemic.

This month, Mukesh Ambani’s Reliance Industries Ltd bought a majority stake in Netmeds for ₹620 crore and Amazon announced it would start selling medicines. Medlife is being bought by bigger rival Pharmeasy to create an entity valued at $1 billion—India’s first e-health unicorn. RedSeer Consulting estimates that the digital health market will expand to $4.5 billion this financial year, as fear of transmission forces doctors and patients to rely on digital means of healthcare.

The government, too, is rushing to digitise healthcare. The National Digital Health Mission, a government body, is working on a gargantuan project to create a unique digital health ID for all Indians as part of a technology-centric overhaul of public healthcare under a regulatory framework that has yet to be put in place.

Even as the new system is being worked out, interviews with a dozen patients, former executives at e-health platforms, several doctors, patient advocacy experts and lawyers reveal how regulatory lacunae is enabling e-health platforms to increasingly reshape healthcare in their image.

These companies swear by data extraction, addictive tech products, ratings-based systems of sorting suppliers and goods (in this case, doctors and medicines, respectively), discounted offerings, product recommendations and other proven internet business-tactics that yield fast growth and soaring valuations. They have loose data policies that allow them to potentially exploit sensitive patient data for commercial gains without having to make case-by-case disclosures to patients. These policies are framed in abstruse language and not displayed prominently.

Whether such methods are appropriate in healthcare, whether they get the best out of doctors and produce the best patient outcomes are questions that e-health platforms haven’t been made to answer.

“You cannot think of healthcare delivery in terms of e-commerce platforms like Amazon or Flipkart," said Dr Oommen John, a digital health expert at The George Institute, a medical research institute. “Tests and medicines are not at the core of healthcare, it’s people-centric care. When we lose that focus, it degrades the medical profession."

To be sure, telemedicine, which includes teleconsultations by patients, health information for patients, doctor-to-doctor consultations and other components, can yield huge benefits in a country that has an extreme shortage of doctors and where a majority of people do not have access to basic healthcare.

It potentially offers a much better way of delivering healthcare—like the sale of medicines, where, currently, many mom-and-pop pharmacies often sell drugs without prescriptions and push dubious medicines. However, telemedicine needs strong regulations to retain many of its benefits and contain its risks.

Questionable practices

Last week, Practo launched its latest marketing campaign titled #HelloDoctor to attract patients. In the video ads, Practo called itself ‘India’s No.1 Doctor Consultation app’ and touted its various services: 24*7 video consultations with doctors, digital prescriptions, medicine bookings and lab tests. The firm also offers a package deal for patients under Practo Plus, offering ‘unlimited doctor consultations’ at a price of ₹399 per month or ₹1199 for six months.

It’s not clear how most patients would benefit from unlimited doctor consultations. But, despite the low prices, it can benefit Practo if it is able to retain patients and sell an increasing number of products and services to them—a business innovation pioneered by Amazon through its Prime program. Practo runs its own service named Prime, with the promise of low wait times for patients and other benefits.

Practo isn’t breaking laws—though doctors are prohibited from advertising, there are no regulations that say that e-health platforms cannot advertise or offer package deals (clinics and hospitals are allowed to advertise but only for the purpose of providing basic information).

Yet, Practo’s claim of being ‘India’s No.1 Doctor Consultation app’ blurs the boundary between a so-called technology platform and a healthcare service platform. Many internet companies have used this semantic bait-and-switch over the years to evade regulation: to regulators, Practo presents itself merely as a technology service provider; to patients, it’s a doctor consultation app.

In its terms and conditions, Practo states that it is not liable for the advice given or drugs prescribed by the doctors on its platform. Regarding the health information on Practo, the terms say: “The provision of such information does not create a licensed medical professional/patient relationship between Practo and you and does not constitute an opinion, medical advice, or diagnosis or treatment of any particular condition, but is only provided to assist you with locating appropriate medical care from a qualified practitioner."

Any firm involved in patient care or healthcare delivery needs to be registered as a healthcare company, said Dr Shenoy Robinson, chairperson of the Confederation of Indian Industry’s technical committee on health. “And they need to be covered under all the relevant health laws, which can be updated. But you can’t say that ‘I’m a technology player and none of these laws apply to me,’" he said.

Not only Practo, most e-health startups try to attract patients—or ‘users’—with similar hooks. But again, these tactics betray a lack of understanding—or disregard—of the difference between users and patients.

For instance, PharmEasy is offering Amazon vouchers on orders above ₹1,699. Netmeds even sells a product called “Covid-19 Immunity + Anti Inflammatory Booster Pack (Curcumin Strips + Vitamin C Strips + Vitamin D Strips) 210’s" although no drug offers immunity against the novel coronavirus.

Such practices flourish because regulators have passed the buck on governing digital health firms, with the result that patients are vulnerable, Robinson said.

Sanskrita Bharadwaj is a case in point. In May, Bharadwaj, then a Mumbai-based journalist, was suffering from a sore throat. Afraid of going to a clinic, she logged on to Netmeds. After paying, she was assigned a doctor on the app. Over chat, she told him that she had a scratchy throat and was feeling “feverish" though she had no fever. Without seeking other details, he suggested the following medicines: antibiotics, anti-allergy pills, an acid-relieving tablet and a constipation-relieving syrup.

Bharadwaj asked him to specify which medicines were for the sore throat and to give her a prescription. Replying half an hour later, the doctor told her that a prescription couldn’t be generated over chat, and recommended that she get a ‘CBC’ (a complete blood count test). Unsatisfied, Bharadwaj consulted two other doctors on Netmeds but couldn’t finish those conversations because the telecom network didn’t hold up. In late March, Manoj K., then a senior executive at a Bengaluru-based education startup, was feeling unwell and wanted to order antibiotics. He placed an order on 1MG for antibiotics and a skin ointment. He was told that he needed a prescription, which the company’s doctors would be happy to provide. Soon, he got a call from a doctor who said he was with 1MG. The doctor, without stating his qualifications and seeking Manoj K.’s consent to consult, both of which are required by the telemedicine guidelines, asked about his symptoms,

As Manoj K. started replying, the doctor said, “Ok, fine," and hung up. The prescription was generated, and the medicines were delivered a few days later.

Conflict of interest

Online or offline, certain basic principles remain central in healthcare, including data privacy, doctor-patient relationship, negligence and liability.

However, the dynamics of e-health, from the process of doctor discovery to ordering medicines to evaluation of doctor services and patient outcomes, are very different from offline healthcare.

Even if e-health platforms are made to comply with present regulations, these laws would need considerable additions.

A big area of concern is the integration of various health businesses under one roof. Because of the ease with which businesses can be built online, e-health platforms have set themselves up as comprehensive healthcare services providers that offer doctor consultations across specialisations, medicines, tests and health content. But this integration has happened without the recognition and disclosure of conflicts of interest that patients should be aware of.

“For example, teleconsultation is linked to diagnosis and treatment, but the pharmacy line is linked to sale of medicines, and this line may have ties with pharma companies that have vested interests in selling their medicines," said Dr Prabhakaran Dorairaj, director, Centre for Control of Chronic Conditions at the Public Health Foundation of India.

“Another troubling area is: What if there are links between a platform and an insurance company and if the platform is selling patient data to the insurance company? We need to identify these conflicts of interests and create regulations and firewalls." he added. Large hospitals, too, of course offer various services under one roof, but these are regulated. The scale of online platforms takes vertical integration to a different order of magnitude altogether, amplifying the potential benefits and risks to patients.

“e-health platforms need to have Chinese walls between their businesses and should be required to disclose potential conflicts of interests to patients in an accessible form and language", said Ashna Ashesh, who works with the public health advocacy group Survivors Against TB.

Despite India’s push to digitise healthcare, the regulatory framework hasn’t yet been made clear.

In an interview with The Indian Express earlier this month, Dr Indu Bhushan, chief executive of the National Health Authority, said that it is using a combination of present laws like the IT Act, the draft Personal Data Protection Bill and various Supreme Court judgments on “data privacy and data security" to determine a data policy framework under the National Digital Health Mission.