See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/363856102

Ethiopian Telehealth Guide 2020 Version 2

Preprint · August 2020

DOI: 10.13140/RG.2.2.31548.51847

CITATIONS READS
0 1,284

16 authors, including:

Hailu Tamiru Dhufera Woldesenbet Waganew Dode

Harvard University Independent Researcher
18 PUBLICATIONS 1,216 CITATIONS 57 PUBLICATIONS 64 CITATIONS

SEE PROFILE SEE PROFILE

Aklilu Azazh Menbeu Sultan

Addis Ababa University Addis Ababa University
69 PUBLICATIONS 1,124 CITATIONS 63 PUBLICATIONS 7,947 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Hailu Tamiru Dhufera on 26 September 2022.

The user has requested enhancement of the downloaded file.

TELEHEALTH GUIDELINE
Practical Tips

የዜጎች ጤና ለሃገር ብልጽግና! MINISTRY OF HEALTH-ETHIOPIA August 2020

H E A LTH I E R C I T IZ E N S FO R P R O S P E RO U S N AT IO N !
FOREWORD

Global pandemic of COVID-19 has impacted the healthcare delivery in different way, threatening
the backslide of significant achievements of health systems. In the context of Ethiopia, COVID-19
has resulted in reduction of health seeking behavior due to movement restriction, fear of possible
COVID-19 infection in health facilities and inadequate awareness creation and health education
campaigns for non-COVID-19 conditions.

To tackle this threatening challenge, the practice of using innovative and new approaches is one
way out. With the use of digital technologies to deliver medical care, health education, and public
health services by connecting with multiple users in different locations, telehealth has significant
benefit on narrowing the above gap.

In this regard this guideline has been prepared to give practical advice to health professionals to
deploy the service for the provision of continuous healthcare service and minimizing client’s visit
to health facilities during COVID-19 pandemic period.

The FMOH would like to acknowledge every member that has involved in the write up, for their
commitment and unreserved effort on finalizing the task in a very short period of time.

H.E DR. Dereje Duguma

State Minister of Health Ethiopia
ACKNOWLEDGMENT

We would like to acknowledge the following individuals and organizations for their contribution
in the development of this document.

No. Name Institute

1. HailuTamiru Dhufera (MD, MPH) MOH, CHAI
2. Woldesen bet Waganew(MD, ECCM) SPHMMC
3. Aklilu Azazh(Prof.ECCM) AAU/CHS
4. Aschalew Worku(MD, PCCM) AAU/CHS
5. Berhane Redae(MD, Surgeon) MOH, Jhpiego Ethiopia
6. Hilina Taddese (MD) MOH, MSDG
7. Menbeu Sultan(MD, Intensivist) SPHMMC
8. Miraf Walelegn (MPH) MOH
9. MuluworkTefera(MD, Pediatric ECCM) AAU/CHS
10. Natnael Brhanu (MD, MPH) Save the Children
11. Getachew Asfaw (MPharm) MOH
12. Rahel Argaw (MD, Pediatric PCCM) AAU/CHS
13. SisayTeklu (MD, Gyn-Obstetrician ) AAU/CHS
14. Sisay Yifru (MD, Pediatrician ) MOH
15. Yakob Seman (MPH) MOH, MSDG
16. Dr. Mengistu Kifle MOH
TABLE OF CONTENTS
1. Introduction ............................................................................................................................................. 1
1.1 Background.................................................................................................................................... 1
1.2 Scope ............................................................................................................................................. 1
1.3 Purpose .......................................................................................................................................... 2
1.4 Definitions ..................................................................................................................................... 2
2. Pre-Requisites and Considerations........................................................................................................ 3
2.1 Care Provider Duty ........................................................................................................................ 3
2.2 Prerequisite for Telehealth Service................................................................................................ 3
2.3 Legal and Ethical Consideration ................................................................................................... 3
3. Principles of Telehealth ......................................................................................................................... 5
3.1 General Principles of telehealth .................................................................................................... 5
3.2 Responsibilities of the Licensed Practitioners .............................................................................. 5
3.3 Quality of Care.............................................................................................................................. 6
3.4 Client Suitability Guidelines ......................................................................................................... 6
3.5 Informed Consent.......................................................................................................................... 7
4. Documentation and Client Records...................................................................................................... 7
4.1 Client Information Required By Clinical Telehealth Program ..................................................... 7
4.2 Responsibility for Records ............................................................................................................ 7
5. Patient Management .............................................................................................................................. 8
5.1 Health Education ........................................................................................................................... 8
5.2 Counseling ..................................................................................................................................... 8
6. Framework for Telehealth ................................................................................................................... 11
6. 1 Consultation between Patient and Licensed Medical Practitioner............................................... 11
6.2 Consultation between patient and licensed medical practitioner through a caregiver ................. 12
6.3 Consultation between health worker and licensed medical practitioner ...................................... 13
6.4 Consultation between licensed medical practitioner and another licensed medical practitioner . 15
6.5 Emergency situation .................................................................................................................... 15
7. Establishing Telehealth Care Service .................................................................................................. 16
7.1 Addressing legal considerations and required approvals ............................................................. 16
7.2 Identifying Telehealth Services and Clients ................................................................................ 16
7.3 Choosing the Technology to be Used and Mode of Communications ........................................ 17
7.4 Design Telehealth Workflow and Develop Standard Operating Procedure (SOP) ..................... 17
7.5 Create a Monitoring and Evaluation Plan .................................................................................... 18
Annex I ....................................................................................................................................................... 21
Annex II ........................................................................................................................................ 22
 Telehealth Guideline: Practical Tips

1. Introduction

1.1 Background

As a result of the ongoing public health emergency related to the outbreak of COVID-19, there is
an urgency to expand the use of innovative methods to help people who need routine care and
keep vulnerable beneficiaries with mild to moderate symptoms in their homes while maintaining
access to the care they require. Limiting community spread of the virus as well as limiting the
exposure to other patients and health care workers within the health facilities will slow the
spread of the virus. In this regard telehealth has emerged as a viable means of continuity of
outpatient care by reduce unnecessary contact and exposure to individuals who might have been
infected with COVID-19. Therefore, health care providers are encouraged to provide healthcare
services via telehealth to the greatest extent possible following this generic guidance.

General Benefits of Telehealth

 Reduces movement of patient travel burden;

 Provides access to a wider range of specialist advice and services;
 Enhance access and time management
 Enhance general health promotion including continuing professional education
 Improve and provide access to quality of healthcare
 Covers preventative, promotive, and curative aspects of health;
 Engages and links all types of users (from highly trained clinicians to minimally trained
community health care workers (CHWs), to patients, to the general population); and
 Can be used as an alternate or complementary approach for almost any health issue
imaginable.

1.2 Scope

This guideline is developed to harmonize for provision of telehealth services to all public
institutions using open source application and Information Communication Technology including
voice, text & video. This guideline is specifically developed for the provision of telehealth services
to clients during COVID-19 pandemic period without the need for the clients to visit health
facilities.

Note: this guideline will not be applicable to use of digital technology to conduct surgical or
invasive procedures remotely.

1
Telehealth Guideline: Practical Tips

1.3 Purpose

The purpose of this guide is to facilitate the utilization of available ICT for the provision of routine
health care services to clients by minimizing visit to health facilities during the COVID-19
pandemic period. Furthermore, the experience we harness from providing telehealth services
will help health facilities to make cost effective healthcare services in the long-term.

The guideline is intended:

1. To ensure continuity of care for chronic care patients

2. To apply in conjunction with all existing organizational standards, protocols, and policies
and procedures for care service provision.
3. To guide clinical practitioners providing assessment, treatment, and consultative services
via ICT
4. To assist, educate and consult remote clinicians to provide safe and effective clinical
care
5. To minimize clients movement and cross-contamination during COVID-19 pandemic
period
6. To establish linkage between prior treating and current treating facilities

1.4 Definitions
 Caregiver: A family member, or any person authorized by the patient to represent the
patient
 Client: A potential or actual recipient of telehealth service
 Consultant physician: is a senior doctor who practices in one of the medical specialties
 Health worker: could be a Nurse, Allied Health Professional, Mid- Level Health
Practitioner, or any other health worker designated by an appropriate authority
 Licensed medical Practitioners: an individual who is licensed or otherwise authorized to
provide health care services
 Medical practice license: an occupational license that permits a person to legally practice
medicine
 Telehealth: is the use of digital technologies to deliver medical care, health education,
and public health services by connecting multiple users in separate locations.
 Telemedicine: is transfer of medical data and information for the purpose of consultation.

2
 Telehealth Guideline: Practical Tips

2. Pre-Requisites and Considerations

2.1 Care Provider Duty

Telehealth service should follow the same principles as face-to-face care. The circumstances to
be considered are as following:

2.1.1 The responsible provider should give the client adequate, current, and ongoing care
instructions
2.1.2 If face-to-face appointments require the use of interpreters, the presence of family
members or a care provider, or other aides, those same supports should be arranged
for telehealth appointments
2.1.3 If second opinions or advice is being given by a consultant, the local clinician is
ultimately responsible for the care they provide to the client
2.1.4 If there is any doubt on point 2.1.3 about roles and responsibilities, the consultant
and local health care provider must reach an agreement before a telehealth
consultation is provided

2.2 Prerequisite for Telehealth Service

The following need to be considered when undertaking a telehealth program:

2.2.1 Have an understanding of the scope of service being provided via Telehealth;
2.2.2 Engage all stakeholders (health and IT professionals) for smooth running of the
system
2.2.3 Understand the limitation of technology and communicating under a variety of
conditions
2.2.4 Train and educate how to use the telehealth system
2.2.5 Prepare operational protocols and procedures should prepare prior to the
provision of any telehealth services such as appointment date, start & end time,
open source, technology, device to use
2.2.6 Establish a physician champion to be resource for all your telehealth service users

2.3 Legal and Ethical Consideration

2.3.1 License: As the existing medical practice license requires direct patient- doctor
contact, the practice should be extended to cover telehealth services.
2.3.2 Consent: there has to be an existing or prior direct patient -doctor relationship as
well as written consent from the patient to use telehealth services.

3
Telehealth Guideline: Practical Tips

2.3.3 Patient doctor relationships: the services covered under telehealth should be
based on prior contact and knowledge of patient medical history.
2.3.4 Fraudulent act and abuse of telehealth: mechanisms to control or avoid false
report of undelivered service should be in place
2.3.5 Data storage: there has to be standardized way of saving and storing data of the
patient for evidence purposes and to monitor patients progress during
subsequent follow up.
2.3.6 Ethics: The principles of medical ethics that are mandatory for the profession must
also be respected in the practice of telehealth.

4
 Telehealth Guideline: Practical Tips

3. Principles of Telehealth
3.1 General Principles of telehealth
3.1.1 The patient-physician relationship should be based on a personal examination and
sufficient knowledge of the patient’s medical history.
3.1.2 The patient-physician relationship must be based on mutual trust and respect.
3.1.3 The physician and patient should be able to identify each other reliably when
Telehealth is employed.
3.1.4 In case of consultation between two or more professionals, the consultant physician
remains responsible for the care and coordination of the patient with the distant
medical team.
3.1.5 The telehealth service providers must aim to ensure that patient confidentiality,
privacy and data integrity are not compromised.
3.1.6 Proper informed consent requires that all necessary information regarding the
distinctive features of telehealth visit be explained fully to clients
3.1.7 Physicians must be aware that certain telehealth technologies could be unaffordable
to patients and hence could impede access.
3.1.8 Licensed Practitioners should not participate in telehealth if they violate the legal or
ethical framework of the country.
3.1.9 Licensed Practitioners should inform clients about availability of an emergency
service via telehealth.
3.1.10 Licensed Practitioners should exercise their professional autonomy in deciding
whether a telehealth versus face-to-face consultation is appropriate.

3.2 Responsibilities of the Licensed Practitioners

3.2.1 A physician whose advice is sought through the use of telehealth should keep a
detailed record of the advice he/she delivers as well as the information he/she
received and on which the advice was based in order to ensure traceability.
3.2.2 If a decision is made to use telehealth, it is necessary to ensure that the clients are
able to use the necessary telecommunication system.
3.2.3 Licensed Practitioners must seek to ensure that the patient has understood the
advice and treatment suggestions given and take steps in so far as possible to
promote continuity of care.
3.2.4 Licensed Practitioners should be aware of and respect the special difficulties and
uncertainties that may arise when he/she is in contact with the patient through
means of ICT.

5
Telehealth Guideline: Practical Tips

3.2.5 Licensed Practitioners must be prepared to recommend direct patient-doctor

contact when he/she believes it is in the patients’ best interests.
3.2.6 Licensed Practitioners should only practice telehealth where they are licensed to
practice.
3.2.7 The licensed medical practitioner can choose not to proceed with the consultation at
any time. At any step, the licensed medical practitioner may refer or request for an
in-person consultation

3.3 Quality of Care

3.3.1 Healthcare quality assessment measures must be used regularly to ensure diagnostic
and treatment practices during telehealth procedures.
3.3.2 The delivery of telehealth services must follow evidence-based practice guidelines to
the degree they are available, to ensure patient safety, quality of care and positive
health outcomes.
3.3.3 Like all health care interventions, telehealth must be tested for its effectiveness,
efficiency, safety, feasibility and cost-effectiveness.
3.3.4 If it is necessary to use telehealth in an emergency situation, the advice and
treatment suggestions are influenced by the severity of the patient´s medical
condition and the competency of the persons who are with the patient.
3.3.5 Entities that deliver telehealth services must establish protocols for referrals for
emergency services.

3.4 Client Suitability Guidelines

Clinical departments/programs should identify inclusion and exclusion criteria for perspective
telehealth clients. The following list includes some factors that can influence suitability:
3.4.1 Level of physical assessment required
3.4.2 Availability of support in the locality or vicinity of the patient
3.4.3 Fitness of the client to participate in remote care such as physical, mental, and
cognitive barriers
3.4.4 Dependency on local availability of associated imaging and lab tests
3.4.5 Client desire to participate in a telehealth consultation
3.4.6 Ability to schedule telehealth session within the timeframes ofa service or program’s
standard of practice guidelines

6
 Telehealth Guideline: Practical Tips

3.5 Informed Consent

The clinical program is responsible for explaining what to expect, in placing privacy and
confidentiality measures and permit the client’s right to refuse care via telehealth. Clients must
be informed that access to a face-to-face consultation is never denied if they opt out of or don’t
wish to receive care via telehealth. Documentation in the client record must reflect client
notification and agreement to the service.

Written consent: is only required by the provider when: Clients are asked to participate in
research projects while in care, or recording a telehealth session is required for program
monitoring purpose.

4. Documentation and Client Records

4.1 Client Information Required By Clinical Telehealth Program

4.1.1 Provider Site: The information required is determined by the respective clinical
department. Generally, it is expected to be the same as what’s required for a face-to-
face appointment and provided in advance of the telehealth appointment or session.
4.1.2 Consultation Report: A report from the telehealth provider is documented and
incorporated into the client record. Telehealth service documentation timelines into
the client record should be consistent with existing face-to-face practice
4.1.3 Client site: Information required by the client site that consists of electronic and paper
charts, diagnostic images and lab reports should in line with provider site
4.1.4 Clinical Telehealth Support Notes: All additional clinical support document
should be recorded in the same timely manner face- to-face events. All supported
document should be also attached for telehealth service.

4.2 Responsibility for Records

The original client record is held with the primary provider. Copies of the Telehealth
consult report and note are shared with the referring sites as they would be for face-to-
face consultations.

7
Telehealth Guideline: Practical Tips

5. Patient Management
If licensed medical practitioner has recommend telehealth service is appropriate, then the
licensed medical practitioner provide Health Education, Counseling related to specific clinical
condition; and/or Prescribe or refill medicines.

5.1 Health Education

A licensed medical practitioner may impart health promotion and disease prevention messages.
These could be related to diet, physical activity, and cessation of smoking, contagious infections
and so on. Likewise, he/ she may give advice on immunizations, exercises, hygiene practices,
mosquito control etc.

5.2 Counseling
Pharmacists shall provide advice on medication related information like side effects, drug
interactions (Drug-Drug, Drug-Food, Drug-herbal and Drug-beverage), adverse drug reaction,
compliance and adherence of medicines and non-pharmacologic approaches (lifestyle
modifications and disease prevention).

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

5.3 Prescribing Medicines

5.3.1 Prescribing medications, via telehealth consultation is at the professional discretion
of the licensed medical practitioner.
5.3.2 It entails the same professional accountability as in the traditional in-person consult.
5.3.3 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
telehealth consult.
5.3.4 A licensed medical practitioner may prescribe medicines via telehealth ONLY when
he/she is satisfied that he/ she has gathered adequate and relevant information
about the patient’s medical condition and prescribed medicines are in the best
interest of the patient.

NB: Prescribing Medicines without an appropriate diagnosis/provisional diagnosis will

amount to a professional misconduct.

8
 Telehealth Guideline: Practical Tips

5.3.1 Specific Restrictions

There are certain restrictions while prescribing medicines on consult via telehealth
depending upon the type of consultation and mode of consultation. The categories of
medicines that can be prescribed via tele-consultation will be further updates and notified
accordingly by FMOH. The 4 categories of medicines that can be prescribed are listed below:

Category 1: This comprises those medicines which are safe to be prescribed through
any mode of teleconsultation
 These are medications which are listed as The Over the Counter Medicine
list for Ethiopian 2ndEdition ( see over the counter medicines list for Ethiopia,
website on.www.efda.org.et

Category 2: These medications are those medicines which can be re-prescribed for
re-fill, in case of follow-up.
 The medicines which are considered in these categories are those
medications which have been used by the patient and stable on it and refill
it!
 The Medicines which included in this category could be different classes
based on the patient cases scenario.
 They are safe and have no potential for abuse and addiction.
 The refill could be only for maximum of twice (2x refill).
 Medicines which are not included in this category are antimicrobials which
could be prescribed for acute cases.

Category 3: These are medications which are needed to optimize the patient
outcome and are safe and effective to use during follow up consultation.
 These medications are those which can be used as an add-on therapy.
 The list of medicines in this category could be different classes based on the
patient case scenario.
 They are safe and have no potential for abuse and addiction.
 Medicines which are not included in this category are : Anti-cancer
medicines, narrow therapeutic index medication ( Example; Digoxin , ) and
High Alert medications

Category 4/Prohibited List: A licensed medical practitioner providing consultation

via telehealth cannot prescribe medicines in this list.
 These medicines have a high potential of abuse, addiction and could harm
the patient or the society at large if used improperly
 The list of medicines included in this category are listed on national list of
Psychotropic substance and Narcotic Drugs of Ethiopia, 2017.
See National List of Psychotropic Substances and Narcotic drugs

9
Telehealth Guideline: Practical Tips

5.4 Prescription Process

5.4.1 Direct Method: Licensed Medical Practitioner shall provide photo, scan, and digital copy
of a signed prescription or e-Prescription to the patient via email, MMS (multimedia
message) or any messaging platform then the patient might bring it into pharmacy.

Licensed Medical Practitioners Patient Pharmacy Patient

5.4.2 Indirect method: Licensed Medical Practitioner send the prescription (Photo, Scan, MMS,
digital copy of signed prescription or e-prescription) directly to a pharmacy then the
patient will get a medicine from any pharmacy of his choice. In this case, the patient
consent must be guaranteed.

Licensed Medical Practitioners Pharmacy Patient

10
 Telehealth Guideline: Practical Tips

6. FRAMEWORK FOR TELEHEALTH

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

1. Patient to licensed medical practitioner

2. Caregiver to licensed medical practitioner
3. Health Worker to licensed medical practitioner
4. licensed medical practitioner to licensed medical practitioner
5. Emergency Situations

6. 1 Consultation between Patient and Licensed Medical Practitioner

Specifically, this section details with the key elements of the process of teleconsultation to be
used in the first consults and follow up consults when a patient consults with a licensed medical
practitioner. In these 2 situations, the patient initiates Telehealth consultation and thereby
consent is implied

6.1.1 Follow-up Tele-Consultation

In a follow-up Tele- consultation, since the licensed medical practitioner - 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 secures interaction between the licensed medical practitioner and the patient. The licensed
medical practitioner has authorized to startup the telehealth consultation and reaches in consent
with client.

The flow of the process steps is detailed below:

1. Patient identification and consent
 Licensed medical practitioner should be reasonably convinced that he/she is
communicating with the known patient, for e.g. if the patient is communicating with
licensed medical practitioner through the registered phone number or registered
email ID
 If there is any doubt, licensed medical practitioner 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.
 Patient initiates the Telehealth consultation and thereby consent is implied

11
Telehealth Guideline: Practical Tips

2. Patient management
If the follow-up is for continuation of care, then the licensed medical practitioner may take a
professional judgment to either:
 Provide health education as appropriate in the case; 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 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
licensed medical practitioner would re-prescribe original set of medications
for a refill (category 2 of medications, which has been previously prescribed
for the patient).
 If the licensed medical practitioner considers addition of a new drug, as an
‘add-on’ medication to optimize the underlying medical condition, then the
licensed medical practitioner can prescribe medications listed under category
3.
 If the follow-up consult is for a new minor ailment necessitating only ‘over the
counter’ medications or those notified for this purpose, medications under
category 1 can be prescribed.
 If the follow-up consult reveals new symptom pertaining to a different
spectrum of disease, then the licensed medical practitioner would proceed
with the condition as enunciated in the scenario for a first-time consultation.

3. Emergency Condition
During follow-up If the patient presents with a complaint which the licensed medical
practitioner identifies as an emergency condition the licensed medical practitioner would
then advice for first aid to provide immediate relief and guide for referral of the patient,
as deemed necessary.

6.2Consultation between patient and licensed medical practitioner through a caregiver

For the purpose of these guidelines “Caregiver” could be a family member, or any person
authorized by the patient to represent the patient.
There could be two possible settings:

12
 Telehealth Guideline: Practical Tips

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 situations:
2.1 Patient is a minor (aged 18 or less) or the patient is incapacitated, for example, in medical
conditions like dementia or physical disability etc. The care giver is deemed to be authorized
to consult on behalf of the patient.
2.2. 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 licensed medical practitioner and
the patient (first or follow up consult) mentioned above.

6.3 Consultation between health worker and licensed medical practitioner

This sub-section will cover interaction between a Health Worker seeking consultation for a
patient in a public health facility. In a public health facility, the mid-level health practitioner
at primary hospitals and Health center can initiate and coordinate the Tele-health
consultation for the patient with a licensed medical practitioner at a higher center at district
or regional or national level. This setting will also include health posts, home visits, mobile
medical units or any community-based interaction.

6.3.1. Telehealth Consultation

Preconditions:
 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 licensed medical
practitioner is required
 Health Worker should obtain the patient’s informed consent
 Health worker should explain potential use and limitations of a telehealth
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 telehealth consultation.

13
Telehealth Guideline: Practical Tips

6.3.2. Exchange of Information for Patient Evaluation (by licensed medical practitioner)
 The Health Worker must give a detailed explanation of their health problems to the
licensed medical practitioner which can be supplemented by additional information
by the patient, if required.
 The licensed medical practitioner shall apply his 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 licensed medical 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., licensed medical 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.
 Licensed medical practitioner may provide health education as appropriate at any
time.

6.3.3 Patient Identification (by licensed medical practitioner)

 Licensed medical practitioner 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
 Licensed medical practitioner should also make their identity known to the patient
 Licensed Practitioner should confirm the legality of the consulting health care provider
in any way
6.3.4 Patient Consent (by licensed medical practitioner)
 Licensed medical practitioner should confirm the patient’s consent to continue the
consultation
6.3.5 In case of Emergency
 The Health Worker would urgently communicate about the underlying medical condition
of the patient to the licensed medical practitioner.
 Based on information provided, if the licensed medical practitioner identified 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.

14
 Telehealth Guideline: Practical Tips

6.3.6. Patient Management

Once the licensed medical practitioner is satisfied that the available patient information
is adequate and that the case is appropriate for management via telehealth, and then
he/she would proceed with the management (health education, counseling and/or
prescribe medications). Health worker should document the same in his/her records.

6.4 Consultation between licensed medical practitioner and another licensed medical
practitioner
It is acknowledged that many medical specialties like radiology, pathology,
ophthalmology, cardiology, dermatology etc. conducting teleconsultation or exchange
information on patients. Guidelines support and encourage interaction between Licensed
Medical Practitioners/ specialists using information technology for diagnosis,
management and prevention of disease. Licensed Medical Practitioner might use
telehealth services to consult with another licensed Medical Practitioner or a specialist
for a patient under his/her care. Such consultations can be initiated by a licensed Medical
Practitioner on his/her professional judgment. The treating Licensed Medical Practitioner
and shall be responsible for treatment and other recommendations given to the patient.

6.5 Emergency situation

In all telehealth consultations, as per the judgment of the licensed medical practitioner, if it is an
emergency situation, the goal and objective should be to provide in-person care at the soonest
possible. However, critical steps could be lifesaving and guidance and counseling could be critical.
For example, in cases involving trauma, the 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 licensed medical practitioner, based on his/ her
professional discretion may advise first aid, counseling, and/or advice referral and further follow-
up. In all cases of emergency, the patient must be advised for an in-person interaction with a
licensed Medical Practitioner.

15
Telehealth Guideline: Practical Tips

7. Establishing Telehealth Care Service

All health facilities intending to provide Telehealth health care services amid COVID-19 pandemic
should follow the following steps or process.

7.1 Addressing legal considerations and required approvals

Although telehealth has the potential to improve several aspects of medical care, such as
facilitating physician-patient communication and monitoring treatment of chronic conditions,
telehealth poses unique challenges in ensuring patient-safety and privacy of health information.
Therefore, Telehealth policies and procedures should address the following elements to
safeguard the integrity of care: licensure, establishment of the physician-patient relationship,
evaluation and treatment, informed consent, continuity of care, referrals for emergency services,
medical records, privacy and security of the patient records and exchange information; disclosure
and functionality of telehealth services and prescribing.

Health facilities should analyze the status of existing regulations for any intended healthcare
service; based on the general guideline develop standard operating procedure (SOP) for the
provision of telehealth services; and seek approval from relevant authorities for the provision of
telehealth services. The relevant authorities will review the SOP submitted by the health facility
requesting approval/licensure and assess the capability of the health facility in providing
Telehealth services before giving permission. In light of the COVID-19 Pandemic, the Ministry of
Health is expected to provide quick approval to health facilities requesting to establish telehealth
services.

7.2 Identifying Telehealth Services and Clients

A health facility intending to establish telehealth services should identify or prioritize healthcare
services which can be provided through telehealth system given its capacity and resources. A
number of health care services can be provided through telehealth. Examples include not limited:
 Non-communicable diseases (NCDs)
 Communicable diseases (e.g. HIV/AIDS and TB)
 Chronic lung diseases
 Mental health
 Dermatology and others

16
 Telehealth Guideline: Practical Tips

Once the health care services are identified, the health facility can easily identify its clients for
the intended telehealth services. Knowing more about who our patients are and what they’re
looking for from their medical practitioners is important, but it is especially important in a field
like telehealth. It is recommended to identify what kind of information communication
technologies and applications are already being used by clients. This will be very helpful in
choosing the technology that the facility will be using to provide the telehealth services.

7.3 Choosing the Technology to be Used and Mode of Communications

Multiple technologies can be used to deliver telehealth consultation. There are different modes
of communication: Video, Audio, still-Image or Text (chat, messaging, email 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 and treatment services.
Therefore the technology to be chosen and apply has to be considered existing infrastructure,
and client’s circumstance.

7.4 Design Telehealth Workflow and Develop Standard Operating Procedure (SOP)
The key elements of the process of telehealth service provision to be used in the first and follow
up consultations between a health care provider and a patient should be clearly outlined and
indicated in the SOP (Sample workflow charts are indicated in Annex 1). It should be noted that
telehealth service provision requires the participation of multidisciplinary team of health
professionals. There may be a need to combine telehealth with in-person interaction, for
example for laboratory tests, imaging, dispensing of medicines etc.

Each health facility has to adopt/develop an SOP specific to its setting for telehealth service
provision. The following critical issues should be addressed in the SOP.
 Management system and organizational structure for the Telehealth services
 The type of Telehealth services provided by the health facility
 The modes of communication and technologies which are used for the Telehealth service
provision
 The process of Telehealth service provision
 Payment schemes
 Type of drugs eligible for e-prescription

17
Telehealth Guideline: Practical Tips

7.5 Create a Monitoring and Evaluation Plan

To track the implementation and effectiveness of this initiative, the presence of sound
monitoring and evaluation mechanisms is essential. Given the key principle of the Ethiopian
HMIS, as much effort should be placed to integrate with and leverage existing the M&E
mechanisms of the health sector. The indicators to be selected should be very simple to
understand, feasible to track and robust enough to understand the process and outcome of the
effort. M&E mechanism such as record keeping, reporting, review meetings, supervisions, rapid
assessment, documentation of best practices and lessons learnt and eventually evaluation of the
initiative need to be employed as appropriate and feasible.

7.5.1 Monitoring

In general, the monitoring of the telehealth service shall follow the usual medical service
monitoring and follow up within the existing structure from the health facility to up to the
Ministry of Health

As stated above, existing record keeping mechanism should be utilized depending on the
activities and the indicators to be tracked and reported. Some new record keeping tools to record
such as clients identified for telehealth services and interim reporting format until telehealth
service tracking becomes part of the standard reporting tool might be prepared as needed. To
standardize the process, reporting of the services provided through telehealth based on selected
indicators has to be incorporated in the health monitoring system during the next round of HMIS
revision. Whichever indicators are tracked and new tools are used, the data should flow based
on the standard HMIS data flow channel and should finally make its way to MOH for action.

Health facilities should implement all relevant monitoring mechanisms for continuous quality
improvement of the telehealth services. Facilities should monitor the Telehealth service
provision depending on their plan and identify and respond to challenges as they arise. Periodic
supportive supervision of health care providers will improve the quality of Telehealth service
provision.

Telehealth agenda should be integral part of existing review meetings, supervisions and other
site visit activities. Equally important is the documentation and sharing of best practices and
lessons learnt and challenges faced using the available mechanism of reporting, mass and social
media as appropriate.

18
 Telehealth Guideline: Practical Tips

System for reporting any violations of Telehealth procedures and addressing any requests or
grievances from patients such as client satisfaction surveys should also be in place. See Annex II

7.5.2 Evaluation
The evaluation of the effectiveness of the telehealth service initiative during the COVID 19
pandemic should be an integral part of evaluation of the overall health and socio-economic
impact of the COVID1-9 and effectiveness of the comprehensive national response to contain the
pandemic and mitigate its impacts. Accordingly, in order to ensure the possible attribution of the
telehealth interventions to the national response, proper documentation of all the inputs,
processes and results registered is a key undertaking in the evaluation process. Therefore, all
actors engaged in the process of service provision, recording and reporting, resource allocation
and capacity building should pay adequate emphasis for the proper documentation of records
and reports and also should actively engage in the evaluation process that should engage relevant
actors.

19
Telehealth Guideline: Practical Tips

References

1. Telehealth Clinical Guidelines: Province of British Columbia Health Authorities, version 9,

2014
2. Telemedicine Practice Guidelines: Medical Council of India, 25 March 2020
3. Krupinski EA, Bernard J. Standards and Guidelines in Telemedicine and
Telehealth. Healthcare (Basel). 2014;2(1):74-93. Published 2014 Feb
12.doi:10.3390/healthcare2010074
4. The Guidelines provide practical advice on how to conduct telehealth consultations: Royal
Australasian College of Physicians. 2020
5. Lacktman NM. Prescribing controlled substances without an in-person exam: the practice
of telemedicine under the Ryan Haight Act. Health Care Law Today, April 17, 2017

20
 Telehealth Guideline: Practical Tips

Annexes I: Flow Chart for Follow up Tele-consultation

21
 Telehealth Guideline: Practical Tips

Annex II : List of selected indicators to monitor the telehealth initiative

NO Objectives/Activities Indicator(s) Data source Means of verification/ Responsible body Reporting
Method of Data collection frequency
1 Print and distribute the No of health facilities which Administrative records  Administrative reports Health facilities and health Once/ Startup
telehealth guideline received the telehealth  Supervisions administrative units, MOH
guideline  Rapid assessments

Number of telehealth Administrative records  Administrative reports Health facilities and health Once /Startup
guidelines printed and  Supervisions administrative units, MOH
distributed  Rapid assessments
2 Build the capacity of health Number of health care Administrative records  Administrative reports MOH, health administrative Quarterly
care workers on telehealth workers trained on Training reports  Supervisions units, partners
telehealth and the  Rapid assessments
telehealth guideline

Number of health facilities Administrative records  Administrative reports health administrative units, Quarterly
which have at least one Training reports  Supervisions health facilities
health care worker trained  Rapid assessments
on telehealth and the
telehealth guideline
3 License medical Number of medical Administrative records  Administrative reports health administrative units, Quarterly
practitioners to provide practitioners licensed to  Supervisions health facilities
telehealth services provide telehealth services  Rapid assessments
(By type of specialty)

4 Implement telehealth Number of health facilities Health facility  Administrative reports Health facilities and health Quarterly
programs implementing telehealth administrative records  Supervisions administrative units
program by a licensed SOPs  Rapid assessments
medical practitioner (By
type of services)

Number of health facilities Health facility  Administrative reports Health facilities and health Quarterly
implementing telehealth administrative records,  Supervisions administrative units
program by a licensed SOPs  Rapid assessments
medical practitioner (By
type of communication
mode (Audio, text, image)

5 Identify clients and provide Number of clients Medical records  Administrative reports Health facilities and health Quarterly
telehealth service identified for telehealth  Supervisions administrative units
services (By type health  Rapid assessments
care services)
Number of clients provided Medical records  Administrative reports Health facilities and health Quarterly
with telehealth services (By  Supervisions administrative units
type health care services)  Rapid assessments
6 Prepare SOPs to guide the Number of health facilities Administrative Administrative reports Health facilities and health Quarterly
process of telehealth which have operationalized records, administrative units
service SOPs Endorsed SOP Supervisions
Rapid assessments
7 Ensure quality of Number of health facilities Administrative  Administrative reports Health facilities and health Quarterly
telehealth services which have prepared records,  Supervisions administrative units
and/or are using protocols  Rapid assessments
for referral for emergency
services
Number of facilities which Administrative  Administrative reports Health facilities and health Semi-annual
carried out client records,  Supervisions administrative units
satisfaction assessments  Rapid assessments

22
View publication stats

የዜጎች ጤና ለሃገር ብልጽግና!

HEA LTH I E R C I TI Z ENS FOR PR OS PE R O US NATI ON!

MINISTRY OF HEALTH-ETHIOPIA