Specialists and GDMOs with PG degree from Wellness Centres/ Government hospitals visiting CGHS Wellness Centres

CGHS Wellness Centres

F.NO.20-2/2021-2021-CGHS/CZ/DIR/CGHS
(E file no. 8139325)
Government of India
Ministry of Health and Family Welfare
Department of Health and Family Welfare

Nirman Bhawan, New Delhi
Dated: /05/2022

Office Order

Subject: Guidelines & Standard Operating Procedure for specialists and GDMOs with PG degree from Wellness Centres/ Government hospitals visiting CGHS Wellness Centres

Background:

Consultations related to various medical specialties are frequently required by CGHS beneficiaries for which they are referred to empanelled HCOs and government hospitals often remotely located. Presently in GDMO cadre, a number of doctors have post graduate degree, whose services can be utilized, thereby easing the burden of time consumed in availing specialty services by CGHS beneficiaries.

With the intent to reduce referrals to empanelled hospitals and increase the in-house specialty facility for CGHS beneficiaries, it is proposed to deploy more GDMOs with PG degree to attend to patients in their area of specialization, in addition to the GDMOs with PG degree already working similarly and specialists/GDMOs from RML and Safdarjung Hospital CGHS Wing who are visiting CGHS Wellness Centres. These GDMOs with PG degree shall be deployed as mentioned above, in Wellness Centres of their city (and preferably in own zone in Delhi) as of now, as a Pilot Project for 60 days. Specialties chosen are Internal Medicine, Pediatrics, Gynecology and Dermatology. (Orthopedics is a preferred specialty however GDMOs with PG in Orthopedics are not currently available in Delhi and outside Delhi Wellness Centres. They shall be included as and when available). The Additional Director of zone/city would be required to create a roster for deployment of GDMOs with PG degree in their zone/city WCs, in addition to the GDMOs with PG degree already working similarly and specialists/GDMOs from RML and Safdarjung Hospital CGHS Wing who are visiting CGHS Wellness Centres.

Guidelines & Standard Operating Procedures:

1. Responsibilities of specialists and GDMO with PG degree from Wellness Centres/Government hospitals visiting CGHS Wellness Centres:
   1. The designated GDMOs with PG degree posted in Wellness Centres shall be visiting other Wellness Centres from 7.30am to 2.00pm. During the Pilot Phase of 60 days, the visit of such doctors would be once a week, to the assigned Wellness Centres. An analysis of the number of patients attended by each newly deployed visiting GDMO with PG degree on a day, shall be carried out at the end of 60 days by the respective zones/cities to decide whether the number of days of visit in the month is to be increased or decreased, for optimum utilization of the GDMO.
   2. The visiting GDMOs with PG degree (VGP) shall not be exempted from emergency duties such as night duties/afternoon duties in the 24 X 7 Wellness Centres in Delhi.
   3. In case of planned/sanctioned leave, the visiting doctor (from Government Hospital or another Wellness Centre) shall inform the CMO I/C of the visited Wellness Centre(s) AND Nodal Officer for 24*7 emergency duties (as the case maybe), well in time before the duty roster is readied, for adjustment of emergency roster and Online Appointment roster, respectively.
   4. Mandatory use of computer while attending to patients:
      1. The visiting doctors (visiting GDMO with PG degree (VGP), specialists/GDMOs from government hospitals and visiting contractual doctors) shall mandatorily use the doctor’s computer module available in Wellness Centres after login to cghs.nic.in, using the user ID created by Addl. Director of zone/city, to attend to patients. This user ID shall be transferred at the end of the day by CMO I/C of the Wellness Centre visited, to the next one to be visited by the visiting doctor.
      2. The visiting doctors mentioned above, shall independently work on the computer module without insisting on assistance for data entry (justification:
         1. Data Privacy Policy of Government of India
         2. past experience with dependence on non-medical outsourced resources for entering patient details and medicines in the computer module has resulted in prescription errors, detrimental to patient care).
      3. All visiting doctors whether from government hospitals or Wellness Centres, shall access the pharmacy stock online to prescribe available medicines in the Wellness Centre, or prescribe from within the CGHS formulary, to the maximum extent possible. The medicines shall be issued from the visited Wellness Centre’s stock and indent placed to the Authorized Local Chemist of the visited Wellness Centre.
      4. While issuing/indenting medicines for a beneficiary, the visiting doctor shall check the “history” of previously prescribed medicines to ensure that the medicines being prescribed are not already available with the beneficiary and that they do not have adverse reaction with medicines being taken by the beneficiary as advised in earlier visits. The total quantity of issued/indented medicines may be adjusted accordingly.
      5. Medicines that are available in the Wellness Centre but have been indented by the visiting doctor shall be rectified online by the CMO I/C, before submission of indent.
      6. In case a beneficiary wishes to get medicines from his parent Wellness Centre rather than the visited Wellness Centre, the visiting doctor would be required to enter online, the NAMES of medicines to be issued/indented with the DOSAGE and TOTAL DURATION mentioned against each, but with quantity as zero, to maintain an online record of the prescription. The beneficiary would be required to visit his parent Wellness Centre and get the medicines issued and indented as per availability in that Wellness Centre and total quantity required (based on medicine-wise dosage and duration already entered by the visiting doctor and seen in “history”). Hand written prescriptions shall not be issued by visiting doctors (whether specialist or GDMO with PG degree or consultant) except in exceptional circumstances when the net connectivity/power/server is down. In such cases, the prescription validity shall not be more than 01 month and during subsequent visit, the details in the handwritten prescription shall be entered online in the module by the visiting doctor.
      7. As a routine, issue/indent shall be done for a maximum period of 03 months; however, if next visit is required after 06 months/ a specified time period, the same shall be mentioned in the “Remarks” Column.
      8. Two copies of the prescription shall be handed to the beneficiary. One copy shall be used on the same day to collect his/ her medicines. The other copy duly stamped by the visiting doctor would be used by the beneficiary as a prescription when they come for subsequent visits in the following months. This copy would be valid only for the duration mentioned (in the Remarks column) by the visiting doctor of the concerned specialty, in the prescription.
      9. Symptoms, examination findings, investigation reports and diagnosis shall be saved in the doctor’s Module under “Examination”.
      10. The visiting doctor of the concerned specialty shall advise investigations as far as possible from CGHS own labs and collection centres using the “CGHS Lab” option in the doctor’s module.
      11. The visiting doctor of the concerned specialty, depending on requirement, shall issue referral to the beneficiary for consultation, listed investigations and procedures, to be carried out in “any empaneled HCO” through the online Referral Module, so that the beneficiary is not required to visit a GDMO of the Wellness Centre again, for an online referral.
      12. Any unlisted procedure/investigation advised by the visiting doctor may be typed in the “Remarks Column” and stamped print out issued to the beneficiary. In case of a pensioner beneficiary, the CMO I/C may refer the beneficiary to the Additional Director for issue of permission for unlisted items.
      13. Visiting doctors requiring hand holding for using the GDMO Module shall email a request to [email protected] along with their mobile number and place of posting. Online training through VC mode (Microsoft Teams/ Google Meet) shall be imparted to groups of visiting doctors. Any inputs for modification in the computer module may also be emailed to [email protected].
2. Online appointment for visiting doctors:
   1. As “Specialist” online appointments can be taken 30 days in advance, CMOs I/C shall ensure that online roster for visiting doctors at their Wellness Centre for the month of visit, is posted online in the Appointment System between 20th and 30th of the current month, indicating the dates when the visiting doctors would be available for consultation.
   2. Number of appointments for the visiting doctors (“specialists”) shall be ordinarily limited to total 60 patients per day (50 for online and 10 for walk-in beneficiaries). (This information shall be widely disseminated to beneficiaries through SMS, and notice board display in Wellness Centres). The number of walk-in beneficiaries can be increased to more than 10, on mutual consent of the visiting doctor and the CMO I/C, over and above the total 60 patients per day scheduled in 50:10 online : walk-in ratio. Beneficiaries who are not computer savvy shall be assisted by staff in the Wellness Centre, to book the 50 online appointments for “specialists”, during the 30-day window period for online “specialist” booking.
   3. In case of emergency leave of the visiting doctor, the beneficiaries who have already taken appointment and wish to get medicines repeated based on a previous prescription by the same doctor, shall be required to meet the CMO I/C for issue/indent of chronic ailment medicines for 30 days or as per discretion of CMO I/C depending on medical condition of the patient.
3. Role of Addl. Director:
   1. The Additional Director of city/zone would be required to create a roster for deployment of GDMOs with PG degree in their city/zone WCs, in addition to the GDMOs with PG degree already working similarly and specialists/GDMOs from RML and Safdarjung Hospital CGHS Wing who are visiting CGHS Wellness Centres. The roster may be created within 05 working days.
   2. Addl. Director of the city/zone shall thereafter, share the SOPs with their Wellness Centres/Polyclinics and issue official orders assigning the visiting GDMOs with PG degree (VGPs), the days and Wellness Centres to be visited, mentioning the name, designation of the GDMO and the field of specialization (Eg., Dr ABC, SMO, Internal Medicine). Saturdays and Mondays may be avoided being days with increased patient load. During the Pilot Phase of 60 days, initially only one day a week for each visiting GDMO with PG degree would be designated for visit to another Wellness Centre.
   3. Addl. Director CGHS (HQ) shall hold meeting with In charge CGHS Wing of RML and Safdarjung Hospital in this regard including mandatory use of computer by all visiting specialists to CGHS Wellness Centres (as directed in the meeting on 11/04/2022).
   4. At the end of the 60-day Pilot Phase, Addl. Directors of city/zones shall analyse the number of patients attended by each VGP in their city/zone and accordingly increase or decrease their frequency of visits.
   5. Addl. Directors of the city/zone shall ensure that user ID and password for logging into doctor’s computer module are created for all visiting doctors whether from Government hospitals or GDMOs with PG degree or contractual doctors. They shall also ensure availability of separate room, internet, availability of desktop computer and peripherals including printer for use by the visiting doctors, along with an examination table, foot stool, BP instrument, folding screen, equipment for PV examination (for gynecologists), autoclave, stadiometer and weighing machine. Full length A4 sheets would also be provided to the visiting doctors.
   6. In order to ensure that the night/afternoon duties of VGPs do not fall on the days of their visit to other Wellness Centres, Addl. Directors of each zone/city shall share the detailed VGP roster with the respective Nodal Officers who finalize the roster for the emergency duties. The concerned Nodal Officers shall ensure that the emergency duties of these doctors do not fall on the same day as their visiting days [for male GDMOs, the nodal officer shall also consider the subsequent day (post night duty off)]. For other duties requiring long absence from Wellness Centre duty, the VGPs may be deployed for such duties as a last resort, to avoid inconvenience to beneficiaries.
   7. After completion of PG Degree, the GDMO doctor on joining back or any fresh appointee with PG degree shall be included in the roster of visiting doctor if consent is provided. Also CMO I/C with PG degree may be considered as VGP, if consent is given, as only once a week visit to another Wellness Centre would be required.
   8. Telemedicine: Shall be conducted from a location in the office of Addl. Director of city/HQ only and not from any Wellness Centre or home. In the event that the patient load for a particular specialty is less, then the telemedicine may be linked to a hub in Safdarjung Hospital (in case of Delhi) where the concerned specialist of Safdarjung would attend to the patients online. Necessary instructions in this regard are to be conveyed to all cities by ADDG (HQ) and to telemedicine team in Delhi by AD (HQ).
4. Role of CMO I/C:
   1. The orders regarding deployment of GDMOs with PG degree with their days of visit may be displayed on the notice board of all Wellness Centres for information to the beneficiaries.
   2. It may also be clearly displayed on the Notice Board that ordinarily 60 appointments per day would be scheduled for visiting doctors in the ratio of 50 online appointments and 10 walk-in appointments. Walk-in appointments can be increased more than 10, over and above the total 60 patients per day scheduled in 50:10 online : walk-in ratio, on mutual agreement with the visiting doctor. Beneficiaries who are not computer savvy shall be assisted by staff in the Wellness Centre, to book online appointment for “specialists”, during the 30-day window period for booking. MCTC may be contacted for hand holding in this regard.
   3. Official stamp to be used on the computer generated prescription, with the doctor’s name, GDMO designation and specialization shall also be provided to the VGP by the CMO I/C of the Wellness Centre visited. (Eg: Dr ABC, SMO, Internal Medicine).
   4. The CMO I/C of the Wellness Centre visited shall place demand to Addl. Director Zone/city for items (if not available) required by the visiting doctor as mentioned in (III) e above i.e., desktop computer and peripherals including printer for use by the visiting doctors, along with an examination table, foot stool, non-mercury BP instrument, folding screen, equipment for PV examination (for gynecologists), autoclave, stadiometer and weighing machine.
   5. The CMO I/C of the parent Wellness Centre of the VGP shall not retain him/ her in the parent Wellness Centre on his specified day of visit to another Wellness Centre, either due to shortage of doctors in his parent Wellness Centre or any other reason, as this would then become a regular feature and the intent behind the whole exercise would fail, in addition to harassment to beneficiaries who have taken appointment for the VGP. However, the VGP on visiting the other Wellness Centre, may be requested by the CMO I/C of that WC, to assist in attending to general patients, in case the requisite 60 patients have not taken appointment for the day.
   6. After the day’s patients are attended by the visiting doctor, after 2.00PM the CMO I/C of the visited Wellness Centre shall transfer his/ her user ID to the other Wellness Centre/parent Wellness Centre, scheduled to be visited by the VGP.
   7. The CMO I/C of the parent Wellness Centre of the VGP/ specialist/GDMO from government hospital shall ensure that information regarding planned/sanctioned leave is conveyed well in time, before the month’s emergency roster/ Online Appointment System roster is readied by Nodal Officer/ CMO I/C of visited Wellness Centre.
   8. In case of emergency leave by visiting doctor, the information shall be posted in the Online Appointment System. In case the beneficiaries who have already taken appointment, wish to get medicines repeated based on a previous prescription by the visiting doctor, CMO I/C shall issue/indent chronic ailment medicines for 30 days or as per discretion of CMO I/C depending on medical condition of the patient.
   9. The CMO I/C of the visited Wellness Centre shall not refuse issue/ indent of 03 months medicines prescribed by visiting doctor to beneficiaries of any Wellness Centre. However, medicines that are available in the Wellness Centre that have been wrongly indented by the visiting doctor, shall be rectified online by the CMO I/C.
5. Role of MCTC and NIC:
   1. The date-wise record of online prescription complete with clinical notes, referrals and medicines prescribed shall be made available to the visiting doctors under “history”.
   2. NIC shall ensure that separate print out can be taken out for medicines prescribed, online referral and examination findings, if required or all on a A4 sheet.
   3. The CGHS dashboard shall be modified to display data related to total number of visiting doctors who are registered in the doctor’s Module and total number who are using the doctor’s Module as visiting doctors to attend to patients.
   4. Number of appointments for visiting doctors shall be ordinarily limited to 50 for online appointment and 10 for walk-in beneficiaries. This information shall be widely disseminated to beneficiaries through SMS.
   5. CMO I/C cannot change a medicine indented by any doctor (GDMO/VGP/specialist from government hospital/contractual doctor), by indenting another medicine of a different brand, without entering the reason in the module. Once changed, the name of CMO I/C shall appear against the indented medicine, along with reason.
   6. MCTC shall conduct online demonstration in groups for visiting doctors to work online using the doctor’s module and for any staff wanting to be trained in booking online appointment (email request may be sent by doctor/CMO I/C to [email protected]).

(Dr Nikhilesh Chandra)
Director CGHS