[OPINION] Telemedicine and the digitization of health care

The “enhanced community quarantine” over Luzon and the pervasive communal fear of contracting COVID-19 have limited population movement, and the effects on Filipinos’ health-seeking behaviors are tangible. Before this pandemic started, many patients would come to our clinic to have a two-day history of dry cough evaluated, or a bout of headache noted after 4 uninterrupted hours of playing Mobile Legends remedied.

Now, more and more Filipinos are limiting their trips to the doctor only for emergent and urgent concerns, at least from the patient’s perspective. And for good reason. After all, the benefits of having one’s allergic rhinitis relieved or one’s acne cleared at this time may be outweighed by the risks of being exposed to and potentially contracting SARS-CoV-2. 

It is, hence, unsurprising why telemedicine is increasingly becoming an attractive alternative. The term “telemedicine” is often used interchangeably with “telehealth,” but the Health Resources and Services Administration puts forth a distinction: the former refers to remote clinical services such as diagnosis and monitoring, whereas the latter includes preventive, promotive, and curative care delivery which would, therefore, encompass telemedicine. The methods of delivering telemedicine are varied, ranging from the use of mobile devices (popularly called “mHealth”), telephones, and instant messaging (IM) software applications, to synchronous live video modalities (also called “videotelephony”).

The Department of Health, aside from setting up hotlines for COVID-19-related concerns, has partnered with Medgate Philippines and Global Telehealth, Inc., among other telemedicine providers, to remotely connect Filipinos to health care professionals. Similarly, many hospitals, clinics, and private practitioners – physicians, dentists, and even veterinarians – have begun to reach out to patients and provide online consultations via telemedicine. (READ: FDA now lets doctors issue electronic prescriptions)

Personally, I have been involved in two such endeavors: one, a chatbot-based initiative under a government tertiary hospital for COVID-19-related concerns; and another, my clinic’s online consultation services using Viber and Skype. For both, the services are rendered for free, as is the case for many other telemedicine initiatives which have surfaced in the past few months.

The most immediately obvious advantage of telemedicine particularly in these times is the potentially reduced exposure to COVID-19, among other infectious diseases to which the patient may be exposed, in and while in transit to the health facility. Telemedicine, however, offers many other benefits which cannot be overstated. Costs of transportation and physical access are virtually eliminated. For instance, though our COVID-19 chatbot-based initiative is physically based in Metro Manila, we have received consults from as far as Romblon and Davao. Telemedicine may also be favorable for home-bound individuals with limited mobility such as stroke patients. (READ: Don’t just build health infrastructure – make it SMART)

Needless to say, however, this innovation has several disadvantages, perhaps the most important of which also stems from its selling point: its non-physicality. Synchronous live video modalities enable the health care provider and the patient to see and communicate with each other real-time. We have had a number of patients who, via such modalities, had a rash or a red eye examined by available online specialists. But there is really no substitute for an actual and thorough physical exam. The doctor may “see” the patient, even in high definition, but he will be unable to auscultate his heart, listen to his breath sounds, nor feel for his pulses.

To illustrate, two days ago, a patient from Bulacan consulted via Skype. The patient was a known case of congestive heart failure, was supposedly faithful to his maintenance medications, and was reportedly fine and symptom-free until two days prior when he began to experience difficulty of breathing. For two days straight, he would feel like he is drowning whenever he would lie down. He had significantly lost his appetite, had been feeling immensely fatigued, and was now unable to sleep. I asked him to check and feel if his feet were swollen and, to his surprise, he could now indent both with his fingers. Without the benefit of an actual physical exam, I advised him to go to the nearest hospital for further evaluation and management.

Second, in telemedicine, data privacy and security become increasingly crucial concerns. A patient divulges highly sensitive information to his doctor in trust; only the doctor should have access to this information. Any breach in the confidentiality of this information is, doubtless, unacceptable. Similarly, though most telemedicine platforms have safeguards against fraud, verification of the patient’s identity is still a concern.  

Thus, in the setting of telemedicine, informed consent – the process by which the health care provider educates a patient about the risks, benefits, and alternatives of a proposed medical intervention and to which the patient consents or declines – can become tricky. Traditionally, the informed consent is established between the doctor and the patient. However, because telemedicine also involves the technology providers, the consent should disclose all other parties involved in the transmission, storage, and protection of information. 

To date, there is no Philippine law specifically concerned with the regulation of telemedicine. As its utility expands, so will the need for clear policies on the extent and limitations of services that can be provided, credentialing of health professionals engaged in telemedicine, telecommunications infrastructure, patient data privacy, and quality assurance (QA) of telemedicine providers. A more elusive though ultimately necessary undertaking is the creation of guidelines on what constitutes “good” or at least acceptable practice of telemedicine – and what, therefore, constitutes malpractice. (READ: FDA orders Shopee, Lazada to stop online sale of medicines)

Without a doubt, there is no replacing face-to-face interaction between doctor and patient. After all, at the heart of every doctor-patient relationship is mutual navigation: both make sense of the patient’s concerns and both ultimately agree upon a particular recourse. But in cases where the benefits of this physical interaction may be outweighed by the risks of disease, danger, or distance, telemedicine presents a promising and novel alternative. – Rappler.com

Jose Ma. H. Zaldarriaga, MD-MBA, a graduate of the Ateneo School of Medicine and Public Health (ASMPH), divides his time as a general practitioner in a polyclinic, a company physician, a moonlighter in a public hospital in Pasig City, and a data analyst for the Department of Science and Technology.