The devastation caused by the coronavirus pandemic has made it clear that profound changes are needed in the way we live. Everything people do -- from work to school, travel and other activities -- is being reimagined.
Even sectors once considered recession-proof, such as healthcare, are being compelled to change. For the last few months, many hospitals have been forced to prioritise treatment of Covid-19 over everything else. Patients seeking treatment of other conditions have been afraid to visit hospitals or clinics for fear of exposure to the virus.
One positive sign that has emerged, however, is that telehealth is finally getting the attention it deserves. Long considered a niche or nice-to-have service, remote consultation and treatment aided by technology is now being viewed as a better way to deliver a lot of basic health services.
Telehealth, also known as telemedicine, employs means such as video conferencing, remote monitoring, electronic consultations and wireless communication to exchange information for the diagnosis and treatment of diseases and injuries, research and evaluation, as well as continuing education of health professionals.
It is seen as a valuable contributor to universal health coverage, offering accessibility and cost-effectiveness, benefiting those in remote areas, vulnerable groups and ageing populations.
When the World Health Organization did a thorough survey of the state of telehealth in 2010, 70% of its member states reported that they had adopted telehealth to a certain extent. Some said they had a specific national telehealth policy and others included reference to telehealth in their national eHealth policy.
At the time, the UN agency said the main barriers to broader adoption of telehealth were a lack of funding to develop and support telehealth programmes, lack of infrastructure (equipment and/or connectivity), competing health system priorities, and a lack of legislation or regulations.
But the Covid-19 pandemic is now driving changes that otherwise might have taken years or decades to bring about. In the healthcare sector, telemedicine in particular is seen as a way to greatly improve the efficiency of service delivery.
With telemedicine, patients don't have to come to the hospital unnecessarily, which frees up hospital resources and caregivers' time for more acute cases. This in turn could lead to financial savings for both public hospital systems and private providers.
"It complements the treatment. For example, video conferencing is very helpful, especially for screening and examination of some parts of the body or determining common injuries," said Dr Itthipon Wongprom, a clinical instructor with the Department of Family Medicine at Ramathibodi Hospital, the teaching hospital of Mahidol University.
Like many other health professionals, Dr Itthipon said he has experienced good outcomes with telemedicine so far.
Even though the Ministry of Public Health has been trying to incorporate some elements of telehealth into medical practice for some time, it has encountered pushback as some practitioners were reluctant to change their behaviour. But the pandemic has changed some minds.
Some doctors, according to Dr Itthipon, are still reluctant to employ telemedicine because of potential legal concerns. Also, there are no clear guidelines on the use of telemedicine in Thailand.
Dr Itthipon Wongprom, clinical instructor at the Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University SUPPLIED
PRIVACY AN ISSUE
He acknowledges that privacy, both of practitioners and patients, is also a major concern as health information is often transmitted over the public internet. "Even though there hasn't been a case, we have to be careful about the aspect of confidentiality," he said.
In the future, he said, more in-house or secure systems, running on virtual private networks, may be developed to improve accessibility and trust.
In the short run, he says, people without internet access at home can be encouraged to visit tambon health promotion hospitals if they need to participate in a video call with doctors or practitioners.
Family physicians such as Dr Itthipon also see an opportunity to utilise telehealth in palliative care practice for people nearing the end of their lives. It is typically difficult for such patients to come to the hospital, so most are looked after at home by caregivers.
"Usually the treatment of palliative patients involves consulting medical records and talking to those who are close to the patient. This can be done using video conferencing," he explained.
"Telehealth cuts unnecessary costs such as coming to see the doctors at the hospital, allowing caregivers to use the saved resources to improve the quality of life of patients in the last stage of life."
The benefits of telehealth can be especially profound for patients with chronic diseases such as diabetes or hypertension. They usually have to visit doctors and spend hours waiting for the results of blood tests, but now they can just have their blood drawn and go home, and receive the results later.
Records for treatment of non-communicable chronic diseases such as diabetes can be combined with telehealth to offer the delivery of healthcare with less complexity.
At Ramathibodi Hospital, the risk of patients being exposed to the coronavirus is also being reduced with the help of telemedicine and related services. Patients who cannot make it to the hospital don't have to come. Those whose medical records indicate a need for follow-up or continuing treatment will be contacted by hospital staff. Medicine can also be delivered to their homes as needed.
While using telemedicine is efficient, it is still not as "lean" as it could be because there are many procedures and complicated protocols. In the future Dr Itthipon foresees that hospitals will be able to improve the system and address some of the underlying issues to deliver services more efficiently.
Another advantage of telehealth is its use in preliminary screening. Doctors can talk to caregivers to determine whether the symptoms can be treated at home or whether the patient needs a physical examination at the hospital.
Even though there is sometimes no substitute for seeing a patient and examining them physically, telehealth is a complementary force for delivering good care. "Some conditions mandate a physical examination. Nothing beats physical contact. Telehealth is not a substitute, but it can complement the treatment," said Dr Itthipon.
Fear of Covid-19 is keeping people away from hospitals, which many now realise they didn't need to visit in the first place, says Dr Kittipob Kirdpun, acting director of Thaicharoen Hospital in Yasothon. SUPPLIED
RURAL PATIENTS
In Southeast Asian nations where hospitals and practitioners are scarce outside of major cities, sometimes patients have to travel a long distance to see a doctor. Telehealth can be utilised in rural areas to help narrow the healthcare disparity. As a means to deal efficiently with everything from minor emergencies to mental health, its importance can be profound.
Dr Kittipob Kirdpun, acting director of Thaicharoen Hospital in Yasothon province, told Asia Focus that even in a hospital as far away from a major city as his, Covid-19 has disrupted how healthcare is delivered. But he sees it as both a crisis and opportunity.
Prior to the pandemic, the 30-bed northeastern hospital with a handful of doctors was usually overflowing with patients, with inpatients filling 70% of bed capacity and 200 to 300 outpatient visits each day. Dr Kittipob and his staff were accustomed to challenges.
"When the pandemic struck, only 25% of the usual number of patients remained," he said. "The fear of Covid-19 made some patients scared to come to the hospital, but it also made them realise that some illnesses don't really require them coming to the hospital since they can go away on their own."
The decline in numbers led to an opportunity to reimagine how healthcare is delivered. Even though patients cannot come to the hospital, treatments can continue.
Thaicharoen Hospital employs telemedicine to deliver uninterrupted healthcare to patients. With the help of the provincial public health office, it is able to seek the help of the network of village health volunteers who are familiar with the community to take care of patients and deliver medication to them, while some patients who need more attention will receive a doctor's visit.
"Normally patients in rural areas are faced with financial constraints as hospitals are usually scarce and they have to pay beyond their means to come to the hospital, even to get their dose of monthly medicine," said Dr Kittipob. "Now hypertension and diabetes patients can just wait and have their medication delivered to their houses."
Non-emergency cases have disappeared at the Yasothon hospital because of concerns about the coronavirus, but that could become the norm even after the pandemic passes if telehealth catches on.
With telemedicine, doctors can talk to more vulnerable people without them having to come in and pay extra money.
Nonetheless, some things cannot be replaced. A physical examination is still important because sometimes patients need to see a doctor to be reassured and advised. But in the future when technology such as virtual reality or holograms are more developed and become cheaper, doctors will be able to perform even more detailed examinations remotely.
For now, with the help of cloud services and artificial intelligence, even small hospitals such as Thaicharoen Hospital are finding useful applications. For example, screening for tuberculosis in the population of 30,000, which usually takes a month to complete, is now digitised and can be done in a matter of days.
"It's more reliable than in the past, time-efficient and cost-effective," said Dr Kittipob.
The Doctor Raksa app developed for Bumrungrad Hospital in Bangkok provides teleconsulting services. Photo: RAKSA APP
FUTURE PROSPECTS
The shift to telehealth is perhaps most profound in the United States where in 2019, even before the pandemic forced a lot of interaction to go contactless, 76% of US hospitals reported using video and other technology to connect with patients and consulting practitioners at a distance, according to the American Hospital Association.
However, there were still barriers to adoption because Medicare usually limited non-traditional medical encounters such as remote consultations. Most telehealth visits were not covered by private or government insurance or doctors' malpractice insurance.
But as the emergence of the pandemic drew attention to the value of remote consultation and treatment, telehealth is being acknowledged by regulatory bodies and rules are being adjusted.
The use of telehealth is permeating all areas of medicine including reproductive health. This even extends to abortion counselling and provision of medication to terminate a pregnancy.
TelAbortion was begun in 2016 by a non-profit group as a research study to evaluate the use of telemedicine for providing a medical abortion to those who prefer to receive abortion pills in the mail. It has now expanded from serving five states to 13. As of April 22, the programme had mailed a total of 841 packages of abortion pills, and confirmed 611 completed abortions.
In Asia, where populations in many countries including Thailand are greying rapidly, telemedicine is expected to be utilised even more. Elderly people with chronic conditions such as diabetes and hypertension need to meet doctors frequently, but coming to the hospital is time-consuming and sometimes difficult.
Japan and Singapore are now exploring the possibility of offering mobile medicine to their ageing populations. For example, diabetes patients can get their blood tested at home and follow up via a remote consultation.
Microsoft has now introduced a cloud service tailored especially for the healthcare sector, allowing participating practitioners and facilities to use it cost-free for the first six months.
The messaging platform Line, the runaway market leader in Thailand, is planning to launch a telemedicine business this summer in Japan to cater to fast-growing demand amid the coronavirus pandemic. It expects more than 2,000 doctors to sign up to its video conferencing system initially.
The new app will be operated by Line Healthcare, in which Line has a 50% stake. Line sees the app as offering seamless service covering medical treatment, drug prescriptions and payment. Although many hospitals and pharmacies have not yet adopted e-payments, Line will encourage them to introduce such services if they use its app.
For many companies, the shift to telehealth is profitable. The new normal has brought a surge daily online consultations. For example, the French telemedicine application Doctolib is seeing boom in online medicine since the virus emerged, with consultations surpassing 100,000 on some days, far exceeding its expectation to reach 2,000 a day by the end of this year.
As patients and doctors go online to avoid physical contact, the company said the number is 100 times higher than the number before the crisis started.