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Telemedicine in the Philippines

When you’re told you only have seven minutes to speak on a topic that is as broad as “telemedicine in the Philippines” but that you can choose three talking points … THAT is difficult! Writing this post to share my “script” -yup, I did something I don’t usually do. I’m grateful to Vladimir Choi for inviting me to this WHO webinar panel. And if you ever find yourself on a panel with Prof. Vivian Lin moderating, be prepared. The most difficult question she asked me was, “If you were in the elevator with your health minister, what would be your pitch for #telemedicine?”

My precious 6 slides (actually it’s only five, as the first is a disclosure slide)

Good morning. I have no disclosures. This presentation is solely my own, as seen from the lens of a clinician and an academic.

Telemedicine in the Philippines. The three points I want to convey are these –
First, human experience, technological opportunity and sustainability are determinants of the implementation outcomes in telemedicine. Second, CoVID-19 pandemic-related use of telemedicine highlighted existing health disparities. And lastly, healthcare workers need telemedicine competencies.

More than a decade ago, Dr. Marcelo wrote about the approach to the implementation of telemedicine in the Philippines. He said, start from where people are. Before the pandemic, I didn’t offer video teleconsultations but now, with the help of their more tech savvy grandchildren, some of my elderly patients are able to see me online. When asked, most of them still prefer in-clinic visits but their families are afraid to let them out of their homes. At one of these televisits, my patient, an elderly woman said, I only need to see or hear you doctor to feel better. Perhaps this poignant, very human experience of telemedicine will lead to its acceptance eventually for the tech-challenged. Yesterday on Twitter, I asked young physicians serving in geographically isolated and disadvantaged areas about telemedicine, and technological opportunity. That the technology to be used in telemedicine should be appropriate, available, accessible and culturally acceptable. And one of them asked me, will it run offline? What happens when there is no electricity? Is the software interface user friendly? While these rural doctors recognize the potential of telemedicine, there is also a realization that telemedicine alone cannot fill in the gaps of a weak health system. For example a telereferral is made and surgery is deemed necessary, but there is no ambulance to transfer the patient. A medication or procedure is advised but it is not available in the locality. Third, sustainability. How can telemedicine be embedded in the local fabric? In 2006, the National Telehealth Center provided remote sites with work stations and broadband internet connection for referral of difficult cases to experts in a central facility. No referrals were made until the system was shifted to SMS. Using mobile phones was already embedded in the remote physicians’ workflow.

The National Telehealth Center was established in 1998 with the mission of engaging communities in the design, development and use of appropriate and progressive information and communication technology towards better equity in health. The center is under the National Institutes of Health in the University of the Philipines Manila, which sits in the National eHealth Steering Committee that oversees the Philippine eHealth Strategic Framework and Plan, that was laid down since 2013 following the elements of the WHO-ITU national ehealth strategy toolkit. In the implementing rules and regulations of the recently passed Universal Healthcare Act, the Philippine Health Insurance Corporation was tasked to incentivize the integration and use of telemedicine. Previous ehealth bills however despite several attempts have not passed the legislature. As part of the pandemic response, the Department of Health issued joint memorandum circulars with the National Privacy Commission and the University of the Philippines Manila for telemedicine to be used as a complementary method for patients to access health services. The Food & Drug Administration has allowed the use of eprescriptions. And lastly, under the Department of Information and Communications Technology Act of 2015, there is the national broadband plan to accelerate the deployment of fiber optic cables and wireless technologies to improve internet speed. All these will hopefully provide an enabling environment for telemedicine in the Philippines.

Amid the pandemic, a group of faculty and volunteer graduate students at the University of the Philippines Medical Informatics Unit drafted telemedicine guidance documents which can be found in the link shown on the slide. We hesitated to call them guidelines, mindful of the existing health disparities. Of what use was it to recommend 2 mbps per user for a video teleconsultation when there were those without wifi access? How could we recommend a 5 to 8 megapixel camera for patients to capture medical images or a private well-lit room for the urban poor? Most would recommend not using social media platforms because of data privacy and security, but what if these platforms have free data packages and are therefore are accessible? What about messaging apps which though clearly not meant for telemedicine, but are already familiar to its users? How about using basic mobile phones and SMS for telemedicine, despite the loss of visual and verbal cues for the already limited virtual consultations, as this is more readily available? How can eprescriptions be sent to those without wifi or email?

And with the rapid shift to telemedicine due to the pandemic, it became obvious that not all healthcare workers possessed the needed competencies. Even before the pandemic, the National eHealth Capacity Building Experts group was already working on an ehealth curriculum for health professions. But now, universities have shifted to remote learning. Be it conserving PPE or quarantine regulations, there are lesser opportunities for students to see patients. Hospitals are full with patients with CoVID-19, effectively denying access to those with non-CoVID conditions like NCDs. And so televisits are being explored as a means to provide training, with virtual objective structured clinical exams for assessment. Various health organizations are crafting clinical practice guidelines for selecting patients appropriate to be seen via telemedicine, describing virtual PE manuevers and helping with the transition from bedside to webside manner.

To close … the Philippines, an archipelagic country with a limited healthcare workforce has always needed telemedicine, even before the pandemic, but maybe despite all the challenges, the time is now. Thank you.

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