HealthUP-PGH's Telemedicine

Information Technology (IT) is a great equalizer. How true that statement is turning out to be in the local health sector. It is what the University of the Philippines-Philippine General Hospital (UP-PGH) looks forward to through the National Telehealth Center’s (NTC) telemedicine program. The NTC shines with the potential to raise the Philippines’ capability to elevate health service in the boondocks to a high-technology level, particularly on the medical advice aspect, through IT. At present, UP-PGH-NTC is already integrating into its curriculum the telemedicine program as a move to train future doctors on the use of the technology. It may take five more years, though, to make it part of the standard curriculum. But even this effort may already take the country into a higher step. “Even in America, their electronic health record is not embedded in the curriculum, so we will be ahead of them,” said Dr. Alvin B. Marcelo, NTC director. More important, a telemedicine program can make available health service to isolated, remote areas that do not have any other access to a doctor. “Having a doctor by telemedicine in an area without a doctor is better than having no doctor at all,” he said. Telemedicine is of a greater need in the country than elsewhere because of its archipelagic nature. “We need e-health more than developed countries. By default, our landscape is already disintegrated. I just came from Sri Lanka. They have a very nice health system. When you look at the map, they’re just one island. You just have to take a bus to go anywhere. Here, you have to wait for a banca, for a good weather,” he said. NTC piloted its telemedicine program three years ago. It reaches out to 54 sites that meet three basic requirements-- presence of a text service or SMS (short message service), presence of at least one doctor, and the lack of the rural doctor’s competence to give a medical advice on the case. The need for a doctor’s service in poverty-stricken rural areas is so abject. There are only about 50 doctors operating in these areas, one doctor for each. Among these sites are Sulu, Batanes, Zamboanga, Tuguegarao, and Ifugao, specifically where the Department of Health (DOH) has assigned doctors under the “Doctors to the Barrios” (DTB) program. These places used to be doctor-less, until natives requested government for one. Unfortunately, there is no agency now that has a complete listing of other unreported doctor-less areas in the Philippines. DOH just learns there are areas like these when a request is made. People may have perceptions that telemedicine involves the sending of Xray, CT (computer tomography) scan, or ECG (electronic cardiogram) images via internet broadband. True, that technology exists. And that’s actually the easy part of telemedicine. But the hard part is what is NTC’s priority. It is in areas where broadband is not available, where there is only SMS, and where the need for medical advice among poor people is at the utrmost. “Places where you have broadband are places where you have doctors. So there’s no great need for telemedicine. Those that need it are the islands and the boondocks where they don’t have (specialists) cardiologists, pulmonologists,” he said. NTC should not really compete with doctors in broadband areas where there are competent specialists, or these doctors could be deprived of opportunities and choose rather “to leave the country,” according to Marcelo. The mandate of NTC, as much as of UP-PGH, is to serve the underserved, the poorest of the country’s poor. Or those that have money, but have already exhausted their resources in private hospitals in search of a faster and better service, only to get their money drained in the end, leaving them to turn to a government hospital. It is for the good of the patients too that NTC does not compete directly with local doctors in broadband areas. This way, when emergency occurs, they can turn to these doctors “who can touch them.” “We don’t want to bypass local doctors. They’re there, they’re good . They can touch the patient, we cannot. They can provide better health care than us. We don’t do telemedicine there, or we’ll even screw up what’s already a screwed up health system.” In telemedicine, a DTB doctor calls for help via SMS to doctors based at the UP-PGH linked through NTC. He sends to NTC a request for a specialist’s advice or an advice on a medical case he does not have expertise in. He sends this request in a specific format—one that contains an objective, a subjective, an assessment, a plan. A complete referral under the medicine profession requires these. “That’s why doctors to the barrios are not deployed without training. They can’t just text ‘A 27-year old female with fever. What will I do?’” The NTC then refers the DTB to a specialist at UP-PGH such as to Dr. Collante on an ear complaint or Marcelo himself on surgery. NTC then sends back the medical advice to the barrio-based doctor. Training of doctors in telemedicine is very important and is one area NTC is carefully putting its efforts into. It plans to integrate this training program in a medical education’s curriculum and also plans to get other schools to use this curriculum under a franchising system. At the scale it has been operating in isolated areas, NTC has observed brisk growth in the need for telemedicine. From only eight referrals from DTB doctors in 2006, this rose to 600 in 2007. With an expansion, this can grow exponentially. The real limitation is in the number of doctors in the barrios.

Such limitation of doctors in remote areas make NTC’s present staff of two doctors and two nurses over-manned. “What we want to do is to increase the number of doctors until we saturate our existing resources, and then we’ll get another block of two nurses and two doctors.” An increase in number of referrals may happen once the program is opened up to more doctors in the country and in more areas. Its application on chronic diseases or preventive health—for diabetes or hypertension—may readily cause an increase in the referrals. If the program ever expands to 2,700 municipalities in the country, it will have 27,000 cases in a year at a rate of 10 referrals per day. For its benefit to reach to more remote islands, support from local government units (LGUs) is a must. But to encourage the support of LGUs and other sectors, drawing up a master plan is also a necessity. The Department of Science and Technology (DOST) already has an IT plan which is one component of an e-health master plan. But a master plan will maximize its application. The Philippines can link with other countries that have their own e-health master plan possibly through a workshop such as one to be held in Luxembourg in April this year. “I can write the master plan myself, but unless you’re in a position to do that, unless there’s an imprimatur, and unless Smart, Globe, the local government, PGH, Medical City will agree on their role in it, it’s nothing,” Marcelo said. Thus, there goes the need for the government itself to do the roadmap. To put up infrastructure for SMS in farflung areas, telecommunication companies (telcos) need assurance that their service will be needed. “If there’s no master plan, efforts will be scattered, telcos will not invest,” he said. Given an opportunity, SMS service from telemedicine can bring huge value to telcos. The Philippines can actually take it from countries like Maldives or Belize that already have their master plans on e-health and collaborate with the International Telecommunications Union on a draft. It can also look at models in successful telemedicine program in countries that have small population such as in Singapore, where all residents have an ID, and in Hongkong. Aside from the investments of telcos on SMS infrastructure, a telemedicine program won’t really require huge costs. On the part of DTBs, the only investment may be on cellphones. A digital camera is an extra useful tool. The presence of a computer in a DTB doctor’s hand is already a bonus. A possible cost on the part of the government is in salaries of doctors, perhaps P50 per hour per doctor, if more DTB doctors will be deployed. Telemedicine for the country’s hinterlands is really simple. But the critical issue here is the authenticity of the transactions and of those involved. Even in face-to-face consultations, misrepresentations are already happening-- non-doctors faking their identities, Marcelo stressed. Ethics and security are an essential part of a successful program. Here is where legislation should come in for which NTC is working with the congressional Commission on Science, Technology, and Engineering (COMSTE). A telemedicine law should define a legitimate telemedicine transaction, how it can be reimbursed by the Philippine Health Insurance system (Philhealth), qualified operators of a telemedicine service, and its monitoring and audit aspects. “We want to make sure it’s quality. How do you know one’s a doctor? It should be heavily regulated because there’s a potential for abuse on many sides. A doctor may say this is a government case, but he may actually be charging the patient.” Philhealth may provide a way for this security system. Transaction payments may be coursed through it. So, all LGUs should ensure their citizens are Philhealth members. “For the very poor communities, LGUs can pay for their premium. It can devise a way to get the unemployed like tricycle drivers and taho vendors to become members in a kind of social health insurance where the ‘strong helps the weak’,” said Marcelo. NTC may at first restrict private hospitals from joining its program. But in the future, settling security issues may provide ways of interconnecting services of PGH, Medical City and other hospitals to it. In a final evaluation, e-health can only work in an integrated service. The presence of NTC’s telemedicine project cannot work without the availability of medicine that can come through government’s assistance. “It’s difficult to attribute a cure only on telemedicine. It has been successful in certain areas because they have medicine. It’s a complex play of different components,” he said. At present, most of the call for telemedicine comes from the highlands of Ifugao or from conflict-ridden areas in Mindanao. In Mindanao, the solution may be to train more Mindanao natives on telemedicine, so their need for a medical workforce can better be met even if many Manila-based doctors are not willing to be assigned there. Telemedicine is hoped to be a solution to the dismal absence of adequate medical service in the countryside. Through an integration with other health services, it should give way to a more equitable access to health for many deprived people. end---------------