of telemedicine have been put in place since January this
year. Although there is no official word on who is responsible
for undertaking the mammoth task at national level, telemedicine
will be commonplace by 2010.
such usage of high technology at public hospitals rob us of
basic patient care needs and replace the doctor-patient relationship?
(not his real name) is a trifle confused. When the medical
officer asked him to talk to the specialist through the television
screen, he sniggered. How can a doctor staring at him from
the screen diagnose his illness? Mohammad, 70, suffers from
high blood pressure and has a poor heart. On top of that,
he has rheumatism.
the tele-consultation session, Mohammad leaves the clinic,
unconvinced that the diagnosis was any better than his previous
visits. Mohammad has been visiting the government hospital
monthly since 1975.
paying more but consuming the same amount of drugs and I do
not feel better. That doctor on the television monitor has
never laid a hand on me, how does he know what is good for
me?'' he asked.
that the doctors keep asking the same questions over and over
again. He wonders if they ever read his medical records.
telemedicine promises a person that his lifetime medical record
will be electronically stored and made available to doctors,
it does not mean that doctors who have such facilities will
read a patient's medical history before examining him or her.
conjures thoughts of doctors dealing with patients using high-tech,
sophisticated equipment and offering prescriptions from a
entails the use of electronic signals to transfer medical
data such as high resolution photographs, radiological images,
patient records and voice from one site to another through
the Internet, intranets, PCs, satellites, video-conferencing
equipment and telephones.
blueprint defines telemedicine as ``medicine at a distance''
using telecommunication and multimedia technologies for the
provision of healthcare.
is used to provide a closer link between providers and receivers
and increase access to specialist care. According to Datuk
Dr Abdul Aziz Mahmood, Ministry of Health deputy director-general,
access to specialist care has been a perennial problem.
fascinates tech savvy medical practitioners and advocates
but not all doctors and the general population have bought
into the rose-tinted dream.
doctor who has been practising for 23 years scoffs the very
idea of telemedicine. ``It won't work because many doctors
are not well versed in IT,'' he argues.
of the technology wryly admit that it is tough convincing
healthcare professionals. According to Rajiv Ramaprasad, managing
director at WorldCare Health (M) Sdn Bhd, healthcare professionals
loathe to adopt new technology unless it has been thoroughly
vetted by respected academics and medical journals, and passed
the muster of regulatory authorities.
that it is especially true in the private sector where a doctor's
main asset is his reputation.
who inadvertently prescribe the wrong treatment or medication
will be hit with malpractice lawsuits,'' he says.
of Perak Medical Practitioners' Society Dr S.R.Manalan agrees
that adopting telemedicine is easier said than done.
of the senior doctors do not have the luxury of learning the
new technology,'' he confesses.
in private practice would count every moment spent with the
patient as money while those in government hospitals struggle
with long lines of patients.
units are being set up at rural health clinics in Negri Sembilan,
Perak, Selangor and Penang to help ease the long queues. Ironically,
some doctors view it as an additional burden to their daily
now, we pick up the phone to cross-check with the specialist
and this method has worked well all these years,'' they say.
Why fix something that ain't broke?
also contend that smaller states such as Penang, Malacca and
Negri Sembilan do not have a need for such units yet.
would defeat the purpose as these health clinics are within
an hour's reach from the general hospital,'' they claim, adding
that it would take the staff the same amount of time to set
up the video-conferencing unit for tele-consultation.
that, all tele-consultation appointments, done through dial-up
connection, must be arranged in advance and pre-fixed to make
sure parties at both ends are available to diagnose an illness.
it is, we worry if the person at the other end will be there.
Can you imagine if we have an emergency situation and need
expert advice during the wee hours of the morning? How do
we resolve that?'' they question.
maintain that the nitty-gritty details of telemedicine need
to be studied thoroughly prior to its implementation.
Abdul Khalid Sahan, former director-general of health, says
that authorities also need to look at the players involved,
current resources available and the way they are being organised.
Issues must be reviewed and problems thrashed out.
other technologies, telemedicine must be given added value
and made easily accessible to the lower income group at minimal
cost,'' he adds.
public hospitals need to address first its long term management
and have a pool of well trained paramedics and educators on
indicate that close to 50% of all doctors are in private practice
but handle only 300,000 patients a year compared to the 1.5
million patients who visit public hospitals annually.
should improve the quality of medical care and focus on essential
things. Telemedicine is not the panacea to resolve all problems.''
physicians feel that in many instances, doctors rely too much
on technology instead of old fashioned clinical skills.
should spend time talking to their patients, to get a good
grasp of their medical history before applying high-tech instruments
for diagnosis,'' declares local chest physician Dr Jeyakumar
that tools such as the CT scan or an ultrasound are not short
cuts to speed up the examination process.
are not disease entities and when we reduce human contact,
it makes the practice of medicine less personal,'' he adds.
your beside manners
doctors and patients the human touch cannot be replaced. Conveying
concern is essential in assuring patients of their condition
in the diagnosis process.
telemedicine proponents dispute that the cost benefits outweigh
these considerations especially in remote locations and emergency
Nair, director of research and development at WorldCare, says
that electronic consultation is a logical step if information
is transmitted across geographic barriers and reports returned
at a fraction of the cost.
that by delivering a case electronically, waiting time would
be shortened and a specialist's opinion can be sought within
48 hours compared to the two-week norm.
use of expensive and scarce specialist time is an implicit
cost benefit,'' he adds.
of telemedicine at East Carolina University's (ECU) School
of Telemedicine David C. Balch echoes his views.
e-mail reply to In.Tech, he points out that doctors ``love''
using telemedicine because it helps them become more efficient
by not having to drive to remote sites to do clinics.
I think their biggest resistance is fear of the unknown,''
he points out.
was involved in the planning for telemedicine in Malaysia
and was here for meetings 18 months ago.
that American physicians have begun changing their practices
because of managed care, capitated payment systems, and growing
who are compelled to learn about it and figure out the most
cost effective ways to implement telemedicine will be industry
leaders five to 10 years from now,'' he says, adding that
telemedicine is still viewed as a foreign thing as it is not
taught at medical schools.
sidebar) has conducted almost 4,000 telemedicine encounters
now and received ``overwhelming positive'' feedback from patients.
The telemedicine team has also done consults in 32 different
clinical specialities and found that telemedicine can fit
into just about any medical environment.
do not try to replace the doctor-patient encounter, but rather
enhance it by providing more frequent and convenient access
to physicians by patients,'' says Balch.
doctors are grudgingly beginning to accept that telemedicine
will permeate their businesses. Consultant surgeon at Seremban
Hospital Dr Davaraj Balasingh surmises that coming to terms
with the issues related to implementing telemedicine is probably
the hardest for medical practitioners.
concurs, saying that it will take between five and seven years
before telemedicine becomes common practise here and is accepted
by both the public and practitioners.
the assurances that all bases will be covered as telemedicine
is implemented, a sense of uneasiness prevails with observers
and sceptics. The presence of the Telemedicine Act 1997 does
little to assuage fears.
quarters have called on the government to study the Medical
Act 1976 and Poisons Act 1953 which may need to be changed
and liberalised to allow the practice of telemedicine.
pilot telemedicine sites are already running in several states
around the country before either of the two Acts have been
a nurse in a rural clinic cannot give a patient a drug prescribed
by a doctor via tele-consultation when she has no authority
to do so by law.
care professionals argue that their ambit of authority is
limited under current law and these get in the way of maximising
technology. While these matters remain unresolved, the quest
for telemedicine continues.
of Health's Aziz explained, the rationale for telemedicine
was driven by higher life expectancy, rising healthcare costs,
shortage of expertise and outdated health infrastructure.
ministry has been looking for a few years now for a new type
of healthcare system that is suitable for Malaysians and we
see tele-health as a solution to some of our problems,'' he
he concurred that adopting technology will dramatically change
the way medicine is practised, Aziz maintains that the principles
of caring, democracy, ethics, tolerance and equitable medical
care will prevail.
are shifting our medical care focus from illness to wellness.
We want to encourage empowerment and utilise data,'' adds
the majority of consumers, this means paying more for services
they are not sure they really need. New technology spells
higher expenses especially for the poor.
Ministry telehealth steering committee advisor Datuk Dr A.
Jai Mohan stresses that the issue is not about whether we
can afford telemedicine.
we afford not to have telemedicine? Our government telemedicine
blueprint is focused on lifelong maintenance of health and
early detection and management of illness,'' he points out.
proponents have reconciled the issue of money, companies involved
in promoting the technology are more cautious.
companies are expected to undertake an all-out effort to educate
the public and outline how the system works. They will also
need to gain the public's confidence by ensuring the checks
and balances are in place to counter major, unforeseen problems.
the general public will learn about telemedicine through the
media, the education process for professionals will be more
care professionals and insurance firms must be shown how they
can make money by using the system. ``Otherwise it will not
be adopted,'' says WorldCare's Rajiv.
the payment for services and cost of infrastructure, proponents
propose a small transaction fee be charged every time a telemedicine
system is used.
disagree with that idea saying that it will work well for
healthcare providers but will cripple telemedicine providers
who have to bear all the capital and start-up costs.
proposes a modified version of the transaction fee of ``capitated
contracts'' which is akin to a poll tax.
instance, a large number of individuals, either employees
of a company or customers of a large company, are covered
under this plan for one low fee per year per person. The regular
payments from them will offset the large capital equipment
and other fixed costs incurred,'' he says.
he suggests a government subsidy to lay the telemedicine network
and infrastructure for its practical implementation.
the cheapest versions touted by vendors and currently being
put in place is the store and forward type of tele-consult.
It can simply be implemented over plain old telephone service
with encryption to protect privacy. Vendors liken store and
forward to how e-mail travels over the Net.
argues that the store and forward method might work with patients
who suffer from chronic illnesses such as hypertension, diabetics
us the store and forward method is not telemedicine but enhancing
the use of IT in the medical field. Telemedicine must be face
to face, to listen to the patient and touch the patient. This
goes a long way in diagnosis.''
patients would agree with that.