MOHAMMAD (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.
After 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.
"I am 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.
He adds that the doctors keep asking the same questions over and over again. He wonders if they ever read his medical records.
Although 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.
What is telemedicine?
Telemedicine conjures thoughts of doctors dealing with patients using high-tech, sophisticated equipment and offering prescriptions from a distance.
The technology 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.
The government blueprint defines telemedicine as "medicine at a distance'' using telecommunication and multimedia technologies for the provision of healthcare.
Telecommunication 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.
The hype fascinates tech savvy medical practitioners and advocates but not all doctors and the general population have bought into the rose-tinted dream.
A senior 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.
Purveyors 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.
He adds that it is especially true in the private sector where a doctor's main asset is his reputation.
"Doctors who inadvertently prescribe the wrong treatment or medication will be hit with malpractice lawsuits,'' he says.
President of Perak Medical Practitioners' Society Dr S.R.Manalan agrees that adopting telemedicine is easier said than done.
"Most of the senior doctors do not have the luxury of learning the new technology,'' he confesses.
Doctors in private practice would count every moment spent with the patient as money while those in government hospitals struggle with long lines of patients.
Tele-consultation 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 load.
"Right 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?
They also contend that smaller states such as Penang, Malacca and Negri Sembilan do not have a need for such units yet.
"It 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.
Above 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.
"As 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.
They maintain that the nitty-gritty details of telemedicine need to be studied thoroughly prior to its implementation.
Tan Sri 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.
"Like other technologies, telemedicine must be given added value and made easily accessible to the lower income group at minimal cost,'' he adds.
Most public hospitals need to address first its long term management and have a pool of well trained paramedics and educators on hand.
Statistics 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.
"We should improve the quality of medical care and focus on essential things. Telemedicine is not the panacea to resolve all problems.''
Some physicians feel that in many instances, doctors rely too much on technology instead of old fashioned clinical skills.
"Doctors 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 Devaraj.
He adds that tools such as the CT scan or an ultrasound are not short cuts to speed up the examination process.
"Patients are not disease entities and when we reduce human contact, it makes the practice of medicine less personal,'' he adds.
Mind your beside manners
For most doctors and patients the human touch cannot be replaced. Conveying concern is essential in assuring patients of their condition in the diagnosis process.
However telemedicine proponents dispute that the cost benefits outweigh these considerations especially in remote locations and emergency situations.
Dinesh 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.
He believes 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.
"Efficient use of expensive and scarce specialist time is an implicit cost benefit,'' he adds.
Director of telemedicine at East Carolina University's (ECU) School of Telemedicine David C. Balch echoes his views.
In an 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.
"But I think their biggest resistance is fear of the unknown,'' he points out.
Balch was involved in the planning for telemedicine in Malaysia and was here for meetings 18 months ago.
He says that American physicians have begun changing their practices because of managed care, capitated payment systems, and growing consumer awareness.
"Doctors 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.
ECU (see 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.
"We 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.
Local 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.
Dr Manalan 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.
Changing Acts
Despite 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.
Some 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.
Ironically pilot telemedicine sites are already running in several states around the country before either of the two Acts have been reviewed.
For instance, 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.
Health 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.
As Ministry 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.
"The 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 said.
While 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.
"We are shifting our medical care focus from illness to wellness. We want to encourage empowerment and utilise data,'' adds Aziz.
Bottomline matters
Yet, for 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.
The Health Ministry telehealth steering committee advisor Datuk Dr A. Jai Mohan stresses that the issue is not about whether we can afford telemedicine.
"Can 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.
Though proponents have reconciled the issue of money, companies involved in promoting the technology are more cautious.
Many 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.
While the general public will learn about telemedicine through the media, the education process for professionals will be more specific.
Health 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.
To offset the payment for services and cost of infrastructure, proponents propose a small transaction fee be charged every time a telemedicine system is used.
Critics 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.
Rajiv proposes a modified version of the transaction fee of "capitated contracts'' which is akin to a poll tax.
"For 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.
Alternatively, he suggests a government subsidy to lay the telemedicine network and infrastructure for its practical implementation.
One of 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.
Dr Davaraj argues that the store and forward method might work with patients who suffer from chronic illnesses such as hypertension, diabetics and asthma.
"For 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.''
And most patients would agree with that.
Related Links:
Putting theory to practice
Full speed ahead
Published in In.tech, The Star, Star Publications.
