By Rodrigo Castro Apablaza (*)
The Digital Health Strategy being developed by the Chilean Ministry of Health is supported by four pillars that guide decision making and focus strategic projects:
1. Strengthening public health with an emphasis on the integration of information from different care levels, with real time, quality records to optimize management.
2. Integrating technological platforms and design information systems to empower and improve people’s quality of life.
3. Ensuring the continuity of patient care with shared health records regardless of geographic location or healthcare provider.
4. Implementing a national repository of data to make secondary use of the electronic health record, with the objective of building themed control panels to improve public policy and healthcare results throughout the population.
Telemedicine is a key care process in the digital strategy and a reality that has been present in care networks across the country for many years. Today, the implementation of the telemedicine strategy is run by the Care Network Administration Division, DIGERA, at the Telemedicine Unit, and it is materialized in the following projects:
Tele-ophthalmology:
The Objective? To carry out detailed examinations of the eyes of patients with diabetes during medical check-ups at Primary Health Care (APS) level.
How does it work?: The images taken by the high definition equipment are sent via Minsal communications networks to a tele-ophthalmology platform which is run by imaging experts and a report on the results is sent to the Ophthalmology Primary Care Units.
Implementation: 14 healthcare services.
Tele-electrocardiograms:
The Objective? To detect Acute Myocardial Infarction (IAM) in patients treated by the Emergency Primary Care Services (SAPU) and the Emergency Services (SUR).
How does it work? An electrocardiogram is sent via the Minsal Communications Network to a Tele-cardiology Center which, twenty minutes later, sends its diagnosis and issues instructions to be followed.
Implementation: All the health services in the country.
Tele-care via basic mobile units:
The Objective? To enable remote connections between general practitioners in low complexity hospitals and specialists in mid- to high-complexity hospitals.
How does it work? Specialist doctors provide diagnostic and/or therapeutic guidance using Wi-Fi communications within the establishments and the Minsal communications network for the delivery of data.
Implementation: 113 basic devices.
Tele-care via advanced mobile devices:
The Objective? To enable the remote connection between specialists in complex networks located in high complexity hospitals to agree on medical treatments, coordinate appropriate transfers and strengthen teamwork across the network.
How does it work? Wi-Fi is used within institutions and the Minsal communications network is used to send data.
Implementation: During 2014 the model was gradually installed, and some complex networks were set up including Child Neuropsychiatry, Tele-oncology, High Complexity HIV Network and the Burns Network, which is currently being implemented.
Tele-radiology:
The Objective? To increase the resolution of the diagnostic support process at high and mid-complexity hospitals via the acquisition of radiological computerized tomography reports.
How does it work? It transmits, via the Minsal communications network, the digital images of tomograms from Emergency Hospital Units (UEH), Critical Patient Units (UPC) and other clinical units, to a data center that centralizes the information in an RIS/PACS system and makes the tests available for remote reporting within a 2 hour period outside of office hours.
Implementation: 300,425 remote reports.
Tele-dermatology:
The Objective? To provide proper access and quality in dermatological care from the Primary Care level.
How does it work? Images are sent from a platform containing patients’ clinical data so that dermatologists can provide remote medical advice.
Implementation: Over 26,000 consults.
Challenges
Although the Chilean experience points to a promising future with regard to the contribution that telemedicine can make to different medical specialties, there are still gaps to be covered and challenges that must be faced.
Chronic diseases are at epidemic levels in Chile, at least 30% of the population suffers from a chronic disease and a lower number suffers from complex chronic diseases and co-morbidity. This segment is a challenge for public healthcare as expenditure on emergency visits and hospitalizations is greater during the year. Here Pareto’s theorem applies: in healthcare 20% of patients represent 80% of the costs in the healthcare network.
So the challenge is to find new IT solutions that can anticipate worsening of the patient’s condition via remote monitoring of complex chronic patients.
Pilot 2016
The model we propose consists of remotely measuring vital signs and other clinical parameters via sensors and mobile devices in the patient’s home. The objective is to anticipate episodes resulting from a decline in condition to avoid unnecessary hospitalizations and unnecessary visits to emergency rooms.
The information gathered by mobile devices will be transmitted online to the Salud Responde platform (a state platform) and if any of the parameters exceeds the established range a clinical care protocol will be triggered at Salud Responde. This could be in person or via remote clinical guidance. The pilot will start work in 2016.
Home Care
Other advances that can be seen in telemedicine are related to home care through emergency units, for instance using ambulances during catastrophes, as well as organizing medical rounds and medical operations.
Technology allows us to extend telemedicine to other medical specialties and, why not, even to remote surgery. Telemedicine does not just involve the sharing of tests and providing synchronous or asynchronous assistance, it is also a useful tool in training the entire clinical team that provides care for patients. Advances have also been made in this area and we have seen several successful experiences of their implementation.
There are also positive external uses of telemedicine, such as virtual patient visits to bring families closer to patients hospitalized at remote centers, allowing them to make contact via videoconferences.
How to empower professionals
The advances and excellent results of the telemedicine strategy in Chile show us that the challenges do not lie with the ICTs but in seeking the proper incentives for doctors and professionals to take part in the different processes and models that exist in telemedicine. Across the world, different ways of addressing the issue are appearing and we should revise them to pick up good practices and adapt them to our distinctive qualities and economic possibilities:
• Public remuneration for doctors and professionals. This is the most common incentive but the literature indicates that if a payment is not associated with telemedicine, it is possible that production of these types of services will fall considerably.
• Payment associated with telemedicine. Some countries are designing payment mechanisms. In Chile, for example, FONASA has for the first time included a limited quantity of telemedicine places linked to direct payment. Although, FFS (Fee for Service) incentivizes production, we must make sure that care processes that are not associated with payments are not left behind in daily routines, generating waiting lists at medical establishments.
• Public recognition. This is an altruistic measure. Many doctors and professionals do not just work for pecuniary incentives. In some countries, the most noted telemedicine professionals receive honorific titles, such as Doctor Honoris Causa (PhD.h.c), from universities that cooperate with the government.
Chile has a solid Telemedicine Strategy to support the entire care network with the objective of reducing barriers of access to specialists, encouraging collaboration between professionals and reducing waiting lists. But to achieve an optimum deployment of all the telemedicine services we must analyze and design a model of pecuniary and non-pecuniary incentives that adapts to local conditions and encourages the use of telemedicine among the different professionals who participate in the care process.
As a country we must make sure that we generate the right conditions for the development of remote monitoring of patients with complex chronic diseases (home-care) to free up emergency departments and avoid unnecessary hospitalizations. In this challenge the health sector must collaborate with academics, private companies and regulatory entities to propose a legal framework that facilitates the implementation and adoption of telemedicine.
(*) Expert in eHealth, mHealth, telemedicine and health economics. Commercial engineer, MSc. Health Economics, University of York, UK y MA. e-Health, University of Applied Science, Flensburg, Germany. He is currently the Head of the ICT Sector Administration Department at the Chilean Ministry of Health and has over ten years’ experience in the Public Health Sector, where he has shared his knowledge of eHealth and health economics at institutions such as the KFW Development Bank, FONASA and the Metropolitano Sur Health Service.
