What Are Telemedicine and Its Regulations and Future Challenges?

What Is Telemedicine?

The so-called telemedicine, or telehealth is the use of information and telecommunications technology to exchange medical and clinical data and expert opinions of patients in two places to overcome obstacles in space and even time. It combines the professional knowledge of computers, communication technology, and medical staff so that doctors can conduct video conferences other doctors and medical staff online, thousands of miles away. They can provide comprehensive medical care for people in remote and outlying areas, and also provide teaching and training for doctors and nursing staff. The definition and content of telemedicine have also changed with the progress of the time. In a narrower sense, telemedicine refers to specialized subjects such as teleradiology, telepsychiatry, and telepathology. In a slightly broader interpretation, telemedicine refers to the act of taking medical care in two places separated by a certain distance. Telemedicine refers to the behavior of long-distance health care, including various clinical medical applications and medical and health education.

COVID-19 Affects the Development of Telemedicine in Various Countries

U.S. Telemedicine Development

About 60% of consumers in the United States express their willingness to use telemedicine, but only 8% of them have used it. Age is an important factor that affects the willingness to use telemedicine. In addition, nearly half of the patients who have used telemedicine are concentrated in the south.

In response to the amendment of the Bipartisan Budget Act of 2018, the Centers for Medicare and Medicaid Services (CMS) for patients with end-stage renal disease, acute stroke treatment, etc., have relaxed Medicare Restrictions of designated areas and facilities. Starting from January 2019, payment will be made for part of the service fees that use communication technologies (non-telemedical services), such as short communication, Virtual Check-Ins, and remote evaluation of pre-recorded patient information.

• Patients receiving telemedicine are located in designated rural areas.
• Patients receive telehealth services in clinics, hospitals, rural health centers, health centers with federal data, nursing facilities, community mental health centers, dialysis centers, etc.
  

Telemedicine can continue to be an important way of providing medical services, whether during the COVID-19 period or after the pandemic is over.

• Increases the patient's chances of getting care
• Reduces patient demand for medical facilities and equipment
• Reduces the chance of contact between medical staff and patients
• Patients with chronic diseases can seek medical treatment through telemedicine
• Telemedicine-related data can be used to improve public health surveillance systems

• Improve telehealth services to make them easier to use
• Screen patients suspected of COVID-19 through telemedicine, or guide confirmed cases
• Treatment of mild patients

• CDC formulates COVID-19 infection prevention and control recommendations for medical institutions, as well as precautions for providing nursing care

• CDC develops a framework for providing non-COVID-19 clinical care during the epidemic

• For pharmacies, clinics, and other places, it is recommended to post notices on the doors, provide masks before entering specific areas, provide separate entrances for patients, etc., and formulate guidelines for pharmacies

• Relaxing Medicare's restrictions on telemedicine
• Penalties are temporarily not applicable to telemedicine activities

• Insurance companies expand the scope of insurance coverage and exempt deductibles

• CDC develops guidelines for the operation and management of medical institutions and provides services through telemedicine
• AMA developed a telemedicine manual to assist in the introduction of telemedicine at the medical site

Japan Telemedicine Development

According to the data of the Japan Medical Innovation Association, 1,250 medical institutions implemented online diagnosis and treatment before April 2020, and it grow to 1,596 in May. In addition, according to the annual report of the Central Social Insurance Medical Council, about 10.7% of the people who have received online diagnosis and treatment. Some patients have chosen to not have online diagnosis and treatment. The main reasons for this are that they wanted to receive face-to-face diagnosis and treatment, or the doctor did not propose to them to go online so they did not feel the necessity of online diagnosis and treatment.

• 1997: With a preference to face-to-face diagnosis and treatment, telemedicine was only limited to specific situations such as for outlying islands and remote areas. No clear standards have been established and the cost of diagnosis and treatment for telemedicine has not yet been reviewed.
• 2008: A conference on telemedicine promotion measures was held, and a report was submitted in July 2008, suggesting that telemedicine can be selected for chronic diseases, health management, etc., and the cost of telemedicine diagnosis and treatment should be reviewed.
• 2015~2017: With the development of ICT and other technologies, it was pointed out that telemedicine could be used in outlying islands and remote areas, and it was proposed to adjust the cost of diagnosis and treatment.
• 2018: Formulate the "Guidelines for the Appropriate Implementation of Online Diagnosis and Treatment", clearly pointed out that the principle of face-to-face diagnosis and treatment was the principle method for initial diagnosis, revised diagnosis and treatment fees, and added online diagnosis and treatment options and fees.
• 2020: To solve the problems after the publication of the guidelines and in response to the impact of the Covid-19 epidemic, reviewed and revised the guidelines, and relaxed the restrictions on face-to-face consultations at first visits in a time-limited and exceptional manner.

• Change the diagnosis and treatment behavior of using communication equipment from telemedicine to online diagnosis and treatment
• It stipulates the matters to be followed and the matters recommended for the online diagnosis and treatment
• Online diagnosis and treatment activities that comply with the matters to be observed in this guideline will not violate the provisions of Article 20 of the Japanese Medical Doctor Act "No diagnosis and treatment prohibition".

• Based on safety and trust, lift the restriction on face-to-face treatment at the first visit
• Telemedicine is based on the principle of imaging
• Safety and reliability need to be comprehensively judged

• Review and revise online diagnosis and treatment guidelines
• Relax the principle of face-to-face diagnosis and treatment for the first visit in a limited time and exceptional manner

• In principle, only patients who meet the requirements of the online diagnosis and treatment guidelines are eligible for medical insurance
• Affected by the epidemic, relax restrictions on face-to-face diagnosis and treatment, and expand insurance coverage
• However, the cost of online diagnosis and treatment is relatively low, which may affect the willingness of medical institutions to introduce

• In response to the government’s goal of fully opening up online diagnosis and treatment, the Japanese Medical Association expressed its opposition to the reason that online diagnosis and treatment would be less paid and resources would be concentrated in large hospitals.

China Telemedicine Development

Before the outbreak of the epidemic, about 24% of people had used telemedicine. Between December 2019 and January 2020, the number of users of China's medical service platform increased significantly, indicating that Covid-19 will accelerate the development of China's telemedicine industry.

• 2018: In response to the "Opinions of the General Office of the State Council on Promoting the Development of Internet + Medical Health", the National Health Commission formulated the "Internet Diagnosis and Treatment Management Measures", the "Internet Hospital Management Measures" and the "Management Regulations for Telehealth Services".
• 2019: The National Medical Insurance Bureau announced the "Guiding Opinions on Improving Internet + Medical Service Prices and Medical Insurance Payment Policies", confirming for the first time that telemedicine can be included in the scope of medical insurance payment.
• February 2020: The National Health Commission announced the "Notice of the General Office of the National Health Commission on Strengthening Informa ionization to Support the Prevention and Control of Pneumonia Epidemic Caused by COVID-19 Virus Infection."
• July 2020: The State Council announced the "Implementation Opinions on Further Optimizing the Business Environment and Better Serving Market Entities", and proposed 6 measures, including further relaxing the scope of telemedicine and including eligible telemedicine into medical insurance.

February 3, 2020: The General Office of the National Health Commission Announcement to support the prevention and control of the pneumonia epidemic caused by COVID-19 virus infection

• Strengthen data analysis applications: Use the Internet to transmit disease data, analyze and predict through big data, as a basis for governance
• Actively develop telehealth services: Encourage remote diagnosis and treatment services in major hospitals to alleviate the pressure of the epidemic; provide training through remote education to improve grassroots
• Deepen Internet + Government Services: Strengthen the single-window service on the Internet to avoid virus infection through long-distance and non-contact
• Standardize online diagnosis and treatment consulting services: Centralize online diagnosis and treatment platforms and hospital websites to promote online consultation, guidance, and other services in hospitals at all levels
• Strengthen infrastructure and security: Strengthen network infrastructure and information security protection

• The "Administrative Measures for Internet Diagnosis and Treatment" only applies to some common diseases and chronic disease follow-up visits, not to newly diagnosed patients; except for specific drugs, doctors can prescribe online
• "Telemedicine Management Specification" defines telehealth services and requirements
• Inviting medical personnel to provide medical services through the platform must apply for the establishment of an Internet hospital, which shall be managed by the "Internet Hospital Management Measures"

• Announcing that telemedicine will be included in medical insurance

• Compared with the speed of policies and regulations, telehealth services are developing vigorously

Taiwan Telemedicine Development

• 2018: The Ministry of Health and Welfare announced the "Communication Diagnosis and Treatment Measures" to relax telemedicine targets:
  1. Mountainous remote islands
  2. Follow-up treatment of acute inpatients after discharge
  3. Long-term care service users
  4. Family physician diagnosis and treatment
  5. Perform follow-up treatment of remote care or home care
  6. International patients
• February 2020:
  The method of medical treatment for the home quarantine or home quarantine of the Ministry of Health and Welfare for quarantine or anti-epidemic measures can be handled by the "Communications, Inspection, and Treatment Measures":
  1. Immediate medical treatment is required: Physician Act §11+ "Communications, Inspection, and Treatment Methods"
  2. Patients with chronic diseases: §7 of the National Health Insurance Medical Treatment Method or "Communications, Inspection and Treatment Method"

  The Ministry of Health and Welfare added:

  1. Evaluate that patient who have medical needs during the quarantine period can be used for telemedicine, and are not limited to non-newly diagnosed patients
  2. When medical institutions implement communication diagnosis and treatment, they should still comply with the items listed in §7
• April 2020: The Ministry of Health and Welfare announced the "National Health Insurance Specialized Medical Service Institutions Provide Instructions for Insured Subjects Subject to Home Quarantine or Quarantine due to the COVID19 Epidemic". The cost of video diagnosis and treatment is covered by the total health insurance budget, and the subject is restricted to cooperating with the quarantine. Those who have been referred by the Health Bureau without fever or respiratory symptoms and have urgent medical needs.

The National Health Insurance Agency announced the "National Health Insurance Telemedicine Benefit Plan", which aims to improve the accessibility of specialist outpatient clinics for people in remote mountainous islands and remote areas and to implement localized medical care.

• Releasing restrictions on the applicable objects of the "Communications, Diagnosis, and Treatment Measures" through administrative letters
• However, when medical institutions implement communication diagnosis and treatment, they should still abide by §7 of the measures

• Open up mountainous areas, outlying islands, remote areas, and remote medical service providers to be included in health insurance payments

• Local governments, medical institutions, and enterprises cooperate to promote telemedicine projects
• Telemedicine platform: Divided into telediagnosis/consultation, monitoring, health management, etc., mainly large-scale medical centers and regional hospitals; there is also a psychological consultation platform

• Health insurance payment package:
  The United States expands the coverage of insurance benefits; Japan adjusts the cost of diagnosis and treatment; China reviews comprehensively including telemedicine into medical insurance. Taiwan will include telemedicine in its health insurance payment in 2021, which is expected to promote the development of related industries. Only the remote platform involves the use of special personal information.
• Post-epidemic era:
  Before Covid-19, telemedicine in various countries was based on the principle of face-to-face, and applicable conditions were restricted. When the epidemic is over, will telemedicine be restored to its original state, or will it be opened up? How to avoid the problem of centralized medical resources caused by telemedicine in large hospitals?
• Diagnosis and treatment methods and restrictions:
  
  • Assess the patient's need for medical treatment, and implement communication diagnosis and treatment methods
  • A way to evaluate patients who are not suitable for communication diagnosis and treatment or have in-person diagnosis and treatment needs
  • Are there restrictions on the number of specific drugs that cannot be prescribed?
• Drug collection and delivery
• There is no sign when the patient prints it by himself; a way to avoid forging prescriptions
• The medicines should be delivered by the pharmacist in person and must not be cross-regional, and the medicines should not be mailed or delivered at home. In the future, it is necessary to review and revise the regulations of the Doctor Law and Pharmacist Law

The COVID-19 epidemic has hit the world and has caused major changes in people's lifestyles or economic and industrial development. The zero-contact and remote medical care model may become the new normal in the future.