Lecture หลักสูตรระบบบริหารสารสนเทศด้านสุขภาพ Module 2 เรื่อง Telemedicine/Mobile Health, PSU Feb 20, 2023

1. Telemedicine
หลักสูตรระบบบริหารสารสนเทศด้านสุขภาพ Module 2
Supharerk Thawillarp, MD, DrPH
February 20, 2022
1

2. 2

3. เวลาพูดถึง Telemedicine ทุกท่านนึกถึงอะไร
ครับ?
4

4. 5

5. What is Telemedicine?
6

6. Definition
• Telehealth, a term used interchangeably with telemedicine, has been
defined as the use of medical information that is exchanged from one
site to another through electronic communication to improve a
patient’s health.
• Dr. Pai’s opinion
• Telemedicine focus on treatment aspect
• Telehealth is broader than telemedicine e.g. preventive, administrative etc.
7
https://www.nejm.org/doi/full/10.1056/nejmsr1503323

7. 8

8. Clinician to Patient
9

9. 10

10. 11

11. แล้วอะไรคือความแตกต่าง?
12
Telemedicine
VS

12. 13
https://nctrc.wpenginepowered.com/wp-content/uploads/2022/07/7.21.22-NCTRC-Webinar-FINAL-PDF.pdf

13. 14

14. 15

15. 16
https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0399

16. Doctor (Real) Chat (Not chatbot) from Finland
17
https://www.jmir.org/2018/12/e10165

17. Clinician to Clinician
TeleICU
18

18. 19
https://www.jmir.org/2020/9/e20143/
https://www.youtube.com/watch?v=4SAKExNJuBs

19. 20

20. 21

21. 22

22. Patient to Mobile Technology
23

23. Babylon Health Chatbot
24
https://www.businessinsider.com/babylon-health-launches-in-us-january-2020-2019-12

24. 25
https://catalyst.nejm.org/doi/full/10.1056/CAT.22.0172

25. 26

26. 27
https://catalyst.nejm.org/doi/full/10.1056/CAT.22.0172

27. Telemedicine Patient Instruction
28
https://www.hopkinsmedicine.org/office-of-johns-hopkins-physicians/education-training/telemedicine.html

28. Wearable devices
29
August 5, 2020

29. Huawei Heart Study
30
https://www.sciencedirect.com/science/article/pii/S073510971936365X
August 5, 2020

30. 31
https://www.sciencedirect.com/science/article/pii/S073510971936365X
August 5, 2020

31. ทีนี้เวลาพูดถึง Telemedicine กับผู้ป่วย
32

32. เหมือนกันหรือต่างกันอย่างไร?
33
Patient
Patient
Doctor
Doctor

33. เหมือนกันหรือต่างกันอย่างไร?
34
Patient
Patient
Doctor
Doctor
คัดกรอง
แพทย์ท่านใดจะรับ
ต้องมีเฉพาะทางไหม
แพทย์ต้องรอรับสายกี่ท่าน
แพทย์ต้องรอรับสายกี่ชั่วโมง
หาแพทย์จากไหนมารอ
ผู้ป่วยเลือกแพทย์ได้ไหม
นัดหมายผู้ป่วยอย่างไร ใครโทร
โทรอย่างไรให้ผู้ป่วยได้ยิน
เมื่อไหร่จะส่งตัวไปยัง รพ
มักเปิดผ่านหน้า App
มักเป็นผู้ป่วยเดิมของ รพ

34. Sync / Async Telehealth
35

35. 36
https://www.nature.com/articles/s41746-020-0279-6

36. Virtual Visit
37

37. 38
https://thematter.co/science-tech/telemedicine-app-in-thailand/119435

38. Virtual Consult
39

39. Mayo Clinic Emergency Medicine Telehealth
40
Emergency Medicine Telehealth Respiratory Failure in Rural Setting: A Simulation
https://www.youtube.com/watch?v=KRO7ekb_dhY

40. Mayo Clinic Emergency Telehealth
41
Emergency Medicine Telehealth Respiratory Failure in Rural Setting: A Simulation
https://www.youtube.com/watch?v=KRO7ekb_dhY

41. Telestroke
42

42. 43

43. 44

44. 45

45. ระบบส่งตัวเป็นอีกส่วนประกอบสาคัญสาหรับ
Telemedicine โดยเฉพาะ รพ
46

46. eVisit
47

47. Patient Portal
48
https://www.gosh.nhs.uk/your-hospital-visit/mygosh

48. Patient Portal Message to Provider
49
https://www.gosh.nhs.uk/your-hospital-visit/mygosh

49. eConsult
50

50. 51

51. 52

52. 53

53. 54

54. Asyn vs Syn Telemedicine
55
https://www.researchgate.net/publication/316300531_Chapter_10_Exploring_Telemedicine_in_Emergency_Medical_Services_Guidance_in_Implementation_for_Practitioners/figures?lo=1&utm_source=google&utm_medium=organic

55. Or just both
56
https://www.researchgate.net/publication/351013947_A_Smartcard-Based_User-Controlled_Single_Sign-On_for_Privacy_Preservation_in_5G-
IoT_Telemedicine_Systems/figures?lo=1&utm_source=google&utm_medium=organic

56. Terms summary
• Telemedicine
• Synchronous (Real-time)
• Virtual Visit (Patient-to-Doctor)
• Virtual Consult (Doctor-to-Doctor)
• Asynchronous (Store and Forward)
• eVisit (Patient-to-Doctor)
• eConsult (Doctor-to-Doctor)
• Referral Network for Telemedicine
• Hub and Spoke
• Distributed Model
57

57. แล้วแพทย์ชอบวิธีไหนมากกว่ากัน?
58

58. 59
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250220

59. Professional in Telemedicine
60

60. Professionalism for Telemedicine?
61
https://nctrc.wpenginepowered.com/wp-content/uploads/2022/07/7.21.22-NCTRC-Webinar-FINAL-PDF.pdf

61. 62

62. 63

63. 64
https://nctrc.wpenginepowered.com/wp-content/uploads/2022/07/7.21.22-NCTRC-Webinar-FINAL-PDF.pdf

64. Physical Examination
65

65. Stanford School of Medicine
Telemedicine Exam
https://medicine.stanford.edu/news/current-news/standard-news/virtual-physical-
exam.html
https://youtu.be/LCvLwnJjmTo
66

66. 67

67. 68

68. 69

69. 70

70. 71

71. 72

72. 73

73. 74

74. 75

75. 76

76. 77

77. 78
https://els-jbs-prod-cdn.jbs.elsevierhealth.com/pb/assets/raw/Health%20Advance/journals/jmcp/jmcp_ft95_5_15.pdf

78. 79
https://www.practicalpainmanagement.com/resources/practice-management/how-conduct-pain-evaluation-using-telemedicine

79. 80
https://www.researchgate.net/publication/327085786_Tele-transitions_of_care_A_12-month_parallel-
group_superiority_randomized_controlled_trial_protocol_evaluating_the_use_of_telehealth_versus_standard_transitions_of_care_in_the_prevention_of_avoidable_/figures?lo=1&utm_source=google
&utm_medium=organic

80. Medical Education
81

81. 82
Telemedicine นักศึกษาแพทย์ การเรียน การสอบ – Let the box filled with ideas (wordpress.com)
JMIR Medical Education - Incorporating Medical Students Into Primary Care Telehealth Visits: Tutorial

82. 83

83. 84

84. โดยสรุปงานของนักศึกษาแพทย์
• อาจารย์จะนัดกับนักศึกษา ก่อนเริ่มการตรวจ เพื่อคุยกันว่า จะทาอะไร และคาดหวังอะไรบ้าง
• อาจารย์จะสอบถามผู้ป่วยล่วงหน้าก่อนวันตรวจ ว่า ok ที่จะให้นักศึกษาแพทย์เข้ามาด้วยหรือไม่อย่างไร
• เมื่อถึงวันนัด นักศึกษาแพทย์จะสอบถามอาการ ซักประวัติฯลฯ 10-15 นาที กับผู้ป่วย เมือเสร็จแล้ว
อาจารย์จะเข้ามาในห้อง เพื่อฟังสิ่งที่นักศึกษาได้รวมถึงแผนการรักษา
• หลักจากนั้น ทั้งสามฝ่าย (อาจารย์นักศึกษาแพทย์และผู้ป่วย) จะพูดคุย และวางแผนการรักษาร่วมกัน
แน่นอนว่ากระบวนการนี้ทาโดยผู้ป่วยอยู่ในห้อง Telemedicine ด้วย คือ พูดคุยพร้อมกันทั้งสามฝ่าย
เลย
• หลังเสร็จสิ้นจะมีการเรียนการสอน 30 นาที
86
https://raynus.wordpress.com/2021/06/12/telemedicine-med-students/

85. TeleOSCE by Oregon Health & Science
University
• ตัวอย่างคือ การสอบให้คาแนะนาผู้ป่วย
เบาหวาน ที่มีแผลที่เท้า
• นักศึกษาจะต้องแจ้งผู้ป่วยให้ถ่ายรูปและ
Upload รูปขึ้นมาในระบบ
• จะต้องให้ผู้ป่วยบรรยายลักษณะของแผล หรือ
อาการได้ฯลฯ ผ่านระบบทางไกล เพราะไม่
สามารถตรวจตรงหน้าได้
• พยายามทาความเข้าใจบริบทของผู้ป่วยจาก
ทางไกล เช่น บริเวณนั้น ไม่มีโรงพยาบาลใน
ระยะร้อยกิโลเมตร
• การสอบจะจงใจให้มีอุปสรรคในการใช้
เทคโนโลยี เช่น ระบบที่นักศึกษาไม่คุ้นเคย ทา
ให้มีการติดขัดบ้าง หรือฝั่งผู้ป่วยไม่รู้ว่าปุ่มอยู่
ตรงไหน เป็นต้น
87
https://www.stfm.org/publicationsresearch/publications/educationcolumns/2015/march/

86. Provider Council Telemedicine
88

87. Perception of Telemedicine?
89

88. Perception of Telehealth
• Convenience
• Reduce travel Time and cost
• Mobility challenges
• Timeliness of care
90

89. Adding value to in-person care
• Convenience
• Reduce travel Time and cost
• Mobility challenges
• Timeliness of care
• Access to care in rural and urban communities
• Access to subspecialty care in austere communities
• Remote family presence
• Language interpretation services
• Multi-provider collaboration
• Device integration for remote patient monitoring
• Patient portal adoption and HIS/EHR integration
91

90. More Telemedicine in Urban than Rural
92
https://stateofreform.com/featured/2019/07/use-of-telehealth-rapidly-increased-according-to-fair-health-report/

91. 93
https://mhealth.jmir.org/2019/12/e13229

92. Tele-………..?
Current trend and the near future of Telemedicine
94

93. Telemedicine > 30x Growth
95
https://www.aha.org/aha-center-health-innovation-market-scan/2021-07-20-fresh-perspective-where-telehealth-growth-will

94. คิดว่าสาขาเฉพาะทางไหนใช้ Telemed มาก
ที่สุด 3 อันดับแรก?
96

95. คาตอบที่ได้รับบ่อยๆ
• ผิวหนัง
• X-ray
• สุขภาพจิต
97

96. Telemedicine
98
https://epicresearch.org/articles/insurance-type-is-the-top-predictor-of-telehealth-use-as-adoption-levels-off-long-term

97. 99

98. 100

99. Tele-rehabilitation
101
https://shrs.uq.edu.au/article/2020/05/why-telerehabilitation-so-important-during-covid-19-pandemic

100. Tele-medicine for autism
102
https://wpln.org/post/could-telemedicine-work-for-autism-therapy-vanderbilt-experiments/

101. 103

102. ฝากครรภ์ก็มีนะเออ
104
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2821%2900668-1/fulltext

103. 105
https://www.kff.org/report-section/telemedicine-and-pregnancy-care-issue-brief/

104. Telepharmacy
106

105. 107

106. 108
https://www.youtube.com/watch?v=rtsdgjQVvuQ
https://www.ashp.org/-/media/assets/pharmacy-informaticist/docs/sopit-bp-telepharmacy-statement.ashx?la=en

107. 109

108. 110

109. 111

110. 112

111. 113

112. 114

113. Telepharmacy Type (American Society of
Health-System Pharmacists)
• ยาผู้ป่วยใน (Remote order-entry review)
• ผสมยา (IV Admixture verification)
• ให้คาปรึกษาผู้ป่วย (Remote patient counseling)
• การจ่ายยาผู้ป่วยอก (Remote Dispensing)
115
https://www.ashp.org/-/media/assets/pharmacy-informaticist/docs/sopit-bp-telepharmacy-statement.ashx

114. Telepharmacy
116

115. 117

116. Wallgreen Kiosk for Telepharmacy
118

117. 119

118. 120
https://www.walgreens.com/topic/promotion/walgreensrxkiosk.jsp
https://www.youtube.com/watch?time_continue=64&v=XF39dqWD4Bk

119. 121

120. Tele Dentistry
122
https://cms-saml.unimelb.edu.au/saml_account_manager?url=http%3A//broadband.unimelb.edu.au/

121. 123

122. 124

123. Future?
In combination with AI/Drone and Robotics
125

124. 126
The Changing Fortunes of Telemedicine in Europe – Past, Present, and Future beyond COVID-19
(healthadvancesblog.com)

125. More care model coming
127
https://www.mckinsey.com/industries/healthcare/our-insights/how-care-at-home-ecosystems-can-
reshape-the-way-health-systems-envision-patient-care

126. 128
https://www.mckinsey.com/industries/healthcare/our-insights/how-care-at-home-ecosystems-can-
reshape-the-way-health-systems-envision-patient-care

127. 129

128. Telemedicine ISO-13131:2021
130

129. Retail care / Convenient Care
131

130. 132
https://nctrc.wpenginepowered.com/wp-content/uploads/2022/07/7.21.22-NCTRC-Webinar-FINAL-PDF.pdf

131. 133

132. Convenient/Retail Care
134

133. Boots UK, LIVI
135
http://www.boots-uk.com/our-stories/boots-uk-pilots-new-instore-video-gp-service/
https://www.livi.co.uk/

134. PingAn Good Doctor
136

135. 137

136. 138

137. 139
https://catalyst.nejm.org/doi/full/10.1056/CAT.22.0311

138. 140

139. Telesurgery
141
https://mgronline.com/china/detail/9640000111454

140. Telesurgery (Retina)
142
https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2781796
https://edhub.ama-assn.org/jn-learning/video-player/18623735

141. Tele-ultrasound
143

142. Tele-ultrasound
144

143. 145

144. 146

145. Telemedicine Equipment
147

146. 148
https://www.usatoday.com/story/opinion/2019/03/23/doctor-patients-need-real-me-not-robot-telemedicine-column/3228504002/

147. 149
https://veeonehealth.com/wp-content/uploads/2021/07/VeeKart-photo-2048x1365.png

148. Telemedicine Kit
150
https://vsee.com/hardware/

149. Smart Ambulance + Telemedicine
151
https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.114.005193
https://consultqd.clevelandclinic.org/when-mobile-stroke-units-meet-telemedicine/

150. Non-English and non-local language medical
translator
• Telemedicine
platform must allow
3rd party joining
• Certified + License
Medical Translator
152

151. Challenges
153

152. Sensitive matters
154
https://www.nytimes.com/2019/03/09/science/telemedicine-ethical-issues.html

153. Liability
155
http://www.wsha.org/wp-content/uploads/Malpractice-in-Telehealth.pdf

154. Huh?
• “This study found no reported cases of medical malpractice in DTC
telemedicine. ” since 2018
• DTC = Direct-to-Consumer
156
https://jamanetwork.com/journals/jama/fullarticle/2729359

155. Why?
• Because of low risk and low acuity?
• Because patients are advised to seek in-person care when telehealth
care doesn’t suffice?
• Not attractive for litigation due to low dollar value
• Remember, the case settle outside the court might not be included
• Even of that, malpractice claims remain uncommon in telehealth
157
http://www.wsha.org/wp-content/uploads/Malpractice-in-Telehealth.pdf

156. OK, What do we have outside of
the court?
158

157. What do we have?
159
http://www.wsha.org/wp-content/uploads/Malpractice-in-Telehealth.pdf

158. Well, however…
• The number, still very low e.g. only 28 cases cumulative before
COVID-19
• Given the available data so far, malpractice claims remain uncommon
in telehealth
161
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9581762/
https://www.thedoctors.com/articles/your-patient-is-logging-on-now--the-risks-and-benefits-of-telehealth-in-the-future-of-
healthcare/?utm_source=pr&utm_medium=referral&utm_campaign=pr_external&utm_content=telehealth_whitepaper

159. Reimbursement
• “Low reimbursement for telehealth was viewed as a critical
disincentive. Without payment, it would be difficult for clinicians to
afford to provide the service, ”
• Telehealth payment parity
• Same or close reimbursement rate for telehealth and in-person visit
• For instance, for a routine primary care visit, such as for a 20- to 30-minute
visit with a physician, Louisiana Medicaid reimbursement for 2020 would be
$33.95 for a telehealth, compared with $62.65 for a physical visit.
• Having payment parity will improve telehealth use
162
https://jamanetwork.com/journals/jama/fullarticle/2766369
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2790920
https://www.healthaffairs.org/do/10.1377/forefront.20210503.625394/full/

160. Store and Forward Telemedicine
Reimbursement in the US
163
https://www.cchpca.org/resources/state-telehealth-laws-and-reimbursement-policies-report-fall-2022/

161. Telephone + email Reimbursement
164
https://www.cchpca.org/resources/state-telehealth-laws-and-reimbursement-policies-report-fall-2022/

162. Remote Patient Monitoring Reimbursement
165
https://www.cchpca.org/resources/state-telehealth-laws-and-reimbursement-policies-report-fall-2022/

163. 166

164. It’s all about money
167

165. Low Digital Literacy, socioeconomic associate
with more ‘audio’ telemedicine
168
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2794548

166. Internet “Broadband” Coverage
• Internet Connection speed and internet speed is also important factor
for VDO Call Based Telemedicine (2x)
• No different on plain Telephone call telemedicine
169
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2797400
https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06746-0

167. Telemedicine impact on prescribing
170
https://ihpi.umich.edu/news/hospital-affiliated-doctors-prescribe-fewer-antibiotics-through-telehealth-third-party
https://publications.aap.org/pediatrics/article/143/5/e20182491/77062/Antibiotic-Prescribing-During-Pediatric-Direct-to?autologincheck=redirected
https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0366
https://www.nih.gov/news-events/nih-research-matters/antibiotics-prescribed-more-often-during-
telemedicine-visits
https://www.childrenshospitals.org/Newsroom/Childrens-Hospitals-Today/Articles/2019/09/Study-
Telemedicine-Visits-Linked-to-More-Antibiotic-Prescriptions-for-Children

168. COST is IMPORTANT!
171
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786700

169. More resources are available..
172

170. 173

171. 174

172. The American Telemedicine Association
175
https://www.americantelemed.org/

173. WHO Telemedicine Implementation Guide
176
https://www.who.int/publications/i/item/9789240059184

174. 177
https://raynus.wordpress.com/2020/05/25/the-telephone-telemedicine-in-clinical-medicine-an-instrument-of-opportunity-risk/

175. Take home message
• Telemedicine is not just a teleconference call, but a part of the care
• Telemedicine is not a substitute but complimentary to in-person care
• Know your customer!
178

176. “64% would have preferred to
see their nurse or doctor in
person”
NPR, the Robert Wood Johnson Foundation and the T.H. Chan School of Public
Health at Harvard Survey
https://media.npr.org/assets/img/2021/10/08/national-report-101221-final.pdf
https://www.npr.org/sections/health-shots/2021/10/18/1044358309/patients-say-telehealth-ok-but-doctor-visits-in-person-better
179

177. 180
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786700

178. 181
https://www.theguardian.com/commentisfree/2015/aug/21/what-do-we-do-to-our-patients-when-we-label-them-as-anxious

179. “Telehealth leaves us with no excuse
not to find the help we need – for
body and soul – no matter where in
the world we are.” – Eric J Hall.
182

180. 183

181. 184