On Asian healthcare’s digital transformation and better quality of care

Norman Deery, Vice President of Clinical Effectiveness, Wolters Kluwer Health APAC, affirms that Asia is all-geared up for a digital revolution in healthcare, and identifies the challenges and opportunities for its realisation.

The future of healthcare is digital, and Asia is poised to take a huge leap to realise its healthcare system’s digital transformation. Norman Deery, Vice President of Clinical Effectiveness at Wolters Kluwer Health for Asia Pacific, believes the region is primed for this as evidenced by the wide adoption of advanced clinical decision support systems during the pandemic. More than 500 thousand UpToDate® users, and a significant number from Asia Pacific countries, have accessed its COVID-19 content topics. 

Deery worked for 30 years in the information technology industry prior to joining Wolters Kluwer, thus, has an excellent understanding of the blueprint underlying digital transformation. Shifting to the healthcare industry because of that “wonderful sense of achievement from helping people and improving the quality of life for others”, Deery shares his vision for a patient-centric health system for Asia – one that could also be prompted by technological innovation.

Digitising healthcare in Asia not only allows for efficient medical processes but also patient safety and clinical effectiveness, which are positively and consistently linked to a higher quality of care. Providing better quality of care, though most vital, is never an easy trail. In Asia, a number of apparent challenges may be addressed through innovative solutions.

Deery observes that physician ratio in the region’s emerging markets is a major problem. To illustrate, the number of physicians per 1,000 people in China is 1.9, in India 0.7, in Malaysia, Vietnam, and the Philippines 1.2, in Thailand 0.4, and in Indonesia 0.2. These numbers are way lower than what communities need considering the increase in the ageing population and the prevalence of chronic conditions and diseases.  All these challenges add to the pressure of providing quality care in the most efficient way possible.  Wolters Kluwer’s solutions help by providing trusted recommendations at the point of care, where it matters most.  A clinician can typically search, locate, and review the information they need in approximately 1 minute.

Healthcare organisations in Asia also struggle to harmonise care across the entire healthcare system. “Medicine has become so fragmented that if you have doctors, nurses, pharmacists, patients, and everyone else in the healthcare continuum all making decisions based on disparate information, you simply can’t provide high quality or very effective care,” Deery says. With an evidence-based clinical decision support tool, however, these providers could have access to up-to-date medical information to help in their decision-making. Hence, they would be able to reduce unwanted variability in care across the system through enhancing medical decision-making and patient assessments, and through proactively alerting prospective patients of issues that need medical intervention.

Another problem, not just in Asia but globally, is erroneous diagnosis and medication. The World Health Organisation reports at least 5 patients dying every minute because of unsafe care, and four out of 10 patients harmed during primary and ambulatory health care due to errors in diagnosis, prescription, and medication. With new technologies like Wolters Kluwer’s UpToDate, healthcare providers can make the best clinical decisions, supported by updated and critically reviewed evidence, to save more lives.

Even in today’s situation where patients and physicians resort to virtual consultations, evidence-based solutions can add value to hospitals. As of date, Wolters Kluwer is working with telemedicine providers in Asia to integrate the benefits of harmonised and evidence-based care to patients. Additionally, Deery mentions that they are currently incorporating their solutions, such as UpToDate, Lexicomp, and Medi-Span, with a variety of Electronic Medical Records (EMR) systems providers so as to contribute to better data management coupled with the improvement of the quality of care.

There is also increasing support from governments and healthcare providers across the region to swiftly employ digital technologies. Over the years, governments are observed to increase their healthcare spending, thereby, increasing confidence that they would give continuous support to the health sector. Healthcare providers and patients likewise show eagerness in using mobile technologies and cloud-based solutions, hence, putting pressure on hospitals to integrate such solutions into their organisations.

Step by step, Asia could transform its healthcare system towards becoming more digital, not because other regions are doing it, but because of the necessity of providing better care for patients through proven technological solutions.

About UpToDate

Researchers at Harvard associated the use of UpToDate, the only clinical decision support resource associated with improved outcomes, with lower mortality rates and shorter lengths of hospital stay. Several other studies confirm UpToDate’s impact on learning, better clinical decisions, improved quality of care, patient safety, efficiency, and mortality.

Top considerations for remote patient monitoring devices

Dr Ravinder Sachdev, Deputy Chief Medical Information Officer, Tan Tock Seng Hospital, discusses how remote monitoring devices can be successfully managed and improved.

With the accelerated adoption of telehealth due to COVID-19, remote patient monitoring (RPM) is also capturing the limelight. RPM is a subcategory of home-based telehealth allowing patients to use mobile devices to monitor physiological data such as vital signs, weight, blood pressure, glucose levels, and heart rate and send it for diagnosis to clinicians.

Tan Tock Seng Hospital (TTSH) in Singapore has used a number of RPM devices over the past decade, including RFID-based automated patient temperature tracking for inpatients, vital signs monitoring devices for blood pressure, pulse, oxygen saturation, blood sugar, and weight, and Bluetooth stethoscopes for remote auscultation.

These RPM technologies are definitely advantageous for both patients and healthcare providers, acknowledges Dr Ravinder Sachdev, Deputy Chief Medical Information Officer at TTSH. Yet, they come with a number of challenges that need to be overcome before being successfully integrated into the industry.

Regulations and data security

Always, the very first consideration with online diagnosis and monitoring are regulations. In Singapore, RPM devices are regulated the same way as the standard medical peripherals. Thus, they need to be approved by the Health Sciences Authority (HSA). 

Also, regulations mandate that data ought to be encrypted and transmitted in such a way that all data stay in Singapore. Hence, if the RPM device uses a public cloud server like Amazon Web Services or Microsoft Azure, the server must also be located locally.

Ensuring data security doesn’t come cheap. It is expensive to use premium, local cloud servers and high levels of encryption, as well as to integrate with backend medical record systems. Still, ensuring confidentiality, data security, and healthcare interoperability must be a top priority in the adoption of RPM devices, and telehealth in general. Dr Sachdev suggests that these “can be built-up incrementally as long as a clear implementation plan is in place”.

User acceptance

With every novel technology comes a challenge on user acceptance, and RPM devices are no exception. Dr Sachdev reveals that both patients and clinicians may not find it easy to accept these new devices, especially if the methodology of data measurement and monitoring are unfamiliar.

Older patients, in particular, have struggled to come to terms with using the new RPM technologies. They could feel uncomfortable monitoring their own health without a doctor or a nurse by their side. More often than not, the older generation faces usability issues even when the hospital attempts to find ways to better engage them, like using touch-screen devices for easier use. However, as the adoption of smart devices increases within this population, RPM technologies are likely to gain traction.

Additionally, doctors may sometimes also be reluctant to embrace these innovations in healthcare. Dr Sachdev shares one instance when he tried to introduce a remote auscultation project. Many clinicians questioned whether the data transmission from the stethoscope was accurate enough for them to make a diagnosis, when, in fact, making a diagnosis was highly dependent on the physician’s skills and not on the device, which was simply a tool just like a standard stethoscope.

Dr Sachdev recognises that this aversion can be attributed to the fact that older devices, which have been through the rigorous process of validation and testing, are recognised as the ‘Gold Standards’ of clinical measurement and monitoring, while newer technologies may be perceived as “less” reliable. To address this, validation studies have been performed on a number of devices to generate local data that demonstrate reliability and accuracy of these novel technologies, but convincing clinicians takes time.

Connectivity and availability

Connectivity can also be a significant issue, as a lack of reliable internet access could limit data transmission. This could be bidirectional, meaning clinicians not being able to receive parameters from patients or doctors not being able to share more information with patients. This limitation, however, has improved over the years, given the increasing adoption of smart devices and infrastructure improvements.

On another note, the availability of RPM devices on certain markets could be a challenge. To illustrate, the Singaporean market is small as compared to the US, Europe, and even India, therefore, it usually takes a while for these devices to reach the island-state and receive approval from HSA.

Additionally, the cost associated with adopting these devices can limit their deployment amongst healthcare organisations as well as patients. In TTSH, various models have been explored, including encouraging patients to purchase their own devices or loaning devices on a subscription model. Dr Sachdev believes that as TTSH is constantly looking at ways to improve access to care, the increasing use of RPM devices will play a big role in this endeavour.

Inclusivity

Since Singapore is a multi-racial state and people speak a variety of languages, the language configuration of these RPM devices can influence their rollout. TTSH has used devices that communicate in English and Mandarin, but patients who aren’t fluent in either of these two languages may feel left out. According to Dr Sachdev, the team has previously worked to include Malay and Tamil into some of the platforms but it has been a slow process. He believes that integrating other languages like Burmese, Tagalog, and Chinese dialects, could also increase patient and caregiver interest and acceptance.

Remote patient monitoring and diagnostic devices could very well be the next big thing in healthcare. In the next few years, as telehealth becomes the new norm, the industry could see more improved technologies that can help facilitate home- and community-based care. For now, though, there is much to learn and change about doctors’ and patients’ perceptions, devices’ attributes, cyber protection, and regulatory environments encompassing RPM.

Tele monitoring for diagnostics, in-patient, and outpatient care – Columbia Asia Hospitals

How do Columbia Asia Hospitals champion remote monitoring technology for diagnostics, in-patient care, and outpatient care? Manisha Kumar, Hospital Head and General Manager, shares how they do it.

The prefix “tele” comes from a Greek word that means “far off”. On the account of COVID-19, “tele” concepts have been widely used: telemedicine, teleconsultation, telehealth, and tele monitoring. For a handful of hospitals in Asia, however, these concepts have been in use since several years ago and have just been adopted more resolutely during the management of the pandemic.

Columbia Asia Hospitals have employed tele monitoring technologies for several years now. In an interview with Hospital Insights Asia, Manisha Kumar, Hospital Head and General Manager, shares how Columbia Asia Hospitals India have extensively used remote monitoring for diagnostics, in-patient care, and outpatient areas.

Tele monitoring technologies

In order to provide access to timely and quality radiologic interpretations that help in diagnosis, the hospital has a “full-fledged tele radiology setup which consolidates radiology operations across the group and works as a hub and spoke model linking all network hospitals to one radiology reporting centre for centralised 24X7 reporting and subspecialised reporting services”. Through this setup, more than 1,500 radiologic images from various hospitals in India, Southeast Asia, the Middle East, and Africa are sent over a secured virtual platform and reported by a pool of expert radiologists.

Columbia Asia Hospitals India also employed the step down ICU (Intensive Care Unit) technology that operates with a centralised monitoring system. This specific tele monitoring setup aims to manage patients who require a level down of critical care services and close monitoring at the same time. Healthcare providers like nurses, caregivers, and physicians, are able to view patients’ vital statistics, such as electrocardiogram, saturation, pulse, and heart rate, on their mobile phones at any time, thus, can review and order instructions remotely. With a centralised monitoring system through a tele-ICU and remote monitoring ICU solutions, Columbia Asia Hospitals India can maintain superior clinical outcomes while successfully managing a large number of critical care patients using the same number of resources.

As with other technologically advanced hospitals, Columbia Asia uses wearable devices, in particular patches and Bluetooth-enabled glucometer devices, for outpatient management of patients with chronic conditions. The hospital does remote monitoring for patients with diabetes and cardiovascular diseases. To illustrate, all data recorded on the glucometer wearable device will be shared with a diabetes educator who is assigned to closely monitor the patient and assist in the timely interventions and titration of insulin levels and medications. Through tele monitoring using medical wearables, healthcare providers can better manage their patients’ health on a real-time basis. Plus, doctor consultations are more meaningful and limited, allowing patients to save both time and money.

Business model for tele monitoring

Apart from helping patients, especially those in outpatient care, cut down on cost, tele monitoring can be monetised. What Columbia Asia Hospitals do is include the cost of these devices in insurance bills sent for claims. However, insurance claims are a challenge for some patients considering the insurance penetration in India is still very low. Columbia Asia Hospitals India implements an additional daily charge of the use of these remote monitoring technologies, which Kumar describes as a “comfortable bet” given the overall cost of care and hospital stay between critical care and step down setup will go down for the patient.

Meanwhile, quite a few of the tele monitoring systems pay for themselves and do not need to be charged to patients at all: the cost of the central monitoring system they use to send patients’ vital statistics to healthcare providers’ mobile phones is covered by the solution itself by justifying the number of healthcare professionals needed per patient bedside.

Choosing remote monitoring devices

The tele monitoring market is anticipated to grow particularly at a time when physical interactions are discouraged. Kumar shares the criteria followed by Columbia Asia Hospitals in employing remote monitoring devices.

First, the device should serve as a solution to a problem faced by the hospital and its patients. For instance, if a high-volume organisation is concerned about the turnaround of beds, specifically to cater to the high demand of critically and severely ill patients, a step down unit or a tele-ICU can solve the problem. Home-monitoring post-surgery and similar technologies may also be viable solutions to free up some much-needed beds.

Second, the device must be compatible with other patient monitoring equipment in use. It is equally important that the technology can be customised according to the user’s needs, and be flexible enough to be integrated into the hospital information system.

Third, the device should have a reasonable cost. Likewise, the cost must be justified by the value that the device adds to patient outcomes.

Additionally, the device should also comply with regulations in the country. In India, the regulatory environment encompassing remote consultations and monitoring has evolved over the years and especially more firmly during the COVID-19 outbreak. Fundamentally, the regulatory framework in India includes taking medical consent of the patient, using devices approved by the FDA, adhering to principles of medical ethics including protection of patient privacy and confidentiality, and ensuring data privacy.

Taking into account all the above considerations, a healthcare provider like Columbia Asia Hospitals not only ensure excellent clinical outcomes despite physical boundaries but also encourage digital revolution in the healthcare industry.

Remote monitoring devices can improve quality of care

Dr James Yip, Group Chief Medical Informatics Officer of NUHS, Singapore, recognises the increasing demand for remote monitoring and the role of diagnostic devices in improving quality of care in hospitals.

The Consumer Technology Association recently found that 2 in 3 physicians strongly intend to use remote patient monitoring technology in the future. Doctors reveal that this technology will positively impact patient outcomes, compliance rates, and patients’ ownership of their health.

At the National University Health System (NUHS) in Singapore, remote monitoring devices have been in use since 2015. When the COVID-19 happened, however, this demand grew as patients were understandably hesitant to make hospital visits. Dr James Yip, Group Chief Medical Informatics Officer at NUHS, says that the technology NUHS employs is classified under a special branch of telemedicine called remote monitoring or vital signs monitoring that allows a non-doctor staff to monitor long-term health conditions at home.

What they look like at NUHS

Some of these remote monitoring technologies include Bluetooth blood pressure sets, POCT (point-of-care testing) blood glucose monitors, and weighing scales, which NUHS charges patients about S$70 per month (inclusive of government subsidies) for use. Since these technologies only monitor blood pressure, sugar levels, and weight, NUHS is also looking into adopting other wearable monitoring devices like POCT stethoscopes for asthma and chronic obstructive pulmonary disease (COPD) for heart failure, home blood diagnostics for fertility treatments, and wearable rings for depression and dementia care.

“The end goal of using these remote monitoring devices is the improvement of quality of care without the need for physical visits. Through the years, NUHS has seen improvement in patients’ Hba1c for diabetics, reduction of heart failure visits, and improvement in ACE inhibitor titration in a randomised controlled trial for post-attack heart patients,” Dr Yip remarks.

Nigel, 61, a diabetic, reviews his experience using blood glucose monitor: “It has been a revolution in convenience, offering a quick and easy way to know my glucose levels.”

Challenges along the way

However, the introduction of such devices in hospitals did not come easy due to user acceptance (both provider and patients) and existing regulations for telemedicine.

Oftentimes, doctors find using such devices stressful as the data received from patients at home can be quite overwhelming to manage on a daily basis. As such, nurses are trained, received certification for each monitoring device to manage specific conditions patients, and assigned to help enrol patients for this programme. “We then train them to follow a clinical protocol to help the patients titrate medication doses and give advice,” Dr Yip adds. The nurses are also assigned a doctor champion to help them with difficult cases.

Hence, change management is of utmost importance for these wearable monitoring devices to be successfully utilised in the healthcare industry. Dr Yip believes that showcasing good outcomes from the use of these devices, in particular better blood pressure and sugar control, high patient satisfaction rate, and a reduction of admissions from heart failure, helps facilitate change management with clinicians.

Taking into consideration the patients’ perspective, NUHS acknowledges that the elderly might find using these technologies difficult. As such, the organisation has made sure that the platform is kept simple and straightforward so that patients will only need to turn the device on and press a button, eliminating the need to enter data into desktops, tablets, or apps. Patients are also required to pass a simple test on device usage before they can be enrolled for home monitoring.

On another note, the regulatory environment also has an impact on the use of remote monitoring and diagnostic devices. In Singapore’s National Telehealth Guidelines, for instance, teleconsultations are advised for repeat-visit patients. During the COVID-19 pandemic, first-visit consultations have been allowed for primary care and selected specialist consultations, though the regulation still permits the cancellation of these teleconsultations when a doctor deems virtual care unsuitable for a particular case. Likewise, doctors doing teleconsultations are subject to the same accountabilities and standards of care that govern traditional in-person consultations. Furthermore, Singapore also requires doctors to undergo a two-hour online training course before being certified to conduct teleconsultations in the island-state.

Projections show that the wearable technology market will grow to $150 billion by 2027, taking into account its use in healthcare. With more healthcare organisations recognising the advantage of online diagnosis and monitoring, telemedicine could very well be stepping up its role in the future of healthcare.

Ramaiah Memorial Hospital uses remote monitoring during COVID-19

Through a remote patient monitoring system, Ramaiah Memorial Hospital in India is able to immediately attend to COVID-19 patients with comorbidities and at the same time successfully implement hospital infection control.

Ramaiah Memorial Hospital (RMH) is an early adopter of remote patient monitoring. Since 2017, the hospital has been using smart remote monitoring solution for post-ICU shift-outs and in cases of accelerated hypertension, chronic obstructive pulmonary disease, heart failure, and bronchial asthma.

Recently, the use of such monitoring system allowed RMH to perform effectively in its pandemic management. In an interview with Hospital Insights Asia, Dr Anil Kumar, Head of Department, General Medicine and Head of COVID Response Team, Dr Arun M S, Associate Professor and Assistant Hospital Administrator, and Dr Jolly Anil John, Assistant Professor, General Medicine, share how RMH utilises a remote patient monitoring system to care for patients and their healthcare staff.

During a pandemic

The remote patient monitoring system that RMH uses is able to measure six key vital parameters in a single monitor, allowing clinicians to view a patient’s heart rate, oxygen saturation, electrocardiogram, respiratory rate, non-invasive blood pressure, and skin temperature. All these data can be monitored in real time and in any location via a smartphone application.

When COVID-19 happened, RMH turned to this very same remote monitoring system for moderately to severely ill COVID-19 patients. The monitors attached to the patients help doctors and nurses receive frequent notification about the key vital parameters that are colour-coded for quick evaluation. For instance, a doctor can easily view a patient’s heart rate and decide to call a nurse if the button turns yellow. If the button is green in colour, it means the patient’s certain parameter is stable. Hence, healthcare providers are easily alerted if there is any deterioration in the patient’s health, thereby, allowing them to take immediate action.

Moreover, using a remote patient monitoring system at a time like COVID-19 enabled RMH to still provide its patients with individual care despite a large number of patients to attend to. Using the straightforward colour-coded display and automatic early warning scores on the monitor, nurses efficiently triaged patients.

Having remotely monitored isolation wards also allowed RMH to protect its healthcare staff from contracting the infection. Suspected and confirmed cases of COVID-19 are managed remotely, thus, requiring lower PPE supply for doctors and nurses and enabling better hospital infection control strategy. In the same way, it also helps RMH protect other hospitalised patients.

From the patients’ perspective, the use of remote monitoring was a welcome approach. According to Dr Kumar, “anxious patients seem more comfortable using the device because they feel they are better cared for.”

A few concerns

While doctors and patients find the use of remote monitoring devices useful, there are always some concerns surrounding their use in healthcare.

For one, patients complain about related disturbances from the device, such as the noise and the wires connected to their bodies. Since the device has an alarming sound, patients’ sleep is oftentimes disrupted. Likewise, the multiple wires attached to them make turning difficult. In these scenarios, it is then necessary for healthcare providers to constantly monitor patients’ comfort besides their health status.

Another concern is on the cost incurred from using these remote monitoring devices. Since insurers usually do not cover the use of such devices, some patients are burdened with the daily charges for the use of the device.

There is also an issue about the accuracy of online patient monitoring. Patients can be quite subjective on their complaints, and the objectivity of doctors in virtual consultations can be another factor.

With regard to data security, however, RMH is confident that the system they use complies with the provisions of the Information Technology Act, 2000 in India, which govern the transfer and storage of sensitive personal information in online channels.

Overall, RMH showed that remote patient monitoring can be agreeable to patients and can elevate the quality of care in a hospital, even and especially during a pandemic like COVID-19.

The future of telemedicine: A perspective from China

Dr Jeffrey Staples, Group Chief Operating Officer of United Family Healthcare in China, shares how UFH utilises telemedicine and how it can shape the future of healthcare.

Telehealth is getting a lot of attention in Asia. It is seen as the most innovative way to continue to serve patients as it enables hospitals to provide services, through technology, despite geographical or physical limitations.

With 7 hospitals and 18 clinics in China, United Family Healthcare (UFH) also feels the impact of COVID-19 on its operations as confirmed by its Group Chief Operating Officer, Dr Jeffrey Staples. During the initial outbreak in China, many of the hospitals’ and clinics’ services were closed per government orders. While things are now largely back to normal, private hospitals throughout the country were not allowed to treat COVID-19 patients. They were also restricted in some of the other services that they could provide, including many elective procedures.

Dr Staples says that many facilities saw fewer patients due to concerns about the virus and hesitation to go to hospitals for a consultation or elective care. Even though people are “more relaxed now” because virus cases have significantly lowered in China, global concern remains as there is no vaccine available yet. Personally, Dr Staples believes that a vaccine cannot be expected to quickly end the spread of the virus, as it will take some time to develop, manufacture, and distribute enough for everyone’s access. Hence, fear and scepticism still remain in many parts of the world.

To address the new disrupted reality caused by the virus, UFH has been offering online consulting services since February. To date, UFH has teleconsultations in many specialties across multiple locations, including pediatrics, obstetrics and gynecology, internal medicine, orthopedics, ophthalmology, mental health centre, assisted reproduction, surgery, general practice, otolaryngology, neurosurgery, heart centre, sleep medicine centre, and dermatology, among others. 

In an effort to provide the community with access to their doctors, UFH piloted a teleconsultation program in partnership with different vendors. Sooner or later, UFH is keen to either develop their own platform or secure a long-term partnership with one of the larger digital platforms in China, such as Tencent, Alibaba, or WeChat. Dr Staples acknowledges that telemedicine will become the new normal for the healthcare industry and will likely be a significant growth-driver for healthcare moving forward: “I think what COVID-19 has done is it has pushed everybody towards digitalization like we are doing right now.  Everybody has been watching this space and thinking about it, but the disruption caused by COVID-19 has forced us to act very quickly.”

UFH currently offers telemedicine consultation services at no charge because their main objective is to help patients access care despite various restrictions. “Across the group, we have done maybe 4,000 or 5,000 telemedicine consultations and we are looking at how we can continue to do this in the long term to better meet our patients’ needs, and whether or not we should charge for it,” Dr Staples adds.

Telemedicine is likely here to stay, and the ultimate challenge for healthcare systems will be how to provide high quality, personalized service that can be monetised.  According to Dr Staples, UFH looks at telehealth from two different strategic perspectives. The first is to provide service to existing patients. The second is to help them provide easier access to more patients and enlarge their patient catchment area. From the pilot program, UFH found that “existing patients who use [telemedicine] have a very high conversion rate to making an appointment with a doctor”. From the new patients they get, the conversion rate is somewhat lower.  This is particularly true for new patients who are accessing UFH’s system via telemedicine from locations where the hospital does not have a physical presence.  

Despite its convenience, telemedicine has its limitations, including existing government policies and potential cybersecurity threats. 

Just like in other Asian countries where the government is instrumental in legitimising this kind of service, China also has its own rules largely designed to protect the patient. In China, doctors are not allowed to do a primary diagnosis or prescribe any treatment through most digital platforms. Hence, the consultation is limited to listening to the patient and giving advice. If a hospital wants to expand its teleconsulting operations to be able to make primary diagnoses, it needs to apply for an internet hospital license, which is a relatively new license category and is difficult to obtain.

An internet hospital in China must have a licensed hospital facility and is allowed to make a diagnosis, prescribe medication, order tests, and deliver medications through a partnership with a delivery company or a retail pharmacy. With internet hospitals, everything can be done remotely, and patients will just be required to go to the hospital for laboratory tests and/or imaging studies. To get a license, a hospital has to have certain clearly defined digital infrastructure capabilities, and this is where partnerships can be made with digital platforms like Alibaba, Tencent, and the like.

Cybersecurity is another challenge faced by the industry, which is accentuated by the push into telehealth. As healthcare providers become increasingly digital, the potential risk of someone hacking into their system and accessing confidential medical and financial information increases significantly.  As of writing, China has been strictly monitoring healthcare organizations in the country and their data security and is taking proactive measures to ensure that healthcare organizations strengthen their cyber-security capabilities.

Despite these restrictions, the healthcare industry is confident that telemedicine will soon be a big wheel of digital health in Southeast Asia. If there’s anything good to come out of this stressful time, it is the opportunity to try out innovative solutions that otherwise remain just ideas.

Telemedicine through the lens of an insurance company – AXA Asia

Gordon Watson, Chief Executive Officer of AXA Asia, recognises that COVID-19 accelerated the rollout of telemedicine and is optimistic about telemedicine’s role in promoting value-based care.

For AXA Asia, telehealth, together with other online services, has been in its long-term pipeline. With the outbreak of COVID-19, its introduction to the market was fast-tracked. Patients restricted with lockdowns as well as fear of contracting the infection if they go to the hospital found telemedicine convenient.

In an interview with Hospital Insights Asia, AXA Asia’s CEO Gordon Watson notes that the rollout of telehealth is “to not only benefit customers but also wider society as part of AXA’s solidarity efforts, driven by [its] commitment to transform from being a payer to a true health partner”.

Acknowledging the need for telehealth in this challenging time, the insurer offers tele-consult across its markets in Asia and integrates both physical and mental health services.

Watson acknowledges that hospitals can be overwhelmed because of the novel infection, thus, patients can find it difficult to get medical advice or even support for routine medical issues. Telemedicine can enter the equation “to alleviate the burden of the stretched healthcare system and divert customers away from overcrowded hospitals”.

Watson also highlights that telehealth can promote value-based care as patients can have improved access to care through leveraging mobile technologies at a relatively low cost. Likewise, telemedicine benefits both patients and healthcare providers as it is a cheaper and more efficient alternative.

As such, AXA Asia has pledged to offer 5 million free teleconsultation services to customers and even non-customers in the region. Besides leveraging its in-house capabilities, AXA has partnered with service providers to address the unique demands of patients across Asia. 

In China, AXA works with Tencent Trusted Doctors to provide 24/7 online medical consultations through a platform supported by 450,000 physicians and psychologists. Meanwhile, in Japan, policyholders can avail telemedicine consults through T-PEC and DoctorsMe.

In Indonesia, AXA partners with Halodoc to support the country’s large population in view of its lack of healthcare facilities. Over the past few months, Halodoc has seen a surge in usage. AXA has also made a free teleconsultation program available to more than 2.6 million existing customers, as well as new ones, for a limited time period in Indonesia.

Similarly, all life and select general insurance customers of AXA in the Philippines have been given free teleconsultation services through MyPocketDoctor, which as of date has already served around 750,000 clients. 

Krungthai-AXA Life also provides teleconsultations for customers in Thailand through its hospital partners, Bangkok Dusit Medical Services and Praram 9 Hospital. 

In Hong Kong, AXA utilised its nurse hotline service launched in 2019 to extend psychological support to COVID-19 patients.

Apart from giving patients a chance to receive care remotely, AXA also understands the importance of providing holistic support to customers. In its telehealth offerings, the company incorporates free mental wellness counselling in China and Indonesia. In Hong Kong, AXA launched its ‘Mind Health Programme’ in January, which is Hong Kong’s first employee benefits cover to provide comprehensive mental health support.

Furthermore, AXA Asia has tapped global expertise from Microsoft’s Azure-bot framework, LUIS Natural Language Processing engine, HealthKeeper, and Sensely to develop Emma, an app envisioned to act as a “customer’s digital health partner”. Emma is already used by customers in Hong Kong and the Philippines, but will soon be introduced to Japan and China as well.

Even though technology is no longer an issue at this day and age for telehealth to be widely used, regulation and cybersecurity issues pose a challenge for its continuous adoption.

For instance, there are no electronic prescriptions in Hong Kong. Therefore, even if patients use teleconsultation services, they still need to go to the physical clinic to get the prescription and medication. While a few healthcare organisations in the city have a license to courier medication to patients, it is observed that telehealth still “remains complementary to traditional clinic visits”.

In other countries, AXA Asia has observed a more relaxed regulatory environment for telemedicine. Japan and South Korea, for example, had a conservative stance on telehealth. But with the outbreak of COVID-19, these countries had encouraged telemedicine services to cater to patients. Similarly, Thailand, Indonesia, and the Philippines have encouraged the use of teleconsultation services during the pandemic.

With regard to the safety of patient data, Watson acknowledges how “big data not only brings opportunities for AXA to provide value-added personalised products and services, but also the overarching responsibility to safeguard such data”. Thus, the company invests heavily on data security and protection. When forging partnerships with third-party providers, AXA ensures that data privacy officers are largely involved. It also has ongoing projects and technology updates to prevent potential breaches. Likewise, AXA Research Fund supports academic research to further understand data privacy issues and therefore better protect its customers.

“The telemedicine market worldwide is growing and is expected to reach $130 billion by 2025,” says Watson. Over time, the industry will mature and with it comes an improved quality that can significantly address the three components of the ‘iron triangle’ of healthcare: access, cost, and quality. That being the case, Watson is confident that moving to value-based care can be hastened with telehealth.

COVID-19 accelerates teleconsultation adoption in Indonesia

For Caroline Riady, Chief Executive Officer of Siloam Hospitals Group, COVID-19 is like the wind that accelerated the realisation of a digital revolution in healthcare.

Digital transformation for Siloam started three years ago. This included multiple customer channels such as the MySiloam mobile app, a chatbot on their website, and a national call centre which can be called from anywhere in the country.

Then COVID-19 happened, and movement restrictions in Indonesia followed. 

Siloam Hospitals’ CIO, Ryanto Marino Tedjomulja

Siloam Hospital Group’s Chief Information Officer Ryanto Marino Tedjomulja acknowledges that the pandemic opened up an opportunity for the hospital group to be creative. “Our goal is continuity of services and treatment”, Tedjomulja remarks, which is why they looked for ways to help doctors return to practice and patients to receive care.

Siloam introduced teleconsultation services on 13 April knowing that patients, especially immunocompromised ones, can suffer serious outcomes when unable to keep up with their treatment plan. People were scared of going to hospitals because of the stigma surrounding the infection, according to Caroline Riady, CEO of Siloam.

With more than 500 specialists doing teleconsultation services, Siloam is able to protect both patients and doctors. Its digital channels provide information about hospital safety, COVID-19 and its symptoms, hospital access, online doctor appointments, and testing facilities. They also have a live chat operated by agents properly equipped with information on the disease, the process of diagnosis and treatment, protocols, as well as a symptoms checker that is able to do the initial screening for patients. 

Currently, however, telemedicine poses a number of challenges, including technological knowledge, government regulations, infrastructure, and cybersecurity.

Because not everyone has the same understanding of how teleconsultation works, some find this new platform difficult to use. Siloam addresses this through change management. They prepare doctors, nurses, and staff to use this new system. They even have people who guide doctors step by step while the latter try and get comfortable with the technology. Likewise, Riady mentions that their doctors do teleconsultation from the hospital so that they are still “under [the] clinical governance umbrella” to better assure patients. Siloam also uses various platforms to “get the right message or information to the right people”. According to Tedjomulja, they maximise the use of their digital channels, their strategic partners like insurance companies and corporate clients, and word of mouth marketing to reach as many patients as possible.

In addition, doctors are not allowed to give a diagnosis to patients through online consultation. This is a policy in Indonesia, but some regulations have eased during the pandemic and so doctors are already allowed to write a prescription online. Riady is confident that guidelines will be reviewed to incorporate the digital footprint set out by the current health crisis.

Another challenge is building a strong foundation for digital transformation, meaning the infrastructure and the team. Since it has been in the pipelines for Siloam Hospitals since last year, the implementation has become easier for the hospital group. In fact, it was able to set up teleconsultation services in two weeks. “If we didn’t start this digital journey a year ago, we wouldn’t know where to start,” Tedjomulja believes.

The threat to data security holds up telemedicine as well. The healthcare industry is still behind when it comes to information security. For Tedjomulja, “there are a lot of things to learn from other industries on how [the healthcare industry] can improve security governance [as well as] how to improve people’s awareness”. Nonetheless, Siloam works to advance encryption procedures and protocols for other parties that access their network. Riady also finds that behaviour change is crucial in reducing cybersecurity risks. With this, Siloam Hospitals implemented steps, such as putting up posters, creating online courses, and even making a trial run on their staff, to spread awareness of the threats that come with digital transformation. “It’s a learning process for the organisation and that is something you can’t do overnight or install within a month or roll out quickly”, says Riady.

Nonetheless, teleconsultation is not the end of Siloam’s digital pathway. Looking ahead, the hospital is open to exploring new technologies that allow for monitoring of patient’s conditions even after hospital treatment. Tedjomulja is confident about a more intensive digital revolution for healthcare with the rise of cloud technology, the Internet of Things (IoT), and Artificial Intelligence (AI).

Telehealth may be running on trial this time, but the confidence on it becoming the next big thing for healthcare continues to grow.

The digital transformation at the heart of Mount Alvernia Hospital, Singapore

Director of Technology and Strategy, Bruce Leong, shares how the hospital is building secure digital healthcare services.

In Singapore, long queues at hospital registration counters are slowly disappearing. Patients can make online appointments, or scan their identity cards at a dedicated kiosk – or even consult with a doctor virtually, especially during these unusual times.

With well-defined strategies and strong support from the government, hospitals in Singapore are creating digital services that make it that much easier for patients to get the treatment they need, giving them more space to focus on their health and recovery. Mount Alvernia Hospital has made this a priority, says Bruce Leong, Director of Technology and Strategy.

He tells Hospital Insights Asia how the hospital is building seamless, secure ways for patients to transact at the hospital, and to lower the risk of human error across teams.

The journey to healthcare 4.0

 The hospital has an electronic medical records (EMR) system which went live in 2018, and which was designed with input from clinicians themselves. “We have a group of doctors who formed a committee to give ideas and suggestions on what they’d like to see,” Leong explains.

Now, the focus is on enhancing it, and “refreshing older systems”. Improving workflows, providing remote access to doctor’s mobile phones, fine tuning the system to reduce ‘alert fatigue’ – these are just some ideas for the future, according to him.

The hospital also uses automated guided vehicles that transport heavy items such as linens and deliver food to wards; and is exploring robotic process automation, Leong says.

It is crucial for any hospital to have an EMR system, he believes. Digital helps to cut the risk of “near misses” – human errors which may occur during changing of shifts or as teams communicate with each other. “On paper, you may have near misses and transcription errors,” he points out.

What’s more, the value proposition of digitalisation for any hospital is to build better patient safety, Leong continues. An EMR system centrally documents patients’ journeys across the patients’ care paths, helps to reduce medication errors, and can flag up patients’ allergies, as just some examples. It is simply better governance too, Leong says.

And no digital transformation is possible without wholehearted support from the top. “When leaders are engaged, it is much easier to cascade down. All of them buy into this journey,” says Leong. It means a lot of training for staff: he shares how the hospital has appointed “tech champions” among nursing teams to help them get used to the new digital ways of working.

“When leaders are engaged, it is much easier to cascade down.”

Digital verification for patients

The hospital has been working with the government in its bid to go paperless – in particular, on implementing the Moments of Life (MOL) initiative. MOL provides relevant information and services to citizens at key moments of their lives, such as when they are about to give birth.

This means digital birth registration, which is more convenient for the patient; previously, the process was on paper forms, says Leong. “From birth, there is an electronic birth record and certificate,” he explains. Since 2018, MOL has been used to register births at KK Women’s and Children’s Hospital, Singapore General Hospital and National University Hospital, the Straits Times reported. New parents can also use the app to apply for the government’s Baby Bonus scheme.

At the same time, Mount Alvernia’s patients can use MyInfo, a nationwide data platform that automatically fills out government online forms for them. It means they do not need to put in their details multiple times, Leong remarks.

The hospital has also integrated SGVerify, an identity verification service designed by the government. It is a secure method to verify patients’ identities and transfer data between patient and hospital, all through scanning QR codes with smartphones.

Keeping data safe and secure

An EMR system needs to be as secure as possible, especially as hospitals handle extremely sensitive data. “The challenge is actually more on security protection, as we exchange a lot of personal information,” Leong notes. “We spend a fair bit of time and effort securing the EMR.”

His team is working with potential supplier on a proof-of-concept of a biometric login function for hospital computers, which will be much more secure than passwords. The added challenge is that doctors are usually gloved up and wearing surgical masks, so the system has to be able to identify them from scanning their partially covered faces, Leong notes. While recent events have thrown this initiative off-course somewhat, he hopes that this function will go live by this year.

There exists this idea of hospitals as overcrowded, inefficient and outdated places. Mount Alvernia and other hospitals in Singapore are leveraging on digital, data and innovation to change this, and build seamless patient experiences.

Inside a smart hospital in Indonesia

Exclusive interview with Adj Prof Hananiel Widjaya, CEO of National Hospital Surabaya.

In stark contrast to Indonesia’s massive economic growth is the country’s track record of poor health outcomes. The government faces several significant challenges in providing adequate healthcare, resulting in a “lack of trust” in the local system and infrastructure, according to a 2018 report by management consulting company Oliver Wyman.

This has resulted in lost revenue of about $48 billion a year from outbound medical tourism, as Indonesian patients seek the services they need elsewhere, the report said. But one bright spot is in Surabaya, where National Hospital Surabaya is shaping the definition of a smart hospital in Indonesia.

“Our hospital is the benchmark for digitisation in Indonesia,” CEO Dr Hananiel Widjaja tells Hospital Insights Asia. He shares how telemedicine, EMR systems and various automations are helping to make a difference.

Smart health

The hospital’s big thing is its teleconsultation capability, which it began piloting two months ago. Patients can have video consults with doctors via an app, and pay for healthcare services online. This reduces the need for patients to physically visit the hospital, Dr Widjaja says. In light of the recent COVID-19 pandemic, the hospital has seen an increase of teleconsultations by 60 percent, according to him.

Meanwhile, the hospital has an established electronic medical records system that has been in use for six years, says Dr Widjaja. “We do not use paper anymore, and we try to integrate all the devices and vital sign measurements directly to communicate with our EMR system,” he explains.

Doctors have an app to ease their workload. The hospital worked with Singapore-based Bot MD to build a chatbot that acts as “a Google for doctors”. It can directly access tens of thousands of journals, along with the hospital’s internal guidance on standards, KPIs and therapies, according to Dr Widjaja.

At the same time, the hospital has introduced a speech-to-text option for doctors to convert their scripts to EMRs. “Doctors don’t have to write or type, they just talk out loud,” he explains. This helps reduce burnout, and in fact adds to a better patient experience, he adds, as the clinician can have more eye contact with their patients.

Moving towards preventive healthcare

Dr Widjaja notes how Indonesia’s healthcare system faces two major challenges. First and foremost, it does not place enough emphasis on preventive healthcare or health education to empower citizens to take charge of their personal health. “The government is only focusing on the curative level,” Dr Widjaja notes. “We need to go forward to prevention.”

“The government is only focusing on the curative level. We need to go forward to prevention.”

His hospital’s target demographic consists of the more affluent members of society, who are generally more health-conscious, he says. “It is possible for us,” he continues.

What’s more, many Indonesians lack adequate access to healthcare. This is a “uniquely Indonesian” challenge: the country is dispersed across over 17,000 islands; there is a lack of transport infrastructure; and income distribution varies widely, according to the Oliver Wyman report. The life expectancy of people in the urban areas outpaces those in the rural ones by 15 years, the report noted.

Teleradiology is helping to fill the gap, at least for hospitals in east Indonesia. National Hospital’s radiologists lend their expertise to these hospitals, and interpret test and scan results remotely, says Dr Widjaja. “They have the devices but they don’t have the experts,” he notes. These radiologists also conduct video consultations with patients remotely, he adds.

His vision for the next few years will focus on “networking and developing an ‘invisible hospital’ in the home”. Dr Widjaja hopes to connect homes with the hospital in a more effective way, so that devices can take over the job of monitoring a patient’s health and vitals. “We are trying to connect home care with IoT.”

This way, patients’ doctors can remotely keep track of blood pressure measurements or blood glucose levels, for instance. “The issue here is the assurance – patients want to be assured that there are health monitoring systems,” he goes on to say.

Another key focus will be on helping patients to manage their health through wearables. Each patient’s health will be tracked, and will feed into the hospital’s existing EMR system, he adds. “Whenever there is an abnormal measurement, it will be automatically connected and we will be notified that you have problems with your vital signs.”

Technology is plugging the gaps in Indonesian healthcare, but access remains spotty – not to mention affordability. There is a tremendous opportunity for hospitals to introduce tools and solutions to provide high-quality healthcare services and a better patient experience all around.