Telemed in PH Webinars 1-3 PDF

WEBINAR #1
Telemedicine in the Philippines

Raymond Francis R. Sarmiento, MD
May 4, 2020
DISCLAIMER & DISCLOSURES
• All statements issued are those of the presenter alone.
• I declare no conflict of interest with any proprietary entity producing health

care goods or services consumed by, or used on, patients, clinicians, or
other consumers.
• I declare no financial relationships with the manufacturer(s) of any

commercial product(s) and/or provider(s) of commercial services.
OUTLINE
• Telemedicine: Definition and Context
• Types, Benefits, and Practice of Telemedicine
• Telehealth and UHC
• Telehealth Policies Drafted
• Legal Considerations
TELEMEDICINE
• Use of medical information exchanged from one site to another via

electronic communications to improve a patient’s clinical health
status
- American Telemedicine Association (2012)
A lack of trained physicians is one of the largest issues
facing healthcare in the developing world.
Patients often make

long journeys to clinics,
only to be referred to
expensive and far away
medical centers for a
diagnosis.
Paper based medical records

further contribute to inefficiencies.
TELEMEDICINE TYPES
Real-Time Store-and-Forward Remote Monitoring
6
BENEFITS OF TELEMEDICINE
P
IMPROVES COST IMPROVES CARE IMPROVES CARE
ACCESS EFFECTIVE DELIVERY QUALITY
Telemedicine allows Telemedicine can reduce

health facilities to the cost of healthcare Telemedicine addresses Telemedicine improves
expand their reach and increase efficiency in patient demand for the quality of
beyond their own service delivery. healthcare services. healthcare services
offices. received by patients.
7
TELEMEDICINE PRACTICE (since 2007)
SMS telemedicine
MMS telemedicine
Email telemedicine
Apps-aided telemedicine
8
BARRIERS TO TELEMEDICINE PRACTICE
• TECHNOLOGICAL FACTORS • HUMAN FACTORS

• Lack of technological • Lack of skilled health workers
infrastructure • Resistance to change
• Poor network coverage • Perceived additional workload
• Diverse information systems • Lack of reimbursement scheme
• ORGANIZATIONAL FACTORS • Risk of liability
• Traditional design of medical care • ECONOMIC FACTORS
model • Implementation costs
• Lack of enabling • Sustainability plan
policies/guidelines
Reference: https://www.ncbi.nlm.nih.gov/pubmed/21719160 (Roig & Saigi, 2011) 9

TELEHEALTH and UHC
Telehealth /
Telemedicine
10
TELEMEDICINE POLICIES DRAFTED
• House Bill 7153 (Philippine
National eHealth System
and Services Act), Feb 2018
• House Bill 4199, Rep.
Rogelio Espina, March 2014
• Draft Administrative Order,
March 2014
• House Bill 6336, Rep.
Joseph Abaya, June 2012
• Draft Executive Order,
September 2012
*Office of Senator Risa Hontiveros
TELEMEDICINE GUIDELINES
• Issued by DOH and NPC
• Serves as a framework for
telemedicine services in the
country in a bid to improve
access to health services
during the ECQ.
• Healthcare providers
conducting these
consultations are allowed
to issue electronic case
reports and prescriptions.
E-PRESCRIPTION GUIDELINES
• FDA Circular No. 2020-007
• Guidelines in the
Implementation of the Use
of Electronic Means of
Prescription for Drugs for
the Benefit of Individuals
Vulnerable to COVID-19
IMPETUS FOR TELEMEDICINE DURING COVID-19
• Lack of Personal Protective Equipment (PPEs) in health facilities when
attending to patients during screening.
• Lack of readiness of rural health units (RHUs) and primary care clinics to
manage COVID-suspected/related enquiries and consults
• Lack of a go-to provider for initial triaging
• Overburdened OPD and Emergency rooms for patients needing screening for
COVID-19
• Food and Drug Administration (FDA) issuance to accept e-Prescription
• Data privacy and confidentiality in health care
ANY SPECIFIC LAWS APPLICABLE TO TELEMEDICINE?
• The Medical Act of 1959 (R.A. 2382)

• Section 10 (What constitutes as practice of medicine?)
• Electronic Commerce Act of 2000 (R.A. 8792)

• Comprehensive Dangerous Drugs Act of 2002 (R.A. 9165)
• Mental Health Act of 2017 (R.A. 11036)
• Anti Wire-Tapping Act of 1965 (R.A. 4200)
• Data Privacy Act of 2012 (R.A. 10173)
TAKEAWAY MESSAGES
• ALWAYS secure informed consent.

• Conduct due diligence.
• Opt for secure telemedicine platforms and systems.
• Opt for trained telemedicine software providers.
WEBINAR #1
Telemedicine in the Philippines
THANK YOU!
This work is licensed under a Creative Commons Attribution 4.0 International License
WEBINAR #2
Setting Up Your Telemedicine Practice
May 6, 2020

other consumers.

OUTLINE
• The Telemedicine Pre-Visit
• The Telemedicine Visit Proper
• The Virtual Physical Exam
• Choosing the right telehealth platform
• Which mode of telehealth care delivery is right for my practice?
• Any guidance on advertising my services as a physician?

THE TELEMEDICINE PRE-VISIT
TECHNOLOGY REQUIREMENTS
 High-speed internet connection.

 Consider dual monitors.
 Position webcam at eye-level.
 Test your speakers and microphone before every visit.
 Turn off other web applications and notifications.
Reference: https://stanford.cloud-cme.com/default.aspx?P=3000&EID=35561&Panel=9
SETTING UP YOUR WORKSTATION
BY PATIENT BY HEALTHCARE PROVIDER
 Ensure room is secure and private.  Ensure room is secure and private.
 Quiet, interruption-free, private space.  Quiet, interruption-free private space
 Adequate lighting.  Wear headphones for better audio, if available
 Wear headphones for better audio, if available.  Angle the screen so no one can walk by and see it
 Angle the screen so no one can walk by and see it.  Wear same level of professional attire as in-person care
 Wear what you would wear when going to clinic.  Adequate lighting
 Avoid visual distractions such as busy patterned  Avoid visual distractions Busy patterned shirts Messy
shirts, messy desks, food and drinks, desks / Food and drinks Photos/posters on background
photos/posters on background wall. wall
 No virtual background (recommended).  No virtual background (recommended).
SETTING UP YOUR WORKSTATION
BY PATIENT BY HEALTHCARE PROVIDER
 Ensure room is secure and private.  Ensure room is secure and private.
 Quiet, interruption-free, private space.  Quiet, interruption-free, private space.
 Adequate lighting.  Adequate lighting.
 Wear headphones for better audio, if available.  Wear headphones for better audio, if available.
 Angle the screen so no one can walk by and see it.  Angle the screen so no one can walk by and see it.
 Wear what you would wear when going to clinic.  Wear same level of professional attire as in-person care.
 Avoid visual distractions such as busy patterned  Avoid visual distractions such as busy patterned shirts,
shirts, messy desks, food and drinks, messy desks, food and drinks, photos/posters on
photos/posters on background wall. background wall.
 No virtual background (recommended).  No virtual background (recommended).
ELEMENTS OF AN INFORMED CONSENT
1. Need to explain what telehealth is
2. Lay out the expected benefits and possible risks
3. Explain security measures
SAMPLE INFORMED CONSENT FORMS: https://www.telehealthresourcecenter.org/
Reference: https://www.cchpca.org/telehealth-policy/informed-consent
THE TELEMEDICINE VISIT PROPER
WEBSIDE MANNERS: GREETING
1. Introduce self and your role.

2. Confirm that your patient can see and hear you.
3. Acknowledge the use of new technology.
 “Alam ko pong panibagong paraan po ito ng ating nakagawiang bisita sa clinic. Salamat po at
pumayag kayong subukan natin ito.”
 “Natutuwa po akong makita/marinig kayo. Pasensya na po at hindi natin ito magawa nang
personal, pero masaya na rin po akong ligtas kayo sa inyong bahay at nakakapag-usap po
tayo.”
 “Maraming salamat po at nakakapagkita po tayo kahit nasa bahay lang po tayo ngayon.”
WEBSIDE MANNERS: MAINTAINING ETIQUETTE
1. Be aware of your actions since they will be magnified on camera. Sit fully upright.
2. Don't fidget, scratch, play with your hair, or touch your face.
3. Look directly at the camera. Patient will perceive this as making eye contact.
4. Position video window of patient's image at the top of your screen below the webcam.
5. Explain and narrate all your actions.
 “Kung mapansin po ninyong hindi ako nakatingin sa screen or malayo po ang aking tingin, ito
po ay dahil may chine-check po ako sa record ninyo para masiguradong tama po ang
impormasyon ko tungkol sa inyo.”
WEBSIDE MANNERS: EMPATHY & COMMUNICATION
1. Speak slowly and clearly. Pause longer between statements to allow for transmission
delay.
2. Type into the chat window to reiterate instructions or next steps.
3. Check in frequently to elicit reactions and confirm understanding.
4. Use nonverbal cues even on virtual visits: Smile often. Use a warm tone of voice.
5. Increase the frequency of empathetic statements to show you are listening.
 “Mukhang mahirap nga po yan, ano po. Ano pa po ang inyong ibang nararamdaman?”
 “Mukhang nag-aalala po talaga kayo sa nararamdaman nyo. Pwede nyo pa po ba ako
kwentuhan tungkol rito?”

THE VIRTUAL PHYSICAL EXAM
QUICK TIPS
1. Take a thorough medical history.

2. Have a keen eye for observing your patient's condition.
3. Consider what you can examine while going through the Review of Systems.
4. Partner with your patient to gain valuable clinical insight.
 Using home monitor, ask your patient or relative to take vitals.
 Ask a family member or relative to conduct palpation maneuvers or assist in testing patient’s
range of motion, while giving instructions.
5. Take advantage of available technology.

 Sharing photos or videos may show lesions that are difficult to visualize on webcam.
CHOOSING THE RIGHT
TELEHEALTH PLATFORM FOR YOU
For Group or Solo Practices

KEY QUESTIONS TO ASK YOURSELF
1. What problem am I trying to solve?

 Increasing patient access
 Supporting patient acquisition and/or retention
 Mitigating physicians’ workload
2. Who are my patients?

 Different patient demographic segments  Varying preferences
 What access points are needed
KEY QUESTIONS TO ASK YOURSELF
1. What problem am I trying to solve?

 Increasing patient access
 Supporting patient acquisition and/or retention
 Mitigating physicians’ workload
2. Who are my patients?

 Different patient demographic segments  Varying preferences
 What access points are needed
6-POINT CHECKLIST FOR CHOOSING A PLATFORM
1. Is it supportable across all devices?
2. Will the quality of service be equal to or better than in-person care?
3. Will remote patient monitoring be included?
4. Is “webside manner” properly addressed?
5. Is this as easy as possible for patients to use?
6. Are all security and privacy concerns addressed?

Reference: https://mhealthintelligence.com/features/picking-the-right-telehealth-platform-for-a-small-or-solo-practice




6. Are all security and privacy concerns addressed? 2012 DPA, HIPAA, HITRUST CSF
REAL-TIME vs.
STORE-AND-FORWARD?
REAL-TIME vs. STORE-AND-FORWARD
Real-Time Store-and-Forward
25
Real-Time • A real-time video based
platform is a complete
program.
• Users must understand the

technology.
• Need to be able to
manipulate the video camera
and present oneself
appropriately to the patient
26
BENEFITS Store-and-Forward
• Maybe more efficient than real-time
because you can treat more patients in less
time
• More appealing to providers where internet

access is limited
• Can still enhance patients’ access to care;

improve health outcomes through a
consistent care delivery; lower costs
• May potentially reduce physician burnout, if

integrated into EHR 27
ANY GUIDANCE ON
SERVICE ADVERTISEMENT?
P.M.A. CODE OF ETHICS
SECTION 4.
• A physician shall not employ agents in the solicitation and recruitment of
patients.
• For the promotion of medical practice, a physician may use professional cards,
classified advertising, publications, internet, directories and signboards.
Signboards shall not exceed one by two (1x2) meters in size.
• Except in internet web sites, only the name of the physician, field of specialty,
office hours or office or residential addresses may appear.
P.M.A. CODE OF ETHICS
SECTION 4.
• The act of the physician in publishing his or her personal superiority, special certificates or
diplomas, post graduate training, specific methods of treatment, operative techniques or
former connections with hospitals or clinics is not allowed. However, these matters may be
placed by a physician within the confines of his clinic or residence.
• For internet web sites, recognizing the right of a patient to know the capabilities and
qualifications of his doctor, special certificates or diplomas, post graduate training and former
connections with hospitals or clinics may be posted.
TAKE-AWAY MESSAGES
TAKEAWAY MESSAGES

• The non-technology components are just as important, perhaps even
more so, than the technology components.
• In choosing a telehealth platform, it must be efficient and not too
clunky for the user.
• Check bandwidth and connectivity.
• Adhere to the Philippine Medical Association (PMA) Code of Ethics.
WEBINAR #2
Setting Up Your Telemedicine Practice
THANK YOU!
WEBINAR #3
TELEMEDICINE:
Incorporating the New Normal in Your Practice

May 8, 2020

other consumers.

OUTLINE
• Elements of an Informed Consent
• Clinic Visits: Face-to-Face vs. Telehealth
• The Virtual Physical Exam
• Billing and Payment

INFORMED CONSENT
FOR TELEHEALTH CONSULTS
ELEMENTS OF A SAMPLE INFORMED CONSENT
1. What is Telehealth?
2. Services provided
3. Expected Benefits
4. Possible Risks
5. Service Limitations
6. Patient Consent
Reference: https://www.telehealthresourcecenter.org/
What is Telehealth?
“Telemedicine is the use of electronic communication such as phones
and/or other electronic devices to enable the patient to consult with
his/her physician or healthcare provider about his/her health condition,
healthcare options, and decisions.”
Services Provided
• “Services include a patient consultation, diagnosis, and recommendation, which may also include
chart review, remote prescribing, appointment scheduling, refill reminders, health information
sharing, and patient education. The information you provide may be used for diagnosis, therapy,
follow-up and/or patient education.
• The electronic communication systems in (state name of platform) will incorporate network and
software security protocols to protect the confidentiality of patient information, including imaging
data, and will include measures to safeguard the data and to ensure its integrity against intentional or
unintentional information breaches.”
Expected Benefits
• “Improved access to care by enabling the patient to remain in his/her

home while the physician or healthcare provider consults and obtains
test results at distant/other sites.
• Care evaluation and management may be done more efficiently.
• Able to obtain expertise from a clinical specialist, as appropriate.”

Possible Risks
• “Delays in evaluation and treatment could be caused by technology or equipment
deficiency or failure.
• In rare events, the doctor may determine that the transmitted information is of
inadequate quality, thus necessitating a rescheduled telehealth consult or
recommending a meeting with your local primary care doctor.
• In rare events, a lack of access to complete medical records may result in adverse
drug interactions or allergic reactions, or other judgment errors.
• Despite best efforts to protect the confidentiality of patient information, security
protocols may fail causing a breach of privacy of personal health information.”
Service Limitations
• “If the patient believes he/she is experiencing a medical emergency,
he/she should go to the nearest health facility or hospital. After receiving
treatment, he/she should visit your primary care doctor.
• The doctor is typically available to respond to telehealth consults on
(insert schedule).
• Responsibility for the patient’s overall medical care remains with his/her
local primary care doctor. If the patient does not have one, he/she is
strongly encouraged to locate one for his/her healthcare needs.”
Patient Consent
“By signing this consent form, I hereby declare that:
• I have read this form and that I fully understand what is stated here;
• I was given the opportunity to ask questions and my questions were
answered;
• I have discussed my medical concerns with my healthcare provider; and
• I fully understand the risks and benefits of telemedicine consultation as
they were shared in a language that I can understand.”
FACE-TO-FACE vs. TELEHEALTH
Face-to-Face vs. Telehealth
Reference: 10.2196/jmir.8033
Face-to-Face vs. Telehealth
PATIENT-RELATED OUTCOMES DOCTOR-RELATED OUTCOMES
 Patient Satisfaction  Doctor Satisfaction
 Perceived Information Exchange  Perceived Information Exchange
 Interpersonal Relationship Building  Interpersonal Relationship Building
 Perceived Shared Decision Making  Perceived Shared Decision Making
NO SIGNIFICANT DIFFERENCES Reference: 10.2196/jmir.8033

QUICK TIPS
1. Take a thorough medical history.

2. Have a keen eye for observing your patient's condition.
3. Consider what you can examine while going through the Review of Systems.
4. Partner with your patient to gain valuable clinical insight.
 Using home monitor, ask your patient or relative to take vitals.
 Ask a family member or relative to conduct palpation maneuvers or assist in testing patient’s
range of motion, while giving instructions.
5. Take advantage of available technology.

 Sharing photos or videos may show lesions that are difficult to visualize on webcam.
VISUAL ASSESSMENT WITH PATIENT ASSISTANCE
 General appearance  Self palpation (or aided by family

 Skin tone and rashes
member / relative)
 Eye redness
 Range of motion
 Icterus
 Clarity of thought and speech  Close-up camera views (e.g., oropharynx,
 Respiratory rate skin lesions)
 Work of breathing  Results from home monitoring devices
 Gait
(e.g., glucometers, peak flow meters)
Reference: American College of Physicians’ Checklist for Video Visits

VISUAL ASSESSMENT WITH PATIENT ASSISTANCE
 General appearance  Self palpation (or aided by family

 Skin tone and rashes
member / relative)
 Eye redness
 Range of motion
 Icterus
 Clarity of thought and speech  Close-up camera views (e.g.,
 Respiratory rate oropharynx, skin lesions)
 Work of breathing  Results from home monitoring devices
 Gait
(e.g., glucometers, peak flow meters)
Reference: American College of Physicians’ Checklist for Video Visits

http://bit.ly/caravantelePE
BILLING and PAYMENT
For Group or Solo Practices

P.H.I.C. BILLING CODES DURING COVID-19
ISOLATION PACKAGE
• ICD 10 code = Z 29.0
• Admission to protect the individual from
his/her surroundings or for isolation of
individuals after contact with infectious
disease
• Amount = 14,000 pesos
Reference: https://www.philhealth.gov.ph/circulars/2020/circ2020-0004.pdf
GENERAL DOCUMENTATION REQUIREMENTS
1. All types of telemedicine visits must include:

 patient location,
 provider location,
 other family members/caregivers present on the call,
 patient consent to telehealth, and
 referring physician (if applicable).
2. Healthcare providers must have documentation that:

 specifies the platforms used, and
 that the patient consented to use of those platforms.

PAYMENT OPTION TYPES
1. Frontload payment
2. Backload payment
HOW MUCH SHOULD I CHARGE?
METRICS
1. Total time spent; or
2. Medical decision-making
DO I NEED TO ISSUE A RECEIPT?
YES !!!
• Always remember that you have registered your business
• The orange BIR notice posted clearly in your clinics is proof.
TAKE-AWAY MESSAGES
TAKEAWAY MESSAGES
• When it comes to doctor-patient communication, telehealth is not
inferior to face-to-face consultations.
• It is time to incorporate telemedicine into your practice!

WEBINAR #3
TELEMEDICINE:
Incorporating the New Normal in Your Practice
THANK YOU!

Telemed in PH Webinars 1-3 PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Telemed in PH Webinars 1-3 PDF

Uploaded by

Copyright:

Available Formats

WEBINAR #1

Telemedicine in the Philippines

• I declare no conflict of interest with any proprietary entity producing health

• I declare no financial relationships with the manufacturer(s) of any

• Telemedicine: Definition and Context

• Types, Benefits, and Practice of Telemedicine

• Telehealth and UHC

• Telehealth Policies Drafted

• Use of medical information exchanged from one site to another via

Patients often make

Paper based medical records

Telemedicine allows Telemedicine can reduce

• TECHNOLOGICAL FACTORS • HUMAN FACTORS

Reference: https://www.ncbi.nlm.nih.gov/pubmed/21719160 (Roig & Saigi, 2011) 9

• The Medical Act of 1959 (R.A. 2382)

• Electronic Commerce Act of 2000 (R.A. 8792)

• ALWAYS secure informed consent.

• I declare no conflict of interest with any proprietary entity producing health

• I declare no financial relationships with the manufacturer(s) of any

• The Telemedicine Pre-Visit

• The Telemedicine Visit Proper

• The Virtual Physical Exam

• Choosing the right telehealth platform

• Which mode of telehealth care delivery is right for my practice?

• Any guidance on advertising my services as a physician?

 High-speed internet connection.

1. Need to explain what telehealth is

2. Lay out the expected benefits and possible risks

3. Explain security measures

SAMPLE INFORMED CONSENT FORMS: https://www.telehealthresourcecenter.org/

1. Introduce self and your role.

 “Mukhang nag-aalala po talaga kayo sa nararamdaman nyo. Pwede nyo pa po ba ako

kwentuhan tungkol rito?”

1. Take a thorough medical history.

5. Take advantage of available technology.

For Group or Solo Practices

1. What problem am I trying to solve?

2. Who are my patients?

1. What problem am I trying to solve?

2. Who are my patients?

1. Is it supportable across all devices?

2. Will the quality of service be equal to or better than in-person care?

3. Will remote patient monitoring be included?

4. Is “webside manner” properly addressed?

5. Is this as easy as possible for patients to use?

6. Are all security and privacy concerns addressed?

1. Is it supportable across all devices?

2. Will the quality of service be equal to or better than in-person care?

3. Will remote patient monitoring be included?

4. Is “webside manner” properly addressed?

5. Is this as easy as possible for patients to use?

6. Are all security and privacy concerns addressed?

1. Is it supportable across all devices?

2. Will the quality of service be equal to or better than in-person care?

3. Will remote patient monitoring be included?

4. Is “webside manner” properly addressed?

5. Is this as easy as possible for patients to use?

6. Are all security and privacy concerns addressed?

1. Is it supportable across all devices?

2. Will the quality of service be equal to or better than in-person care?

3. Will remote patient monitoring be included?

4. Is “webside manner” properly addressed?

5. Is this as easy as possible for patients to use?