Telehealth during the COVID-19 pandemic in the Philippines

To the Editor,

In a very timely Editorial published in this journal, Fisher and Magin rightfully concluded that during this COVID-19 pandemic, telehealth has the potential to bridge healthcare inequity and increase access for vulnerable and disadvantaged populations. At the same time, they also added that it has the potential to exacerbate existing inequity.¹ With these interesting perspectives, I would like to validate and flesh these claims by pointing out both their advantages and disadvantages, especially in the Philippine primary care context.

In the Philippine healthcare system, health outcomes are generally improving, but the stagnant maternal mortality ratio and neonatal mortality rate, and the sluggish rate of improvement in health outcomes compared to neighboring countries, are worrisome. Addressing health system inefficiencies and health inequities due to disorganized governance, fragmented health financing, and devolved and pluralistic service delivery remain critical challenges to the Philippine health system.² Primary care can play a significant role in the COVID-19 response by differentiating patients with respiratory symptoms from those with COVID-19, making an early diagnosis, helping vulnerable people cope with their anxiety about the virus, and reducing the demand for hospital services.³ Telehealth or telemedicine is one way of improving the country’s healthcare system. Telemedicine is a method of seeking professional medical help with the use of technologies and devices such as smartphones to remotely gain information regarding their health status.⁴ The technical support provided by this alternative method matters a lot. One example of this is H4D’s Consult Station. H4D is an international company specializing in clinical telemedicine that enjoined the international effort to fight the COVID-19 pandemic by offering healthcare facilities, local authorities, and senior residences a fast, efficient, and reliable solution to facilitate patient care. The Consult Station allows patients not only to take their own vital signs but also to carry out teleconsultations with a doctor through a videoconference. These teleconsultations are done with the assistance of all the instruments and sensors necessary to perform a clinical examination, a diagnosis, and a prescription if necessary.⁵ Teleconsultations in the Philippines can now be done through COVID-19 hotlines, websites, and mobile apps launched by several agencies and businesses. These include the Department of Health (DOH), Medgate, KonsultaMD, Medifi, HealthNow, AIDE, DOCPH, Yo-Vivo Health, and Lifeline.⁶ Some doctors also have their personal Facebook pages and Viber accounts utilizing the respective video app for online consultations. The Philippine Health department engaged with more than 100,000 patients a month in the first quarter of 2021 on Cisco Webex, a video conferencing platform developed by Cisco Philippines. The agency conducted 17,400 sessions over Webex in 2020, equivalent to more than 2.3 million minutes of meetings and teleconsultations.⁷ In addition, Albay 2nd District Representative Joey Salceda has filed a bill that would enable the telemedicine and electronic health industry to expand in the country. This is House Bill No. 7422 or the Philippine E-Health and Telemedicine Development Act of 2020, which would be beneficial as the country continues to grapple with the COVID-19 pandemic, especially as more services could be provided to underserved communities.⁸ This bill will basically promote the delivery of health and medical services through the use of information and communication technology. The practice has proven to be useful and worth considering in some situations. The proven benefits include reduction of the risk of spreading the virus by patients, chronic health management, comprehensive family engagement with the doctor, and many others.

On the other hand, telemedicine is not always applicable to all situations. A thorough analysis of the patient’s condition must be taken into consideration since there are also disadvantages that are pointed out by health experts. These considerations cannot be taken for granted as it involves an appropriate diagnosis by doctors, which is a must for all types of patients, immunocompromised or not. What then are the disadvantages of telemedicine? First, the basic procedure of a physical checkup done on a patient is traditionally the use of a stethoscope by a doctor. The stethoscope is an instrument used for listening to sounds produced by the body. It is used primarily to detect and study heart, lung, stomach, and other sounds in adult humans, human fetuses, and animals. Using it, the doctor can hear normal and abnormal respiratory, cardiac, pleural, arterial, venous, uterine, fetal, and intestinal sounds.⁹ It is still one of the most efficient tools in helping doctors to find an accurate diagnosis, especially for cardiovascular disease. In a teleconsultation, the doctor makes an initial diagnosis by hearing the sound data that is obtained from an interactive stethoscope since the traditional type is not possible. However, when other electronic devices such as cell phones are present, digital stethoscopes sometimes tend to malfunction, interfering with the typical optimal performance they have become known for.¹⁰ The accuracy of the initial diagnosis may be sacrificed at times. The patient cannot just simply describe this sound to the doctor by self-listening. In relation to this, doctors must rely heavily on patient self-reports during the online checkup and this may require doctors to ask more questions to ensure that they get a comprehensive health history. If a patient leaves out an important symptom that might have been noticeable during in-person care, this can compromise treatment.¹¹ Second, telemedicine may also cause security and privacy issues. There can be a lack of transparency between health care professionals and their patients and the difficulty in verifying their respective identities. It is hard to know if the doctor on one end and/or the patient on the other are really who they say they are. The doctor may also ask for more data for the medical record of a patient. When the records are shared with other health care professionals or organizations for referral or billing services or are supplied to third-party service providers, the confidentiality, integrity, and availability of the data may be compromised.¹² Hackers and other criminals may be able to access a patient’s medical data, especially if the patient accesses telemedicine on a public network or via an unencrypted channel. Lastly, when a patient needs emergency care, accessing telemedicine first may delay treatment, particularly since a doctor cannot provide life-saving care or laboratory tests digitally.¹¹

Telemedicine provides a range of benefits for both patients and healthcare providers. However, it has also limitations and may not be applicable at all times. It is important to understand its benefits and limitations to avoid any potentially dangerous situations or cause health inequity. I argue that this method must be availed only on a case-by-case basis, that is if the patient is limited by his/her physical capacity to go to the hospital for a checkup or any medical procedure. This can also include a situation where the hospital is too far from the patient’s location and traveling for a longer period of time will be too risky and requires much effort. In the same way, one has to consider the strength of internet connections and the clear quality of equipment to be used for audiovisual data. Telehealth is a helpful alternative to the traditional patient-doctor appointment especially during a pandemic, but it cannot guarantee the same high level of healthcare management like that of the in-person setup.

Conflict of interest

The author declares that he has no competing interests.