Latest Initiatives in Telemedicine and Online Medical Consultations

Now that the Guidelines are in place, the next challenge is to elaborate on policies to encourage the dissemination of online consultation after it is validated through evidence and case studies

Based on what you’ve said, there was a huge change in the topics of debate before and after the Guidelines were set. What were the issues being discussed before and after the Guidelines were put in place?

There are provisions regarding security in the present Guidelines. Basically, it is clearly stated that the patient is to select the appropriate tools after he is made aware of the risks and has provided consent. The final point of discussion was about where online consultation would be offered from. It is not about deciding where it is practical or not. For example, to protect privacy, there should be a rule telling doctors to carry out the consultation from a private room. Or, if one wishes to use a public hall to gather a large and specific set of people, it would acceptable only after the patients have been registered in healthcare facilities, because of public health risks.

The challenge which followed the formulation of the Guidelines is seeing that they are applied rigorously in order to further disseminate online consultation. Now that the rules have been defined and online consultation is included in the schedule of reimbursement of medical fees, it is expected to be disseminated to some extent. The important thing to do as online consultation expands is to collect evidence and case studies to check whether it is being disseminated in a desirable manner. If not, then we would have to check the shortcomings in the current Guidelines. If online consultation expands in a desirable way, the MHLW should consider how to further its dissemination from multiple angles. Another point that was mooted when formulating the Guidelines was that of doctor training. Doctors who are professionals in the use of online medical consultation could understand quality issues I talked about earlier. When it comes to issues of information security, there are parts which will remain hard for doctors to understand. It is currently difficult to know and judge which of the services and businesses offering information systems, devices, and applications are safe. This matter, too, falls under the responsibility of MHLW, and we have to come up with some policy to deal with it.

Yes, the current Guidelines are silent about social networking services (SNS) and there are questions whether general, free services such as Skype are good or bad. Are you discussing this issue, perhaps while looking at overseas trends and guidelines for reference?

One of the inherent risks of using free SNSs is the fact that their servers may be located outside Japan, so we cannot be sure how information exchanged over them is handled. For example, you would think that information exchanged via Voice Over IP is immediately deleted. As a matter of fact, a company may choose to save this data and there is no way to guarantee it won’t be leaked. To put it extremely, the country that has the server has the information. It is the role of MHLW to make sure that doctors doing medical consultations online have a correct understanding of attendant security matters in order to prevent accidental leaks.

It is ideal for academic societies to spearhead the training that doctors need to achieve professional autonomy

Please tell us about what initiatives in doctor training will become necessary in addition to current in medical education.

Following what I’ve just said about security, I would like to create a training environment in which doctors could learn about various topics besides security, like how to approach online consultation so as to improve the quality of care, things to be mindful of when conducting online consultation like the fact that color tones can change when transmitted over smartphone screens, or how to effectively start conversations with patients while taking into account that online consultation can affect a patient’s thinking, and so on. MHLW will also need to cooperate with the Ministry of Education, Culture, Sports, Science and Technology (MEXT) to determine whether or not these items must be introduced into pre- and post-graduation education.

That is the next item in the agenda. MEXT’s basic line of thinking is based on the “Model Curriculum.” Discussions are expected to take place there concerning the inclusion of online medical consultation in their detailed training curriculums. Accordingly, we urge doctors carrying out online consultations to undergo such training and announce it publicly in order to reassure the public. MHLW will not formulate regulations restricting the practice of online consultation to doctors who have undergone training so as to incentivize its adoption.

An American paper has reported that, after mystery shopping at various clinics, they discovered a wide variation in the quality of online medical consultation offered. It is preferable that bad practitioners are naturally weeded out rather than by using regulations and penalties, but perhaps that’s an issue that faces every country.ん。

The ideal would be for academic societies to spearhead training on healthcare quality. The Japanese Telemedicine and Telecare Association formulated guidelines in the past that we used as reference when drawing up the current Guidelines. In the medical field, unnecessary government intervention may provoke resistance from practitioners. I therefore think there should be autonomy and independent progress. At present, the government is leading the initiative, but I do think this is a very good thing. Isn’t this preferable that professionals should lead, and advance things together with the government?

Regulations for online medical consultation should be written based on knowledge gained through parties reaching a common understanding on what is needed for the proper provision of healthcare treatment

Regulations are necessary for disseminating online medical consultation based on the understanding that services may be inadequate and unpredictable circumstances may emerge. But on the on the other hand, overly-restrictive regulations would hinder peoples’ ability to be apply them appropriately. Were there challenges when deciding how strict to make regulations when setting up the current Guidelines?

Yes, there were. Particularly with regard to security. It’s naturally good to put in place very strict rules for security to make it airtight. But not only would that raise the initial price of the service, it would be difficult for developers to meet the standards. When formulating the policy, it was easy to reach a consensus on this point. I would want everyone involved to be able to agree that’s the obvious way of going about it. That’s because, when it comes to regulations, it is often perceived that the government will forcibly bring restrictions to bear. However, I am aiming to create a process in which standards are established based on convinced agreement, where parties feel that the agreed-upon standards are the natural way things should be. There may be people who think the current Guidelines are strict. But, since we are starting from nothing, we have opted to set things firmly so as to prevent the proliferation of inadequate services. If the service grows in the future, the Guidelines will be loosened.

Surely, using the word regulations gives the impression of restriction.

There is a nuance in that the Guidelines are required rules based on common understanding to ensure the proper implementation of online medical consultation. The current Guidelines involved representatives of many organizations, allowing us to reach a consensus on many points.

Collaboration between policymakers and practitioners is indispensable for collecting and distributing evidence

Based on interviews so far, many people believe that it is a challenge to decide how to collect evidence. What are your thoughts concerning the evidence you have mentioned in the interview today?

We can collect many types of evidence, including clinical. For example, we could gather case reports which chart treatment outcomes of patients where online consultation was used or collect statements of medical expenses to observe which areas are seeing an expansion in medical consultation. We could compare how the health of patients changed before and after online consultation, and, from the perspective of safety, monitor the incidence of accidents associated with online consultation. To start with, we need to think about which information to gather, and what it would shed light on. This is the role of the MHLW.

On another front, I would like to see developers of online consultation technology and healthcare facilities cooperate in evaluating healthcare quality. That is one of the principles written in the Guidelines. If clinical doctors actively presented data and wrote papers to share their opinions from a technical perspective, it would improve the quality of online consultation. Wouldn’t it be a good thing if policymakers and practitioners collaborated in accumulating high-quality evidence? 。

Expectations for the spread and normalization of online medical consultation and for further technological innovation

Concerning the vision of the future, what objectives do you expect online consultation and ICT healthcare policymaking to have in the years 2025 or 2035?

I do acknowledge that the current expansion of online consultation is limited. In the future, we expect it to be widely disseminated. The rise in the number of elderly has been accompanied by an increase in people who find it difficult to go outside of their homes. The dissemination of online consultation would make it possible to offer such people better care. Online consultation has started to spread in urban areas. But, if I had to give a representative example of online consultation being carried out according to the Guidelines in outlying islands and remote areas, after researching the matter, I reached the conclusion that there aren’t any exceptional examples to report. I hope that henceforth, online consultation would penetrate further to these places.
Although it will be more challenging, I expect that future innovations in technology will bring about greater use of online medical consultation.