Challenges in transcending disciplinary boundaries to spread online medical consultation

To begin, some of our readers may have the impression that healthcare information and communication technology (ICT) is the speciality of the Ministry of Health, Labour and Welfare (MHLW), so please tell us about the position and the role of the Ministry of Internal Affairs and Communications (MIC) in this field.

Unlike the MHLW, the MIC’s jurisdiction does not cover healthcare. The MIC is concerned with how to spread ICT widely throughout society and, in particular, to determine how to do this in a way that enhances the lives of the public. We construct rules and provide support as necessary to achieve these goals. The MIC is concerned with promoting the use and application of ICT in many fields including education and disaster prevention, not just healthcare. Healthcare ranks among those fields.

Do you mean that the MIC is particularly focused on the fields of healthcare, education, and disaster prevention, or did you name those fields as examples? Also, please explain the division of roles between the MIC and the MHLW.

I mentioned those fields as examples, but the truth is, the MIC is particularly focused on how to promote the introduction of ICT in healthcare, education, disaster prevention, and agriculture. A survey of local governments showed that the ICT adoption rate for healthcare and nursing was particularly low compared to other fields, so the MIC is actively pursuing ways to increase ICT utilization in healthcare.

Concerning our division of roles with the MHLW, the MHLW develops systems or infrastructure like the one it is currently building for the nationwide health insurance healthcare information network that is set to begin operation in FY2020. On the other hand, we at the MIC consider it a major risk to suddenly change a system or to create wide-reaching infrastructure, so we started by consulting with the MHLW about what their infrastructure will need in terms of ICT. We are now working to process that and the challenges we discovered. If the MIC’s pilot is successful, we can fulfill our role by making it easier to write rules for nationwide use or to get the MHLW to alter their infrastructure. For the medical field, the MIC is mostly focused on patients and their families. But while the MIC works to get people to use ICT to provide the best healthcare and nursing from the viewpoint of the individual patient, it is also our role to view the situation concerning the state of ICT as it is used in other fields to cross boundaries and determine what will create the greatest happiness for the public.

To give an example related to the topic of this interview, we will run a pilot project to verify the security and other aspects of the new items pertaining to online consultation in the health insurance reimbursement fee schedule that goes into effect this fiscal year or in the policies outlined in the “Guidelines on the Proper Application of Online Medical Consultation” (hereafter, the Guidelines), both of which appear in the government’s “Future Investment Strategy 2018” growth strategy. The MIC and MHLW will then combine their efforts to revise the Guidelines using those findings or to link them to future changes in reimbursements for online consultations in pursuit of the use of ICT in the field.

I believe coordination between the MHLW and the MIC is an important point among the topics you just discussed. I have heard that similar coordinated efforts between the ministries were not as common in the past. I have the impression that they have been coordinating their efforts more frequently, especially in the last four or five years. What was it that led to all this cooperation?

People are starting to recognize the possibilities of ICT and its necessity in many fields, starting with telemedicine in the medical field. This recognition has grown as technology has advanced and become more common. As this becomes a matter of policy for the government, I feel cooperative bonds between ministries are growing stronger. For example, as you mentioned, we worked with the MHLW to hold telemedicine pilot projects in various regions throughout the entire country as recent as four or five years ago, around 2011. The results were compiled in the MIC’s “Telemedicine Model Reference Book.” As this example shows, we have cooperated in the past, but now more people recognize the necessity of ICT and the potential of its proper use, our cooperative bond has grown stronger than before.

Our counterparts at the MHLW were passionate and positive in promoting ICT utilization, and they have made great strides to implement ICT in the medical field, so I think the alliance we formed in our joint projects was effective. With funding from the MIC, businesses also held pilot projects to prepare for the construction of the nationwide medical insurance information network in FY2020. As those projects progressed, the MIC, the MHLW, and representatives from non-government outsourcers worked together closely by holding a two-hour meeting every week for a year. To construct a good system, we worked beyond our normal roles to make the best use of each of our specialities and have earnest discussions.

What policies are the MIC pursuing to encourage ICT use in the medical and nursing fields? Please give us an overview.

To name the three biggest ones, first are our efforts to create an ICT usage framework for constructing online networks between health care providers, medical and nursing staff, and specialists, or that enable services like online consultations that make it easier to provide medical care and nursing. The second one concerns Personal Health Records (PHRs). With permission from patients, we are constructing methods to utilize individual medical, nursing, and health records. For example, we think PHRs may be used in a way that helps individuals track their own health. Third is the utilization of high-quality ICT like artificial intelligence (AI), the Internet of Things (IoT), and 8K display technology in the medical field. For example, advancements are currently being made in high-quality internal cameras or in the development of diagnostic support system AIs. That is my overview of what the MIC is currently working on in the field of medical ICT.

Next, please tell us how the MIC perceives the necessity of online medical consultation.

When considering how to make the most efficient use of medical resources when they are currently limited and unevenly distributed, we believe that using technology effectively to provide consultations online may make it possible for adequate medical care to reach those who had previously been unable to access it. With ICT’s abilities to transcend time and location, we can provide caregivers with tools to easily accumulate and examine data. Currently, it is normal to have patients come to hospitals, but for patients suffering or in great pain, it is ideal for the doctor to go to them instead. Given the shortage of medical care resources, there are practical limits to having doctors visit every patient at home. Until recently, our tools were not robust enough to make online consultations a possibility. Technology has advanced and everyone has a smartphone, so we think the tools are ready. Given this situation, we see that it is now possible for us to take a big step closer to the ideal situation by introducing telemedicine. While we recognize the fact that face-to-face consultations will continue to be important, we think telemedicine can progress in a way that will benefit both doctors and patients.

The most recent revision of the health insurance reimbursement fee schedule had new fees for online consultation and there was a package for them in the Guidelines. How significant are these changes?

They were a major step forward. First of all, the fact that online consultation was openly approved is substantial. And, as indicated by the Future Investment Strategy, the criteria for online consultation outlined in the most recent revision of the health insurance reimbursement fee schedule are not yet complete. It has been mentioned that online consultation will be reevaluated in the next revision in 2020 and in other future revisions, so the MIC is currently thinking of how to contribute going forward. Also, items new to the Guidelines receive updates annually, and I think the MIC must contribute to that as well. The fact that there are now entries for online consultation in the Guidelines and the health insurance reimbursement fee schedule means there are now rules for the aspects of its implementation that involve money. Looking forward, I think there are not yet enough real-world examples to demonstrate how online medical consultation should be conducted. I believe our pilot and other efforts will reveal which parts of the current Guidelines and health insurance reimbursement fee schedule will need to be changed.

I agree that the recognition of a fourth form of medical treatment was a major step forward. However, there are still very few filings for online consultation. That leaves me vexed, because I thought people had been eagerly awaiting it. Do you think there may be obstructions in the clinical setting that are causing this?

It seems to me that many of the doctors currently engaged in providing online medical consultation are extremely passionate about the subject. The reason why it cannot be done by anyone else is because we are working in an environment where there are not yet enough case studies to support the idea that it is a good thing to provide. This means we have to work extremely hard together with developers to fine-tune the system through trial and error. It may be impossible to construct the system until extremely passionate people are involved in the effort. After all, the benefit of tools like ICT is that they enable people to focus their efforts on their main purpose, in the area in which their skills are sharpest. It is important for doctors to harness their skills in examining patients and online consultation has not yet been sufficient for that purpose. Currently, doctors must trouble themselves with determining how to use ICT effectively to provide online consultation or with constructing systems to do so. If we do not improve this situation, it may not be possible for online consultation to become the norm or be taken up by doctors whose experience is limited to face-to-face consultations. To gain recognition of online consultation as a viable option among doctors and patients, I think the MIC must provide easy-to-understand guidelines, perhaps in its model reference book.

For doctors, examining patients that come to medical facilities is the norm. To introduce online consultation to that system, doctors must make an investment, learn rules, and educate patients to whom the service will be provided. It is not an easy process. Can you think of any other reasons why doctors might be discouraged from providing online consultation?

I think some are still waiting to see how things turn out. If there are no examples that visually demonstrate how online consultation fees will be evaluated in the health insurance reimbursement fee schedule, it means that those who try online consultations may end up going unevaluated. This will have major effects on the administration of the facilities that try it. It will cause trouble for people, which I think discourages some from setting up online consultation systems. Additionally, I think there are also concerns about how to build control systems or manage patients’ private information through reliable information security measures. We might be able to change this situation at least a little by providing a clear and effective solution for these concerns. I want for us to solve these issues one at a time and contribute to rulemaking so that doctors and patients can achieve what they want to without obstruction.