Healthcare community meeting kärajad: remote services are here to stay

Representatives of parties related to the field of healthcare came together in research and business campus Tehnopol to discuss the pros and cons of remote services. They collectively admitted that the coronavirus crisis in the spring acted as a huge push to develop and implement services.

Connected Health Cluster Manager Piret Hirv specified that e-services and remote services have been on the table for quite some time – the eHealth strategy plan reveals that we have been attempting to tackle the same issues for five years.  We are still faced with questions such as who should pay for the services and how, how to develop them and what is the role of the state and companies in all of this? At the same time, Hirv offered assurance that cluster companies want to bring innovation closer to us for better health.

COVID led to the need to move forwards quickly

Kalle Killar from the Ministry of Social Affairs said that there may be several strategies and development plans, but COVID led to the need to address them quickly and established the desire to advance.

Information and convenience services which must be available were reviewed in the time of crisis. “We managed to create self-assessment mechanisms and communication robots,” said Killar, “we successfully brought together several companies and created a coronavirus app with cooperation between the private and public sector. As a matter of urgency, it was made possible to grant services access to health data (consent service).”

Killar highlighted the fact that, initially, no consideration was given to the judicial space or how life has adapted to this. “It was more common to come up with a solution and then form the judicial space around it based on people’s needs and convenience,” he said. “For example, it took one weekend to create a solution that allowed people to report their illness and a judicial space was formed thereafter.”

The question now is how do we move forwards and not return to the same old process? How do we put the pilot projects that proved their worth into wider use? “During the crisis, we had many ideas – oh, here’s a great one but there’s no time to do it because we are in a hurry – so how do we keep them on the table?” said Killar.

“I believe that partnering up with the private sector may have been chaotic during the crisis and we could certainly build a better support system and framework.”

The experience of a private hospital: rise in online services during the emergency situation

Dr Ivo Saarma spoke of remote services in private healthcare based on the example of private hospital Fertilitas. Fertilitas was the first private hospital in Estonia and started its virtual clinic as a pilot project in 2018 after being approached by Minudoc.

“We started in 2018, with specific specialties: gynaecologists, midwives and paediatric nurses,” said Saarma. “The volumes were not large and the feedback was positive. When the emergency situation was declared and scheduled healthcare was shut down, we continued with and expanded the online service. Customers were able to reach us through the following channels: Minudoc, Skype, phone consultations, e-mail and Facebook.” Saarma also added that such channels can only be used for communication to the extent that does not include personal and health data.

The hospital expanded its activities during the emergency situation by adding physiotherapists, a cardiologist, otolaryngologists, a dermatologist, a sleep specialist and a urologist.

“It is not always possible to perform professional physiotherapy at home – for example, you may require specific aids. However, there is a place and an opportunity for remote services,” said Saarma on the experience of different doctors. “A cardiologist is in a good position to counsel patients with chronic conditions should they have any questions about their illness during the emergency situation – this puts significantly less stress on the system because those patients would otherwise come for an appointment. However, there are limitations when it comes to specialties that require examinations with special equipment and objective observation. A dermatologist is well-equipped for telemedicine whereas urology requires check-ups and examinations.

There were also cases where we had to tell the patient that there is no need to seek emergency care, but we advised them to see a doctor once as the emergency situation ends. Such cases still constitute double effort, taking more time and resources because those patients now want to see a doctor and have likely caused waiting lists to grow longer.”

According to Saarma, remote appointment patients came from all over Estonia. There were also expatriates and people who were stuck abroad in lockdown.

Saarma admitted that while the use of video services exploded, it also became apparent that different specialties allow different levels of support – adequate decisions were not possible in specialties that rely on examinations and analyses. Saarma feels that Skype and other communication tools are primarily suited for additional consultation and giving further instructions, provided that the information does not contain sensitive personal data.

“Different specialties have different possibilities even though remote appointments are no substitution for a visit to the doctor,” said Saarma. “It was easier to get more experienced specialists to agree to consultations. Digital medicine reduces the number of follow-up visits by 10-30%, but it sometimes requires more time and resources. Patients may find remote appointments more convenient and less costly, but this is not the case with medical institutions.”

Remote appointments helped relieve the complete halt of scheduled treatments

Kitty Kubo, Innovation Manager of Estonian Health Insurance Fund talked about what they are doing to bring remote services to Estonia’s healthcare system.

“Our hypothesis was that remote services are adequately evidence-based and other countries have sufficient routine experience in using such services,” said Kubo. “It then turned out that regulations are not what is keeping us from using remote services – it’s all in the way we think. Regulations don’t say anything about appointments needing to take place in one and the same room, that’s just something we have construed ourselves as medical institutions and funders. Our habits that have grown over time are getting in the way of implementation.”

Remote services in healthcare, i.e. telemedicine, was divided into remote appointments, remote therapy and remote monitoring. Remote appointments in turn were divided into telephone, video and webchat appointments.

Even before the coronavirus crisis, there was an action plan in place to enable remote appointments by funding healthcare services and to stimulate it as a model process. “When the emergency situation was declared (12 March), the rules had already been developed, allowing us to quickly put them together, have a discussion and send them to different facilities,” explained Kubo. “On 16 March, we received news that the Estonian Health Insurance Fund would be funding remote appointments for outpatient appointments. This provided some relief for the complete halt of scheduled treatment.”

According to Kubo, the following rules were established for remote appointments. “The assumption was that service quality would remain the same or improve,” she said. “This rule was actually intended for regular circumstances. The healthcare professional conducting the remote appointment will decide whether it is appropriate and the patient must consent to the remote appointment. The condition was to have the appointment at the agreed time and register it in the appointments schedule to give both parties a chance to prepare without needing several calls, etc. We permitted the use of telephone, video and webchat options provided that the ICT solution is secure.

The responsibility of identifying the person was left to the medical institution. The price of the remote appointment must be equal to the price of in-person appointments because it would not be implemented if it were more affordable – it was also agreed that administrative communication would not be paid for (e.g. interactions to inform of cancelled or postponed appointments or positive analysis results).”

“While the scope of application was heavily expanded during the emergency situation for testing purposes, the scope has now been dialled back,” added Kubo, specifying that, “as of 1 September, it is no longer possible to have remote therapy appointments and, instead of initial appointments, only repeated appointments can be remote – therapy relationships should be established based on in-person appointments, at least until a system is formed and people get used to it.”

In the first month of the emergency situation, almost 60% of appointments were performed remotely. In the second month, some of the scheduled treatments were restored and people could choose between in-person and remote appointments.

“Patients’ feedback on remote appointments was positive,” said Kubo of the patients’ experience. “90% of patients said that they saved time by attending a remote appointment and 70% said they saved money. Patients also noted that the doctor was more focused. The downside is that remote appointments do not work for everything and everyone – if the problem requires physical examination, then the appointment cannot be remote and it would be the wrong way to handle the issue.”

“The experience of the emergency situation accelerated the reception of remote services and allowed us to have our first experiences and success,” said Kubo. “The most common medium used during the emergency situation was the telephone, but going forwards, we will be looking more at video options to have remote appointments be more on par with in-person appointments. One of the obstacles to this, for example, is the lack of technical means in medical institutions. A security requirement would have imposed another obstacle and, for this reason, we opted for accessible communication solutions (Skype, messenger) – ones the patients have experience using.”

“There was no systemic implementation during the emergency situation,” recognised Kubo, “we need to rethink the new service model and work processes, find a secure and user-friendly technological solution and help users learn new skills. There are those who have reverted to their former routine.”

Pursuant to the plan of the Health Insurance Fund, remote appointments (in more narrow terms than during the emergency situation) will be on the list of healthcare services as of 1 September. Remote therapy should be added in January and remote monitoring is not due to be added to the list until 1 January 2022.

The meeting Tervisekogukonna kärajad took place in Tallinn on 8 September.

The Connected Health cluster led by Tehnopol Science Park is Estonia’s biggest healthcare tech community, uniting health service providers, health tech companies and all other key interest groups in the field. With the help of the cluster, it is possible to carry out national cooperation projects and export health technology solutions to other countries.

The activities of the cluster are co-financed by Enterprise Estonia.