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Telemedicine: Providing Health Services Safely during the COVID-19 Pandemic

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Since the issuance of Presidential Proclamation No. 922, s. 2020, pursuant to Republic Act. No. 11332 declaring a State of Public Health Emergency due to the rise of coronavirus disease (COVID-19) cases and the announcement of Proclamation No. 929, s. 2020 placing the Luzon under enhanced community quarantine, the government has taken steps to provide health services such as developing a framework for telemedicine. With hospitals and health care facilities rapidly becoming high risk places for both patients and healthcare workers, telemedicine has been viewed as a game-changer in mobilizing resources [1].

 

In an attempt to improve access to health services during the Community Quarantine, the Department of Health (DOH) and the National Privacy Commission (NPC) has issued Joint Memorandum Circular No. 2020-0001 entitled “Guidelines on the Use of Telemedicine in COVID-19 Response” dated March 28, 2020. 

 

The Joint Memorandum Circular (JMC) aims to enable patients to receive health services while staying at home during quarantine periods or lockdowns except for serious conditions, emergencies, or to avail of COVID-19-related health services. In particular, the policy aims to prevent the surge and minimize risks posed by patient traffic in hospitals and health facilities, support the implementation of community quarantine, and ensure efficient, safe, and secure use of telemedicine by healthcare providers. 

 

The guidelines shall be applicable to all patients who are vulnerable to COVID-19, all public and private, national and local healthcare providers regulated by the DOH and the Philippine Health Insurance Corporation (PhilHealth), and various telemedicine providers. 

 

Telemedicine, defined.

The JMC defines “telemedicine” as the practice of medicine by means of electronic and telecommunications technologies such as phone call, chat, or short messaging service (SMS), audio-and video-conferencing to deliver healthcare at a distance between a patient at an originating site, and a physician at a distant site. An Electronic Medical Record or EMR is a computerized medical record used to capture, store, and share information of a patient between healthcare providers in an institution or organization. 

 

Meanwhile, an Electronic Prescription or an “ePrescription” refers to either (a) “optical data, which is a captured image in pdf, jpeg, or other photo file format, issued or made by a licensed physician generated, sent, received, or stored through email and messaging applications as defined by the Food and Drug Administration (FDA) Circular 2020-007 on the Guidelines in the Implementation of the Use of Electronic Means of Prescription for Drugs for the Benefit of Individuals Vulnerable to COVID-19, or (b) a complete medical prescriptions with date, generic name and strength and dosage form and total amount of each prescribed drug, and directions issued by a physician to a patient, sent from a mobile number under the possession and control of the physician or his/her hospital or clinic as shall be authenticated by the local pharmacy.  

 

The guidelines state that “healthcare providers” can pertain to either (a) a physician which includes all individuals authorized by law to practice medicine pursuant to R.A. No. 2382 or the Medical Act of 1959, as amended, or (b) a health facility which refers to a public or private facility or institution devoted primarily to the provision of services for health promotion, prevention, diagnosis, treatment, rehabilitation and palliation of individuals suffering from illness, disease, injury, disability, or deformity, or in need of medical and nursing care. 

 

Standards to be Followed in the Practice of Telemedicine

Telemedicine services are mandated to follow standards of practice of medicine as defined under R.A. No. 2382, its IRR, and other applicable policies and guidelines, taking into account the absence of physical contact. Nonetheless, while telemedicine is encouraged, the gold standard for clinical care is face-to-face consultation. 

 

It is established that the patient-physician relationship shall be based in full knowledge of the patient’s medical history and a physical examination given the circumstances of a lack of physical contact such as by inspection only. When a physician is physically inaccessible (e.g. such as during a national emergency with community quarantine in effect), telemedicine shall be employed in the management of chronic health conditions, or follow-ups after initial treatment. Further, the patient-physician relationship shall be founded on mutual trust and respect in which they both identify themselves reliably during a telemedicine consultation. In case the patient is referred to a health facility, the physician who initially sees the patient shall be responsible for the coordination of care.

 

Emergency and serious conditions, where face-to-face assessment and physical contact are most essential, should not be managed via telemedicine.

 

The use/implementation of telemedicine shall respect the universal principles of ethics, legal standards, and guiding principles on primacy of human rights and protection of health privacy as defined by Philippine laws, international instruments, rules, and other applicable policies. All healthcare providers and telemedicine partners shall implement the minimum organizational, physical and technical security standards and measures as set by the National Privacy Commission (NPC) and the Department of Information and Communications Technology (DICT). Proper informed consent must be established with ali the necessary information regarding the features of the telemedicine visit fully discussed with the patient, including, but not limited to: i. How telemedicine works; ii. How referral is to be done; iii. Privacy concerns; iv. Risk of technology failure including confidentiality breach; and v. Policy on care coordination.

 

While the DOH’s collaboration with the NPC is expected to raise concerns on data privacy and confidentiality, Secretary Francisco Duque said that the DOH-recognized telemedicine providers are also registered entities of the NPC, “All doctors providing telemedicine services are licensed and certified to provide telemedicine consultations.” 

 

Duties of Healthcare Providers and Telemedicine Partners

Under the JMC, all healthcare providers:

  1. Shall help unburden local health systems and health facilities by engaging in telemedicine practices with a DOH telemedicine partner to provide essential primary care consultations, both for COVID-19 and non-COVID-19 health related concerns.
  2. Are encouraged to subscribe to a DOH telemedicine partner which can augment a health facility’s medical services like health promotion services, triaging for both COVID-19 and non-COVID-19 health-related consultations, medical advice, referral to a doctor for home visit as necessary, and others. Medical consultations that require physical contact shall be handled by the local health office upon referral from a telemedicine consultation.
  3. Shall be given fifteen (15) days to engage with a DOH telemedicine partner from the date of effectivity of the JMC. Additional cost for setting up shall be charged using their own administrative funds.
  4. Are authorized, in the interim, to issue documents like electronic clinical abstract, consultation summary, and/or referral form (if applicable) to the patient. These documents must be suitable for optical character recognition (OCR) by being typewritten. The documents shall be issued via email or acceptable modes under the Electronic Commerce Act of 2020.
  5. Shall provide all clinical abstract/consultation summaries which shall have the following content: a. Patient Information (Name, Age, Birthdate, Sex, Address), b. Brief Clinical History and Physical Examination (i.e., notes from inspection by video camera, if applicable), c. Travel and Exposure History (for COVID-19 screening), d. Diagnosis/Assessment, and e. Plan of Management
  6. Shall recognize and deem equivalent the electronic clinical abstract, consultation summary, prescription, and referral form issued by the physician for all intents and purposes.
  7. All physicians whose services are sought through telemedicine shall keep records of all electronic clinical abstracts/consultation summaries, prescriptions and/or referral forms issued in coordination with the DOH telemedicine partner.
  8. All licensed physicians shall issue electronic prescriptions in accordance with FDA Circular No. 2020-007 and any subsequent FDA guidelines.
  9. Shall, at all times, ensure that patient confidentiality, privacy, and data integrity are not compromised.

 

Meanwhile, telemedicine partners shall:

  1. Provide an information or application system that can securely store and/or process patients’ data according to established rules and regulations on confidentiality, privacy, and data integrity.
  2. Comply with the requirements of the DOH to be able to link and/or interoperate with electronic medical record (EMR) systems or applicable health systems.
  3. Secure clearance from the DOH on all policy decisions affecting processing as regards to COVID-19-specific triaging algorithm, and the data collected in a telemedicine consultation.
  4. Allow physicians to sign up, and in the interim, volunteer their services with safety and security assurances for them to operate.
  5. Define or establish mechanisms to refer patients to appropriate health care providers in coordination with the Local Government Unit (LGU) in a network set-up, and following DOH and PhilHealth policies.
  6. Forge a memorandum of agreement with an LGU for the deployment of health professionals for home visit from a primary care facility, should it be deemed necessary.
  7. Receive calls escalated from the DOH COVID-19 hotlines as follows: 02-894-COVID (02-894-26843) and 1555, and any other iteration henceforth.
  8. In coordination with the LGU, report a suspected COVID-19 patient identified during the consultation to the respective Regional or City Epidemiology and Surveillance Unit (RESU/CESU).
  9. Submit reports to DOH as shall be defined to monitor performance of this Joint Memorandum Circular.
  10. Provide these services free of charge until the enhanced community quarantine is lifted.

 

Both the DOH and the NPC shall regularly undertake monitoring and evaluation activities to assess the quality of implementation, including adequacy of control mechanism to ensure confidence and acceptance of telemedicine services by healthcare providers, patients, and those in authority. Finally, the criteria for monitoring and evaluation of telemedicine services shall include outcome measures, performance measures, summary measures, and operational measures. 

 

 

[1] Cornelius Kalenzi. Telemedicine can be a COVID-19 game-changer. Here’s how. World Economic Forum. Available at https://www.weforum.org/agenda/2020/05/telemedicine-covid-19-game-changer/. 13 May 2020.

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