This week’s topic in #HI201 #MSMHI is #telehealthphilippines. Unlike in previous weeks where I could clearly integrate both the driving question and the task, this week’s seemed like a dichotomy: the driving question being: “How can telehealth support healthcare delivery in the Philippines? ; and the assignment was to pick two sections in the proposed telehealth bill, evaluate and suggest revisions if any.
How can telehealth support health care delivery in the Philippines?
Telehealth as defined in the proposed House Bill 6336 by then Congressman Joseph Emilio Aguinaldo Abaya, as the “delivery of medical services and information across a distance and …recognizes and accepts [telehealth as a means] of addressing problems of uneven provider distribution and discontinuous and inequitable health system development, especially in unserved and underserved areas.” 
A clearer definition would be that from the Nebraska Telehealth Act: i.e., “the use of medical information electronically exchanged from one site to another, whether synchronously or asynchronously to aid a health care practitioner in the diagnosis or treatment of a patient. Telehealth includes services originating from a patient’s home or any other location where such patient is located, asynchronous services involving the acquisition and storage of medical information at one site that is then forwarded to or retrieved by a health care practitioner at another site for medical evaluation and telemonitoring.” Further defined is telehealth consultation, which is any contact between a patient and a health care practitioner relating to the health care diagnosis or treatment of such patient through telehealth; and telemonitoring which is the remote monitoring of a patient’s vital signs, biometric data, or subjective data is a monitoring device, which transmits such data electronically for a health care practitioner for analysis and storage.”
In some unserved and underserved communities, telehealth offers the best chance of overcoming or reducing barriers and facilitating access to health care and services. It fills a palpable void of a lack of health care practitioners in rural communities. It addresses the difficulty of attracting and retaining health care providers in unserved and underserved areas. The inadequate and uneven distribution of health care practitioners, lost to brain drain, or concentrated in urban areas and some suburban communities, telehealth can be the great equalizer, providing services where they are wanting. Instances when a difficulty in obtaining support for local health facilities exists, compromising the range of health care services, telehealth can fill this void. [1,2]
Telecommunications is envisioned to “deliver health care services that can reduce health care costs, improve health care quality, improve access to health care, and enhance the economic health of communities in medically underserved areas. “ 
Why is there a need for a Telehealth Bill?
Perhaps to address lack of monitoring and regulation of current telehealth practice in the Philippines, and the need to define standards and unify existing systems, the existence of such a bill can be argued.
In June 2012, then Congressman Joseph Emilio Aguinaldo Abaya, filed House Bill No. 6336, known as the Telehealth Act of 2012, during the second regular session of the Fifteenth Congress of the House of Representatives, Republic of the Philippines.
This brings us to our second task of evaluating at least two sections of the Telehealth Act as proposed.
Telehealth Bill of 2012. Which sections need a second look?
Section 5. Telehealth as an authorized procedure. The delivery of health care via telehealth is recognized and encouraged as a safe, practical, and necessary practice in the Philippines. All health care providers shall be encouraged to participate in telehealth pursuant to the Telehealth Act, in using telehealth procedures, health care providers shall comply with all applicable State guidelines and shall follow established state rules that are consistent with the accepted safe clinical norms, as well as security, confidentiality and privacy protections for health information.
The Department of Health (DOH) and Philippine Health Insurance Corporation (PHIC) shall require telehealth practitioners in both originating and distant sites to undergo accreditation, through the National Telehealth Reference Center.
Comment on Section 5:
In the sentence “The delivery of health care via tele health is recognised and encouraged as a safe, practical, and necessary practice in the Philippines…”, the word “encouraged” leaves me squirming in my seat. It is unclear what the real intent of the law is. When they say “necessary practice” is this only for remote communities without access to health care? Applicability of this phrase needs to be defined clearly in the law. Moreover, no telehealth can replace an actual physician-patient encounter, and its applicability, may perhaps be limited only to the remotest of communities without quick access to health care and specialists. The law needs also to define the limits and applicability of a private telehealth enterprise, perhaps even provide laws that will regulate such a practice. Does telemedicine, for example, constitute the practice of medicine? Does one need a professional regulatory commission license?
When the law says “All health care providers shall be encouraged to participate in telehealth pursuant to the Telehealth Act, in using tele health procedures...” , it is not clear what the law means by a “tele health procedure.” Further, it states, that “Health care providers shall comply with all applicable State guidelines and shall follow established state rules that are consistent with the accepted safe clinical norms…” , at this point, there are no norms. Who defines safe clinical norms or practice guidelines for tele health?
The complete sentence “…health care providers shall comply with all applicable State guidelines and shall follow established state rules that are consistent with the accepted safe clinical norms, as well as security, confidentiality and privacy protections for health information.” is grammatically incorrect as written. Does the law mean health care provides shall comply with all applicable State guidelines ….on security, confidentiality, and privacy protections for health information? This statement remains unclear as there were no provisions with regard to informed consent, and explanation of data security and protection was not even alluded to.
When the bill says “The Department of Health (DOH) and Philippine Health Insurance Corporation (PHIC) shall require telehealth practitioners in both originating and distant sites to undergo accreditation, through the National Telehealth Reference Center.“, does the National Telehealth Reference Center accredits the tele health system or the tele health practitioner? Certainly it seems appropriate that what the National Telehealth Reference Center accredits is the tele health system, and should be clearly stated as such. Nonetheless, it still leaves the accreditation of the tele health practitioner hanging. Who is in charge? Who defines ethical practice? What are the rules? Who accredits the practitioner?
Section 12. database — All telehealth centers and originating sites shall coordinate with the National Telehealth Reference Center for consolidation of patient databases.. The NTRC shall maintain and manage a national database for consults on clinical cases, as well as health and medical education exchanges made through the NTHS. It shall submit reports annually to the Committee and to the DOH on the status of and relevant health information derived from the database. A plan for long term outcome evlaution of telehealth service utilizing the cases registries shall be developed with one (two) years of passage of the Act by the NTRC in consultation with the Advisory Committee on Telehealth Service. Implementation of this plan shall be the responsibility of the Advisory Committee.
Comment on Section 12:
This section imposes coordination with the National Telehealth Reference Center, implying that ALL should coordinate for database consolidation. ALL is such an ambitious word. Is the bill talking about both the public or government tele health system or including also private endeavours in tele health? What are the minimum data sets required for sharing for database consolidation? Do the patients know their data will be shared?
It [the National Telehealth Reference Center] shall submit reports annually to the Committee and to the DOH on the status of and relevant health information derived from the database. A plan for long term outcome evaluation of telehealth service utilizing the cases registries shall be developed within one (two) years of passage of the Act by the NTRC in consultation with the Advisory Committee on Telehealth Service. Implementation of this plan shall be the responsibility of the Advisory Committee.
At the present time, even at the National Institute of Health, our case registries remain incomplete. Is there a national registry in place? That needs to be constructed and defined, and fully implemented before the tele health bill can “interoperate” so to speak with these registries. The roles of the National Telehealth Resource Center, the Advisory Committee, the National Telecommunications Center have no clearly defined roles and function. Each of these entities deserve a separate section in the bill.
Do we need a tele health bill?
In summary, do we need a tele health bill? Affirmative. But the tele health bill as it is written needs some major revisions and rethink. Even better perhaps, is to craft a more encompassing bill, such as an eHealth Bill. We need more graduates of MSHI, we need more thinkers, we need more interested personalities with their heart and mind in the right places. Perhaps, then we can move on eHealth, including tele health.
- Telehealth Act of 2012. http://www.congress.gov.ph/download/basic_15/HB06336.pdf Accessed November 15, 2014
- Nebraska Telehealth Act. http://dhhs.ne.gov/publichealth/Licensure/Documents/NebraskaTelehealthAct.pdf Accessed November 15, 2014.
- Marcelo, Alvin B. Telemedicine in developing countries: Perspectives from the Philippines. http://www.idrc.ca/EN/Resources/Publications/openebooks/396-6/index.html#page_27, accessed November 15, 2014.