Indexed in MEDLINE, SCI & KoreaMed
pISSN 1011-8934   eISSN 1598-6357
Open Access, Peer-reviewed, Weekly
    J Korean Med Sci. 2021 May 03;36(17):e103. English.
    Published online Apr 01, 2021.
    https://doi.org/10.3346/jkms.2021.36.e103
    © 2021 The Korean Academy of Medical Sciences.
    Review

    Towards Telemedicine Adoption in Korea: 10 Practical Recommendations for Physicians

    Hun-Sung Kim1,2
      • 1Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Korea.
      • 2Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
    • Address for Correspondence: Hun-Sung Kim, MD, PhD. Department of Medical Informatics, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea. Email: 01cadiz@hanmail.net
    Received December 14, 2020; Accepted February 07, 2021.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Abstract

    Due to the coronavirus disease 2019 (COVID-19) outbreak, consultation and prescription via telemedicine were temporarily allowed in the Korean population. However, at this point, it is difficult to determine whether telemedicine fulfills its role as a health care strategy. Arguably, if we had enough previous experience with telemedicine or sufficient preparation for its application, telemedicine could be more smoothly and flexibly adopted in the medical field. As it is still not possible to predict when the COVID-19 pandemic will end, phone consultation and prescription are likely to continue for some time. Hence, it is expected that telemedicine will naturally settle in the medical field in the near future. However, as we have noticed during this outbreak, improvised telemedicine without adequate guidance can be confusing to both patients and health professionals, thus reducing the benefit to patients. Medical staff requires preparation on how to appropriately use telemedicine. Thus, here we present some suggestions on implementing and preparing for telemedicine in the medical community.

    Graphical Abstract

    Keywords
    COVID-19; Delivery of Health Care; Information Science; Telecommunications; Telemedicine

    INTRODUCTION

    Telemedicine is a kind of health management practice in which medical staff and patients perform remote communication and care.1, 2 For telemedicine for proper health management, medical devices used by patients, platforms in which data is stored and displayed, and medical feedback (service) provided by medical staff to patients must be organically harmonized.1, 2 Due to the coronavirus disease 2019 (COVID-19) outbreak,3 the Ministry of Health and Welfare has temporarily allowed “phone consultation or prescription (PhoneTx).”4 “PhoneTx” is based on remote communication similarly as telemedicine; however, it differs in purpose and method from the existing evidence-based telemedicine.5 Conventional telemedicine aims at lifestyle management, while “PhoneTx” only aims to avoid visiting hospitals.5 Therefore, it would not be reasonable to sustain the legalization of telemedicine in the future based on this experience of telephone consultation.5 In addition, the use of telemedicine for acute diseases like COVID-19 is considered to be quite limited at this time.

    The prolonged COVID-19 outbreak has provoked a dire demand for medical staff and patients to use telemedicine (non-face-to-face care). However, notably, the endpoint of the temporary allowance of PhoneTx is not clearly specified.4 As the COVID-19 outbreak prolongs, the endpoint of COVID-19 also grows uncertain.6, 7 Feasibly, this type of telemedicine could be further prolonged and be settled in the medical fields beyond the COVID-19 outbreak.

    In the face of this prolonged COVID-19 outbreak, medical staff should seriously consider preparing for evidence-based telemedicine, and not just for PhoneTx. PhoneTx could be used not only to avoid visits to the hospital (Table 1) but also as evidence-based telemedicine that is really helpful for the health management of patients.1, 8

    Table 1
    Differences between phone consultation or prescription and telemedicine

    Unprepared telemedicine can cause serious confusion for the medical staff and patients.2 Although the medical staff does not need to agree or disagree with telemedicine, they need to understand all medical situations and be prepared to adopt telemedicine if necessary. Therefore, assuming that the extensive use of telemedicine will be approved in Korea, in this study, we offer suggestions on how to adequately prepare for the adoption of telemedicine. Although not officially approved, the information hereby provided summarizes the actual needs based on the existing literature. The 10 suggestions provided in this document are intended for consultation purposes only and not for legal advice. The decisions of the medical staff working in the medical field are of utmost importance for situations that can take different directions. Notably, depending on the patient's situation, the medical staff may change or adjust our advice.

    REALISTIC CONSIDERATIONS FOR STARTING THE PRACTICE OF TELEMEDICINE (Table 2)


    Table 2
    Ten suggestions to consider before starting telemedicine

    1. Primary priority: Telemedicine cannot replace face-to-face treatment

    It is crucial to remember that telemedicine can fully replace face-to-face consultation. Physicians should not forget that the basis of medical care consists of inspection, auscultation, percussion, and palpation.9, 10 Telemedicine is based on health management systems using medical devices and platforms.1, 2, 11 To this end, it is essential to consider how much medical devices and platforms can complement face-to-face medical care basics (inspection, auscultation, percussion, and palpation). Because of this, information and communications technology (ICT)-based telemedicine could not fully replace face-to-face treatment. Hence, the correct approach is to use telemedicine to supplement health care services provided to patients with certain medical conditions.12

    2. Telemedicine could be used in patients who had a face-to-face meeting with the physician at least once

    The first thing to know is whether the patient (disease group) is suitable for telemedicine practice.13 In this sense, telemedicine is recommended for patients who have received face-to-face attention for the same condition before.14 For example, in patients with diabetes mellitus (DM), telemedicine is recommended only for matters related to blood sugar control or the evaluation of related complications.15, 16 If a patient with DM experiences sudden abdominal pain or headache, face-to-face treatment is preferred. In other words, continuity between face-to-face treatment and telemedicine is important. Nevertheless, national emergencies such as COVID-19 can pose exceptional challenges.4

    3. Proper consent and education are required for participating patients

    If a doctor has determined that patients will be followed up using telemedicine after the first face-to-face consultation, the doctor needs to first obtain the patient's consent before starting telemedicine and document, record, and save this information.17, 18 To avoid unnecessary misunderstandings with patients regarding the method of telemedicine and the limitations of the technology, it is essential to provide sufficient explanation and obtain consent from the patients.19 Doctors would ideally inform users of any restrictions imposed by treatments provided through telemedicine. In this regard, the patient could be advised on how to prepare for follow-up treatment. There are still various unexpected problems and liability issues for remote medical attention. Although oral consent is often acceptable,20 it is recommended to obtain written consent from the patients whenever possible. In the case of using the medical platform, it is recommended to obtain an additional “platform-related agreement.”

    4. Determination of target disease, method, and scope for telemedicine

    It is necessary to identify the characteristics of the hospitals in which telemedicine is to be conducted and define which diseases will be targeted (DM, hypertension, asthma, etc.), which methods or programs will be used (telephone, online, etc.), and to what extent medical services (repeat medication, medical consultation, etc.) will be provided.13 This means setting strategic goals by considering the hospital's (or doctor's) specialty and financial impact. To achieve this goal, it is good to set a target number of patients to be treated per day using telemedicine. Sufficient consideration is required regarding the duration of each consultation (in fact, phone consultation may take more time than face-to-face treatment), the expected revenue compared with that of face-to-face treatment, and the hospital's capabilities.21

    5. Select suitable medical devices and platform

    Traditionally, medical devices and platforms are essential for telemedicine for health care.1, 2, 11 Once physicians have determined the target disease and method for telemedicine, they need to select medical devices and platforms to be used: for example, a glucometer device for people with DM16, 22 and a blood pressure for people with hypertension.23 If the hospital aims to manage sleep disorders, an appropriate medical device and platform need to be selected.24 It is crucial for physicians to choose a platform (or application) that can record and display the data they upload. Of course, there can be various medical devices of the same type, in which case it is recommended that the medical staff acquire as much experience as possible with medical devices and platforms. Inadequate use of medical devices and platforms may adversely affect patient health management.25 Medical device or platform malfunctions, downtime, slowdowns, etc. may eventually cause the patient to have a negative experience with telemedicine.

    6. Organization of medical teams and collaboration with other institutions

    Certainly, the number of members in a team will vary depending on the size of the hospital, but it is essential to share roles among members.26, 27 If there are financial resources, the team could consist of a person in charge of actual health care, a specialist who can help in the management of telemedicine (training users of medical devices or platforms or in charge of continuous updates at the request of users), and an ICT specialist in charge of the medical devices and platforms. The success of telemedicine depends on the appropriate team organization. However, it would be impossible to organize all team members in a local clinic. In the case of a local clinic where it is difficult to organize a team, it is a good idea to reduce the scope of telemedicine or collaborate with a tertiary hospital. In Korea, the “Digital Health Coordinating Center (DHCC)”8, 16, 25, 28 would be ideal for this purpose. To ensure the proper use of the medical device and the platform, the patient's ability to access and use these services and technologies may also be considered. This may require ongoing patient education. This role would preferably be played by a tertiary hospital. In this way, the medical staff at the local clinic can focus on providing treatment, while other issues (such as ICT and education) are handled by the tertiary hospital.

    7. Guideline and clinical pathway (CP) of telemedicine

    Before starting telemedicine practice, preparing a basic “patient management protocol” is important.29, 30 In fact, a continuous exchange of information on specific diseases among hospitals is crucial, and it is recommended to use the same “CP” across hospitals (Fig. 1). As mentioned above, the tertiary hospital would be responsible for creating this CP and providing it to the local clinic. The sharing of information on handling methods (i.e., technical know-how) among hospitals that treat patients with the same disease is an important process for improving telemedicine programs. In addition, a large exchange of experiences could allow predicting otherwise unexpected scenarios. Emergency services need to be regularly considered, and a protocol for this needs to be prepared as well.

    Fig. 1
    Examples of critical pathways for telemedicine operation. It is possible to change the target disease at the judgment of the researcher. (A) Long-term plan example. To initiate telemedicine, the patient must first visit the hospital. It is also advisable to schedule regular hospital visits depending on the type of disease (e.g., every 3 months). During periods of non-hospital visits, telemedicine checks the patients condition. (e.g., every month). Telemonitoring checks the patient's condition, and if the condition is unstable, stop telemonitoring at any time and switch to face-to-face treatment. Data uploaded by patients can be evaluated and analyzed weekly according to the patient's condition, not monthly. In all these cases, face-to-face treatment should not be stopped entirely. (B) First month's detailed example. When a patient visits the hospital for the first time, medical staff should perform various tests to see if it is suitable for telemonitoring. After that, the data posted by the patient every week are checked. In this case, there are various details such as vital signs or weight.

    8. Conduct telemedicine and face-to-face treatment the same way

    The basic treatment principle for treating patients with telemedicine is to first follow the treatment guidelines used in face-to-face care. The drugs prescribed in telemedicine are also not different from those prescribed in face-to-face treatment. In both telemedicine and face-to-face consultations, treatments and medications could be prescribed according to the same guidelines. However, it is crucial to pay special attention to the prescription of new drugs, rather than to previous prescriptions, in remote treatment. Preferably, physicians would refrain from prescribing drugs with strong side effects and give detailed explanations to the patient. A face-to-face consultation is recommended for the prescription of treatments and drugs that may cause substance abuse, such as opioids, sleeping pills, antibiotics, and steroids.31, 32 Of course, there can be exceptions in emergencies, such as in cases of COVID-19. Exceptions can also be made in emergencies that require the careful judgment of the medical staff. If telemedicine is not suitable or if the practice of telemedicine is deemed difficult to maintain, visiting the hospital can be an option. Documenting and recording all this process is crucial.

    9. Look beyond the visit: continuity of care

    Telemedicine is better for continuous management than for temporary treatment (in fact, this is the key point of continuity of care for telemedicine).33, 34 In patients using telemedicine for the first time, continuous follow-up care is recommended. We also recommend establishing long-term plans for telemedicine, especially in uncertain situations, such as during the COVID-19 pandemic, whose end is not yet in sight. It is suggested that long-term follow-up care be allowed in telemedicine based on long-term lifestyle management rather than on a single treatment.

    10. Improve patient's confidence in the system

    Medical professionals need an early approach to increase patient confidence in telemedicine.2 For this reason, it is advisable to prepare a satisfaction survey for patients in the early stages of telemedicine practice.25, 26 In this relation, it is desirable to also include a questionnaire on the management of the medical team. Moreover, the medical team could focus more on negative feedback than on positive feedback from the patient. In addition to the survey results, doctors could constantly monitor the physical surroundings of the telemedicine room. Continuous communication between medical staff and management staff is of utmost importance. Active promotion of telemedicine, formation of social consensus, and telemedicine business models are also an important part.35 This would be handled as the main axis in the DHCC.

    DIGITAL HEALTH COORDINATING CENTER

    The 10 suggestions mentioned above are essential rather than optional. In reality, it seems almost impossible to abide by all these 10 suggestions at a local clinic. However, at this point, telemedicine mainly proved and targets chronic diseases, such as diabetes and hypertension, or elderly diseases such as Parkinson disease, dementia, or sleep disorder.11, 13, 36 Moreover, it would be much better that the management of these diseases be centered on local clinics rather than tertiary hospitals. Therefore, the above 10 recommendations are most necessary to start telemedicine practice in a local clinic with the support of a tertiary hospital (the DHCC in this case).8, 16, 25, 28 All types of treatment involved in patient telemedicine are operated by the local clinic, but all the know-how and methods necessary for the telemedicine process, making of CP, and monitoring are managed by the DHCC. This is the reason for recommending the separation of treatments carried out at local clinics and the management of other aspects carried out at the DHCC. This would reduce the cost, labor, and time needed for the management of telemedicine at the local clinic and is a way to strengthen the expertise of the DHCC. The role of tertiary-care hospitals for DHCC will vary, including monitoring the patients' data, sending the patients' summary to the local clinic, training and technical support of local clinics, and supervision of management.5

    CONCLUSIONS

    In the near future, telemedicine will be settled as a part of the medical field. However, the medical staff is not necessarily qualified to handle the process of telemedicine.37 During the COVID-19 outbreak, clinicians accustomed to evidence-based patient management will need to consider in advance how to respond wisely to the social issue of telemedicine.

    The possibility, clinical effectiveness, and cost-benefit of telemedicine have already been established through various studies.1, 13 As a next step, medical staff could focus on how to successfully settle telemedicine in the medical field. Although the scientific basis for telemedicine has already been proven, whether its use can be successfully extended in the medical market is a different matter. In practice, telemedicine is likely to be used mainly by some patients who simply do not want to visit the hospital, regardless of other factors (only for repetitive medications). Various side effects and problems can occur. Even if the medical professionals follow appropriate telemedicine recommendations, their “ethical responsibility” remains unchanged. In this regard, various unexpected levels of responsibility can be involved in telemedicine. For this reason, the exchange of information among clinicians and researchers is critical to prevent repeating the same mistakes.

    The importance of telemedicine in Korea is indeed relatively lower than in other countries, as Korean patients have good medical access. However, in Korea, many studies have already been conducted on patient management through a combination of ICT and medical fields. ICT and medicine have developed together, and the use of information technology in medicine is now inevitable. Korea is the country with the highest potential for the commercialization of evidence-based telemedicine. In this field, Korea can easily gain global competitiveness, grow rapidly, and differentiate itself from other countries in the medical field.

    Currently, clinicians have to adapt to the changing medical trends. Now is the time for medical staff to rely on proper evidence-based judgment. In addition to securing scientific evidence for telemedicine, continuous efforts for commercialization are required. In telemedicine, attention to evidence-based positive outcomes can help improve the patient’s experience, reduce medical costs, and increase patient satisfaction, which points to the importance of active interest and participation of medical staff.

    Notes

    Funding:This work was supported by the Technology development Program(S2726209) funded by the Ministry of SMEs and Startups (MSS, Korea).

    Disclosure:The author has no potential conflicts of interest to disclose.

    References

      1. Kim HS, Kim H, Lee S, Lee KH, Kim JH. Current clinical status of telehealth in Korea: categories, scientific basis, and obstacles. Healthc Inform Res 2015;21(4):244–250.
      1. Kim HS, Cho JH, Yoon KH. New directions in chronic disease management. Endocrinol Metab (Seoul) 2015;30(2):159–166.
      1. Velavan TP, Meyer CG. The COVID-19 epidemic. Trop Med Int Health 2020;25(3):278–280.
      1. Temporary allowance of telephone consultation/prescription and proxy prescription. [Updated 2020]. [Accessed March 10, 2020].
        http://www.mohw.go.kr/react/al/sal0101vw.jsp?PAR_MENU_ID=04&MENU_ID=040102&CONT_SEQ=353269.
      1. Kim HS. Lessons from temporary telemedicine initiated owing to outbreak of COVID-19. Healthc Inform Res 2020;26(2):159–161.
      1. Bae TW, Kwon KK, Kim KH. Mass infection analysis of COVID-19 using the SEIRD model in Daegu-Gyeongbuk of Korea from April to May, 2020. J Korean Med Sci 2020;35(34):e317
      1. Noh J, Chang HH, Jeong IK, Yoon KH. Coronavirus disease 2019 and diabetes: the epidemic and the Korean diabetes association perspective. Diabetes Metab J 2020;44(3):372–381.
      1. Kim HS, Sun C, Yang SJ, Sun L, Li F, Choi IY, et al. Randomized, open-label, parallel group study to evaluate the effect of internet-based glucose management system on subject with diabetes in China. Telemed J E Health 2016;22(8):666–674.
      1. Ferguson CM. Inspection, auscultation, palpation, and percussion of the abdomen. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Boston, MA, USA: Butterworths; 1990.
      1. Yeston NS. Inspection, palpation, percussion, and auscultation = connection. Conn Med 2002;66(12):757–758.
      1. Kim HS, Lee KH, Kim H, Kim JH. Using mobile phones in healthcare management for the elderly. Maturitas 2014;79(4):381–388.
      1. Kim HS. Decision-making in artificial intelligence: is it always correct? J Korean Med Sci 2020;35(1):e1
      1. Kim HS, Hwang Y, Lee JH, Oh HY, Kim YJ, Kwon HY, et al. Future prospects of health management systems using cellular phones. Telemed J E Health 2014;20(6):544–551.
      1. McGrail KM, Ahuja MA, Leaver CA. Virtual visits and patient-centered care: results of a patient survey and observational study. J Med Internet Res 2017;19(5):e177
      1. Sun C, Sun L, Xi S, Zhang H, Wang H, Feng Y, et al. Mobile phone-based telemedicine practice in older chinese patients with type 2 diabetes mellitus: randomized controlled trial. JMIR Mhealth Uhealth 2019;7(1):e10664
      1. Kim HS, Yoon KH. Lessons from use of continuous glucose monitoring systems in digital healthcare. Endocrinol Metab (Seoul) 2020;35(3):541–548.
      1. Segura Anaya LH, Alsadoon A, Costadopoulos N, Prasad PW. Ethical implications of user perceptions of wearable devices. Sci Eng Ethics 2018;24(1):1–28.
      1. Odhiambo R, Mars M. Patients' understanding of telemedicine terms required for informed consent when translated into Kiswahili. BMC Public Health 2018;18(1):588.
      1. Nittari G, Khuman R, Baldoni S, Pallotta G, Battineni G, Sirignano A, et al. Telemedicine practice: review of the current ethical and legal challenges. Telemed J E Health 2020;26(12):1427–1437.
      1. Gordon EJ. When oral consent will do. Field Methods 2000;12(3):235–238.
      1. Cho JH, Choi YH, Kim HS, Lee JH, Yoon KH. Effectiveness and safety of a glucose data-filtering system with automatic response software to reduce the physician workload in managing type 2 diabetes. J Telemed Telecare 2011;17(5):257–262.
      1. Cho JH, Kim HS, Yoon KH, Son HY. Are information technology-based systems the way forward for diabetes management in Asia? J Diabetes Investig 2013;4(1):1–3.
      1. Omboni S, Caserini M, Coronetti C. Telemedicine and M-health in hypertension management: technologies, applications and clinical evidence. High Blood Press Cardiovasc Prev 2016;23(3):187–196.
      1. Singh J, Keer N. Overview of telemedicine and sleep disorders. Sleep Med Clin 2020;15(3):341–346.
      1. Kim HS, Choi W, Baek EK, Kim YA, Yang SJ, Choi IY, et al. Efficacy of the smartphone-based glucose management application stratified by user satisfaction. Diabetes Metab J 2014;38(3):204–210.
      1. Broens TH, Huis in't Veld RM, Vollenbroek-Hutten MM, Hermens HJ, van Halteren AT, Nieuwenhuis LJ. Determinants of successful telemedicine implementations: a literature study. J Telemed Telecare 2007;13(6):303–309.
      1. Lazzara EH, Benishek LE, Patzer B, Gregory ME, Hughes AM, Heyne K, et al. Utilizing telemedicine in the trauma intensive care unit: does it impact teamwork? Telemed J E Health 2015;21(8):670–676.
      1. Kim HS, Shin JA, Chang JS, Cho JH, Son HY, Yoon KH. Continuous glucose monitoring: current clinical use. Diabetes Metab Res Rev 2012;28 Suppl 2:73–78.
      1. Rosen D, McCall JD, Primack BA. Telehealth protocol to prevent readmission among high-risk patients with congestive heart failure. Am J Med 2017;130(11):1326–1330.
      1. May C, Ellis NT. When protocols fail: technical evaluation, biomedical knowledge, and the social production of ‘facts’ about a telemedicine clinic. Soc Sci Med 2001;53(8):989–1002.
      1. Huskamp HA, Busch AB, Souza J, Uscher-Pines L, Rose S, Wilcock A, et al. How is telemedicine being used in opioid and other substance use disorder treatment? Health Aff (Millwood) 2018;37(12):1940–1947.
      1. Pepin D, Hulkower R, McCord RF. How are telehealth laws intersecting with laws addressing the opioid overdose epidemic? J Public Health Manag Pract 2020;26(3):227–231.
      1. Omboni S. Telemedicine during the COVID-19 in Italy: a missed opportunity? Telemed J E Health 2020;26(8):973–975.
      1. Cho JH, Chang SA, Kwon HS, Choi YH, Ko SH, Moon SD, et al. Long-term effect of the Internet-based glucose monitoring system on HbA1c reduction and glucose stability: a 30-month follow-up study for diabetes management with a ubiquitous medical care system. Diabetes Care 2006;29(12):2625–2631.
      1. Chen S, Cheng A, Mehta K. A review of telemedicine business models. Telemed J E Health 2013;19(4):287–297.
      1. Jung AR, Park JI, Kim HS. Physical activity for prevention and management of sleep disturbances. Sleep Med Rev 2020;11(1):15–18.
      1. Kim HS. Apprehensions about excessive belief in digital therapeutics: points of concern excluding merits. J Korean Med Sci 2020;35(45):e373
    Cited by
    PubMed Central 10
    Scopus 11
    Web of Science 10
    MeSH Terms
    COVID-19
    Delivery of Health Care
    Health Occupations
    Humans
    Information Science
    Korea*
    Medical Staff
    Prescriptions
    Telecommunications
    Telemedicine*
    Metrics
    Share
    Links to
    Figures
    slide

    1 / 1

    Tables
    slide
    slide

    1 / 2

    ORCID IDs
    Funding Information
    PERMALINK