A proposal for a hybrid telemedicine model

For a different view on telemedicine, today we interview Azèle Mathieu, Innovation Lead at MSD Belgium. Her experience with health startups and working at a big pharma company give her a unique perspective to understand the health ecosystem. In this interview she vouches for a hybrid model different from the model presented by co-host Bart Collet in our previous interview. 

MSD Belgium is hosting the Integrated Cancer Patient Pathways challenge of Hack Healthcare, whose objective is to provide cancer patients with a more convenient and connected patient care experience by offering a personalised, integrated care pathway including off-the-shelf telemedicine solutions, especially teleconsultations.

What’s the difference between telehealth, telemedicine and teleconsultation?

The three terms are related, they just go from broad to specific: telehealth includes all the health related activities that are done remotely; telemedicine is part of telehealth and includes only the subset of medicine related activities that are done remotely; and teleconsultation is the part of telemedicine that deals exclusively with the remote consultation. All of them are part of distributed care. This graph by EvolutionROAD, can be helpful to visualize how these terms are related to one another. 

Another aspect that is interesting to take into account is if the contact is done synchronous (like a call, with all parties discussing in real time) or asynchronous (like email or chat, where one side sends a message and the other side reads it whenever she decides to). 

What kind of problems does telemedicine solve?

Telemedicine might solve different problems and it depends on who is using it.

For patients: 

• for patients in a remote or rural area it might allow easier access to more healthcare services; 
• for patients living far from a specialized center, it may allow them to access a service that would be otherwise unavailable or difficult to access; 
• thanks to telemedicine we may also imagine that different specialists located in different places could be joined to give a second opinion on a diagnostic or treatment to a patient;
• during the pandemic, given that cancer patients are immunosuppressive, avoiding a clinical setting where they could have been contaminated makes even more sense;
• if well organized and integrated with other digital solutions, telemedicine might decrease the number of steps to go through: take an appointment, go to the doctor, forget to get the prescription, come back to the doctor, go to the pharmacy… If all those steps could be done remotely through one or several clicks it would make everybody’s lives easier.

For clinicians:

• if the telemedicine tool is well integrated with the electronic agenda for taking appointments and connected to the electronic health record, it might ease the organization of their work.

For hospitals: 

• it might contribute to less hospital overcrowding and less re-hospitalisations, because after an hospitalization doctors can better follow-up their patients remotely.

What’s the situation of telemedicine like in Belgium? Is the adoption of telemedicine accelerating?

Yes, the adoption of telemedicine is accelerating in Belgium, but it has to catch up as it is picking up pace later than other countries,  like France for example. 

Since the first Coronavirus lockdown the use of the telemedicine has known a strong acceleration in Belgium, with increasing pressure on health authorities to authorize the use of telemedicine and to reimburse it. This was achieved in June 2020, although for a determined period only (see La télémédecine et les applications mobiles Health – INAMI (fgov.be)). 

Belgium was originally against teleconsultation and it took many months to overcome this resistance. This opposition came from a 2017 notice of the medical association (Ordre des médecins, the council board of general practitioners in Belgium) where they stated that having a consultation without physical contact with the patient would be dangerous. Patients in Belgium really follow the advice of their general practitioner, and if their doctor was against teleconsultation there was no way that this service would develop. 

At that same time France and other countries were already allowing telemedicine and teleconsultation. I think that telemedicine was allowed in France first because, beyond human needs, France is a larger country and has what we call medical deserts: areas where there are not enough doctors available. This might have been a reason why the telemedicine was allowed and reimbursed sooner than in Belgium. 

Now that the government has allowed teleconsultation reimbursements we will see faster development of services. There are companies that have been around since 2016  (like the former ViviDoctor and Advelox among others) demonstrating a need, but whose development was hampered by the notice of the order of doctors against teleconsultation. 

The medical association did raise a good point when it said that there’s no possibility of touch in teleconsultation, which can be helpful for doctors. In my view teleconsultations should be combined with physical consultations when needed, neither should preclude the other. Some examples for the use of teleconsultation: giving a prescription for a known condition, to inform you about results of the laboratory tests, etc. 

What underlying problems does telemedicine solve for patients, clinicians, and hospitals? 

One of the first things that came up during the Coronavirus lockdown was triage of patients, which is used to choose who to treat first based on the urgency and importance of their condition. Two hospitals contacted me because of my work with digital startups in the health sector in my former position as manager of lifetch.brussels. They wanted to reduce the workload at the hospital and do the triage remotely. 

Another thing they were concerned about was that patients and their families worried about symptoms after the consultations and they wanted to be able to stay in contact with the patients, to be able to give them advice remotely, and to avoid rehospitalization of patients. They were very satisfied with the solutions I suggested (Bingli and Moveup). For example, patients can check if their COVID symptoms are important or not, and if they are important then the patient contacts the doctor remotely, who can choose to refer the patient to the hospital, instead of everybody going to the hospital. Telemedicine reduces the risks of COVID infection for patients and hospital staff. I would like to see them extending these telemedicine services to other areas beyond COVID.  

What do you see as the biggest challenges for the adoption of telemedicine?

I think the weakness of the original telemedicine solutions was that they were offered as standalone solutions, only providing a teleconsultation service. This has a lot of costs regarding customer acquisition, because they had to convince every single clinician, as they were not part of a larger software company already selling software to those clinicians and medical centers. They had to be part of a larger platform, to integrate with appointments and other services. Some first movers had rapid success in getting a lot of users, such as Livi in France. Now they are clearly more integrated in larger solutions as part of their business model. 

From the patient perspective I think that they were waiting for the teleconsultation service to be provided by their doctor or hospital of reference, they were not ready to just move to a teleconsultation service and end up working with a clinician they do not know. 

From an infrastructure perspective, teleconsultation has to be integrated with electronic health records, which is another important factor to favor integration and interoperability with the larger platforms. The telemedicine solutions offered in Belgium have to integrate with the Belgian electronic health record system.

A challenge for the patients has been the awareness of their electronic health records. Thanks to the integration of the COVID test results in these records, a lot more citizens know now that they have an electronic health record and how to access it. Teleconsultation without access to the patient’s electronic health record makes no sense. Clinicians need to have access to the patient’s record before the consultation and, then as the consultation is ongoing, to add to the record and have their notes, test results, prescriptions and diagnoses integrated for themselves and other clinicians to work with in the future. 

Another challenge is that the designers of digital medicine solutions have to take into account that we don’t all have the same literacy when it comes to interacting with computers (be it on a desktop, mobile phone, tablet or any other device). I think that it is important to take into account, for example, the Eight Caring Technology Principles (FR) for more human centric health technologies, developed by the King Baudouin Foundation and the Fund Dr Daniël De Coninck. We cannot lose the human perspective on the use of these tools. 

Not all patients are equal regarding the digitalization of healthcare and we also need to take that into account. In the 2020 Digital Health Consumer Adoption Report by Rock Health and the Stanford Center for Digital Medicine it is clearly said that “telemedicine is not reaching new demographic populations in large numbers (yet). The most likely users of telemedicine in 2020 remained consistent with past years: higher-income earners, middle-aged adults (aged 35-54), highly educated, and those with chronic conditions”. 

We need a change of perspective. As outlined in that same study, “the future of tech-enabled care models may not be reflected in how consumers are currently using telemedicine. During 2020, the most common reason for accessing telemedicine was a medical emergency, and the most common channel was through a patient’s own doctor/clinician. We see these as COVID-19- necessitated behaviors, but they are not the contours of how we envision telemedicine best serving patients in the future when tech-enabled care models are proactive, continuous, and outcomes-oriented.”

Should telemedicine replace medicine as we know it?

Telemedicine should complement and enhance traditionally delivered medicine, not replace it. We should not oppose digital tools in medicine. We have to see them as means, as tools for healthcare practitioners and patients to make their lives easier. They should be combined with the traditional medicine acts, not replace them. The challenge is to find the right equilibrium and the right tool at the right time for the right objective. 

What are the concrete things you believe need to happen soon to accelerate the adoption of Telemedicine?

I strongly believe that we need more evidence on the benefits of telemedicine, on the way it is managed, and on the experience of patients. 

Then the system must be willing and able to move forward with that evidence and with the services it provides. An example I’ve recently experienced through a friend is that the test labs were not able to follow up timely with test results after the increase in teleconsultations, there was a bottleneck. The rest of the experience was great. 

From the clinical perspective teleconsultation must be well integrated in the software system used in Belgium. 

We need to make telemedicine really accessible. For this we may need to form the persons who are less digitally oriented. 

During Coronavirus telemedicine and teleconsultations have been widely adopted to solve immediate problems. Do you think their use will keep accelerating? 

With the positive evolution of treatment of COVID and of the pandemic we will see a slowing down in the usage of teleconsultation and some other telemedicine services, but I do not think that they will go back to pre-Coronavirus levels. It depends on the will of the service providers and on the demands of patients.  

This pandemic has been an exceptional event, and with it we have witnessed an exceptional growth of telemedicine services. As we manage to limit the danger of COVID and return to normality this exceptional peak of growth will not be maintained, but there will be clearly a higher use than before the pandemic. Patients and healthcare professionals have already tried telemedicine and teleconsultation services and their advantages, they will not want to let them go. I think there will be a bigger push for these services in a hybrid model that mixes tele with in person medicine and consultations now that more people have gotten a taste of it, and with this push there will be more  and faster growth that we could foresee before living through these trying times.   

What more can telemedicine do for cancer patients?

A lot. We can already see among specialists that oncologists and hematologists have been using telemedicine the most during the Coronavirus lockdowns, and they have also registered more as new users. This shows that there is a need to use telemedicine for cancer patients. 

It might be useful for prevention testing (like the colorectal cancer yearly campaign in Belgium) and may be useful in diagnosis (tricky with the need of personal contact), but what really matters is to have the advice of patients and specialists, it is a challenge for the community to find out when it could be more useful. Also at which moment in the care journey it would be the most useful. Maybe it could be used to receive a second opinion for treatment and diagnosis, especially for reaching out to specialists that are far away or in another country. 

Nowadays there are more and more treatments that you can receive at home and maybe the followup needed could be provided remotely. If you have an adverse event in your treatment that is not severe, you could ask advice from the clinical team that is taking care of you. 

There are a lot of touchpoints around the care pathway and many can be done remotely. 

All these have to be integrated into a digital care ecosystem, a digital platform for communication among patients and clinicians where it is clear what the patient has to do and avoid, and teleconsultation has to be integrated into it (for more on this subject, see this interview on the management of health data). 

Who do you think should be driving the acceleration of Telemedicine? And who do you think will most likely be the one actually doing it?

Integration has to happen at different levels, but data is the backbone of it. It is important to understand why all these companies are interested in the data. 

I think there are three usual suspects that come up repeatedly: managers of electronic health records, insurance companies, and mobile phone ecosystems. 

First, the companies and institutions managing electronic health records. Teleconsultations need to be paired with the data of the patients, and there’s a lot of patient data being generated and added to the electronic health record.  

Then insurance companies, who are very interested in the prevention of disease and are well positioned to provide solutions. I’m seeing an appealing association between telehealth platforms and insurance companies proposing preventive services to citizens, so that they can get a teleconsultation meeting if they want to check their health and get advice. 

Lastly, the mobile phone ecosystems. There’s a lot of data in our phones that we can expand even more with apps like fitness trackers. A logical step would be using the insight from that data to trigger a teleconsultation when needed. Teleconsultation is a communication interface between medical teams and patients and generates even more data to be integrated in the electronic health record. 

We need to build the infrastructure first to get the communication going. Some of it already exists, but it is not well explained nor well known. Data is already being stored and you own your own data. We could use all that data stored at hospitals to improve patients’ experiences and outcomes, to make analysis, to make studies… The problem is that most people don’t understand what’s being done with the data nor who’s doing it, which does not promote trust. At least in Belgium your electronic health record allows for these services and for the patients to check the available information. 

About MSD BeLux

MSD is one of the world’s leading research-based biopharmaceutical companies with a history that goes back more than 125 years. We have made it our mission to contribute to improving health around the world. Our company is called MSD (Merck Sharp & Dohme) everywhere except in the USA and Canada, where it is known as Merck & Co., Inc., Kenilworth, NJ, USA. MSD Belgium was founded in 1965 in Brussels.

MSD BeLux is one of more than 50 countries in which MSD conducts clinical research. Belgium has one of the largest MSD manufacturing and packaging plants in Flanders. The company is committed to strengthen health literacy and health economics, among other things. In 2018, MSD Belgium received the “Top Employer” and “Top Employer Europe” certifications for the third time in row.

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