In order to achieve sustainable healthcare, momentum is growing worldwide for the use of novel technologies and innovations (health technologies) that improve productivity in medical settings and make medical system design more efficient and effective. This year, in Japan, the Revision of Medical Service Fees included a number of newly established evaluation criteria relating to medical ICT, with a particular focus on telemedicine and online medical consultations, and complete with guidelines on their proper implementation. What’s more, the Basic Policy on Economic and Fiscal Management and Reform 2018, otherwise known as the “Big-boned Policy,” that was adopted this past June by the Cabinet, clearly states the goal of further enhancing online medical consultations as a whole, including online drug administration guidance. With such significant actions and initiatives surrounding telemedicine and online medical consultations, anticipation is rapidly growing regarding the form under which related services would be rolled out to the public.

To that end, Health and Global Policy Institute (HGPI) hosted an Evening Seminar at which case reports were shared on the implementation of online medical consultation, and discussions were held on why telemedicine and online consultations are important as well as how they should be used and managed in the future.

■Seminar Overview
Date & Time: Wednesday, September 26, 2018, 19:00-20:30
Venue: Otemachi Sankei Plaza 3F, Room 301/302, 1-7-2 Otemachi, Chiyoda-ku, Tokyo
Organizer: Health and Global Policy Institute (HGPI)
Participants: Healthcare and medical professionals, academia, patient groups, media, etc. (approximately 140 participants in total)
Program: (In no particular order / Honorifics and titles omitted)
19:00-19:05 Opening
     Kiyoshi Kurokawa (Chairman, HGPI)

19:05-19:35 Online Medical Consultation Case Reports
     Takuya Ono (Director, Ono Cardio-GP Clinic, Toui Medical Association)
     Naoki Uchida (Director, Taro Clinic, Suzuran Medical Corporation)

19:35-20:15 Discussion
     Shinsuke Muto (Chairman, Integrity Healthcare Co., Ltd.)
     Takashi Hasegawa (Board Member, Japanese Telemedicine and Telecare Association)
     Daisuke Sato (Senior Researcher, National Institute of Public Health, Research Center for Economic Evaluation of Healthcare)
     Mamoru Ichikawa (Director, Japan Broadcasting Corporation (NHK), Scientific & Environmental Programs Division, Production Center One) (Moderator)

■Overview of Online Medical Consultation Case Reports

“Implementing Online Medical Consultations – A First Point of Contact”
Takuya Ono (Director, Ono Cardio-GP Clinic, Toui Medical Association)

I currently work in internal medicine in Koto Ward, treating patients who span a wide range of ages as well as nationalities. We have been providing online medical consultations since July 2017. Regular exams are very important to our patients living with chronic diseases, but there is some drop-out due to reasons such as patients being “too busy” or “too weak.” For such patients, providing online consultations enables the continuation of treatment. Even if something happens which makes it difficult for a patient to visit the clinic, rather than simply switching to an in-home visit, we also have the option of doing a one-time online consultation. It is even possible to switch between clinic, online, and in-home consultations.

Compared to standard, face-to-face consultations, I think that by asking patients or caregivers who use online consultations to record their daily data (blood pressure, condition, etc.) on the internet, there is a higher likelihood that they will seek care after first taking this data into account and thinking about health-related questions and concerns for themselves. We too, as doctors, can learn in detail about a patient’s condition, data, and records. The ability to share daily patient data with doctors in a way such as this is extremely important, and it enables more efficient use of our limited consultation time. Rather than simply eliminating the inconvenience of clinic visits, online consultations have helped patients to begin understanding the importance of health management. For instance, our clinic provides online consultations to a patient living with muscular dystrophy and type 2 diabetes. In addition to reducing the burden of clinic visits on the patient and caregiver, regular exams have become possible, and hemoglobin A1c levels are improving. The patient had become pessimistic due to ill health, but during online consultations the patient’s outlook improves, and this leads to positive outcomes.

During face-to-face consultations, we treat patients while filling in medical records, but during online consultations, we become keenly aware of making eye contact on screen, making it possible to address patients physically, emotionally, and mentally and to communicate with them on a wide range of topics including their daily lives. To conduct online medical consultations, we also need to work on our medical history-taking skills.

“The Effectiveness of In-home Visits”
Naoki Uchida (Director, Taro Clinic, Suzuran Medical Corporation)

I work at Fukuoka City’s Enhanced In-home Care Support Clinic, where I am actively involved in end-of-life care. We have many elderly dementia patients who use long-term care insurance. Although I had been thinking about implementing online medical consultations for the treatment of forgetful outpatients, I implemented them as part of the “Fukuoka 100” project promoted by the city.

Our clinic first began using online consultations in August 2017. A patient whom I first saw in September 2016 with moderate Alzheimer’s disease, was also living with comorbid malignant lymphoma and diabetes. With a life-expectancy of 2 months due to lymphoma, and no longer able to visit the clinic, the patient was switched to in-home care. I then implemented online consultations, conducting pain control as well as diagnostic imaging. During online consultations, I was even able to check types of convulsions. Being able to closely monitor the patient’s condition in a such a way, online consultations enabled us to quickly recognize when the end-of-life was nearing and inform the patient’s family. As a result, even family members residing elsewhere were able to be present to say good-bye. Family members living with the patient who had initially felt unsure about smartphone consultations, also came to realize that in emergencies as well, online consultations make it easier to contact physicians.

Although up until now we have conducted telephone consultations for in-home care, despite listening to a patient’s condition, it has often been challenging to make decisions. Online consultations are more convincing to patients than telephone consultations, and hearing the words “You’re fine!” from a doctor can provide peace of mind, so I also think that we have increased the “quality of reassurance” that patients feel. In addition, since daily schedules are extremely tight for those doing in-home visits, responding to emergencies can easily put a significant burden on physicians and their staff. If we could respond to emergencies online, then we could also lessen the burden on physicians.

That said, trust-based patient-physician relationships are an essential prerequisite for the smooth facilitation of online consultations, so much so that I believe they are their foundation. It is also difficult to implement online consultations when neither the patient nor the caregiver can use a smartphone, and the suppression of medical service fees seems to have become a bottleneck to implementation. Although I believe that at the present moment, amidst various limitations, we cannot entirely replace face-to-face consultations, I think that after putting online consultations to the test in the real world, we have been able to increase quality of care.

■Discussion
     Shinsuke Muto (Chairman, Integrity Healthcare Co., Ltd.)
     Takashi Hasegawa (Board Member, Japanese Telemedicine and Telecare Association)
     Daisuke Sato (Senior Researcher, National Institute of Public Health, Research Center for Economic Evaluation of Healthcare)
     Mamoru Ichikawa (Director, Japan Broadcasting Corporation (NHK), Scientific & Environmental Programs Division, Production Center One) (Moderator)

Discussion Points

     The positioning of telemedicine and online medical consultations in Japan
• Online consultations have made it possible for medical professionals to acquire daily patient activity data, and by making early detection and intervention for lifestyle-related diseases possible, we can now prompt patient behavior modification. Moving forward, we need to continue to consider how we will tie the accumulation of daily patient activity data into the delivery of precision medicine, i.e. medical and long-term care services optimized to each individual.
• Online medical consultations have been positioned as a problem solving tool for issues such as physician maldistribution and physician work-life balance reform. They are being promoted by the united efforts of not only the Ministry of Health, Labour and Welfare, but also relevant ministries and agencies such as the Ministry of Economy, Trade and Industry, and the Ministry of Internal Affairs and Communications.
• Twenty years ago in telemedicine, diagnoses had to be made on the spot over videophone. We have seen major changes since then. Not only are current online consultations conducted on-screen, they have evolved along with the times to meet changes in Japan’s medical healthcare system and medical care, and online consultations are now used for purposes such as the management of chronic disease symptoms.
• The FY2018 Revision of Medical Service Fees includes newly established elements such as “online medical consultation fees,” and their implementation is underway around Japan. Real-world examples are emerging that suggest online medical consultations can actually prevent the progression of disease and improve quality of life.

     The dissemination of telemedicine and online medical consultations
• Telemedicine and online medical consultations should be rolled out as services covered by public insurance rather than as services that are not covered. By promoting the transition to medical ICT, online consultations will further strengthen the function of primary care physicians, and as a result, they will increase the quality of care, while also leading to increased degrees of patient satisfaction and decreased physician burden.
• Because the simultaneous management of two medical facilities is now possible as a measure against physician maldistribution, as part of integrated community care systems, by effectively combining online consultations with face-to-face consultations when physicians are present, it is now possible to assure the quality of community care even at clinics lacking full-time physicians.
• Online medical consultation systems should be designed for universal ease of use, with an emphasis on the viewpoints of users such as patients and physicians.
We are presuming three types of users who will be considered eligible for online consultations:
     (1) Patients who are unable to visit the clinic regularly due to a variety of circumstances
     (2) Patients for whom, after changing place of residence, changing their primary physician is contraindicated
     (3) Patients who have trouble visiting the clinic due to reasons including frailty (to reduce caregiver burden and caregiver attrition)

     Merits of implementing telemedicine and online medical consultations from the physician standpoint
• Daily patient measurement data (biometrics etc.) can be reviewed prior to exams, leading to increases in quality of care.
• Necessary information that applies to a patient’s disease (up-to-date medical guidelines as well as pharmaceutical information) can be viewed on-screen.
• Not always having to travel to the patient’s locale will lessen physician burden in terms of time and energy.

     The evaluation of online medical consultations in the FY2018 Revision of Medical Service Fees
• This Revision includes the drafting of policies focused on how to assure the quality of care provided by online consultations, and some feel that the regulations covered in the Guidelines on the Appropriate Implementation of Online Medical Consultations (hereafter “Guidelines”) are rather strict. Nevertheless, basic rules for implementing online medical consultations will be developed, and moving forward, discussions will continue on the types of issues that surround the individual operation of online consultations and the type of review needed to address them.
• The new establishment and scoring of criteria related to online medical consultations on the Medical Service Fee Schedule represents a major change. In the future, the form of the Guidelines should also be modified to suit the actual roll-out status of online consultations.

     The quality of medical care delivered by telemedicine and online medical consultations
• Professional autonomy is important in terms of assuring quality of care, but it is not necessarily the only factor. Guidelines have been developed in Japan to assure the quality of care delivered during online medical consultations. With case examples of online consultations continuing to accumulate, in order to assure quality, some sort of framework is necessary that does not depend entirely on professional autonomy. Providing online consultations on a regular basis is also likely to enable the promotion of public understanding.

     The evaluation of outcomes from telemedicine and online medical consultations
• Amidst changes to the definition of “quality of care” itself, it is important to consider evaluation criteria that place emphasis on the outcomes of online consultations, using real world evidence including medical service fee claims data and registry data. The United Kingdom, for instance, manages a nationwide database of online consultation clinical trials, and research is underway.
• The outcome, in this case, was that the use of ICT and online medical consultations improves quality of life. Evaluation criteria such as changes in diabetic patients’ hemoglobin A1c levels were suggested, but numerical criteria that can point directly to improvements in quality of life are necessary.
• There are three types of outcomes from the transition to medical ICT and online medical consultations — (1) clinical outcomes, (2) economic rationales, and (3) in-home care patient satisfaction levels. Hospital emergency medicine and disease management at specialized outpatient clinics are also potential targets for online medical consultations. It will therefore be necessary to continue adjusting the evaluation criteria applied to online consultations in accordance with their place of use.
• Not only should we look for particular outcomes such as how much life expectancy increases after implementing online consultations in the case of treatments that used to be delivered face-to-face, we also need to think about outcomes in terms of telemedicine and online consultation usage data, such as treatment continuation rates among patients and reductions in time between disease discovery and initial treatment.

     The positioning of telemedicine and online medical consultations in 2025
• The transition to medical ICT has been faster than we imagined. Based on an interview survey addressing online medical consultations that was conducted by Health and Global Policy Institute (HGPI) and Healthcare Innovation with TeleCommunication (HITEC), we know that the government as well is also supporting these actions and initiatives. Seven years from now, in 2025, the medical service fees and long-term care service fees will undergo simultaneous revision. Throughout considerations on the formulation of Regional Medical Care Visions and Community-based Integrated Care Systems, we need to continue thinking about how to incorporate and evaluate telemedicine and online medical consultations in forms that suit clinical settings.