“Until recently, mobile health (mHealth) was primarily the domain of consumer technology for tracking health conditions like diet and exercise. Today, mHealth and telemedicine are converging to make mobile telemedicine a reality.”
– Michael Morris
Introduction
The outbreak of the 5th wave of COVID in Hong Kong has left the city’s healthcare facilities stretched to the brink. The recent challenges faced by the SAR illustrated the important needs to establish reliable, resilient, and robust patient care and health services.
To this end, the implementation of telehealth and telemedicine technology as it can safely enable communication with physicians and health specialists through virtual channels to minimize the spread of infection, all the while, will provide Hong Kong with a potential channel to use mainland’s unutilized medical resources remotely. Application of Blockchain technologies in this approach further enhances the immutability of patient records.
As such, it is crucial to look into whether Hong Kong’s existing laws allows for the practice of telehealth as well as other legal developments across the globe, where if appropriate, mirroring of such approaches may be considered.
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What is Telehealth | Definition & Terminology
Telehealth or remote health is the delivery of healthcare services in a setting where patients and providers are separated by distance, using information, sensors and other integrated communications technologies for the diagnosis or treatment of diseases and injuries.
Initially made popular in places where travelling for healthcare is an issue (from the continent-wide nation of Australia to mountainous regions of Japan and Taiwan), COVID has spurred wide adaptation, bringing health services historically concentrated in urban centres to remote rural locations.
Global Legal & Regulatory Overview | Implementations & Progress
Telehealth is by no means a novel innovation and has been implemented in jurisdictions where long distance travel is a problem. The following are a list of notable early adaptors and their corresponding laws and regulations governing telehealth:
- China (“PRC”): it is noteworthy the use of telehealth is permitted in China (though such services are restricted to within the borders of China – hence not delivered into Hong Kong). Telehealth in China is commonly referred to as “internet plus healthcare” and was made possible after a series of administrative rules were promulgated on 17 July 2018 by the PRC National Health Commission (“NHC”) and National Administration of Traditional Chinese Medicine pursuant to PRC State Council’s Opinion to Promote “Internet Plus Healthcare” promulgated on 25 April 2018.
- Hong Kong: telehealth or telemedicine has been in use in Hong Kong and is covered in the Ethical Guidelines on Practice of Telemedicine issued by The Medical Council of Hong Kong in December 2019, which follows the definition of telemedicine in the World Medical Association Statement on the Ethics of Telemedicine. The guidelines effectively bring any medical advice provided over telecommunications under the auspices of the Medical Registration Ordinance (Cap. 161). To this end, only medical professionals registered within Hong Kong may deliver telehealth services to Hong Kong’s population. Overseas medical resources will therefore not be utilized under existing laws.
- Australia: whilst initially limited due to Medicare restricting registered healthcare providers to delivering their services from a registered location, the outbreak of COVID resulted in Telehealth and Telephone Attendances) Determination 2020 (Cth) (“Telehealth Determination”) came into force on 30 March 2020 when a range of healthcare services delivered via telehealth that previously could not be subsidised under Medicare became eligible for subsidy. The shortcoming of current legislation is that a pre-existing clinician-patient relationship is required before telehealth can be administered.
- Bahrain: telehealth is a fully regulated industry in Bahrain. Notable legislations include the Supreme Council of Health’s Decision No. 2 of 2019 relating to the Technical and Engineering Requirements of Health Care Facilities and the NHRA Telemedicine Dispensing Procedure (2020).
- Belgium: On 16 March 2020, in response to COVID, the Belgian Minister of Social Affairs and Health announced that reimbursement will be made possible for telephone consultations for medical services such as triage and advice regarding possible COVID-19 infection, and for continuous medical care.
- France: telehealth has been authorised on an ‘experimental’ since 2009. It has been fully authorised in France for a number of healthcare professionals since the adoption of Law No. 2009-879 of 21 July 2019 on hospital reform and relating to patients, health and territories (“HPST”).
- Japan: one of the most advanced telehealth jurisdictions, medical institutions are allowed to decide whether to adopt telehealth systems and is generally subject to the Medical Practitioners’ Act and various guidelines issued by the Minister of Health, Labour and Welfare and other government agencies. Telehealth services, including dentistry, are generally available in Japan and are provided by videoconferencing/teleconferencing apps.
- New Zealand: telehealth is available for a range of healthcare services in New Zealand, including general practice, optometry, dentistry, adult and women’s health, counselling, addiction support and other mental health services, palliative care reviews, fitting hearing aids, physiotherapy, and paediatrics. The Ministry of Health’s National Telehealth Services provides free telehealth services which mainly focus on addiction and other mental health issues.
- North Korea: As the internet is largely restricted in North Korea, it is presumed that telehealth is not widely adopted in this jurisdiction.
- Russia: telehealth has been adopted in Russia since 2017 when Article 36.2 (provision governing telehealth) was added to the Federal Law “On Basics of Health Protection of Citizens in Russia” No. 323-FZ dated 21 November 2011.
- Saudi Arabia: telehealth has been widely adopted in Saudi Arabia and is regulated via Minister of Health Decision No. 7/88 dated 25/04/1441H, the official instrument approving the Regulation Governing Telehealth (Telemedicine) and The Regulation Governing Telehealth (Telemedicine), issued by the National Health Information Centre.
- South Korea: with trials having taken place as early as 2005, the groundwork was laid when South Korea revised the nation’s Medical Law in March 2002 and built the legal grounds for providing telemedicine services.
- Singapore: telemedicine is regulated by the upcoming Healthcare Services Act with full implementation anticipated in Q3 of 2022.
- Taiwan: Taiwan has set the development of telehealth services (provision of remote care) as one of the island’s top healthcare policy goals for years (with vast populations situated in mountainous regions of the island). The process has accelerated greatly as a result of COVID-19 pandemic with the implementation of new regulatory policies to foster telehealth, including expansion of coverage, service, and payments.
- United Kingdom: one of the first adopters of telehealth, with the outbreak of COVID, the use of telehealth has grown significantly with a range of different healthcare providers are making use of new and innovative technologies in order to provide services to patients.
- United States of America: whilst one of the early adopters of telehealth, owing to the lack of regulation at the Federal level, telehealth is regulated and administered at the state level, making laws and general practice varying by significant degree between state lines.
All in all, it can be easily seen that telehealth is by no means a new innovation and stands to be a significant asset especially in the face of COVID where visitation to a healthcare facility (by a number of persons with similar concerns) may end up becoming a nosocomial flashpoint.
Telehealth and Blockchain | Bottleneck Solutions | PDPO Issues
In recent times, the implementation of remote consultations in various countries enable efficient healthcare access and offer better care coordination and treatment outcomes. That said, centralization is a key impediment in existing telehealth and telemedicine systems which in turn, poses the risk of single point of failure. This factor is further worsened by the fact that centralized data is prone to a variety of external and internal breaches compromising the reliability and availability of systems.
To this end, Blockchain can address such crucial weaknesses given the fact that the decentralized distributed nature of blockchain can be leveraged to manage a shared ledger of health records with all ledger copies are kept verified and synced with every node affiliated with the blockchain.
Telemedicine enables healthcare professionals to remotely monitor, diagnose, and treat patients while mitigating the risk of exposure of physicians, staff, or patients to COVID. With an ever-increasing number of infections amongst medical staff in recent days, wider implementation of telehealth seems to be a natural solution.
Further, given the exceptional nature of the 5th wave, bridging of cross-border telehealth services may be employed in order to alleviate an already exhausted healthcare system, with medical practitioners being able to reinforce Hong Kong’s stretched infrastructure remotely. Patients can first be diagnosed remotely and only upon referral should those in actual need be diverted to physical facilities, thus resolving a critical bottleneck.
At the same time, the adoption of blockchain technology into existing telehealth systems can bring numerous possibilities and opportunities for secure digitization of healthcare, such as successfully establishing the provenance of clinical data, legitimacy of users seeking patient data, managing identities of devices used for remote patient monitoring, preserve patient anonymity, and automate the payments settlement. These includes:
- Extend reach and expand healthcare services to patients;
- Improve effectiveness of utilization of outpatient slots;
- Convenience in resolving long ques forming at bottleneck locations;
- Throughput – enabling more physicians to serve more patients (and more safely);
- Resolve workforce limitation by minimizing patient access issues;
- Prevent delays which exposes patients (waiting at high-risk locations);
- Prevention of airborne nosocomial infections (e.g., various COVID variants); and
- Enhance social distancing measures (current long ques are not ideal).
Again, one of the chief complaints seen at recent measures include busy lines of newly set up facilities by the government. Implementation of pre-existing technology, enhanced by blockchain technologies, stands to provide the government with significant benefits.
Whilst immutable patient records offered by blockchain solutions will, undoubtedly be a benefit, issues of patient data privacy, which at present is governed by The Personal Data (Privacy) Ordinance (Cap. 486) (“PDPO”), will also have to be addressed.
The decentralized nature of blockchain data storage meant that the PDPO may also have to be updated in order to account for data stored on the blockchain and how such personal data may be adequately secured.
Under-Utilized Resources | Use of Artificial Intelligence and Smart Contract Solutions
Another underutilized technology (which is already in existence) includes Artificial Intelligence (“AI”) and smart contracts. The City’s current Leave Home Save App, is at best, an analogue innovation (despite the fact that Hong Kong remains an innovation incubation centre for the region).
An easy improvement upon existing application may be AI-assisted diagnosis whereby, aside from simply recommending users to undergo testing, a questionnaire can be sent to at-risk individuals to better gauge their situation and recommend the appropriate follow-up action at the appropriate levels. No doubt, the city’s stretched medical services will benefit greatly where raw data is automatically processed into actionable knowledge.
The effectiveness of virtual care and health monitoring depends on the integrity of the EHRs that include a patient’s medical history, diagnosis, medication, and treatment plans. It remains to be seen whether the government will integrate the city’s pre-existing EHR systems to assist with COVID treatment.
Conclusion
“In an age where the average consumer manages nearly all aspects of life online, it’s a no-brainer that healthcare should be just as convenient, accessible and safe as online banking”
– Jonathan Linkous, American Telemedicine Association
All in all, both telehealth and blockchain technologies hold great potential to resolve (or at least alleviate partially) Hong Kong’s 5th wave COVID crisis. To this end, the traditional telemedicine systems mostly rely on outdated methods to store, maintain, and protect patients’ data which can be a vulnerability. Blockchain is a solution that can complete and trustworthy medical history of a patient can be maintained and tracked by the authorized users through immutable records.
In this connection, it should be noted that there has been a push by the Legislative Council to mirror the new implementation of Singapore’s Healthcare Services Act of 2022 in the Medical Registration (Amendment) Bill 2021 which may include the introduction of a licensing scheme for telehealth service providers. At the same time, the Bill will also aim to make it easier for overseas doctors to practice in Hong Kong in the hopes of solving the city’s shortages of medical practitioners.
All in all, it remains to be seen whether a comprehensive set of legislation will be made by the Medical Registration (Amendment) Bill 2021 targeting specifically telehealth in Hong Kong and how they may be delivered, and if appropriate, allow a channel for health resources overseas to be channelled into Hong Kong in situations of emergency.
“Despite the recent growth in usage of teleconsultations amidst the pandemic, the long-term development of telehealth services may require the Government to step up efforts on various fronts. These include laying down a clearer regulatory framework and guidelines on the applications of technology in the healthcare sector, encouraging service providers to develop innovative solutions, and boosting adoption of the solutions among healthcare professionals and patients.”
– Ivy CHENG, Information Services Division, Legislative Council Secretariat
This article was first published in the Hong Kong Lawyer, the official journal of The Law Society of Hong Kong.