HST Coverage
Kaohsiung Medical University Chung-Ho Memorial Hospital (KMUH) has been providing medical service to outlying areas throughout Kaohsiung over the long term. There are no medium-to-large hospitals yet along the South-Link Highway of Taitung County. Ophthalmology, ENT, and dermatology services are available only in downtown Taitung. KMUH particularly collaborates with the Taitung County Government in constructing a telemedicine platform that combines digital otoscopy introduced through Far EasTone Telecommunications in order to realize 5G telemedicine in disciplines such as ENT, ophthalmology, and dermatology.
Superintendent Inn-Wen Chong of the KMUH visited related medical teams at public health centers throughout Taitung County, Taitung MacKay Memorial Hospital, Taitung Christian Hospital, and Taitung St. Mary's Hospital in person along with his team, including the six public health centers in Daren Township, Dawu Township, Chenggong Township, Changbin Township, and offshore islands such as the Green Island and Orchid Island. Despite the not necessarily identical needs at each of the public health centers, the commonplace is the particularly powerful demand for the disciplines concerning five senses. Deputy Superintendent Ming-Kuo Huang indicates that there are diabetic patients that require ophthalmoscopy once every six months. Due to the relatively small population in outlying areas, however, it is not required for each public health center to have one specialist. Therefore, KMUH joins efforts with Hualien Tzu Chi Hospital and Taitung Mackay Memorial Hospital in adopting one-to-many and many-to-many video conferencing-based clinics for disciplines at public health centers throughout Taitung County. The idea of zone defense is applied to help with medical care in outlying areas of Taitung. Each video conferencing-based clinic that is made available may have three to four public health centers linked under this model at the same time. With an actual ophthalmology clinic available at each public health center, it may only see six to seven patients. With proper arrangement of time, by including patients at respective public health centers concurrently in one clinic, it not only reduces the troublesome travels of people in outlying areas but also improves the accessibility of healthcare services. This model is more cost-effective.
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(Figure 1) KMUH Works with Taitung County Government and Far EasTone Telecommunications in Setting up Telemedicine for Public Health Centers in Six Townships
Industry, Government, and Academia Work Hand in Hand to Minimize Urban and Rural Differences in Medical Care
A zone defense model is created with Hualien Tzu Chi Hospital and Taitung Mackay Memorial Hospital through cross-disciplinary cooperation among the industry, the government, and the academia. This project is spearheaded by the Taitung County Government, with assistance from public health centers of Taitung County. Far EasTone Telecommunications builds the 5G base station with features such as high-speed transmission, low-level delays, and multi-links. KMUH forms a cross-disciplinary team to be devoted to the research and development of the project.
The R&D team builds the telemedicine platform, deploys the 5G network, increases the bandwidth speed, and ensures real-time image transmission and smooth uploading of images during remote diagnosis and treatment. A 5G network is advantageous primarily in that its data transmission rate is far higher than that of prior cellular networks; it can be as high as 10 Gbit/s, nearly 100 times that of a 4G LTE cellular network. Another strength is its relatively little latency that is below 1 ms (30-70 ms for 4G). KMUH has indoor devices deployed so that the 5G signals may be received in ophthalmology, ENT, and dermatology clinics. Related digital instruments and equipment as well as a 5G network are set up in public health centers to greatly increase the bandwidth speed to 600 Mbps for uploading and 50 Mbps for downloading and to ensure smoothness in the transmission of images and in uploading captured images.
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(Figure 2) KMUH and Far EasTone Telecommunications Deploy 5G Network and Builds Telemedicine Platform
In terms of how patients are seen, registration and the capturing, sharing, and uploading of the images of patients were originally done through a tablet. Registration was pegged to how a doctor sees a patient, that is, the process has to be completed for one patient before that for the next patient may begin and it is impossible to interrupt any process for the sake of beginning other steps first or to effectively increase the number of patients being serviced. Once this project is activated, the web-paged registration mechanism will be added for registration purpose. Registration can be done through any computer inside a public health center and it will not affect remote diagnosis and treatment. In terms of capturing images, the offline mechanism is added. Patients who have make an appointment can arrive on site early to have their images taken in order to spread out the time needed for patients to have their images taken and to reduce the time spent on waiting by the patients.
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(Figure 3) APP Screen of Telemedicine
In terms of image transmission, images of patients taken were originally retained only in the computer of the public health center and accessed with a memory stick that was brought back to the hospital and then manually saved in the examination report system of the hospital. With this project, the uploading mechanism is reinforced and uploading is changed to be done automatically. The patient's national ID number is adopted as part of the image file name, too.
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(Figure 4) Remote Diagnosis and Treatment Procedure
High Level of APP Security with Telemedicine and Real-time Remote Access Made Possible through Cloud-based Medical Records
Public health centers can log into the Telemedicine APP during clinic hours and provide diagnosis and treatment service through telecommunication. The standardized video conferencing-based procedure and the real-time medical record retrieval and exchange mechanism set up at the hospital and the public health center are known for their highly secure privacy protection and encryption mechanism in terms of information security and data backup.
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(Figure 5) Encryption illustration
The fool-proof mechanism is also added to the IT system in light of the fact that errors are likely with manual input of patient data when there are relatively more patients. For the system interface, it is switched to bullet-point and interactive input, with additional interactive messages so that staff in public health centers can confirm the data again prior to submitting the information for registration purpose. Meanwhile, the data check feature is reinforced to fundamentally check and prompt the accuracy of specific data, such as the national ID number or the resident permit in order to effectively enhance the accuracy and convenience of data.
Secondly, in order to enhance image transmission security, the system will verify the list of patients seen for the current clinic so that staff in public health centers can click on data according to patients' names and upload the data; this prevents against transmission of wrong images. The system will automatically concatenate cloud-based image data so that they are combined in the examination reports at the hospital and image data in both places may be synchronized in real time to ensure consistency in the image data during remote diagnosis and treatment.
As far as medical records are concerned, patients will register in Taitung first and physicians at public health centers can see them, prepare their medical chats, perform related imaging tests, including ophthalmoscopy. Image data are transmitted through 5G to KMUH and cloud-based real-time medical records are provided and shared. Data are transmitted applying the simple and easy-to-understand common file format and the open-ended interlinked communication system or text of examination reports is provided indirectly through inter-hospital electronic exchange to be kept and quoted by physicians.
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(Figure 6) Illustration of ''real-time transmission of five-sense images''
With the utilization of remote diagnosis and treatment, this project has effectively improved care efficacy. Statistics show that the number of people referred from outlying areas in Taitung to KMUH has dropped by 14 over the past six months and it is estimated that up to NTD 1.4 million of medical expenses may be saved a year. Such an amount seems unimpressive in metropolitan areas; it is crucial for an outlying area. In addition, due to the possibility of timely and early discoveries and early dispositions or referrals through remote diagnosis and treatment, it prevents residents in outlying areas from dying as a result of a delay in addressing the condition and deterioration, the death rate has gradually dropped compared to that prior to intervention.
Tripartite Consultation Enables Patients in Outlying Areas to See Physicians at Medical Centers and to Receive Thorough Medication
Besides technical support, the SOP is created for the whole process where the physician sees the patient. Video conferencing-based clinics are opened at KMUH. Clinic hours are also available at local public health centers. To reduce the time spent on the process, patients must have their visual acuity checked and intra-ocular pressure obtained upon their arrival at public health centers prior to ophthalmoscope photography. Such data are all uploaded to the computer while they are waiting to be seen. Once the data are uploaded, local physicians at public health centers will interview patients first with ophthalmologists at KMUH present online. The whole process is carried out through video conferencing by the three parties. It is like a patient is being seen by two physicians. The local primary care physician and the remote specialist see the patient at the same time. This is tripartite consultation.
(Figure 7) Illustration of remote clinic
For the prescription afterwards, medicine equivalent to that available at KMUH is available at the public health center, too. Deputy Superintendent Ming-Kuo Huang indicates that prior to activating the remote clinic, a checklist of medicine that should be available in all three disciplines is discussed with each public health center and advice is provided regarding the addition of medicine in order to prevent against repetition in the same type of drug in stock and to facilitate prescribing suitable medicine reflective of patient's condition. Meanwhile, inquiries about the medication habit and history of allergies of patients are reinforced at public health centers in order to provide patients with advice on medication more cautiously.
Other than that, reflective of common diseases and regional demand of different public health centers, KMUH also provides advice on the addition of medicine. For public health centers on Green Island and Orchid Island, for example, tourists are often cut by the coral reef or stung by the coral while they engage in water activities during high seasons. Therefore, related medication as well as basic health education materials shall be added for basic wound disinfection and disposition. In case of fierce itchiness, besides antihistamines, steroids are needed and so are preventive antibiotics. For topical use, on the other hand, with reference to existing medicine at public health centers, advice is provided on the addition of steroidal and antibiotic medications in order to make the best of basic routine medicine available at public health centers without limiting the use to only one condition.
In the future, the KMUH plans to further embark horizontally on collaboration with Hualien Tzu Chi and Taitung Mackay Memorial Hospital and create a zone defense model so that 5G is deployed throughout Taitung County to facilitate remote diagnosis and treatment in the three disciplines, namely ENT, ophthalmology, and dermatology in 2022. During a remote clinic, specialists at the hospital can instruct healthcare professionals in the field to provide assistance in real-time assessment and disposition. Advice may be provided in real time whether the patient may be treated locally or is to be transferred to the hospital as part of the patient triaging effort. It improves the overall utilization of healthcare resources, effectively resolves issues arising from insufficient specialists in outlying areas, and enhances the quality of and satisfaction with local medical care.
Government to Be Open-minded about Telemedicine to Make Sustainability Possible
Deputy Superintendent Ming-Kuo Huang indicates that only when the government is open-minded about telemedicine with regards to its payment can it be sustainable. The one-to-one telemedicine is not cost-effective enough while the one-to-many approach aims to maximize the scope of service and to realize sustainability. Hospitals need to be open-minded in terms of the model if they wish to become part of it. Joint collaboration is the only way to more effective application.
Superintendent Inn-Wen Chong indicates that the government also needs to think that some mild conditions may be addressed through telemedicine. Once advice is provided by the physician, patients do not necessarily need to come to the hospital. It helps prevent against cross-contamination that can occur when patients come to the hospital and reduce the daily workload in the hospital. In the post-pandemic era, further efforts are needed in the initiation of changes in how hospitals function by switching part of the diagnosis and treatment model to telemedicine. Telecare helps extend prognosis monitoring of patients, or, when used in combination with personalized smart devices, measure physiological parameters and enables patients to manage their own health through their cloud-based personal health information.