Telemedicine

Executive summary

In 2005, following the formation of WHO’s eHealth strategy, the international organizations accepted telemedicine as a tool to overcome the barrier of distance, time, and cost for providing healthcare. Myanmar health professionals also agreed and the Golden Zenekka Public Co. Ltd. (GZP) kick-started telemedicine in 2015 in private clinics. There were success stories of saving the lives of patients in rural areas. In 2017, we founded another company named MyanCare in collaboration with IT professionals to provide teleconsultation services nationwide. In 2018, we were able to advocate the decision-makers of the public sector and launched telemedicine as a Public Private Partnership (PPP) project in 3 townships of Mon State.

The project was successful in the early stages. But after 2019, the operations slowed down due to waning interest of local General Practitioners (GPs) and the community. Finally, in 2021, the telemedicine functions of GZP in the townships were non-operating due to the effects of the COVID-19 epidemic and the political crisis. However, MyanCare, is still prospering with an increasing number of users. Currently, GZP is reviving the Telemedicine project that will be aided by Artificial Intelligence (AI), and research as well as training programmes integrated.

I. Introduction

Historically, telemedicine can be traced back to the early 20th century when there was a publication about electrocardiograph data which was transmitted over telephone wires1. Telemedicine means all of the ways the patient and his/her doctor can use technology to communicate without being in the same room. It includes phone calls, video chats, emails, and text messages. Synonyms are Telehealth, Digital medicine, e-health, or m-health for “mobile”. The requirements for telemedicine are a reliable internet connection and a phone, smart phone, computer, or a similar electronic device like a laptop or tablet. Telemedicine is a convenient tool for everyone, but it’s especially helpful if he/she lives in a rural area, far from his/her doctor’s office, has limited movement, time, or transportation, or needs medical care while he/she is away from home.

The World Health Organization has adopted the following broad description for telemedicine:
“The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities”².

The Health System of Myanmar was currently struggling to overcome challenges such as limited human resources for health and the rising cost and demand for quality healthcare services. These shortfalls caused frustration among citizens regarding the health system of the country. As a result, many people are going abroad every year for seeking healthcare. In this context, the senior health professionals at the national level noticed that the main issues in healthcare services were quality, cost, time, and distance. Then, they selected telemedicine as a tool to overcome these barriers.

II. Implementation

Recent changes in Myanmar’s telecommunication infrastructure provided an opportunity to galvanize Information Communication Technology (ICT) for health and development. The mobile penetration rate in the country had increased significantly in the past few years. There was an opportunity to expand quality health services throughout the country by using ICT in a timely, effective and efficient manner. The GZP launched a telemedicine project as a pioneer in Myanmar as follows:

Phase 1

The project implementation was begun in 2015, when a clinic chain was developed as a private business and in a Hub and Spokes model. That includes the Parami General Hospital as a central hub and 8 clinics at different levels of the health system (Division, District, Township, and Village level) as spokes. The general practitioners from respective areas were involved in that project and the implementers acquired a lot of clinical and administrative experience. The following success stories were documented³:

Case #1

Time: June 2015; Place: KyiekHto

A 28-year-old male came to Shwe Hin Thar Clinic due to blunt trauma to the chest by being a bull gored by an hour previously.

Chest X-ray (C X R)was taken and the image was sent to GZP Central Hub, Yangon.

The finding was Gas Under Diaphragm (GUD) and no bony fracture was detected.

GZP sent back the report to Shwe Hin Thar Clinic within 25 minutes. It was a case of intestinal perforation. The patient was transferred to Thahton District Hospital and operated in time.

Case #2

Time: December 2015; Place: KyiekHto

A 25-year-old, female came to Shwe Hin Thar Clinic with the chief complaint of tightness of the chest (TOC) for two days.

A chest X-ray was taken and an image was sent to GZP Central Hub Yangon.

The diagnosis of Right-sided Hydropneumothorax was sent back to the clinic in 25 Mins. She came to Yangon immediately and took the necessary treatment in time.

Case #3

Time: March 2016; Place: Kim Mon Chone village, Htandabin township, Taungoo district

A 21-year-old, female came to Kin Mon Chone Clinic with the chief complaint of fever and shortness of breath for two days

A chest X-ray was taken and sent to GZP central hub; the finding was left-sided massive pleural effusion.

The physician (Yangon) advised referring to Taungoo Hospital.

The patient was too ill, could not afford to go to Taungoo and the MO has little experience in thoracic drainage.

The Physician from Yangon gave online instruction for urgent aspiration (1 Litre of pus was aspirated).

The patient improved dramatically.

Establishment of MyanCare

In 2017, the senior health professionals of GZP formed MyanCare Co. Ltd., with the intention of developing teleconsultation services for all patients in collaboration with a private hospital and an IT engineer who served as the CEO of the company. Under MyanCare, there were two main projects: “MyanCare Online” application for all ages and “Yin Thway Call Centre” for paediatric cases. In the initial stage, there were only three national shareholders, but now has three additional international investors. The services of MyanCare include online video consultation, telephone consultation and Electronic Medical Recording (EMR).

Phase 2

In 2018, the stakeholders of GZP were able to advocate to the health authorities at the national and state/division level. Then, they were able to expand the telemedicine project as Public Private Partnership (PPP) with the public sector in Mon state in three townships (one clinic in each township). The following activities were undertaken in project townships:

• Digital x-ray machines were installed;
• Local health staff were trained;
• And local community members were provided teleradiology service.

Progress of the Telemedicine project

The functions of telemedicine were successful until 2019, then declined gradually in private clinics because of declining interest of local GPs. Unfortunately, in early 2021, due to the impact of the COVID-19 epidemic and political crisis, the functions of telemedicine were non-operational in the field. The company lost contact with some staff members on project sites. However, the equipment was maintained at project sites and some clinics are now ready to resume their activities.

At the same time, utilization declined at MyanCare until late 2021 and then recovered gradually. Now, MyanCare is prospering with an increasing number of users and, specialists from the central hub are practicing teleconsultation through MyanCare applications. Teleconsultation is clearly moving to be an effective system for follow-up and a 2-way referral for patients from remote areas.

Case #4

Time: July, 2022; Place: Parami General Hospital, Yangon

A 6-month-old girl from Pha Kant township, Kachin state was brought to OPD with the complaint of frequent attacks of cyanosis and difficulty in breathing since birth. The paediatrician/cardiologist saw the case, took a chest x-ray PA view, an echocardiogram and then diagnosed it as Cyanotic Congenital Heart Disease, Tetralogy of Fallot. Medical treatment was given and a follow-up visit was scheduled in 6 months.

The paediatrician referred the mother to her GP in Pha Kant for that follow-up and also for any other emergency problems at home. The doctor explained that the GP will contact the specialist in this hospital by using the MyanCare application. The OPD staff installed the MyanCare application on her phone and also gave a referral letter to the GP at Pha Kant.

The mother was pleased because she would be able to consult the specialists in Parami hospital, Yangon through her GP in Pha Kant which is about 1000 kilometres away from Yangon, and the cost of travel for a mother and a baby to Yangon is about 700,000 MMK for a round trip. Now, she will be able to save a lot of money and time by using telemedicine, the MyanCare application.

Lessons learned4

Achievements

1. Was able to advocate to the Government about the advantages of Telemedicine.
2. Developed a model as a pioneer for PPP with Government.
3. Saved the lives of the patients in an emergency.
4. Promoted the quality of healthcare at a reasonable price.
5. Maximized the use of radiologists’ available time.

Reasons for success

1. The local authorities of Mon state were committed to this project.
2. Got assistance from technical strategic partner 5C, India.
3. Obtained the collaboration of local professionals especially radiologists.

Weaknesses

1. Was successful at the beginning but not sustained.
2. Lost project budget every year;

Reasons for weaknesses

1. Had no definite policy for the retention of doctors/staff.
2. Human resources for health was insufficient.
3. There were no regular training courses for doctors for Emergency Medicine.
4. Supervision, monitoring, and marketing were weak.
5. Other national and local healthcare providers used other public media (like viber) in their practice and they become competitors.

III. Future Plan

The GZP company is reforming the project based on past experience and implementing the followings:

a. Formulation of a new project

A new project team has been formed with new members and implementation will be initiated in September 2022, in which the Hub and Spoke model will be applied. In that structure, newly developed Dagon Medicare Hospital (DMH) and Parami General Hospital (PGH) will be the central hubs and selected clinics and hospitals will be the spokes. In the project areas, the following activities will be conducted:

1. The advocacy meetings for clinic owners, specialists, and GPs,
2. Development of Training materials,
3. Technical training courses for technicians,
4. Management training courses for clinical staff;
5. Setting equipment for each clinic.

The activities will be started as a pilot phase in selected areas and then expanded based on human and financial resource availability. Myittar Parami Specialist Clinic, Thaketa Township, Yangon will be a pioneer where specialist services for maternal and child health, teleradiology, teleconsultation, and teleultrasound for AN care will be provided. At this stage GZP will focus on teleradiology and she will use the MyanCare application for teleconsultation and Electronic Medical Records (EMR).

b. Develop partnership

GZP has already signed MOU with the following strategic partners:

1. Philips of the Netherland for assisting modern equipment for telemedicine
2. Kishoki Medical Corporation of Japan for implementing and training on cutting-edge technologies in maternal health, and
3. VinBrain of Vietnam for operating teleradiology by using Artificial Intelligence (AI).

VinBrain is an international business company specialized in telemedicine. There are different projects under VinBrain. The GZP has signed MOU with VinBrain for launching a teleradiology project named DrAid. It is an online application and the process is:

1. The data from a digital x-ray machine (DICOM images) are sent directly to the VB One box (AI) at VinBrain centre in Vietnam.
2. The AI reads the data and gives a result to VinBrain data centre.
3. The diagnosis from AI is sent to Dr Aid server.
4. The final diagnosis is sent to the user doctors/consultants.
5. The radiologist panel in Myanmar reviews the diagnosis and sends it to the respective doctor/clinic. The users will get the final diagnosis in less than 24 hours.

Source: VinBrain, 2022⁵

The purpose of using teleradiology (DrAid) is for diagnosis, training, and research/development. The possible research topics under teleradiology are:

• Distribution of diseases among chest x-ray read by DrAid,
• Prevalence of pulmonary TB,
• Validity of teleradiology results,
• Consistency of diagnosis between DrAid application and radiologist panel of Myanmar.

The GZP and VinBrain have jointly considered the issues relating to the confidentiality of data, non-disclosure agreement (NDA), and issues about medicolegal problems.

The GZP will advocate for other business partners for project expansion.

IV. Conclusion

Telemedicine is accepted internationally as a tool for overcoming the barriers of distance, time, and cost for improving healthcare services. The GZP and MyanCare have already got experience in project implementation and the strategic partners are on board. However, the challenges of inadequate human resources and financial constraints still exist. We believe that if the socio-political conditions of the country are encouraging, we will be able to overcome these barriers. Then, telemedicine will be a magic bullet for solving problems in healthcare delivery.

References

1. WHO. Telemedicine, Opportunities and developments in Member States, Report on the second global survey on eHealth, Global Observatory for eHealth Series-Volume 2, 2010.
2. WHO. A health telematics policy in support of WHO’s Health-For-All strategy for global health development: report of the WHO group consultation on health telematics, 11–16 December, Geneva, 1997. Geneva, World Health Organization, 1998.
3. GZP, Revised booklet and Presentation for Telemedicine by Dr. KTH, 2019
4. GZP, Presentation for Summary of Telemedicine Project, 2020
5. Vinbrain, vinbrain.net/teleradiology, DrAidTeleradiology, 2022

Author Information

Dr.Kyaw Thin
Executive Director, GZP Co. Ltd.