# Session Overview By the end of this session you should be able to: · differentiate between the different types of e-Health · understand the potential for these to be traded across borders · appreciate the benefits of this type of trade as well as the risks it involves # 1. Introduction The term e-Health covers all the applications of ICT to the health sector, including the clinical and non-clinical functions. A key subset of e-health is telemedicine, which involves delivering health care from a distance, through the use of ICT. All forms of e-health are being traded across borders, and the size of this market is increasing. However, telemedicine is the most sensitive of these applications, given its uses in diagnostics and service delivery. This trade raises a number of issues, including concerns regarding quality standards and litigation procedures, but also brings the potential to enhance health service delivery for both countries involved. This session will cover the definitions of e-health, provide an overview of international trade in these services, and give an account of the issues this arises. ## 1.1 Key terms in this session [[E-Health]]: The applications of information and communication technologies to the health sector, including clinical and non-clinical functions. [[M-Health]]: Delivery of health care from a distance using information and communication technologies. It encompasses all the clinical aspects of e-Health. In other words, m-health refers to the use of mobile phones to deliver health care services. m-Health is one of the two subsets of telemedicine. The other one is tele-care. [[Telemedicine]]: Delivery of health care from a distance using information and communication technologies, can involve professionals providing care through other professionals to a patient in a distant health centre. ## 1.2 Introduction to the topic E-health is utilized for the remote provision of health services, where neither the patients nor the healthcare providers need to travel. ## 1.2.1 What is e-health? The most important type of traditional technology to deliver healthcare services from a distance is the postal service. It is used to send samples, to a remote location, which may be in a different country or even in a different continent. The samples are then analysed and the results are sent back to the health facility of origin. The term e-Health encompasses these non-traditional technologies, and is commonly defined as “the application of information and communication technologies across the whole range of functions that affect the health sector”. You will notice that this definition is not restricted to the clinical functions of the health sector, but that it also includes non-clinical tasks, such as medical transcribing. Medical transcribing involves physicians recording their medical notes and someone transcribing them at a later stage. ==This form of care is currently being explored in remote communities that do not have easy access to health care facilities,== with recent initiatives launched in remote areas of Canada and Scotland. They provide patients with better quality of care, and more dignity by allowing them to be monitored from their home, rather than at the hospital. This has the double benefit of cutting health care costs, as hospital stays are usually a major component of the health budget. Let us look at the different applications of telemedicine in more detail. The applications can be divided into three categories: current applications, emerging areas and potential areas (Figure 1). It is worth noting that telemedicine has mostly been used in diagnostic procedures, although there is potential for its utilization in treatment and preventative services. In addition, there are areas where telemedicine is not currently used, but where it has the potential to greatly enhance care. These include surgery, paediatrics and emergency services. These areas are currently being considered by telemedicine providers and users, and will likely experience further developments in the next few years. As we saw with Medical Tourism, regional trade plays a very important role in the overall e-Health picture. ==There are three countries that are currently the ‘top players’ in the field of e-Health: India, Philippines and Cuba.== In terms of importing countries, the United States is currently the biggest ‘buyer’ of cross-border e-Health services. The size of the e-Health market is hard to determine, but it is commonly estimated to be worth between US$1 billion and US$1 trillion. However, there are issues with the quality and quantity of the data used to calculate this estimate. The issue of data quantity and quality often arises when dealing with trade in health services; and e-Health trade is no exception to this. There is currently no systematic collection of data on e-Health flows; neither on the quantity of trade that takes place nor on the revenues that are made from it. Therefore, whatever estimates are available in the literature; they are often based on anecdotal evidence. Lack of data brings problems to health care planners, as they are often not aware of how much of this trade is going on. In addition, decision-makers often base decisions on whether or not to engage in trade in this type of services on ideology rather than on evidence of the potential risks or benefits this would bring. # 2. Should countries engage in e-health? ## Opportunities Importing countries and exporting countries: import who buy, export who provide. Most exporting countries are LMICs because it's cheaper and the importing countries can make substantial savings. Second advantage of entering trade in e-health is reduced waiting time. Importing countries are often not able to cope with the demand for health services they face, and as a result have long waiting lists for non-emergency procedures. By outsourcing some of their health services, for example radiology services, the health systems of these countries will be able to deal with more cases. An example of this would be patients suffering from conditions where prompt treatment enhances the chances of recovery. The third advantage of telemedicine is that it can result in improved health service coverage by remotely providing care for populations that live in isolated communities. A final advantage of e-Health from the perspective of importing countries is that by outsourcing ‘routine’, common conditions, health professionals can concentrate on the more complicated cases, allowing them to specialise and improve the overall quality of care provided by the health system. Entering e-Health trade also has several advantages to exporting countries (those that provide the services). As with other forms of trade in health services, the main benefit is a financial one. Exporting countries stand to make huge profits from selling e-Health services, both clinical and non-clinical, to importing countries. India, for example, made an estimated US$47 million in 2017 from cross-border provision of health care services (https://www.statista.com/outlook/312/119/ehealth/india#market-revenue). A proportion of these profits can be invested back into the public health system, which can then benefit the population as a whole. This is especially important in countries where the government has invested into e-Health services. These countries can for example use the revenues from their international e-Health programmes to subsidise their national operations. Another important benefit trade in e-Health services for exporting countries is a reversal of the brain drain. As we saw in the Medical Tourism session, exporting countries can use the high revenues made from e-Health to offer better career prospects and working conditions for health workers. This can stop them from migrating to other countries or lure them back if they have already migrated. In order to attract e-Health contracts, exporting countries are likely to invest in technology. Finally, exporting countries have an incentive to improve their skill set, in order to offer good quality services and thrive in the global e-Health market. This will inevitably benefit the health system in general, as health professionals will have better access to technologies that will enhance their ability to provide care. ## Risks Data security and privacy In order to deal with this, international regulations have been developed that deal with safe data storage and handling, such as the Health Insurance Portability and Accountability Act. Exporting countries are increasingly adhering to these in order to send a reliability signal. Another important challenge faced by importing countries is the quality of the services provided. There is a fear that different protocols may be used in the exporting country, or that the quality of the services falls below the standards used in the importing country. This can have detrimental consequences for the patient, as well as for the wider health system. For instance, if a condition is misdiagnosed the wrong treatment will be provided, followed by more tests, followed by further treatment, resulting in worse overall quality of care and higher costs. Exporting countries are aware of this, and they have adopted measures such as employing accredited or foreign trained health professionals, and double-checking all results before sending them back, in order to appease importing countries’ worries. A further concern associated with the quality of care is the issue of malpractice. Regardless of how good the quality of the health services delivered is, errors will eventually occur, and when they do, it is difficult to establish who is responsible or which authority the case will be taken to and in which country. This is because cross-border e-Health services take place in cyber-space, which is not restricted by geographic boundaries. Finally, as with all outsourcing, importing countries face a potential loss of jobs if other professionals in a different country can provide the same services for a fraction of the price. This can have an additional consequence: a loss of skill set, as trainees will not be exposed to the procedures outsourced, which are often the more simple, routine ones. Exporting countries face some risks when providing e-Health services too. First, given the profitability of this type of trade, there is a risk that resources will be diverted towards providing care for other countries, rather than serving the local population. For instance, there have been many e-Health initiatives set up in low and middle-income countries with the aim of providing care to remote and hard to reach communities within these countries. However, given that offering e-Health services to other countries is much more profitable, there is a worry that the local population will receive fewer services and those services will be of worse quality. In addition, governments and private health care providers may be more likely to invest in these sophisticated technologies that bring higher revenues than in the primary care the local population may need. As with Medical Tourism, there is also a danger that an internal brain drain may occur as a result of e-Health trade. This is again due to the improved working conditions and career prospects that e-Health companies can offer to health professionals. As most of the global trade in e-Health services takes place through the private sector, there are worries that health professionals will leave the public sector to work for this more profitable industry, further exacerbating the health worker shortages exporting countries currently face. ## Trade Agreements At present e-Health is traded through national health systems or insurance companies purchasing services from specialised companies based in other countries. This takes place under a multi-lateral system, where several countries trade with several others. This occurs within the framework of the General Agreement on Trade in Services, or the GATS, which has been discussed in previous sessions. In addition to the multi-lateral trading system, there have been several regional e-Health initiatives set up in recent years. Regional initiatives have the advantages of the services being provided by health workers of a similar culture, and possibly the same language. Finally, France, Germany, the World Health Organization, the International Labour Organization and the World Bank have set up the providing for Health (P4H) Initiative, an international health systems platform with the aim of facilitating dialogue and collaboration, which includes e-Health. The final type of trade agreement that we will discuss in this section is bi-lateral trade. There is little evidence that there is a lot of trade in e-Health services that takes place under this modality, although there are some examples of success, such as e-Health contracts between India and Singapore. This type of trade relationship holds great potential for both the importing and the exporting countries involved. This is because it is a relationship between two countries: one importer and one exporter, where a contract can be drawn stating a set of pre-conditions and arrangements. In this way, importing countries can ensure that data protection regulations and standards are being adhered to and the quality of the services is of an acceptable standard. In addition, the litigation procedures to be followed can be pre-established in advance of any cases of malpractice occurring. In terms of exporting countries, procedures can be put in place so that a share of the revenues is spent on the health care of the local population, and to ensure that foreign cases are not prioritised over national ones. Furthermore, a two-way relationship can be set up whereby the importing country can provide services, such as e-education programmes to increase the number and skills of health professionals in the exporting country and in this way address the problem of the brain drain. ## Reflective activity 2 1. List two advantages e-Health trade would have on your country - Indonesia has more than 10,000 primary care centers, with the outer part of Indonesia closer to the neighboring countries as opposed to the urban part of Indonesia. With the e-Health trade coming in full force, policymakers in the capital city are bringing health services without worrying about the "hardware enablers", such as road infrastructure, and focusing instead on "software enablers," such as the internet. In addition, Indonesia can also deliver healthcare services to indigenous people around the country, making services available to 2-3 million additional people. - Second, it would solve the physical and logistical barriers to access health services. At the moment, even though national health insurance claims they have 95% coverage, Indonesia's Service Coverage Index is quite low, reflected in Indonesia ranked 7 out of 11 among other ASEAN countries. Engaging in e-Health will benefit those who are currently "invisible" to those in the cities. 2. Identify two disadvantages your country would face by engaging in e-Health trade - It might exacerbate the existing healthcare worker shortages in the underserved regions. Also as stated in the lecture note, workers might be lured by more profitable services to other countries as opposed to providing services to the rural and remote areas. Thus, engaging in e-Health might widen the inequities rather than solve them. - Second, given that the current President of Indonesia already expressed concern regarding medical tourism, engaging in e-Health might give the government more reasons (and revenues) to engage and invest in medical tourism and allocate more resources to enhancing these services rather than in the primary care. 3. Name the three e-Health subsets that would be most relevant for your country to engage in - First, tele-pathology. With increasing non-communicable diseases, particularly in oncology, and a small number of pathologists in Indonesia, it is rational to engage in tele-pathology. - Second, tele-radiology. Indonesia is one of the countries with the highest burden of tuberculosis. Having extra healthcare services delivered will relieve the burdens on already overworked local healthworkers. 4. Name two subsets of e-Health that would pose the biggest risk to your country. Why? - Emergency services, as explained in the second question, because currently, Indonesia is still working on providing basic healthcare to all Indonesian people. Having the option to have emergency services without having to visit a health facility will sway people to have it delivered remotely with its respective risks. The policy and implementation of this service might undermine the public trust. - Surgery. With the development of robotic surgery, and surgeons doing the surgery from afar, my concern involves the stability of the internet during operation, as well as the post-operation recovery process. Without a proper and functioning health system, sophisticated services such as surgery won't be possible. ## Reflective activity 3 | Advantage/Disadvantage | Multilateral | Regional | Bilateral | | ----------------------------------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Financial (cheaper/revenues) | More country options to explore, market force will lower prices due to increased competition | Less country options than multilateral, but perhaps more appealing for patients (similar to medical tourism preference) | Controlled trade agreements to estimate savings/revenue for both countries involved in the agreement | | Reduced waiting time | Better options in this advantage, due to wider options | Less then multilateral | Probably the most viable agreement than multilateral/regional, especially if the service are non-emergency/elective procedures, such as elective surgeries | | Provide care for people in remote areas | Probably the worst option because more competition will involve varied economic power and people may seek more complex, sophisticated treatments rather than providing care for remote areas | May be a safe option because it may strike a balance between number of healthworkers, competition, and similarity of economic strength between neighboring countries, with similar culture and probably language, making pepople in remote areas as "addressable market". Usually in regional-level countries also have a Secretariat, e.g., ASEAN, EU. | Perhaps the best option. More controlled and targeted agreement to provide care for target population, minimal unintended consequences and minimal risk of widening the health inequities | | Improve healthworkers skillset | Potentially the best to improve healthworkers skillset because more people to learn from but there might be cultural/language barriers to learn from. Also, there is a risk of deskilling due to increasing experience in telemedicine-related diseases and less experience with more in-person conditions, e.g., emergency care. | In theory, the best to improve skillset because the links to medical tourism market, the familiarity of local patients with other countries' guideline and standard of care | If there is a significant gap of skillset between two countries, the improvement will be significant for the less-skilled healthworkers due to an increase in competition level. | | More resources to improve overall health system | Unpredictable because of the highest competition among other options | Less unpredictable than the multilateral option | Best option because of the predictability | | Data security | The most complex on because more parties involved, more national policies to be aligned and harmonized with | Mid option, with increased complexities compared with bilateral agreement | Same argument with above, perhaps best option because of a more controlled agreement | | Quality of healthcare, incl. malpractice | Most complex due to the same reason above | Mid option due to the same reason above, but easier because in regional they have established secretariat or agreement in other sectors that may have standards, so it can be overcome | Best option to ensure protection against malpractice, countries can ask to work only with the health facility with the same standardization/accreditation with the home country, and clear legal framework that can cater to both countries involved in the agreement. | # 3. Case study of a bilateral telemedicine trade relationship between the UK and India Basic thing. Just to overcome the disadvantages posed above, esp. data security, protection against malpractice. # 4. Summary This is the end of the session. By now you should hopefully be aware that health services are increasingly traded across borders without the need for patients or health professionals to travel. This session has concentrated on the clinical aspect of the provision of cross-border health services: e-Health. E-Health has the potential to make the health system of importing countries more efficient by decreasing waiting lists and lowering costs of care. However, these countries risk data safety and security, quality of care and malpractice. On the other hand, exporting countries can bring in foreign exchange, tackle their brain drain and improve their skill set, but must ensure they are not diverting resources from the local population or creating an internal brain drain. E-Health can be provided through different trade agreements: multi-laterally, regionally or bi-laterally. The current system is a multi-lateral one, but as we have seen in this session, issues associated with e-Health may be better dealt with by engaging in a bi-lateral relationship. We would like to finish this session by highlighting again the problem of data scarcity. In the current system, it is very difficult to know how much cross-border e-Health trade is taking place, or what effect it is having on the importing and the exporting countries. This means that when policymakers have to decide on whether to open their health systems to this type of trade, they are more likely to base this decision on opinions, ideology and anecdotal evidence than on hard evidence and facts. # 5. Reflective activity # 6. References ## 6.1 [[Essential readings]] [[@aaviksoCrossborderPotentialTelemedicine2013]] [[@gerberAgendaActionGlobal2010]] ## 6.2 [[Recommended reading]] [[@steventonEffectTelehealthUse2012a]] [[@martinezalvarezHowTelemedicinePerceived2011a]] Key Learning Points: This paper will provide further information for the case study on a bi-lateral trade relationship between the UK and India provided in the lecture. The paper reports on a study carried out to explore the perceptions of stakeholders in India and the UK on telemedicine in general, and with reference to a bi-lateral relationship between the two countries specifically. The results from the study show conflicting accounts on whether this type of trade is already taking place between the two countries, and outlines a series of barriers that inhibit further trade. The study further suggests sectors within e-health that lend themselves to this type of trade. In general, the stakeholders involved in the study were optimistic about India providing telemedicine services to the UK. [[@marsGlobalEHealthPolicy2010a]]Global Health E-Policy A Work in Progress Key Learning Points: This paper begins by describing the global e-health scene in the different parts of the world. It highlights that most e-health activities actually take place within countries rather than across borders. The paper then proceeds to compare different policies in different regions of the world, including the EU and the 'developing word', and the different legislations that individual countries have adopted. The paper concludes by drawing attention to the fact that policies on e-health are being drawn at the local/national level, rather than at the global level.