The World Health Organization (WHO) defines telemedicine as “The delivery of health care services, where distance is a critical factor, by all health care 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 health care providers, all in the interests of advancing the health of individuals and their communities” (WHO, 2009).

Illustration photo (source: internet)

It is important to underline that telemedicine does not replace face-to-face care. The two should be developed in a complementary and coordinated manner. They must be rolled out in such a way as to ensure that the end result is of the same quality and nature as a face-to-face medical service. Telemedicine services must always be patient-focused and carried out to the patient’s benefit.  

Telemedicine sits within the broader concept of eHealth or digital health. The ISSA Guidelines on Information and Communication Technology (ISSA, 2019a) include a section on eHealth and a specific guideline on the provision of telemedicine and telehealth services by social security institutions.

Telemedicine has been developed primarily to facilitate access to medical services by populations living in remote areas with limited health resources – to address, for example, the challenge of “medical deserts”, as outlined in an International Social Security Association (ISSA) article (ISSA, 2021a). It also enables information to be more easily shared between different organizations and their staff, thereby permitting the coordination of resources (PAHO, 2016). Its areas of application are very wide-ranging, with telemedicine services found in the vast majority of medical disciplines. In particular, it enables the use of teleconsultations for the remote diagnosis, treatment and monitoring of patients.

Telemedicine services can be categorized according to the parties involved and the nature of the interaction.

Radiological, dermatological and psychiatric services can currently be provided through the medium of telemedicine, and patients can also be cared for in their home by monitoring a series of biological parameters. Advances in robotics, virtual reality and artificial intelligence have also made it possible to develop remote surgical services (telesurgery).

The role that telemedicine has played during the COVID-19 pandemic cannot be understated, since it has helped to maintain the link between health-care professionals and their patients while keeping physical contact to a minimum. The article on Building more resilient health systems (ISSA, 2021b) features some of such experiences. According to the Pan American Health Organization (PAHO), telemedicine kept many key clinical services operating during the pandemic (PAHO and IDB, 2020). On the other hand, the need to mainstream these services required adaptations at every level, such as the relaxation of technical regulations in the USA to allow commercial tools to be put to domestic use (Marin, 2020).

The ISSA Good Practice Award competition for the Americas (2020), among other ISSA activities, revealed that although some social security organizations had already embarked on the road to rolling out telemedicine services, during 2020 this process gathered steam owing to the health emergency prompted by the COVID-19 pandemic.

Summary of results achieved by social security institutions

Health-care and social security institutions in the Americas have been increasingly employing telemedicine techniques, but this process intensified during the COVID-19 pandemic. The positive results, which are summarized below, have brought about a diversification of the care model in line with the challenges set out by the different organizations.

Experiences of implementing telemedicine in social security

Institutions’ approaches to and strategies for implementing telemedicine vary, as they are responding to differing needs and objectives. This said, all of the aforementioned experiences put into practice recommendations contained in the ISSA Guidelines on Service Quality (ISSA, 2019b), as well as in the ISSA Guidelines on Information and Communication Technology.

In Argentina, the Mutual Association for the Protection of the Family (Asociación Mutual de Protección Familiar – AMPF) prioritized optimizing access to medical consultations while maintaining the quality of care. The aim was to improve and speed up access to health care, making it possible to book appointments without delay and facilitating diagnosis by enabling communication between professionals of different specializations.

An integrated teleconsultation system was introduced (combining voice and video calls). This system provides a simple and effective means of booking an appointment via a virtual platform and subsequently attending the appointment through the same channel, all the while maintaining the quality of the doctor-patient relationship.

The system also optimizes health-care professionals’ time by allowing them to prescribe medicines, diagnostic imaging and/or clinical tests online, as well as to view test results and monitor patients remotely.

At the Ecuadorian Social Security Institute (Instituto Ecuatoriano de Seguridad Social – IESS), the approach taken seeks to provide a health-care solution via a computer or smart device for patients who have scheduled an appointment through the call centre but are not able to attend in person.

The aim is to ensure that the majority of the population, throughout the country, can receive a virtual medical consultation from home, although priority is given to patients/users in vulnerable groups. In this way, it helps patients to avoid the need for face-to-face visits, thus reducing their risk of contracting COVID-19.

However, challenges that have come to light include difficulties in accessing the system faced by people living in rural areas and those with limited Internet access.

In Peru, EsSalud – Social Health Insurance Institute (Seguro Social de Salud) rolled out its telemedicine solution for patients with chronic conditions in direct response to COVID-19 following the Ministry of Health’s recommendation to suspend in-person consultations and diagnostic tests to avoid exposing the population to infection with COVID-19.

A process was designed to provide patient care making full use of information technology. The process includes features such as analysis of demand, remote access to patients’ medical records, an online booking system, telemonitoring and the issuing of prescriptions with a digital signature.

In this way, EsSalud was able to continue providing services to patients with chronic conditions, including children.

Mexico’s State Employees’ Social Security and Social Services Institute (Instituto de Seguridad y Servicios Sociales de los trabajadores del Estado – ISSSTE) has been using telemedicine since the 1990s. New technologies, in particular that of satellite communications, began to be introduced in the first decade of the twenty-first century.

When the COVID-19 health crisis hit, this wealth of experience, together with all the processes already in place, proved a real strength for the country’s health services, helping them to maintain timely medical care, limit patients’ need to travel and broaden the coverage of specialist medical services.

The ISSSTE approach consists of a multi-network operating model boasting three levels of health care. “Telemedicina ISSSTE” is a platform providing remote medical appointments through a high-resolution videoconferencing system connecting doctors and patients. This mechanism gives patients living in remote areas access to the medical specialists they need and also minimizes waiting times, with medical attention often available in 24 hours or less.

In Uruguay, the Social Insurance Bank (Banco de Previsión Social – BPS) is making its first foray into telemedicine. In this case, there is a dual focus: on the one hand, remote medical consultations are possible using videoconferencing technology; on the other, it is used to determine a worker’s ability, or lack thereof, to remain in active employment.

Following the adoption of Law 19689 of 2 April 2020, endorsing the general guidelines on the use of telemedicine in health care, and the Ministry of Public Health’s approval of the use of teleconsultations in health care, the Catholic Workers’ Circle of the Uruguay Mutual Fund (Círculo Católico de Obreros del Uruguay Mutualista) began to use teleconsultations in outpatient care.

Challenges and critical factors

While the development of telemedicine services confers benefits, it also poses significant challenges with respect to the implementation of advanced technologies, the quality of connectivity, digital inclusion, and legal and ethical aspects relating to health care (PAHO, 2016, and WHO, 2010).

One of the key aspects identified is the complexity of implementing advanced, extremely specialized, and constantly evolving technologies. Likewise, connectivity is critical, both for medical services and for their users, especially when it comes to synchronous telemedicine. As such, the digital inclusion of patients is vital, particularly the availability of devices.

We also cannot overlook the legal and ethical issues posed by telemedicine – issues that will need to be resolved by the organizations planning to use it. Some patients may be reluctant to be recorded in a videoconference or worried about confidentiality or data protection. To allay such concerns, teleconsultation, data exchange and medical record systems will need to be adequately protected by robust data security and privacy mechanisms. In addition, the exchange of data between health-care professionals must be covered by a legal framework that is fit for purpose, for instance one based on the informed consent of the patient in question.

There are also concerns about a loss of face-to-face contact between professionals and patients. However, as previously highlighted, technology does not replace people; it is instead a supplementary tool enabling solutions that would otherwise not be possible to be found and developed.

Training emerges as a critical factor in all the good practice case studies presented, all of which concur on the importance of providing solid instruction to both health-care professionals and users of the health‑care system.

The AMPF in Argentina carried out actions to familiarize professionals and members with the platform and to communicate the purpose of this care model and how it should be used. In Ecuador, the IESS trained medical personnel in the use of the technological tool and created and published user handbooks for the general public. In Peru, EsSalud worked hard to define a new process that had the buy-in of all areas as part of a team effort that ensured the process was effective and could be rolled out and replicated.

Conclusions

Telemedicine is increasingly becoming a service model that provides added value. As demonstrated by the good practices presented by a number of social security organizations, as well as by the webinar presentations looked at in this article, it is clear that incorporating technology in health-care processes through tools such as telemedicine is a road that many organizations have successfully embarked on.

In the context of the COVID-19 health crisis, telemedicine in general and teleconsultations in particular have proved to be a key tool since they have enabled people to receive high-quality health care without leaving their homes and regardless of their geographical location, thereby protecting both the patients themselves and wider society from the risk of infection. As such, it has demonstrated its potential for use in the care of older people and patients with chronic conditions, permitting the remote monitoring and follow-up of their biological parameters in conjunction with other eHealth tools such as medical databases.

On the other hand, the implementation of telemedicine practices poses challenges in terms of the technological, legal, social and ethical aspects. In particular, the digital inclusion of users – both their access to tools and adequate connectivity and their ability to use them – is a decisive factor in the success of said practices.

The training of health-care professionals and the creation of guidelines for users are critical when it comes to rolling out telemedicine services, since the aim is to generate the atmosphere of trust and security that is essential to ensuring quality of care.

To sum up, telemedicine does not replace, but instead complements, the traditional care model, helping to improve the accessibility and universality of services as well as patient care in crisis scenarios such as the current health emergency. The use of a variety of care models and techniques will only serve to enhance the quality of the health-care process, taking into account the evolving needs of society. In a post-pandemic context, telemedicine will prove to be a discipline of high added value when it comes to improving the health of the population and the quality of health-care services, especially given the ageing of the population.