 All right, let's begin. Hi everyone, my name is Dr. Rohini Pasrecha and I am one of the members of the WANCA YDM group. I am the current chair of the Polaris or the North American Young Doctors Movement. And I'm honored to be able to speak with all of you today in facilitating this month's webinar in collaboration with our working party on eHealth. And today we will be speaking about the role of digital health in family medicine. We have some very, very exciting speakers from around the world to be able to share their insights with you. And so what I would like to do before we begin is to introduce our speakers as well as our moderators and our translators. We're honored today to be able to have three translators, Dr. Elaine, Dr. Sitian and Dr. Brando Cantu who will be helping to assist with translation, Dr. Elaine and Dr. Sitian with the Mandarin translations and Dr. Brando Cantu who will be helping with the Spanish translations. If this is your first time using the translation applicabilities of Zoom, what you can do is to go down to the bottom panel and you can change your translation to the specific channel of your choice. I also wanted to take this time to thank Nikita Pasrecha, a member of our Polaris executive team and our social media coordinator who will be helping to moderate today's webinar. What we will do is that if you have any questions throughout the webinar for all of the speakers, for our team in general, I would like you to use the chat function. Please note that the chat function will be moderated throughout and at the very end of our session, we will be having a Q and A portion. So Nikita, we'll keep track of your questions. If you have specific questions for any of our speakers, please direct that in your question as well. I also wanted to take the time to now welcome Dr. Sankha Randhanikumar, who is the chair of our Young Doctors movement and who will be speaking a few words before we begin our panel discussion. Dr. Sankha, to you. Thank you, Rohini. Thank you very much. As the Young Doctors representative of Wonka Executive on behalf of all my colleagues in the YDM committee, I'm welcoming you all from all over the world. And thank you very much, Rohini, for organizing this webinar with your colleagues. And I'm deeply thankful to the Wonka Working Party on eHELS because they collaborated with us and supported throughout to set up this webinar. And we have a great bunch of resource persons from all the regions. And I welcome you as well. And I think without further ado, we have to go to the webinar and we'll listen to our speakers who'd be giving a great view and overall picture about the use of eHELS around the world and which was, of course, became very, very visible. The use of eHELS in medicine and family medicine was visible in the times of pandemic. So I think now we are fortunate to have a great team of speakers. And let's go to that. So thank you very much. And I hope that you will have a great day. Thank you very much, Rohini. Thank you very much, Dr. Sankarandanakumara for those words. And now, Dr. Pramendra Pasad, I will welcome him to who is the chair of the Working Party on eHELS to share a few words as we begin the webinar. Dr. Pasad, okay, no problem. We will come back towards Dr. Pasad at the end. He may be having some technical difficulties. So what I would first like to do is we have our very first speaker, Dr. Shakira R. Carroll, who will be speaking with us. Dr. Shakira R. Carroll is a family medicine specialist working in both the public and private healthcare sectors in the Bahamas. She completed her medical and residency training throughout the University of the West Indies School of Clinical Medicine research in the Bahamas campus where she is currently an associate lecturer in family medicine. Dr. Carroll is a member of the Caribbean College of Family Physicians where she previously served as the online continuing medical education coordinator. She was also the first Caribbean representative for Wonka Polaris with the Polaris executives interaction being primarily virtual. Dr. Carroll has noted a significant albeit anecdotal increase in the use of virtual care platforms and services locally since the onset of the COVID-19 pandemic. And it's great opportunity to share her overview and insights of the impact of the pandemic has had on its utilization of telemedicine. I would like you to join me in giving Dr. Carroll a warm welcome as she speaks to us today on telemedicine and the impact of the COVID-19 pandemic on its utilization. I'll now hand over the call to Dr. Carroll. Okay, good morning, everyone. Can you confirm that you can hear me, Rohini? Yes, we just cannot see your screen, Dr. Carroll. Okay, not a problem, I'll set that up shortly. And just a reminder to all of our participants as well, if you can just keep yourselves on mute throughout the presentation just to avoid any background noises. Thank you so much. Perfect, we can see your screen, Dr. Carroll. Great, one second here, perfect. All right, so good morning, everyone. Thank you, Patricia, for the introduction and thank you to Wonka Polaris and the Working Party on eHealth for the invitation to speak to you all this morning. I have no disclosures to me. And what I'll be sharing with you today is an understanding, oh, sorry, these are my terms of reference, my apologies. And what I'll be sharing with you today is an understanding of what telemedicine is, how it came about and evolved over time and how the COVID-19 pandemic affected the use of telemedicine as we know it. Now, you've most likely heard of a variety of different terms used to describe telemedicine, some of them used interchangeably. For example, the American Federal Communications Commission defines telemedicine itself as the use of information and communication technologies or ICT by physicians to facilitate or provide healthcare to patients. They define telehealth as the provision of this care by professionals other than physicians and telecare as the technologies such as apps, sensors and other wearables like electronic blood pressure monitors, which allows patients to safely maintain their independence at home. However, for simplicity, I'll be using the World Health Organizations or WHOs take on telemedicine where it is a functional subset of health telemedics. In their report from the group consultation on health telemedics way back in 1997, the WHO defined a telemedicine as 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. And research and evaluation and for the continuing education of healthcare providers all in the interest of advancing the health of individuals and their communities. The delivery of this healthcare can be synchronous, meaning the provider and patient are interacting in real time. For example, with video conferencing or asynchronous like sending emails or WeChat message and waiting for a response. Telemedicine can be direct where the interaction is between the provider's device and the patient's device. Pub and spoke where the patient calls in or travels to facility where the provider will link in from another site or large scale talk down evaluations where telemedicine is integrated and with other digitally based services as part of e-health. Telemedicine can also be characterized by the medium use to deliver the service although much of the literature focuses on video conferencing. But how did telemedicine begin? The technology itself began in 1837 with the invention of the electric telegraph which sent a code and eventually alphabetical letters over dedicated underground wires between two locations. Samuel Morse later standardized the code transmitted. The first recorded use of the telegraph to provide medical services was in Australia in 1874 where Dr. Charles Goss gave medical direction to wounded workers over 1,200 miles away. Then Alexander Graham Bell invented the telephone and three years later, the first mention of a physician conducting a telemedicine visit was made in the Lancet Journal. In the early 1900s, equipment was invented for the purpose of transmitting hard sounds and the radio was used to provide medical care to persons out at sea. Then in 1925, Hugo Gernsbach predicted the creation of a radio doctor, the concept of which interestingly resembles that of robotic surgery. With the widespread use of telemedicine in some specialties, as well as rural care and with medical practices moving from patients' homes to offices and hospitals, physical house calls declined to less than 1% by 1980. Since then, telemedicine moved into its developmental years with the creation of the internet, more affordable access to information and communication technologies, more investment in telemedicine and those services becoming reimbursable by insurers. Thus, telemedicine was recognized as an augmentation to in-person services, a convenient alternative for non-urgent visits and the means of increasing equity in healthcare in rural areas or other places lacking specific healthcare providers. The WHO noted in 2010 that telemedicine had a great potential to address some of the challenges faced by both developed and developing countries in providing accessible, cost-effective, high-quality healthcare services. Family physicians recognized this as well but in a large AAFP 2014 survey, they cited various to telemedicine including lack of training and reimbursement for services. Thus, beyond hospital-based settings in specific specialties, the adoption of telemedicine as a mainstream modality of healthcare remained low with less than 16% of physicians in the US working in practices which used telehealth and this was primarily via video conference. Then along came COVID-19, the pandemic would exponentially change telemedicine on a global scale. The Organization for Economic Cooperation and Development in their 2023 report noted that the use of telemedicine increased at least 40-fold in several countries including the US, Belgium, Canada and France. Interestingly, despite the uptick in telemedicine use, in his analysis of medscape commentary from healthcare workers in more than 46 countries, the perceptions about the benefits and quality of telehealth before and during the pandemic while improved did not change much. It was also noted that US-based workers discussed the framework and logistics of providing telehealth while non-US workers discussed the practice of medicine generally during the pandemic. These findings suggest that the legal, organizational and cultural environments would influence the perceptions and use of telehealth. The OECD had noted that while multiple countries globally, primarily European ones made legislative changes to improve telemedicine use, the changes were only temporary in several countries. With regards to the implementation of telemedicine, Zathunia Matenge and others, including past Wonka President, Dr. Michael Kidd authored an international literature review of changes to the provision of routine primary care services during the pandemic and found that there was significant disruptions to patient care due to the cancellation of appointments, prioritization of acute and COVID related complaints, and efforts to prevent the spread of infection. However, while in-person contact was limited, individual primary care practices made efforts to contact at-risk patients to ensure continuity of care. The authors also noted that legal changes accelerated telemedicine uptake with multiple modalities used, the telephone being the most common. Thus, in less than a year into the pandemic, telemedicine evolved from massively underutilized to mainstream. During the pandemic, physicians and patients shared similar concerns, including aversion to telehealth, issues with access to and safety of devices, internet and infrastructure, as well as cognitive and language and technological barriers. Primary physicians noted a loss of income and patients noted the loss of community experienced in the waiting room. So what is the future of telemedicine, especially in primary care? To answer that question, I encourage you all to think about where and how you currently train or practice medicine and appreciate that while telemedicine has its advantages and challenges, understanding from whence it came will help to shape its future. You must also learn to adapt to changes you cannot prevent, apply your clinical acumen and experiences as best as possible and advocate for positive changes to improve the utilization of telemedicine in the care of your patients. These are my references and I thank you all for your time and attention. I welcome any questions you have and comments about your experiences at the end. Thank you. Well, thank you very much, Dr. Carroll for that very thorough and informative presentation, going through with us and sharing with us about the role and the inception of telemedicine and how the COVID pandemic kind of sparked that increase in the role of telemedicine too and getting us to start to think about where telemedicine is going in the future. Before we begin with our next panel speaker, I want to take the chance to pass on the microphone to Dr. Pramendra Prasad Gupta, who is the chair of the Working Party on eHealth. Over to you. Yeah, thank you very much. So I am Dr. Pramendra Prasad Gupta, chair of Working Party on eHealth. I welcome all of you on the behalf of One Cup Party of eHealth and sorry for being late because I was in a duty. So just now I became free. So I joined in the webinar. So I think it will be a fruitful webinar regarding the digital health and digital health one of the, nowadays it's been overwhelming in all the countries and especially after the COVID, most of the country has a digital health policy and regulation of their own countries. And we are trying to develop some guidelines through One Cup for in digital health, especially in EMR or using up telemedicine. And we are also trying to connect with WHO for non-communicable diseases, something to do on telemedicine. So I think this webinar will be fruitful to all of you. And if any person is interested to join our Working Party is welcome to join. And we are about to finalize young leaders in our Executive Committee of Working Party. And even what we are thinking like, we are thinking to make one representative of each region which will coordinate with the leader which will be selected for Executive Committee of Working Party so that we will coordinate with the young doctors group of all the regions. So thank you, thank you for letting me and getting me a chance to introduce myself. Thank you very much, Rene. Thank you very much, Dr. Pramanda Gripta. I really appreciate you taking the time out of your busy working schedule too to be able to share that insight with us. So I now want to take the chance to introduce our next speaker, Dr. Naweed Lan. Dr. Naweed Lan is a family doctor with a master's in healthcare management and is currently pursuing a doctorate in business administration. Professionally, he maintains an active clinical practice in Malaysia and he also conceptualized and co-led the IMU, Aksana Fundamentals of Telehealth Microcredential Course, Malaysia's first educational program in telehealth. Dr. Naweed is particularly interested in leveraging digital health to improve healthcare access and outcomes. With his experience of co-founding an early stage digital health startup since exited, he brings unique perspectives on how to integrate digital health into real world clinical practice and business. Today, Dr. Naweed will be speaking to us about the use, implementation and limitations of telemedicine in family medicine. Welcome, Dr. Naweed. Hello, thank you. Would you need for the kind introduction and thank you Shakira for the insight through presentation earlier. May I just do a sound chat to Arugini? Could you hear me? Yes, Dr. Naweed. All right, thank you for the confirmation. Right, I think a little about myself, Rohini. I'm building on what Rohini has already said. Currently, I'm currently in the 12th year of clinical practice, eight of which are in general practice. And tech-wise, I co-founded a telemedicine startup in Malaysia called JomDoc in 2020. As a director of strategy, I was involved in looking at the regulatory landscape of locally and in Malaysia and globally, taking the co-design platform architecture and design the go-to-market and implementation strategy, although I left in 2022 before some show of fun. And currently, apart from my full-time clinical practice, I'm also building the telehealth micro-credential course, the telehealth co-developed by Angkana Hel with the renowned private medicine school in Malaysia, the International Medical University. Angkana Hel is an early-stage startup, digital startup, providing specific solutions to specific problems in final care. I'm both happy and humbled by the invitation and of the long-term to this webinar to share some experience of my own in telehealth so far. And looking forward to learning from all of you for the other team speakers today. What I hope to achieve in today's short session is to achieve the following three objectives, define telemedicine and telehealth, address the appropriate use and benefits of telemedicine, address the limitations of telemedicine and provide a future outlook that will depend on it. Well, Shakira has covered some of these that's set in stage further by looking at some definitions on telemedicine, telehealth, and sugar health. We'll begin from the middle, telehealth. So telehealth refers to a broad scope of remote healthcare service. And this includes remote non-clinical services such as provided training and administrative meetings, continued medical education, in addition to clinical services. Well, telemedicine is a type of telehealth that refers specifically to remote telemedicine clinical services. And digital health, as an overall digital health refers to digital technologies and tools such as mobile health applications, wearable sensors, and other digital devices in your self-accommodation care. It encompasses various aspects of healthcare delivery including diagnosis, treatment, monitoring, and prevention. Now it's interesting to note that while telemedicine was commonly used in the past, it is now gradually being phased out in favor of telehealth, which is now a more universal term from the current broad array of applications in the field. It uses, it's because it's used across the most health-related disease, including now dentistry, counseling, physical and occupational therapy in health and even disaster management. It has also expanded beyond traditional diagnostic and monitoring for consumer and professional education. And this is a statement made by the Center for Connected Child Policy in New York. And in this presentation, therefore, telehealth and telemedicine is used interchangeably in the context of this presentation. Well, next, let us look further into the four domains of telehealth, which includes teleconsultation, telemonitoring, telecollaboration, and telesupport. Adding some color commentaries to what is already stated. In teleconsultation, the actors involve our patient to healthcare professionals. In telemonitoring, or in some, from related, some similar terms, it is also known as remote patient monitoring. The actors involve the patients or the caregivers and with two healthcare professionals. In telecollaboration, these are mainly between doctor to doctors and these are usually between specialist doctors and non-precious doctors. Or between like healthcare professionals and doctors. And last but not least, in telesupport, these are usually the interactions between patients or caregivers to healthcare professionals. And for the purpose of the context of the presentation today, our focus is on teleconsultation. Perhaps in discussing telehealth, two key terms here are similar to what the Shakira has done with the product, synchronous and asynchronous mode of telecollar. Essentially synchronous is real-time communication. Asynchronous, in some literature, we may find it as store and forward, or essentially non-rail time mode of teleconsultation. And asynchronous, this is essentially storing and sending information remotely. Typically in non-emergency conditions, where health data and images are submitted digitally for analysis at a later time. And this has been used for various specialties of this, the pathology and radiology. Asynchronous real-time, it is pretty much understood. And next we have video visit, audio visit, and audio visit is usually synchronous. Text-with-it, text-with-it may be synchronous and asynchronous, where a healthcare professional connects with a patient asynchronously via a patient portal, email or telehealth platform to provide clinical aid. And on the most right, I put up this information where a recent February, and even three after, by Bain and Paul, introduces the term digital native companies, or app, and provider-owned apps. Well, digital native companies were specifically founded to provide telemedicine services. And provider-owned apps are traditional healthcare providers that have added telemedicine as a service to their existing options. This difference can impact the approach to service delivery and their ability to scale and integrate with existing healthcare. Examples of digital native telemedicine companies, or apps. Let's see if any of them sound familiar here. Digital native telemedicine, Teladoc, the US based company, KRY, Swedish telemedicine company that offers video presentations, the doctors, typology, the other, right. And closer to me, in Southeast Asia, it's doctor anywhere, the Singapore based telemedicine company that offers online medical consultation, medical medication delivery and health screening to its app. And doctor to us is also another example from Malaysia. Whereas the examples of a provider-owned telemedicine apps includes, number one, Mayo Clinic in the US, it is a helpful provider in the US that offers telemedicine services to patients, including virtual consultation with doctors, remote monitoring of patients with chronic condition and three consults for other health. In Europe, in the UK, we have Babylon, Babylon Health, it's a UK based telemedicine company that partners with healthcare providers similarly. In Asia, there is Pingan Goodgov. It's a Chinese telemedicine company that takes partners with healthcare providers similarly to offer online consultations, medication delivery and other healthcare services to patients. But as I stated, the classification by a timeline that this is not yet the form of coverage. Let's look at how telehealth is changing the healthcare landscape across the world. Well, two facts I put forth. In the US, in March 2020, only 13% of the American telemedicine member have provided telephone or video visits to patients and by May 2020, which is the peak of the pandemic, 94% of members were regularly linked. So, and in Australia, this is on top of Shaker's example of a Belgium and then France in Australia between March 2020 and March 2022, around 70 million Australians have utilized over 100 million telehealth consultations during this two year period. We now know that telehealth is a valuable tool in delivering healthcare services, accelerated by the pandemic, and it's projected to remain an important tool beyond that. However, it is worth emphasising that it's not for all cases. Common perception when it comes to hearing telehealth, for the first time, as shown in the picture on the right of the screen, is like attempting mission impossible. But this is far, fortunately, this is far from the case. Determining the clinical utility or clinical appropriateness is vital. It is important to also to acknowledge the limitations of telehealth, such as not being able to physically examine the patient. Therefore, the mindset shape is here. How might we use this additional tool to gather the necessary information we need? And in France, what are the elements of our existing practice in an effort to improve patient care and outcomes? Use appropriately, telehealth increases the efficiency of our work. For example, whole-up appointments, medication management, certain conditions that require limited physical examination may be delivered through telehealth. Patients will be happy to, as they're saved on the need to travel, save time, save expenses, that care is now able to be extended to those who are unable to come to the care. All in all, telehealth is not a one-size-fits-all solution. It is important to determine if clinical utility or appropriateness on a case-by-case basis, and while there are limitations, the mindset shape is crucial in fully benefiting from telehealth and account for current practices. But this slide outlines the clinical utility of telehealth by the American Association of Family Physicians in 2020. In its 2020 publication, which is the tool for building and growing a sustainable telehealth program in your practice. It is a good way for anyone interested in telehealth as it provides an overall view of what telehealth can use for and how to set up your practice appropriately. And as outlined, the AAFP also suggests that telehealth can be applied in selected conditions. And you'll hear this example of this patient group from generally healthy patients, to children, to pregnant women, to all the persons, and for mental and behavioral issues. In the same document, many primary physicians at AAFP find that only four conditions work well virtually. Behavioral health follow-ups and medication management. Secondly, conditions for treatment are really bringing towards a visual exam that can easily be conducted on camera, for example, at me. Thirdly, triage questions. For example, accepting a laceration for the need of a surgeon. And last but not least, chronic diseases management that require frequent check-in. Money check-ins, food money check-ins, for example, diabetes. Well, some considerations of using telehealth is on the outcomes or intentions that we are trying to achieve. For example, for stable acute conditions, what we are trying to achieve. Questions like, we are trying to achieve safe management, treatment, and installation therapy. For stable conditions, including chronic conditions, are we trying to ensure long-term stability of the condition that delay complications, prevent deterioration or... But here are some examples of the public medication message on the clinical utility of telehealth. Provided by the Ministry of Health, suitable conditions include stable chronic conditions, edX, minotons, burns, skin condition, cough, and snickering. Now, telemedicine is a game changer for patients and providers because telehealth is more convenient for patients to work or have family. They can now see the doctor without significantly obstructing their trip. Patients who have transportation challenges but shadow limitations are more easily able to access care to telehealth now. And physicians report improved attendance at routine visits and better adherence because of improved convenience and access. Also, physicians say many patients would have delayed or neglected care during the pandemic. Were it not for telehealth, that telehealth enabled them to be treated sooner and ultimately receive better care. On the right, I attached recently the February 2020 announcement from the Minister of Health, Malaysia that telehealth is available now in 376 family physicians left of famous nationwide across Middle East. And this exercise aims to increase the convenient healthcare services they find and cost, as well as reduce weighting. Well, next, as we understood the various definitions and cruises of telehealth, let us look at how possible one of the ways in how to get started. Well, as outlined there, but it's a simplified five-step stuff that explain three people. Well, it may differ from practice to practice, as such, in some context, more practice and private life. Right, the established rules and responsibilities. Well, in small practice, we need a practice manager and then in large practice, we need a net director for operations, or anything like that. Step number two, to check regulatory requirements and make sure we are compliant to local health and all individuals including data privacy and protection law. Number three, customize clinical appropriateness. Decide on what conditions work best for you. Vendor selection is a platform in implementation adjustment, which is where we have two work flow written down. Right, let me pause here for a moment to allow you to speak. And after which, I will also provide additional commentary. Well, let me draw your attention to two points on this slide. First, on Vendor selection and a readily available platform, now which in the previous slide referred to as a digital native, as opposed to using Zoom in our conventional Zoom teams for compliance, because they will take a lot of headache out of you on the IPA security and privacy requirements or any data protection, data privacy requirements in your country. Apart from, they will also assist you on your work flow with design plus patient onboarding and education theories. So this is the advantage of engaging with that. Besides Vendor experience, product functionality, cost and training support in terms of important activities. And next under implementation and important consideration in the development of workflows, it's scheduling practices, which I will further address for you. Right, when it comes to implementation considerations of carrying an optimal environment, this is where the use of lighting, privacy, and noise would be sure is important. Managing a schedule also will come to a shortage and documentation and consent environment is very important. And if you see there, although it's a bit small here, the additional points that we add to a telehealth control would be the three activities, the telehealth operation, telemodality, and time loss. In addition to what we already usually do with this project, we will update that first minute. A lot to make some kind of commentaries on the different ways to manage the telehealth. These are the possible things that you might consider. Some block, portion of the days, this is called time block. For example, evenings, 3 to 6 p.m. This may not be accessible enough for patients. Some block, certain days, some blockers block certain days. These are called telehealth days. For example, Mondays and Wednesdays, telehealth days. And this might be challenging to deal with the full day of the telehealth operation. Some offer visits outside working hours. These are called on-call scheduling. For example, evenings and weekends. Well, now, when it comes to work-life balance, it's important to check. And we may also attempt open schedule. This method involves free telehealth in between actual work-walking visits. Well, it may, this open schedule method may be a logistically challenging to manage overlaps and conflicts between the walk-ins and the schedule telehealth work for millions. You can imagine a patient working in an empty clinic who need to realize that he or she has to wait for more than an hour that the doctor is filled with the telehealth of coins. So overall, there is no single model that will express all physician's perspective. You generally have to consider that it's more common. Well, acknowledging telehealth's limitations is also important. And we'll see how we can address the challenges. As telehealth relies heavily on visual cues and patient-reported people, it's very challenging to perform a physical exam, actually. In addressing this challenge, physicians and guide patients will self-examine patients or collaborate with in-person health and health services to obtain necessary physical access. To do that, physical physician education on telehealth is important. Next, we talk about reimbursement, reimbursement policies for telehealth services vary by countries. For example, Malaysia do not have the in-person policy for telehealth yet. Still, predominantly, out of this thing explained, the lagging in widespread adoption versus discomfort on Singapore or India, Indonesia according to the Bain and Code report that I shared earlier. And to address this challenge, you need to advocate for telehealth coverage, pushing for implementation and reimbursement policies and encouraging influencers to increase their coverage. So revisiting the earlier discussion on the digital native and provider role according to the same Bain and Code report, immature market as the US and Europe provide a pre-dominant and successful in scaling up digital health services in the existing ecosystem. But in emerging Asian market, we're at a point where private health insurance valuation is low, up to 10%, private provider groups are fragmented, digital natives of telehealth companies are able to play a more meaningful role. And this further intensifies the role of reimbursement policy in catalyzing digital health adoption. Then we look at the tele-technology limitations while this is very clear. All patients have access to a comfortable technology such as the video conferencing and addressing the challenge. We need to provide training and resources for patients to use a second telehealth technology, improving internet access and maintaining understood communities and adjusting technical challenges could help with shipping. When it comes to full legal and regulatory framework, as the meeting was in policy, different countries at a different stage are finding the regulations on telehealth, the lack of legal private gravity because telehealth can also pose challenges for healthcare providers and patients. So the method of addressing the challenge we can advocate for up-to-date knowledge policies and educate long-distance long-distance healthcare. Now, what's the future of telehealth? Now, let us listen to this short video clip. I hope it works. So, I'm going to interview with Dr. Christopher Chen, founder and CEO of ChenNet. They're one of the largest primary care providers in the world. Dr. Nai, don't believe we can hear the audio. If you try sharing your audio feature, we might be able to hear it then. Right. In the interest of time, I guess I will... Rohini, I think I'll put the link in the chat so that anyone who wants to listen to it can listen to it after that. That's a question. Right, Rohini? Yeah, all right. Because technically challenging them. Right. So yeah, that's the end of my presentation. I hope you enjoy it. Happy to entertain or answer any questions in my column. Thank you, Rohini. Over to you. Thanks very much, Dr. Nai. I know I learned a lot from that presentation about how telemedicine works, the different modalities of it, how to implement different types of telemedicine and which one is best fit for certain environments, but also remembering that telemedicine is not a complete replacement for the in-person examination and that there are limitations to it as well. So, thank you for that. I wanted to now take the chance to introduce our third speaker, Dr. Adele Yeski. Dr. Yeski is a family medicine physician who finished his residency recently and is working in the kingdom of Abdulaziz Medical City, the National Guard Health Affairs in Riyadh. He is also the chief technical officer for the Saudi Society of Family Medicine. Dr. Adele is also the representative of the Kingdom of Saudi Arabia in the Young Doctors Movement Al-Razi Movement and the Secretary of the Movement as well. Please join me in giving a warm welcome as Dr. Adele Yeski will speak to us today on the use of applications in e-health. Welcome, Dr. Yeski. Hello, everyone. Hello, everyone. Can you see me? Yes, Dr. Yeski. Okay. So, hello, everyone. My name is Dr. Yeski. I'm a family medicine physician from Saudi Arabia and today I would like to first thank the committee for working partly on e-health in Wonka and in Polaris and Dr. Rahini for trying to achieve this webinar where we can share our expertise and opinion on the applications of e-health. So, I would like to also thank Dr. Shakira and Dr. Wa'ana on the introduction that they made. They made my way much easier to go over and explain the applications of the e-health. So, let's start. Our objective for today is to explain about e-health or what is the way that we are developing in this field and the applications that are surrounding us and the new solutions in the horizon also to share some numbers and challenges in the field and how can we improve those and overall take on how you can implicate those solutions into your environment. So, this is me. I'm a family physician in King Abdulaziz Medical City in National Garden Real. Also, as Dr. Rahini mentioned, I'm working the CTO of the Soldier Society of Family Medicine and also I'm representing for Saudi Arabia and Arrazi Young Doctoral Movement. So, this is some picture or these are some pictures from real where Saudi Arabia would like all of you to have the chance to come and visit us. Here we can see the main roads in King Fahad Road and also those pictures from Boulevard and the part of this real season and the last two pictures from my place to work is King Abdulaziz Medical City where I'm practicing family medicine and also we would like all of you to join us in the coming real expo in 2030. So, moving to our topic of the day which is the health e-health when which are the ways we are developing in this field starting by the shorter version of the definition which was shared by Dr. Shakira is the use of the information and communication technology and supporting of healthcare and healthcare related fields. As you know that both pandemic now we made a huge decision in our practices over worldwide to have more efficiency and to deliver more healthcare to our populations and such way we needed to develop our ways in using e-health. So, what type of e-health application that we're used are being developed right now? So as Dr. Naum was focusing on telemedicine which can give a huge chance for more accessible choice for medical care. Also, we have the mHealth which is mobile health and wearables where we can have minute to minute follow-up and updates on our patients even if they are not with us in the clinic or they can manage their chronic diseases on their own or if they want to follow-up on daily routine or healthcare, healthy lifestyle choices. Also, we have the electronic healthcare record system which can enhance the healthcare as a whole it can provide a lot of solutions and we will be talking about those subjects inshallah in the coming slides. Education and management of healthcare at big and it's a choice but for us we will not be covering that for today as it's out of the scope. So, what are the applications that we are having in our healthcare systems day to day basis? Starting by using telemedicine, she's using telecommunication and to support the delivery of all kinds for medical and diagnosing and treatment related services usually by doctors and focus on the telemedicine and doctors because they are the first line face-to-face with our patients. You don't know the background behind telemedicine that you need your staff, you need your records, you need your nursing system, you need your labs one at most is the technological part behind it. So, the benefit of these is to have the time and resource efficiency. So, one doctor can serve much more population are using telemedicine also with a better and larger access to care. So, we can cover huge numbers of patients without using telemedicine also to have faster results and decisions. So, if we have urgent cases, we have urgent referrals we need to diagnose something fast we can use telemedicine to develop these decisions. And how to implicate those solutions we need to have great communication infrastructure. So, we cannot just go to any country just say that we want a system we need to have infrastructure for telecommunication based on the country's availability. So, after that we need to have bigger availability for smartphones or the mean that they can use the telemedicine with. So, we expect to serve a narrow population who are using smartphone but luckily that smartphones are becoming more available cheaper prices. So, also we need to have more technological literacy. So, we need to have this part in our assist and our facilities where we can teach the elderly or people who are not very familiar with telemedicine and how to get to that service and make it easy as possible for them to, I'm sorry, make it easy for them as possible to get into these services. So, from Saudi Arabia I would like to share some success stories both pandemic or actually it was motivated by the pandemic where we have this two initiative one called 937 which is a common number or one known number now in the region even in the Gulf area where you can call from any mobile or any telephone and you will have a doctor responding to you within 10 minutes which is a great service which was a huge advantage for medical staff and the ministry of health in our region to cover patients especially in COVID times. But after that it developed it can now cover all the referrals or the lab results if you have any questions about any medical indication you can call this number and follow up on what you would like to know about. The second is the Sahab virtual hospital which is one of the biggest in the regions and the biggest in the world. First time in the Middle East which is a new concept where the ministry of health gathered around 30 specialties. They are providing access for all rural hospitals around 130 hospitals which they can consult and they can refer online to all those big names and consultants and specialized very specialized fields. This move made the access to expert opinion is very easy and also provided access for patients in rural areas so they don't have to travel they only need a consultation and it will be done for them. You can see in the QR code you can scan it and there is a good documentation about what is the Sahab virtual hospital and how can you make use of it and how to implement such a solution in your country. So for mobile health moving from telemedicine to the use of mobile world technologies for public health. So what does this does for me as a physician or does to me as a patient? So first it can raise more public awareness about healthy lifestyle. You can see that people are now motivated to move to achieve more numbers. Also to have to follow up on their chronic conditions like diabetes, we can have monitoring more minute to minute and real time. Also on how we can do that just by wearables as you can see it's a growing field, mobile apps by surveys and point of care devices. Also we can have AI enabled medical assistants such as any glass AI which are developing the algorithm now and how we can screen come up with a new medical programs or medical decisions for our patients. So the examples for as I was mentioning about medical monitoring, we have contactless we have glucometers, we also have wireless ECG devices you can put for your patients, cardiac problems. Also for we have sleeping problems you can give your patients about sleeping trackers where they can follow up at home. You don't need to bring them home to bring them to the hospital to have a sleep study. While having a healthy lifestyle people can now have water intake counters. Also you can see in your mobile as weekly we can have the screen time usage which reminds you on how to modify your lifestyle and get better usage for your technology. Also as we can have now noise detections it's all part of the telehealth and e-health development and the field is growing. So those are the implications for general population. So you can see in your mobile and your watch so point of care and this is the emerging field we have more investment in that. So we can have point of care labs it's all the intervention but in developing now to have it in your patients, near your patients so you can have it in a primary care next to you or you have it in a pharmacy where people can go and do this. Also point of care imaging developing as ultrasound especially in growing in need in ER and urgent care clinics. One of the point of care can be the neuro link which is one of the new inventions developed trying to diagnose at a spot on medical activities or medical conditions such as that attached to your body. So also with distant diagnosis we can have the screening apps like we have in the mental health related issues. Also we can have medical AI bots as I mentioned where we can have the class AI or we can have different screening modalities. So going from there, the electronic health records I think now it's a real time patient centered records that provide immediate and secure information to authorized users. So benefit of that efficiency and easy daily clinics where you can go for your medical records for the patient fast. Also you can have more clean data to follow up and to develop research and to have decision supporting system or maybe trying to do like antibiotic cross reference or trying to medication that maybe develop allergy for the patient in different areas. So this is one of the benefits that you can implement the electronic health records in your clinics. So for that you need a digitalized infrastructure. So you need a good supporting system for technical support. Also you can have clear clinical pathways and connectivity between all the departments that's working on this. Also to have well-documented data governance. So you need to protect this data and see them and who has access to them. So moving from there to the number of challenges maybe in some information that can be shocking or surprising. So in 2022 we reached investment around 22 billions worldwide in e-health. So it's a growing fee where people are trying to achieve a lot of this growing attention. For us as medical providers we need to keep an eye and try to keep up and jump on this wave. It will be a lifetime chance where we can join this movement. So 72% was the increase since COVID pandemic 2019. The all high record was 2018 before and we broke that. And 4.2, 4.3 billions was the telemedicine alone funded in 2022. 26.5 billions for digital health and all time high when they got funded. So startups and companies and solutions are all heading toward e-health because it's a growing field and we are expecting increasing and investing in that field. So what are the challenges of this beautiful solution that we are all talking about we are trying to implement all over in our systems. First, we need more research. Look around you for the problem that you can solve and you have it in your daily practice and how to make it easier for all parties involved. From there, you can develop a solution, work with a private sector because they are seeking a more business side also to have a more practical business oriented establishment. So maybe in our healthcare system, they are different. Some of them are based on governmental support, some of them based on private sector. So developing goes faster in private sector. Implementation, we encourage you to implement a new technology, don't be afraid. Try to have it on a small scale from there you can go and grow bigger and the field is eager and will accept your change if it's working well and saving time for everyone. Overall, take some advices on how to govern and leave the change in your practice regarding e-help. First, empower, find the enthusiast in your establishment and we saw one example with Dr. Gupta today that he is saying that we need more representation from young doctor movements and this webinar me as a young doctor movement participating in this is one of the empowerment examples. Initiate and suggest the changes implement in your daily routine, include everyone despite opposition, even if that they are not convinced with your solution with the idea that you have, try and push harder. Facilitate the movement, the change in your field. Don't even, don't be the one who is saying no, try, adapt. Dr. Rana mentioned earlier, create and set goals with a roadmap to the solution that you are testing. Always seek feedback on how things are going on and don't just leave it on people to estimate that what they are getting benefits of. No, have the feedback and try to improve more. And with that, I would like to finish my presentation today. Thank you very much for this opportunity. If you have any questions, please feel free to reach me on Twitter and LinkedIn or just email. Thank you very much. Thank you very much, Dr. Adelieski, for taking the time to speak with us on the applications of eHealth, going through various amounts of applications that can be used, as well as sharing with us personal examples of what is being done in the region of Saudi Arabia and the 937 project, I think that is very exciting. And I think, like Dr. Yeski was saying, this is one of the benefits of this kind of webinar where we can learn from one another and each of our regions. So thank you for that. I want to now introduce our final speaker of today, Professor Dr. Nick Goldemond. Professor Nick Goldemond holds degrees in medicine and electrical engineering and a PhD from Maastricht University. He is the CEO and founder of the Medical Field Lab, which focuses on innovation and medical curriculum development. In 2017, he became the Professor of Healthcare and Public Health at Gdansk Medical University and Leiden University Medical Center in the Netherlands. In this role, he is an advisor on transformation of health systems across global health. Professor Goldemond worked as a clinical researcher on numerous health innovation projects, often in collaboration with partners in the pharmaceutical, medtech, health, IT, and finance sectors. As a key expert on eHealth and integrated care, he is a member of the WHO Working Group Digital Health and a consultant for eHealth programs in various countries, NGOs, multinationals, and startups. Professor Goldemond also serves as the coordinator of EU, EIP on healthy and active AEP. We'll just have you mute yourself. Apologies for that. Professor Goldemond also serves as the coordinator of EU, EIP on healthy and active aging, and is a member of the ISO Strategic Advisory Group on Aging Societies. He is also editor of the Journal of Integrated Care and served as a member of the editorial board on the European Medical Journal from 2017 to 2021. Last but not least, let us welcome our final speaker, Professor Dr. Nick Goldemond, who will speak on digital-enabled primary care services. Welcome. Yes, thank you very much, Amy. Thank you very much. Too much words. Yeah, thank you for speaking here on the swanka and webinar. So, let me share my slides just a moment. Right, can you see my slide? Yes, we can. Okay, very good. Yes, so I'm going to talk a little bit about digital-enabled primary care services from a systems perspective, but I hope also to elaborate a little bit on the experience from different countries, different continents on the experience with implementation of e-health and digital health. Okay. Well, just as an introduction, I think we should consider digital health in the context of the challenges we're facing in many countries on various continents with healthcare systems which are not quite able to cope with the current challenges of increasingly patients which are more complex due to chronic diseases and comorbidities and aging populations. And we have still very reactive, very hospital-oriented healthcare systems, and they are not sustainable. Not in the West, not in the Netherlands or the UK, not in the US, but also not in China. So, we have many challenges we share together which is basically a very hospitalised, reactive system, often very mono-disciplinary or organised, not so much involvement of primary care or other relevant social care services in the community, as so that's illustrated by the left-hand side while we have to move to the right-hand side and this of course has specialised care to be still there of course, but we should look for a more important role for community-oriented care, typically organised in community-based health centres, mono-disciplinary, so a combination of different disciplines, not only family medicine but also dieticians, physiotherapists, social care workers and with a strong link to those relevant in the communities to support also informal care networks so you could also think about social organisations and employers, it might be religious organisations who can help in this process. So this type of integrated approach we know is more effective in dealing with the typical increasingly more complex problems and e-health, digital health is essential to make it work, this more integrated approach and also it might provide much smarter ways on how to provide care to patients. I want to also highlight this importance because we see these patients with more complexities and we have to combine these different sort of approaches from different disciplines, different sectors, social sector, medical sector. We should think about this multi-disciplinarity but also that typically these problems are not a single issue and not only relevant at one point in time. We have to think about this sort of interaction over the course of time. Usually what we know if you look to schizophrenia or diabetes, this can fluctuate strongly over time. Accordingly, we have to have our interaction with patients more dynamically and not only as a single professional but also as a system. So how do we deal with this complexity which requires more multi-disciplinarity and also often very strongly fluctuating in time and also think for example about palliative care where many complexities come together in a relatively short period of time and still how does it work also from a primary care perspective to support optimally these people in their end stage of life. So what we actually are facing is quite complex in terms of how do you organize this house coordinated. Well, had this sort of challenges we already know from a long time before the pandemic and for example in Europe had this sort of aging population in combination with increasingly smaller budgets and having less workforce available to cope with these challenges was already before the pandemic problem. Then we had of course the pandemic which is more like instantaneous threats to the system with infection outbreaks and it's coming on top of our systems and also the pandemic show that the stability of our healthcare systems whether you look at the Netherlands, the UK, the US, Germany, also in Asia they are typical examples where countries had problems also countries who done relatively well but these systems becoming unstable and also a sign that we can't cope and have to organize differently. So to also show had this sort of challenge we have. So what do we see in the digital landscape in order to support this more integrated person centered care in communities? Well, from what we currently know from evidence from all the different let's say applications whether you look at diabetes management, cardiovascular risk management, there are some promising results how to manage specific problems. Online also think about mental health, panic disorders, depression, etc. So they are encouraging hopeful examples where online or hybrid models might work. However, those are quite still very single solution problem oriented as so like the systems are currently are organized mono disciplinary often single diseases or single problems have we don't see so much yet more integrated let's say solutions in digital health which also is a bit of a problem. As some of my colleagues presented her so the uptake of let's say digital interaction was due to the pandemic raised quite sharply but still had the sort of using WhatsApp or Skype or whatever type of digital solution. It's not the same as providing coordinated care among different disciplines and also had with community and social care networks. So the fragmentation in systems you see it basically also in digital health solutions and this poses also a huge challenge even in what the so called well developed healthcare systems with high advanced IT systems also there you see this basically it's fragmented care but in an online mode. So in order to move to better outcomes we have to look on how to integrate online services in the total process of care. And that's what is what we also learning from implementation of digital solutions is that if you want to really contribute to health outcomes for most disease area areas especially where you have these multiple complexities it should be integrated in an operation process means that just having an app or platform is not sufficient you should look on how people work together different professions how the different networks are connected the informal social network also in a more physical way and so in this poses also a different story on implementation because it's not the digital solution as such but you have to look how people are organizing care in a very operational approach and this touch upon a huge challenge in implementation across the globe because all these stories all these hypes all these investments and the previous colleagues also pointed to that it doesn't lead to really integrated solutions and so we shouldn't distract ourselves by consultancy or marketing talk about if you buy a solution you are solving problems it might be for a little extent but not for the most type of the patients we see on a daily basis. So what we know what is needed and what should work sorry for that so we know that coping with high case loads in increasingly burden on system with a high workload more complexity etc we know that gatekeeping systems gatekeeping in primary care works the best to make the system more efficient because at primary care level and this can also be a digital sort of access if you do the proper screening you can separate the more complex problems from the simple problems and for example in well functioning primary care systems like for example Canada or the Netherlands about 90% of the problems are solved at primary care level only 10% is referred to specialized care which is also good for specialized care because you can really dedicate your work to the more complex problems you don't want to see normally had a very simple problems except if you see that's a sort of business model which is often not which is good for business but that's for people so ideally had the sort of digital solutions and the sort of filtering the screening should happen at primary care level and that applies also to digital solutions so we know that there are some more integrated platforms used in countries which have this function of as a sort of primary care digital service center where the sort of triage and screening taking place and afterwards there are some models for referral and within Wonka just for the pandemic we did some screening some research on these platforms also with the current president at Wonka and Staffdahl but also some other well-known members also Bamenda was part of the working group on this so what we currently see and you have some variation depending on the type of platform or country or solution so we see increasingly that platforms are working with a sort of symptom center sort of filtering system which separates the problems and provide recommendation to an online doctor who eventually take the decisions in these platforms again depending a bit on their functionalities you see that there are some broker system platforms which looks for the proper online doctor or the doctor available in online or you see for example these online doctors are located in one type of center which is a sort of virtual hospital and also the previous speaker touch upon that you also find those models in China for example there might be also some decision support automated decision support based on the input from patients and the sort of algorithms in the sort of screening and the sort of treatments connected to those sort of diagnosis what we see is that they provide a sort of recommendation to a real doctor and based on his experience and background he can make eventually the decision what we do see well I'm going to elaborate on the next slide on the sort of consequences so there are monitoring systems to follow up online the treatments and have a sort of certification rate for example in China where we evaluated one of the platforms was Ping Anku doctor which is a very extensive platform and more than 300 million users per annum so you also quite talk about a considerable number of people a platform who's capable of handling a lot of of a high volume of patients in a relatively short time so we see cost reduction efficiency reduction evidence is still something which needs to be settled so if you look from the perspective of patients looking for care needs the sort of conclusion you might draw from the sort of experience we have with these platforms some of the platforms are doing quite well in reaching out to those patients with care needs this might also be marketing but we should be careful because also these type of platforms business driven not always transparent and provide objective information so that's a point for attention a pro is that usually there are 24-7 available so that's also good in terms of access we also know that using these platforms requires some literacy also in general literacy and digital skills so we see particularly a young group people who are tech savvy digital in using phones but not so much in an elderly population although people with less education deprived socioeconomically so that's also a point of attention usually the platforms have a high responsiveness although for example in the Netherlands the digital platforms we have experienced here usually the connection with the physical world and physical doctors the real family doctors is not so well organized so we have some failures with digital platforms in the Netherlands because eventually there were no doctors available but in general we see high responsiveness also it saves travelling and time from patients what we often see is that the access and the early let's say request and use of the platform is at low cost but the problem is that some of the costs might be hidden further down the process also the appropriateness and comprehensiveness of care is not always ensured still we see very single solution a focus so more complex patient are not always served well served through these platforms also not in the referrals in terms of let's say evidence or what we know is that all these platforms they are successful they mentioned that they are so wonderful they have a high satisfaction rate but still the real hard medical outcomes are not so much available so that's a point of attention as well so a bit from the professional perspective I think the back plus is centralized data usually in these platforms although it's not always connected to national information systems so some concerns also is with these sort of commercial platforms with data ownership, privacy and data protection and how data is viewed so we see an increase in caseload productivity but still if you look to the underlying technologies in terms of algorithms and how well these algorithms are working from a clinical methodological point of view they are much on clarity on how this might function and again the complex patients are really the problem so single let's say single simple problems are not so much of concern but it's more about these real complex patients with complex needs so that's on the technology algorithm parts if you look to more the clinical reasoning and the involvement of the real clinician in the process so we see that decision support might help and these examples experience we also know from radiology it might improve that's very good still we see also that very much online doctors are in control but we have some indication that all these recommendations from algorithms they increase the sort of over diagnosis and over treatment and this is also opposing well requirements for the skill and competences of doctors because if you are seeing patients online or on maybe just only by sort of recommendation from the chatbot it really is really often very difficult to make right judgments on the situation and we saw also in some of the situation that quite a young and experienced doctors who are quite let's say cheap or maybe the employer or the platform are using this algorithm recommendation so that's the post of some concern from a clinical competence perspective and again so quick response in comparison to maybe offline sort of accessibility but yeah and what I want to say here as a last point is that the handover from the digital platform to the physical world that might be a real doctor in a community center or referral to a psychologist or a hospital usually it's not well organized and so all these bigger digital platforms they're working somewhere remotely they don't have let's say the feet on the ground in the different areas especially if you're talking about rural areas or countries who are business wise from investor not so interesting and there's not so much investment in creating this strong connection between the digital world and the offline world so that's also something where we have to look how should work in typical low resource countries this brings me to the last concluding sort of experiences is that in general from a healthcare systems perspective digital health, digital platforms they could increase access to healthcare I think considering also the previous slide we have to be aware that it could create inequality because not all people are well connected or have to sort of skills also there might be business models which create further affordability and also there might be sort of risk selection from these platforms and the use so in terms of healthcare services within a healthcare system I think the use of real time information connected to digital services is good for decision making and inside how the system is functioning the whole idea of personalization might work well if it's well implemented we could have cost reduction efficiency and also digital is more scalable but we are quite concerned about the business models of these large... many investments are made but the investments have to pay back to those investors this is not money which goes into the system to improve general health and well-being of people but going to investors so we should really be careful on overall strategy well market dominance monopoly I wouldn't further elaborate on this but lock in with these type of platforms as said service integration with all these partners in the system is still quite a challenge and also the regulation on this matter so the overall conclusion might be as so we see developments and we see some pros and some cons which are illustrated but for this really integrated approach and we screened more than 80 national strategies and health plans over the last decade we don't see so much a real success in an overall implementation and one of the problems is probably that you need as well a bottom-up approach from people like you who are using the system and work on how to optimize these services as well as that you need a governmental sort of approach and facilitating this process so if you do the sort of mapping on different systems then typical had a more western type of healthcare system are doing well in ticking the boxes but I can assure you also here in the Netherlands we are still faxing and so on a daily basis family doctors are not well supported by more than 20 years digitalization we still are stuck in very fragmented approaches despite all this consultancy work all the money has been paid about large IT companies and this is again in the context of healthcare systems under pressure this is I think really concerning and also for the upcoming countries like Saudi Arabia there's a lot of investments or in China on yeah paying consultants about how to define and building the system but the lessons learned from let's say the old western type of healthcare system like the Netherlands, the UK, the US, Canada, New Zealand it is still we are not so doing so well so we have still a lot of things to do and I think that we as family doctors as in the front line of healthcare and using digital tool we should be more central in the discussion on how these digital functions should work and that we accordingly should also design the strategies, the national plans regulations, implementation investments for upscaling digital health so I want to thank you very much and my colleagues for their presentations and I hope we can push this discussion further also with your support thank you very much Thank you very much, Professor Dr. Nick Goldemann for your presentation and for sharing with us not only your perspectives but also some of the efforts that the Working Party on eHealth is taking to further implement digital health it's very interesting to also learn about the role of AI and how it can be helpful in reducing resource burden on the healthcare system so with that I wanted to thank all four of our panelists speakers for taking their time to speak with us and share their insights today as well before we move on to the Q&A portion I know that we are running slightly over time and so I just want to be respectful of everyone's time we will do about a 10 minute Q&A session that will be moderated by Nikita before we do that I want to thank all of our participants for taking their time to come and listen to our webinar today as well as Nikita and our three translators too for making this webinar possible we would like to take a group photo so if everyone can unmute their videos in order for us to take a group photo that would be amazing and if you're unable to put your webcam on that is completely okay too and so Nikita I'll get you to take the photo whenever you're ready for sure I'm just waiting I think some people are still turning on their cameras I'll just give it a minute or so and bear with me there's a few screens so hold your smiles for maybe just 30 seconds if that's okay okay I'm going to go ahead and take them okay amazing I think I've captured all the screens amazing thank you Nikita for that so if you all feel comfortable leaving on your videos this is the interactive portion the Q&A section and I will pass on the microphone to Nikita to lead their Q&A session for sure yes thank you so much and thank you to all our speakers today so I was trying to moderate the chat throughout the webinar and I know that there was some back and forth dialogue with certain questions so I just tried to pick out the questions that there was not too much dialogue in in the chat and if there's anything that I've missed please feel free to jump in or unmute or re-put it in the chat so one of the questions is is telemedicine already part of health financing and is it already covered by your country's health insurance and I know that there was some dialogue but I'll re-put this in the chat and I don't know that it was specific to any speaker so if anyone would like to answer that question okay good morning can you hear me yes okay so in the Bahamas right now telemedicine is not a formal part of the system and so what happens is that the telemedicine visit is charged or built in the private sector as an in-office visit and in the public sector like I was mentioning to someone else in the chat it depends on whether or not that doctor and patient already have an established relationship to the point that they have their personal phone numbers because again there's not a government phone that's assigned to every physician and therefore the physician would have to share their private information and also have a rapport with that patient usually it's the more long-standing ones but as it stands it's not integrated I'm not sure if there's anywhere in the Caribbean at least from a governmental perspective whether telehealth is integrated into the payment systems as far as insurers go I think that it's not well defined at this point and so it's built as a general visit for the most part that clarifies the question I can confirm with the Shakira that in the Caribbean at least for the Dutch part financing and reimbursement is not so well organized in Netherlands we have some experience with for example in mental health and so in some examples some use cases it worked well but usually in family medicine it's the problem that often it's more let's say beneficial to see the patients still rather than do a full online let's say consultation although you see now also because the caseload and shortages of time and you see this sort of online communication is increasing and not necessarily only by the family doctor but also by the practice assistant or anyone else who can do the sort of more simple cases I think in general so still we see that the financial models are not so much aligned with the existing way of working and accordingly has usually also a problem in upscaling because if it's not really beneficial for people financially then it's not a very good incentive well and to add on that as far as Malaysia is concerned then medicine is still in a very early stage where pockets of developments are seen in terms of employers for such health insurance where additional medication for example in patients covered in the employer hand-sponsored plans they may now continue their long-term medications like the tension in the families paid by the employer through third party administrators or patients as my colleague said we have in Saudi Arabia the system is based on two sectors so for the general public we all have free access to healthcare so the governmental telemedicine is free for everyone but if you have insurance the insurance companies follow national council for insurance where they set the rules and the and the enforcement rates for each visit while with that the government also supports the telemedicine private sector so they will maybe pay for half of the visit or half of the money needed for this visit and the only thing that is controversial a bit is the amount of medications or investigations if they are following the guideline or they are not following the guideline so if they are following the national guideline they will be embarrassed if not they will not get the payment but it's fully supported by the government amazing thank you all so much for sharing your individual sort of perspectives and what happens in each of the countries that you are in and so the other question there were a few questions in the chat relating to finances and then there was also a question that I'll put it in the chat but it reads do you think it will change the perception of the population about our professional ethics and again I'm not sure it was directed to any particular speaker so whoever would like to speak first please go ahead sorry Nikita I did see that question in the chat I'm wondering if the physician can clarify what they mean by the perception of professional ethics because that's what threw me off and that's why I didn't respond initially just to clarify what she means by perception of professional ethics does she mean that patients will think that the visitors of less quality because it's being conducted by a digital means does she mean that the perception will be that it's performed by a healthcare professional who may not be up to the standard to perform that service what does she mean by that I don't know if you can allow her to open her mic or if she can put it in the chat meanwhile maybe some of the experience for example in Brazil was a sort of perception of family doctors of primary care and also the public often the public system is different from let's say more the specialized care and there's also in Brazil the problem that people are prefer to go to the hospital and the specialist rather than go to the family doctor so I can imagine so if digital services are provided if they are in good quality and taking consideration had a different sort of needs and aspects of the patient so it creates sort of confidence okay this is a real quality service it might I think leverage also position of primary care it might also work the other way around that if people are not well treated and have a better experience eventually with so called digital services connected to the perception of primary care they still might incline to see okay I have to go to hospital or specialist for issues and I think this also points to you really need an approach from the government from the ministry from the associations on how digital health and also the changes in health should look like because you have to engage the people you have to let them understand okay we have to change and in all the let's say policy papers and what we know from WHO OECD primary care is really central if we look to the future of healthcare considering had a type of problems we should align the digital services but in order to make that happen and also to create the understanding you have to target different stakeholders and patients so this requires a real let's say elaborate strategy and ministries can't ask only family doctors to push this forward this is also pointing to this sort of need for an overall strategy so maybe a bit broader touches upon I think this sort of ethics and procession from patients yeah if I can piggyback off that so the guildement mentions a lot of important things with regards to how telemedicine or telehealth is implemented and the fact that it's not only a multidisciplinary approach but the fact that it's complex you have to have an understanding from the public as to the importance of telemedicine and the benefits that it can have in terms of efficiency, time savings cost savings but also you have to have buy-in from all stakeholders it can't just be like the family physicians it has to be the administrators the governmental official it has to be the insurers the persons providing the tech support because you have to have people who can create and maintain these platforms in order to make it sustainable so the other thing too is that the point about quality and I hope that persons on the ground can advocate from their own perspectives but a lot of times persons don't view family medicine or primary care as important or at the same level of quality of some of the other specialties and I think that plays a role too and how they perceive the implementation of telemedicine and telehealth especially since a lot of it is going to be coming from the front lines of primary care and family medicine so again the public education and buy-in is probably going to be the driving force at the end of the day. Amazing thank you so much for answering that question and I think I see one last question in the chat here that I will read out loud and then that'll probably be the end of our Q&A session so the question reads are there any recognised platforms globally or locally where registered doctors can provide their care and a bit of context to this is that there are many brilliant doctors who are currently not working due to personal or private problems and are looking for professional platforms so I'll re-copy that down below just in case you didn't catch all of that I don't know if any of the speakers have any ideas of any potential platforms maybe I would like but maybe also my colleagues want to say something I think you're providing medical care and you carry a huge weight of medical legal responsibility and accountability also about communications so I don't think that you can provide a global platform for everyone to access maybe if you can look up some of the regional organisations maybe doctors without beyond boundaries or maybe if you have the red crescent or the green crescent maybe like those organisations can provide you access other than that I think you should be looking maybe you can be the initiative in your region and develop something like that yeah if I may compliment and I agree with Adele Adele what we see for example in China with this Ping An type of platform it functions relatively well I think the problem in China is the handover to family medicine in the real world so because the primary care is largely absent in the Chinese system it's really difficult to provide a proper handover so if you look from a sort of quality platform with also sort of hybrid model it's maybe not the best example although the Chinese government is working on this I think they're very interesting examples in the Nordics Scandinavia and Finland where you see both let's say digital platforms like DrSE and Cree which are I think nice examples sometimes also with this combination hybrid models community care centres with digital platform you have some platforms from Poland as well so I think there are some examples across the globe and locally local provided the bus country in Spain for example is really interesting it's more national oriented regional I should say in Spain but it's for the region of Spain so there is no let's say Babylon of course in the UK but also there are some concerns and some mixed experiences on how it works I think what we should and could do as Wonka is that we could feed governments European Commission in Asia you also have some umbrella organisations in healthcare and we could set the standards or requirements for how it should work I think also Adele there's a lot of going on in the Middle East currently both in how the system is changing as well as the use of digital so there's a lot of let's say things happening over there and also where we can learn from so I think if you look globally we should mobilise our expertise but also our requirements and communicate this to authorities in order that they can set the requirements on how these platforms should look like we shouldn't be very practical and go on with more let's say the simple solutions to make this bottom up top down approach successful Thank you so much to all the speakers who answered the questions and spoke today and thank you as well to the participants who asked such insightful questions during this Q&A period so at this time I'd like to pass it back to Dr Rohini to switch her but before I do so just would like to also thank her for all her efforts today in helping to organise this amazing webinar I know I truthfully can say I learnt a lot and with that I will pass it back to Dr Rohini to switch her Thank you very much Nikita and so with that I hope you all enjoyed this webinar the recording will be available after the webinar too if you would like to watch it again or certain sections of it and so thank you all for taking the time and wishing you all a wonderful rest of your day Thank you again Dr Pasricha, thank you to my fellow panelists, thank you Nikita and thank you