ABDUCENS AC A D E M I C B U N D L E O F C R E AT I O N S P CC A M S C 2 0 1 9 - BY A M SA U N H AS
SCIENTIFIC
PAPER
Inaccessible Healthcare System: The Role of Telemedicine and Its Comparison to Direct Consultation Arief Abdurrazaq Dharma, Diva Fauziah Faqih, Anastasia Elisabeth Sarira, Aqilla Putri Milleni Udinsiah DISTRICT 6 WINNER FOR SCIENTIFIC PAPER
INACCESSIBLE HEALTHCARE SYSTEM : THE ROLE OF TELEMEDICINE AND ITS COMPARISON TO DIRECT CONSULTATION Asian Medical Students’ Association Universitas Hasanuddin
Written By: Arief Abdurrazaq Dharma Diva Fauziah Faqih Anastasia Elisabeth Sarira Aqilla Putri Milleni Udinsiah
ASIAN MEDICAL STUDENTS’ ASSOCIATION UNIVERSITAS HASANUDDIN MAKASSAR 2019
INTRODUCTION Health is a basic human needs to be fulfilled. Everyone should have access to the health services. However, there are some barriers in accessing healthcare such as the lack of healthcare providers, geographical problem and financial problem which can subsequently worsen the health problems. It is indicated that there will be around 42,600 to 121,300 physicians will enter their retirement age by 2030.(Association of American Medical Colleges,2018) There are still many areas who dont have enough access to health care providers, which either be caused by the inexistence of health care insurance or the tendency of health care professionals to locate themselves in relatively urban and suburban areas. People who live in rural or inaccessible areas might have problems when they want to go to the nearest health care provider (Newkirk & Damico, 2014). Moreover people without health care insurance might think twice to go to a doctor cosidering that they have to pay for only a consultation. These barriers sadly also exist in Indonesia and should be considered as a national health problem. Moreover the distribution of medical practitioners in Indonesia is not equal. For example the ratio of number of doctors and the population of Papua is reported to be around 4.9% compared to Jakarta with 77,6% (RI Ministry of Health, 2017). The imbalance of medical practitioners distribution subsequently made those who live in rural areas is difficult to access the health care facilities. They have to go to another town only to get medical consultation and treatment. We need to find a way to make sure that every people can get access to medical practitioners despite all those problems that exist. Not every people is able to spend their time to directly go to a doctor even if there are no barriers for them to go to see a doctor. The rise of telemedicine nowadays becoming a brilliant issue to be talked about. The existence of telemedicine can solve all the barriers that limit access to health care system. Telemedicines provide more efficient, practical, cost-effective, and, importantly, high-quality methods for patients to have medical consultation whenever they need it. Telemedicine has being growing globally especially in developed countries, and the use of telemedicine is also adopted and implemented rapidly in Indonesia.(Wan Ahmad, et al, 2016). The healthcare practitioner used the telemedicine application to evaluate patient in healthcare services by making a medical decision, remote sensing and monitoring in the
real time and store and forward management of patient by a distance (Jaber et al, 2014). Telemedicines are supported by the availability of internet networks, and of course it’s relevant to the number of internet users. The data showed that 53.7% of Indonesian peoples already used the internet and it keeps going up each year. In Indonesia itself, According to the survey from APJII(Asosiasi Penyedia Jasa Internet Indonesia) the recent survey in 2017 showed the precentage of internet users is 54,68% out of 262 million people in Indonesia. According to age, the most number of internet user is 13-18 years old(75,50%), followed by 19-34 years old are 74,23%, then 3554 years old are 44,06%, and for >54 years old are just 15,72%. The number of user in urban area was reported to reach 72,41% , 49,9% in rural-urban, and even 48,25% in rural area. The data somehow showed that Indonesia is ready enough to apply Telemedicine for the availability of internet is great. Eventhough telemedicine and direct consultation already been impelemented in various countries, yet there is still lack of evidences showing the comparison between those two methods particulary in Indonesia. Moreover the data on cost & benefit of Telemedicine is also lack, therefore this study was made in order to give further details on both direct consultation and Telemedicine as well.
MATERIAL AND METHOD Internet is currently claimed as one of basic human needs. The number of internet user is increased each year, not only for entertainment but also for self improvement including health. The number of those who use internet to seek for health information in the form of telemedicine even reaching 51,06% in 2017, yet there has been no data which can show the beneficial and possible flaw of telemedicine. This was a cross-sectional study using simple random sampling method to a number of participants with 13-34 range of age. After passing through the inclusion and exclusion criteria, finally there were 96 samples suited the result of Slovin formula with 90% of confidence interval. Those participants were asked to fill up 20 questions in the form of online questionnaire which aimed to compare the effectiveness as well as satisfactory level between telemedicine and direct consultation. The result of questionnaire then analyzed using paired t test in SPSS 23.0. Further analysis regarding cost and benefits were also done on Telemedicine by using online questionnaire. Finally, the results of this study were shown in the form of Table and Chart.
RESULT This study was done in Makassar, South Sulawesi, Indonesia by involving 96 samples which had passed the inclusion and exclusion criterias. The results of study were shown in the form of Table and Chart. Table 1 showed the age categories of all samples involved in this study. There were 12 (12.5%), 36 (37.5%), 25 (26.0%), 17 (17.7%), and 6 (6.3%) participants in the range of 13-17, 18-22, 23-27, 28-32, and 33-34 year of age, respectively. Moreover, there were 42 (6.3%) participants were male, and 54 (56.3%) were female (Table 2). Table 1. Age Category Age (year)
Frequency
Percent (%)
13-17
12
12.5
18-22
36
37.5
23-27
25
26.0
28-32
17
17.7
33-34
6
6.3
Total
96
100.0
Table 2. Gender Frequency
Percent
Laki-laki
42
43.8
Perempuan
54
56.3
Total
96
100.0
Picture 1 showed the level of satisfaction for telemedicine according to 8 aspects; time, registration, interaction, expression, explanation, question, information, cost. There were 15 participants found to be very satisfied, 66 were quite satisfied, 14 were less satisfied, and 1 participant was unsatisfied for the duration of consultation in telemedicine. As for the registration of telemedicine, there were 26, 56, 12, and 2 participants reported to be very satisfied, quite satisfied, less satisfied, and unsatisfied, respectively. Moreover, there were 20, 53, 21, and 1
participants reported to be very satisfied, quite satisfied, less satisfied, and unsatisfied, respectively, for the intercation of telemedicine. In the parameter of chances given to express their problems, there were 23, 56, 16, and 1 participants reported to be very satisfied, quite satisfied, less satisfied, and unsatisfied at all, respectively. Other than that, there were 14 participants reported to be less satisfied with the explanation given by the physician through telemedicine, while 2 participants were reported to be satisfied enough. As for the quality of questions given by the physician, 21 participants were very satisfied, 55 were quite satisfied, and 20 were less satisfied. There were 21, 62, 12, and 1 participants who were very satisfied, quite satisfied, less satisfied and unsatisfied, respectively, for the explanation given by the physician about the disease and its treatment. Lastly, there were 39 participants reported to be very satisfied of the cost spent and 2 participants were unsatisfied.
70
66 56
60
53
62
59
56
55 48
50
39
40
20 10 0
Very satisfied
26
30
2021 1514
12
1
2
11
23 16
21 14
1
2
2120
21
Quite satisfied
12 1
7 2
Less satisfied Unsatisfied
Picture 1. Level of satisfaction for the use of telemedicine
Picture 2 showed the level of satisfaction on direct consultation between patient and physician based on 8 parameters. Based on time spent for consultation,
23 participants were very satisfied, and only 1 participant were reported to be unsatisfied. On the parameter of registration, 26 participants were very satisfied, 53 were quite satisfied, and only 3 were reported to be unsatisfied. As for the interaction to talk on direct consultation, 22 respondents were very satisfied, and only 3 participants who were unsatisfied. There were 24 participants who were very satisfied for the chances given to express their problems on direct consultation, and only 2 participants who were unsatisfied. There were 27, 48, and 19 participants who were very statisfied, quite satisfied, and less satisfied on the explanation given by the physician. According to the questions asked during direct consultation, 29 participants were very satisfied and only 1 who was unsatisfied. As for the information given regarding the disease and its treatment, 26 respondents were very satisfied, 54 were quite satisfied, and only 3 participants who were unsatisfied. Finally, there were 41 participants who were satisfied for the cost spent and only 2 participants who were unsatisfied.
70
60
58
55
53
54
50
48
50
45
45 41
40 30 20
Very satisfied
26
23
2221
14
15
29
27
24
19
21
15
0
2
21
2
Less satisfied 13
10 1
Quite satisfied
26
2
1
3
Unsatisfied 7 2
Very much unsatisfied
Picture 2. Level of satisfaction on direct consultation
100
20 10
88
88
70 60
56 40
36
40 30
90
80
70 50
87
77
80
60
88
87
90
58 38 26
19
16 9
9
8
6
8
8
0
Yes
No
Picture 3. Effectiveness of Telemedicine
Picture 3 showed the effectiveness of telemedicine according to 12 aspects. There were 40 participants who got late responses from their physicians and 56 participants were the opposites. There were 77 participants got enough care from their physicians, and only 19 participants were the opposites. As for the information about the disease given by the patient, 87 of participants already got enough information and 9 of participants didn’t get enough information about the disease. There are about 34 respondents who agreed that doctors answered to the given questions, meanwhile the other 60 respondents felt the opposite. About 58 respondents claimed that they were given the opportunity to discuss the further plans for their treatment, however the other 38 were given the opposite. 88 respondents were given suggestions on their symptoms, the other 8 were not given any suggestions on their symptoms. There are 70 respondents who claimed that they were not interrupted during their consultation and 26 others were interrupted during their consultation. About 87 respondents agreed that the information was told in an understandable language and manner while the other 9 felt that the language spoken by the doctors were not understandable. There are 90 respondents
who claimed that they were treated in justice and 6 others felt that they were not. About 88 respondents agree that the access to the health facilities were easier, and the other 8 disagree. As for the registration system, 80 respondents agree that it was in fact more difficult to access, while the other 16 agree that it was more accessible. For the cost itself, 88 respondents agree that the consultation cost were cheaper and the other 8 agree for the opposite.
94
100
88
90
83
80
88
84
89
80 66
70 60 50
63
56 50 46 40
40
54 42
33
30
30 20 10
8
13
16
12
8 2
7
0
Picture 4. Efectivity on direct consultation Yes
No
We use Wilcoxon nonparametry test to see the difference of effectiveness as well as level of satisfaction between telemedicine and direct consultation. Table 3 showed the comparison between telemedicine and direct consultation where the p value for effectiveness is considered as significant (p=0.007) therefore it is concluded that there was significant difference between telemedicine and direct consultation. Moreover comparative analysis on the parameter of satisfaction showed no significant difference (p=0.286) which concluded that the level of satisfaction among consumers were not significantly different between the use of telemedicine as well as direct consultation.
Table 3. Statistical analysisa Effectiveness between
Level of Satisfaction
Telemedicine and Direct
between Telemedicine and
Consultation
Direct Consultation
-2.711b
-1.067c
.007
.286
Z Asymp. Sig. (2-tailed) a. Wilcoxon Signed Ranks Test b. Based on positive ranks. c. Based on negative ranks.
80 70
68
60 50 40 28
30 20 10 0 Agree
Disagree
Picture 5. Participant's opinion on the use of telemedicine
Picture 5 showed number of participants who agreed on the use of telemedicine (70.8%) and number of participants who disagreed on that (29.1%). Moreover, picture 6 showed the reasons why participants agreed on the use of telemedicine. 63 of them stated it was quite easy to be accesed, 56 of them stated about the cheaper cost they spent on telemedicine, 53 of them stated telemedicine is good for the information can be saved and even reopened once they need that.
Moreover there were 51 participants who agreed on the use of telemedicine for its easier registration, 28 stated the communication was much more enjoyable since they don’t need to directly meet the doctor, and finally 18 participants chose telemedicine since the information they got in telemedicine was more complete compared to what they got on direct consultation.
70
63
60
51
56
53
50 40 30
28
20 10 0
Picture 6. Reasons why perople agree on the use of telemedicine
18
30
28
25 21
21
20 15 10 5
3
0 The doctor is untrusted
Inability to do examination
The network is not good
Possibility for misperception
Picture 7. Reasons why people disagree on the use of telemedicine
Picture 7 showed why participants didn’t agree on the use of telemedicine. Among 28 participants who disagreed, all of them stated that the use of telemedicine is not good since it is impossible to have an examination by the doctor. Moreover 21 of them stated that the doctor on telemedicine is untrusted and the network is somehow not good enough. Finally 3 participants made the possibility of misperception as their reason to not prefering the use of telemedicine.
DISCUSSION This study focused on effectiveness, satisfaction rate, agreement rate and costbenefit analysis in Telemedicine consultation and its comparison with direct consultation. Our data shows that there are similiarities satisfication level between online consultation and direct consultation by comparing the duration, registration, interaction, patient’s chances to speak, explanation, question, information, and the cost. There are no significant differences of satisfaction level of telemedicine compared to direct consultation.
with telemedicine because they only have to pay for the cost of being telemedicine users and they dont’t have to spend more cost for transportation to the Public Health Centre. The third reason is the reaccessible information, because telemedicine only use chat rooms as the media to consult, so the previous chats and the treatment recommendations that has been given by the doctor can be stored and it can be an anticipation if the complaint is to happen again. The last one is about the easy registration system, the registration system of telemedicine can be done anytime and anywhere compared with the registration system of direct meeting that require us to come directly to Public Health Centre. For those who disagree to use telemedicine, they mostly chose on the absence of additional physical examination and other modalities. The solution for this issue is in the future, media of telemedicine must be developed again, such as the upgrade of the media from chat rooms to video calls and the upgrade of telemedicine technology, for example telemedicine can assess patients’ vital signs. The next reason is the lack of trust to the doctors and the minimum network range support. These reasons can be solved by looking for doctors that can build trust to the patients and to widen the network range to the rural area with decent connection. Compared to the research that has been done by The British Journal of General Practice, the research suggested that — at least for GPS and administrators — the assumed potential of Tele-Doc (Telemedicine) for increased efficiency is difficult to achieve. But, with the solution that has been given and the further support by the technology that keeps on developing continuously as well as the improvement of network range that continues to be widespread we believe this problem can be tackled down. This study has limitation, which only focused on sole persprection from the patients, not from the doctors and application developers.
CONCLUSION There was significant differerence between the level of satisfaction of telemedicine and direct consultation, yet the effectiveness of those parameters were somehow the same. The data showed that telemedicine can become a brilliant alternative with the same level of efectiveness with direct consultation.
The patient still can ask questions and have a good interaction even if they don’t physically meet their doctor. It shows to us that it is possible to implementing telemedicine to have online medical consultation. In terms of the comparison of the effectiveness, there are some differences between Telemedicine and direct consultation. Our survey shows that Telemedicine is more effective than direct consultation. In general Telemedicine is way much better than direct consultation, except on future treatment aspect. We assess 12 criterias, which are doctor’s responses, careness, information, answer, action, advice, interuption, language, unprofessional, access, registration, and cost. Our data shows that there are 3 aspect of Telemedicine that different compared to direct consultation which are the cost, registration system, and access. From the access and cost aspect, Telemedicine is way much better compared to direct consultation. The patient does not have to spend much money to use telemedicine because it only takes internet access to use telemedicine. The patient does not have to pay transportation to have medical consultation. The use of telemedicine can cut the cost that patient should pay to reach primary health care(Hasibian, et al, 2016). A research in Bangladesh shows that the use of telemedicine can cut 94% of the cost compared to direct consultation, also the telemedicine is more easy to access compared to direct consultation(G. Sorwar, et al, 2016). From the registration aspect, Telemedicine is better compared to direct consultation. In direct consultation, the patient must come to nearest primary health care to register their name while in using telemedicine they don;t have to do any mobilization activity. They can regist from anywhere and anytime they need medical consultation by using Telemedicine. On effectiveness doctor-patient consultation, additional examination is needed to make the diagnosis. The result of our research shows significant differences on medical consultation via telemedicine compared to direct consultation. Direct consultation is more effective than online consultation because doctor and patient can directly interacting and have a discussion about the future plan of treatment based on patient’s disease. 68 of 96 respondents agree to use telemedicine.
Most of them agree with
telemedicine because of accessible location, the low cost, the reaccessible information, and the easy registration system. Accessible location got chosen the most because with the use of telemedicine people don’t have to come directly to a Public Health Centre especially if the Public Health Centre is far enough from the patients’ location. Next, the low cost got the second most voted reason. The low cost become one of the reason why people agree
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