Telemedicine – the future of healthcare in Central and Eastern Europe

Telemedicine has been growing in Central and Eastern Europe (CEE) for years, but the pandemic was a catalyst for more rapid progress in tech and healthcare practices, with limited regulatory reforms. High levels of digitalisation in the region, innovative local companies and an ageing population will lead to further leaps forward, with benefits for patients and healthcare systems. Regulators will need to keep pace.

Summary of key points:

• Telemedicine is developing as part of the new post-pandemic reality in the region
• Telehealth, telemedicine, and telecare have some overlap, but the terms cannot be used interchangeably
• CEE is witnessing “harbingers” of telemedicine regulation and, importantly, many successful private and public projects

The pandemic has greatly accelerated the acceptance of remote medical care

With the unprecedented measures adopted during the coronavirus pandemic, new solutions needed to be developed in the healthcare industry to ensure the safe treatment of patients. The pandemic affected the healthcare system in many ways. We faced a reduction in preventive and routine health care, a shortage of physicians and an overload of the entire healthcare system. This highlighted the weaknesses of the existing healthcare structure but has also led to the rapid expansion of telemedicine services. As a result, telemedicine (or telehealth) has emerged as a critical component of health care.

In 2018 prior to the pandemic, the European Commission estimated in its Market Study on Telemedicine that by 2021, the annual growth of the global telemedicine market would be approximately 14%, yet it likely exceeded that figure due to Covid-19. According to the Kenneth Research Report on the Europe Telehealth Market 2020-2030, telehealth accounted for US 6,185.4 million in 2019 and will grow by 18.9% annually during the period 2020-2030. For countries in CEE in particular, technological development is a major opportunity to ensure access to health care in a cost-effective manner.

Lastly, a long-term factor in favour of the digitalisation of the health care sector and the development of telemedicine in CEE is the ageing population.

According to the 2021 Ageing Report issued by the European Commission, from 2019 to 2070 the share of the age cohorts above 65 years in the EU population is expected to rise from 20% to 30%, with the share of those aged 80 and over doubling from 6% to 13%. The projections show that whilst ageing has a notable effect on health care expenditure growth, it also very much depends on whether gains in life expectancy are spent in good or bad health. It is therefore important that telemedicine continues its expansion in order to connect the increasing number of patients with the decreasing number of healthcare professionals and to improve the delivery of healthcare services while ensuring the sustainability of healthcare costs.

What are telehealth, telemedicine, and telecare?

As the popularity of remote health care has grown significantly, we often hear various buzzwords, namely telehealth, telemedicine, and telecare. Although these terms are similar in many ways, they cannot be used interchangeably. In fact, each of these terms refers to a different way of delivering health care remotely.

Telehealth

Telehealth encompasses a broader range of telehealth technologies and services that include not only medical treatment and the doctor-patient relationship, but also non-clinical services. Thus, telehealth also covers alternative and complementary services such as training, patient education and adherence, administration and software supporting certain medical methods such as radiological diagnostic equipment, etc.

Telemedicine

Telemedicine includes remotely provided medical services, such as consultation, diagnosis and treatment. Telemedicine represent a subset of telehealth techniques which facilitate and develop the doctor-patient relationship, so as to provide clinical support, i.e. the abovementioned consultations and diagnosis, with the overall aim to overcome geographical barriers and improve the patient’s health. Though it is not perhaps the most frequently used method of primary diagnosis during normal periods (i.e. not during a pandemic), it is usually a good choice for follow-up consultations or treatment (i.e. monitoring a patient’s progress after treatment, management of chronic conditions, medication management) and the provision of medical prescriptions.

Telecare

Telecare is the use of technology to provide support from a distance in patients’ homes. Telecare is mostly used to monitor the state of health of patients during treatment, to minimise risks and to facilitate provision of immediate medical attention. Telecare thus often takes the form of “wearables”, i.e. intelligent electronic devices which collect relevant medical data.

And in addition

eHealth

eHealth is defined as the use of information and communication technologies to support health and health-related fields. eHealth refers to the intersection of medical informatics, public health and business and refers to medical services and information provided through the internet and related technologies, such as:

• telemedicine;
• electronic health records, including the use of Io(M)T (Internet of Medical Things) devices and tools;
• mHealth, i.e. health monitoring and research through mobile applications.

Telemedicine highlights and trends in CEE

Telemedicine is viewed as a cost-effective alternative to more traditional face-to-face medical care. Similarly as in other regions, new technologies (such as medical devices, wearables, software applications or solutions using artificial intelligence and remote access tools) are changing the healthcare market in CEE.

The most common telemedical solutions include teleconsultation, telemonitoring and telediagnostics. Despite the slow pace of digitalisation of the health care sector, the private e-health sector has introduced many new solutions and has grown tremendously in recent years.

Central and Eastern Europe is characterised by a relatively high level of digitalisation in society, and there is considerable scope for further development in telemedicine.

The success of CEE companies active in the healthcare market with telemedical services adds credence to a growing belief that it is possible to create telemedicine technology in CEE with international potential.

Successful examples of telemedicine start-ups in CEE

• Romanian Telios Care – a telehealth platform which connects patients with healthcare professionals;
• Medic.Chat – a telemedicine platform and app which offers patients easy access to doctors, created by a Romanian doctor and a Romanian entrepreneur;
• StethoMe – AI-powered automatic and remote lung and heart screening;
• Getvig.Health – a Romanian telemedicine platform which provides access to a wide range of medical specialisations;
• HomeDoctor, a Polish digital healthcare provider of online medical consultations and delivery of healthcare services to patients’ homes;
• Polish startup Jutro Medical is a telemedicine platform which offers virtual healthcare;
• UROLOG-ONLINE.cz is a Czech start-up focused on the prevention of urological disorders;
• Telemedycyna Polska provides telecardiology services for individual patients and medical facilities in Poland;
• Czech application Medevio is a communication platform for doctors and patients;
• Romanian Medicai offers tools for medical teams to collaborate on complex cases;
• S-Case – a Czech start-up developing a diagnostic and portable solution that combines intelligent sensors (IR thermometer, pulse oximeter, glucometer, blood pressure monitor) and health management through a digital, medical platform;
• Infermedica is a Polish startup developing an AI-driven teleconsultation platform that delivers rapid symptom triage and instructions to speed up patient healthcare;
• Telemedico is a Polish digital healthcare platform which provides a telemedicine solution by combining medical expertise with technology for insurance, assistance, healthcare and financial companies;
• HigoSense – a Polish startup which provides a mobile medical examination device that is supported by a mobile app and an online AI-powered health diagnostic platform;
• Hedepy is an online psychological assistance platform from the Czech Republic.

Telemedicine and (the lack of) its regulation in CEE

As mentioned, telemedicine and related services have experienced steady growth over the last few years.

This requires sufficient legal regulation, so that its further development has a reliable, predictable and sufficient legal framework which will guarantee certainty and security for patients.

Below we present an overview of some first of the “harbingers” of telemedicine regulation in CEE countries.

Czech Republic

So far, a coherent and universal legal framework is not in force in the Czech Republic. The latest amendment to the Healthcare Services Act effective as of the beginning of 2022 enables consultation services to be provided via remote access, in the patient’s own social environment or in another location where the patient is located.

Quite recently, the Act on Digitalisation of Healthcare was passed in the Parliament. The Act represents the first phase of healthcare digitalisation and adopts rules which regulate data sharing in the medical world using three registers: a register of healthcare providers, healthcare professionals and patients. They will be part of a non-public system, available for access only to authorised persons and patients, who will be able to enter the system via the secured eHealth Portal.

Apart from this, the Ministry of Health is drafting a legal regulation of telemedicine which is expected to come into effect at the beginning of 2024 at the earliest. In addition, the Society of General Practice, a scientific body for general practitioners, published guidelines for recommended diagnostic and therapeutic procedures in the field of telemedicine.

However, health insurance companies are preparing a system of evaluation of telemedicine projects, on the basis of which they will select those which will start to be covered by public health insurance.

In terms of the reimbursement of telemedicine services, currently only limited procedures performed by general practitioners or other specialists are reimbursed by public health insurance.

The outcome of the pending pilot projects will be available by the end of 2022. The core criteria are usefulness to the patient and the healthcare system, economic advantage and safety.

Romania

Faced with the COVID-19 pandemic and lockdowns, Romania acted quickly and took steps to regulate telemedicine starting as early as 2020. This was first done for the duration of the state of emergency and for medical services reimbursed from the health insurance state budget, and subsequently for both private and public health systems irrespective of whether the costs are reimbursed from the health insurance state budget and without limitation to the state of emergency.

The concept of telemedicine was included in the Romanian legislation prior to COVID-19, since 2018, but the provisions were lacunary, were related only to the doctor to doctor relationship and were restricted to rural telemedicine and defence forces telemedicine. Although there were discussions to further enact regulations on telemedicine, all progress was halted until the emergence of COVID-19.

The current legislation introduces several regulations on telemedicine, which is defined as all remotely provided medical services, without the physical presence of medical personnel and the patient, in order to (i) establish a diagnosis, (ii) determine treatment, (iii) monitor diseases, or (iv) provide remedies for preventing diseases, through the use of technology and electronic means of communication. Telemedicine comprises teleconsultation, tele-expertise, teleassistance, teleradiology, telepathology and telemonitoring.

However, the methodological norms for the application of telemedicine have never been enacted, although the Romanian Government had 45 days as of the entry into force of the telemedicine regulation in November 2020 to do so. Almost two (2) years later, the norms are still awaited; such norms should clarify (i) the medical specialisations and services which can be provided through telemedicine, (ii) the organisational and functioning conditions of telemedicine and (iii) the responsibility for establishing and verifying the quality of telemedicine services. A draft of the methodological norms was published on the website of the Ministry of Health in February 2021, but it seems that it is no longer accessible.

The legislation is certainly not perfect, as it has its shortcomings and does not include the long-awaited methodological norms for implementation, but it sets the ground for telemedicine to function and represents great progress for the Romanian medical system and an improved tool for the treatment of patients who were confined to their homes while suffering from COVID-19.

Poland

Despite relatively widespread access to telemedicine services, telemedicine has neither been defined nor comprehensively regulated in Polish legislation. The possibility of providing telemedicine services is allowed based on a very general regulation contained in the Act on Medical Activity, according to which health services may be provided through IT and communication systems. In addition, the possibility of providing telemedicine services is mentioned in the acts regulating certain medical professions, e.g., medical and dental practitioners. Although the Polish law defined “teleconsultations” as early as 2015, the online visit gained practical significance only after it was included in the category of a guaranteed, i.e., publicly financed, healthcare service in 2019. From that moment forward, a teleconsultation or, an online visit, has been treated in the same way as an in-person visit.

In order to develop the digitalisation of the Polish healthcare sector, public IT systems and healthcare databases were gradually adopted and successively implemented. One of the key projects, which enabled the issuing and use of e-prescriptions, e-referrals, facilitated the provision of teleconsultations and introduced the Internet Patient Account (in Polish: Internetowe Konto Pacjenta, IKP) was the implementation of the Electronic Platform for Collecting, Analysing and Sharing Digital Resources on Medical Events, a so-called P1 Platform.

Telemedicine on the individual level (doctor to doctor, doctor to patient) is largely associated with access to electronic medical records. An important regulatory trend is the gradual shift from paper to electronic medical records, facilitated by the provisions of the new Medical Records Regulation adopted in 2020. In accordance with these provisions, the electronic form is considered to be the primary form of medical record keeping, with only certain exceptions allowing for paper medical records. By enabling electronic medical records to be collected in a central system, such as the P1 Platform, the ultimate goal is for every doctor and patient to be able to access these records from anywhere. This will open new treatment possibilities, and the patient will no longer be bound by the location of the nearest clinic – health services could be provided anywhere.

As the Polish healthcare system is largely financed from public funds, an efficient reimbursement system of telemedicine services is crucial for the development of telemedicine in Poland. So far, the public payer funds finance a limited number of telemedicine-related services, such as oncology, cardiology and geriatric tele-case conferencing, as well as hybrid cardiological rehabilitation.

Tele-case conferences are remote consultations conducted by a GP participating in a conference together with a medical specialist and the patient. They include an interview and analysis of tests or examination results (e.g., in the case of a cardiological tele-case, the analysis of an electrocardiogram (ECG) recording), as well as the determination of the optimal treatment for the patient. Hybrid telerehabilitation for cardiac patients allows for complex rehabilitation in the patient’s home conditions. The first stage is carried out in the hospital or outpatient clinic where the patient is instructed about the planned treatment and rehabilitation. The next stage consists of the patient’s individual training at home under the supervision of equipment monitoring rehabilitation sessions.