ETHICAL AND LEGAL ASPECTS OF TELEMEDICINE SERVICES IN THE INDUSTRIAL REVOLUTION ERA OF 4.0

Oleh: Dr. dr. Hj. Trini Handayani, S.H., M.H.

 

The disproportionate distribution of doctors throughout Indonesia, is a barrier to accessibility to health facilities exacerbated by distance and the uneven distribution of network infrastructure in developing telemedicine making it difficult for the government to improve general health development. Health development has a noble goal which is to increase awareness, willingness and ability to live healthily and to realize a high general health status. It is an investment for the development of productive human resources, both socially and economically. The uneven physician distribution in Indonesia creates long waiting lists and a decrease in quality of health services. Research on doctors, licensed to practice (SIP), showed a decrease in the quality of empathy. Some research shows that doctors experience barriers to display empathy, have little time availability, lack skill in developing empathy, and experience burn-out. These components may cause the doctor to fail to fulfill the patient’s rights [9]. Telemedicine has been present for a long time. Before the invention of electronic communication devices, in the 18th century, patients sent urine samples to be examined by a doctor to determine the disease (telepatology).

William Einthoven introduced a tele-stethoscope examination that amplified the heart’s rate through a stethoscope and sent it over a telephone network for 1.5 kilometers. Doctors in the United States tried to transmit images of heart records (Electrocardiography = EKG) [2]. Independent of the uneven physician distribution, telemedicine, supported by the internet network, can facilitate people’s access to health services. Consultation of patients with doctors can be conducted through the internet. If the patient’s presentation does not require further examination and simply requires a prescription, it will save on medical expenses, transportation and time. Several studies have shown that many patients can be serviced through telemedicine activities, patient hospital referrals can be reduced and doctors can take appropriate action for patients in emergency situations. The development of telemedicine in Indonesia began in 2012 with a teleradiology pilot project and, in the following year, a radiotherapy pilot project. In 2012, teleradiology was developed and centered at Cipto Mangunkusumo Hospital (RSCM) and telecardiology was centered at Harapan Kita Hospital. Hospitals, designated as telemedicine centers, provide therapeutic management guidelines that need to be carried out by peripheral health care operators, before referral, should patients require referrals to telemedicine center hospitals. The RSCM also conducts online seminars through webinars. The Indonesian government has designed a system for developing health information, through the National Health Information System (SIKNAS), which is managed by the Ministry of Health but has only limited collection of health data that is used for health statistics and only as health administration services (e-health). A very simple telemedicine relationship, between doctors and patients, is being established through consultation via cell phone about complaints, results of investigation (including laboratory results, EKG results, results of technology, anatomical pathology results, USG Results). Doctors can offer suggestions, based on clinical symptoms and the results of investigations, so that not all patients need to return for consultation if the results of the examination do not show any abnormalities. Telesurgery technology or remote surgery was first performed by a surgeon named Jacquest Marescaux in 2001. The doctor did a cholecystectomy operation in a 68-year-old female patient over a distance of 6,230 (sixty thirty thirty) kilometers from where the doctor was located. Doctor Jacquest was in New York, while his patient was in Strasbourg, France. This operation is known as the Lindberg Operation. Operations are carried out by robots that are controlled remotely, while the connection is connected through the technology of Asynchronous Transfer Mode (ATM). The operation was carried out within 54 (fifty four) minutes without any complications and the patient was sent home 48 (forty eight) hours later [2]. Telemedicine regulation in Indonesia is based on the Minister of Health Regulation Number 409 of 2016 concerning Trial Hospital Video-conference and Teleradiology-Based Telemedicine Service Programs. In this regulation are listed, the Flow of Service, Procedures for Submitting Claims, Payments, Communications, Force Majure and Settlement of Disputes between Advising Hospitals, in this case the National Brain Center Hospital and Regional Hospital [10]. It has not touched the realm of ethics or the law of implementing telemedicine in Indonesia. Even though the financing aspect has been included it is still unclear if the intended fee is used for any component. Regulations related to telemedicine services are needed, such asminimum requirements that must be met in the implementation of telemedicine, human resources needed by both medical personnel and non-medical personnel, and the ethical and legal aspects related to telemedicine services. Practice Permit, Medical Record, Informed Consent, Safety of patient data and confidentiality of patient data still need to be addressed.

As technology and information improve rapidly, people are competing to get various facilities in everyday life, especially in the field of health services. Telemedicine is a solution in the field of health services in Indonesia, considering that Indonesia is an archipelagic country with uneven distribution of health workers, especially doctors. If telemedicine is carried out optimally, it will reduce the number of unnecessary referrals to hospital and the quality of services will increase, considering that during the patient consultation, the referring doctor will learn from the results of the referral consultation. Some studies show that the referral rate has dropped dramatically after telemedicine was implemented in several countries, which should save on health costs.