Using information technology to clinically treat patients at long distance has come into its own during the covid-19 pandemic. Known as telemedicine, demand for it grew as patients sought to avoid long periods in packed doctor waiting rooms for fear of contracting the virus. As the advantages of telemedicine became apparent, so too did the delivery and receipt of broader care services via information technology (IT). Virtual care companies pounced on the opportunity. The market for telemedicine and virtual care exploded. Investment amounting to $3.1 billion (€2.6 billion) poured into the telemedicine sector globally in 2020, more than in any other health tech category and about three times the funding seen in 2019, according to Start Up Health’s 2020 year-end Insights Report. Although telemedicine has existed since the 1960s its use has been patchy. The pandemic catalysed a digital movement across industries, with remote work and virtual healthcare leading the way.
Telemedicine and virtual care have arrived to stay. How fast the huge change in health care will trickle down to reach those with sparse IT access remains to be seen. Healthcare in many parts of the world primarily remains a business with a strong focus on the bottom line and where demand outstrips supply. Making telemedicine more accessible may largely depend on the financial and organisational support garnered by marginalised populations. It is still unclear who will spearhead these efforts.
In high-income countries—including the US, parts of Europe and Japan—a number of hurdles prevented the widespread uptake of telemedicine prior to the arrival of covid-19. The obstacles mainly involved insurance reimbursement and concerns about privacy, both of which were quickly resolved during the pandemic. “In this post-covid world, more and more telehealth solutions are being reimbursed,” says Unity Stoakes, co-founder and president of StartUp Health, a company that offers insights into the global health tech space with more than 300 health tech companies in its investment portfolio.
But for people without insurance and living far from medical services, these developments are irrelevant. More specifically, people living with a non-communicable disease in low-and-middle-income countries (LMICs) often need chronic disease management and without access to telemedicine, seeing an appropriate specialist may be nearly impossible.
ADAPTIVE SOLUTIONS CALLED FOR
While much of the developed world has been able to embrace telemedicine, obstacles remain for senior citizens, people in LMICs, and for the disadvantaged in rural areas. Primarily, the barriers to adoption of telemedicine are an absence of technological knowledge, a lack of access to technology, and weak broadband infrastructure. Experts point out these are all barriers that can be dismantled, given the right investment. They also caution that communities regarded as marginalised may already be benefiting from remote care in ways not recognised by more developed countries. The key distinction is that the delivery model may look vastly different from the norm in more affluent populations.
“The poor and rural get telephone calls and the rich get video calls—that doesn’t sound very good,” but the service provided may be the same, says Ateev Mehrotra, associate professor of healthcare policy at Harvard Medical School and a practising physician. Mehrotra’s research focuses on global medical delivery innovations such as retail clinics, e-visits, and telemedicine, including their impact on quality, costs, and access to health care.
Underestimating the scope of telemedicine is common and agreeing on a definition is a key challenge. Telemedicine and virtual care are often used interchangeably and while video visits may be what comes to mind, text messaging and telephone calls are also included in the definition. “We can agree that texting is less effective than a video call, but if the alternative is nothing, then it’s certainly better than nothing,” adds Mehrotra.
A primary and obvious barrier for telemedicine is lack of access, whether to a mobile phone, ideally a smartphone, or any internet-enabled device. But by the end of 2018, 5.1 billion world citizens subscribed to mobile communication services, accounting for 67% of the global population, according to GSMA, a mobile network industry organisation. “People are surprised by how many people in low-income communities have smartphones,” says Mehrotra. “In rural areas, we’ve seen communities skip the landline altogether and go straight to a mobile or smartphone.”
Startup Health’s Stoakes agrees. “The challenges of a decade ago are getting resolved. They may not even have running water, but they have a smartphone,” she says. Because smartphones have become so multi-functional, people have prioritised them over buying luxuries, adds Mehrotra. Smartphones are used for communication, but they are also used for banking, healthcare, news, research, and a number of other daily tasks.
MODELS FOR REMOTE DELIVERY
While not everyone has a smartphone, much of the world has access to the internet, including 89% of rural regions in South Africa, Mauritius, Kenya, and Malawi, according to a study published by Harvard Medical School in 2019. More developed regions will have at least the same level of access in most cases. The value, says Mehrotra, is that internet access enables the creation and use of community telehealth centres where even elderly people unfamiliar with IT can receive help to see a doctor virtually. All of a sudden, these services no longer depend on every individual having a smartphone or the know-how to use one.
Parau, a rural village of about 3750 people in the northeast of Brazil, has no bank or high school and the largest city with substantial medical care is about four-and-a-half hours away by car, if one is available. While most in the community never had a landline, many have smartphones. A Catholic church in the village centre offers free Wi-Fi and at a basic medical centre a general practitioner is sometimes available, but no specialists. “People here still don’t have the custom of doing video visits, but you know, if we need to talk to a specialist in a different town, we can talk to them on the phone. I did that recently for my mom,” says Vera Amorim, a community leader and resident of Parau. It helps that Amorim is educated, well-travelled and in a better financial position than most in the village. She also has relationships with doctors in other cities. But without a system for a doctor to get reimbursed or compensated for such quick calls, formal access to telemedicine remains out of reach.
Internet access enables the creation and use of community telehealth centres where even elderly people unfamiliar with IT can receive help to see a doctor virtually
To close the gap between demand and supply in parts of the world without organised health care, specialised health-tech start-ups are beginning to offer innovative approaches to virtual care that go beyond the video call between patient and doctor that has become familiar in some advanced economies during the pandemic. In Africa, telemedicine is seen as a way of increasing access to care—an opportunity for innovators and local organisations to partner and provide essential healthcare services that are affordable, reliable, and tailored to local needs, according to The Africa Report, a leading news organisation on the continent in an article on e-health in Africa published in March 2020.
For the chronically ill living with a non-communicable disease (NCD), care often involves symptom management as well as keeping the disease at bay. Frequent medical visits and medication adjustment are required. In remote rural areas, even something as non-threatening as recurring migraine headaches can leave a patient largely disabled if untreated. Companies like Vezeeta, based in Egypt, are working on ways to resolve the issue of getting health care to the remote patient.
SPECIALISED TELEMEDICINE PLATFORMS
Vezeeta originated as a booking platform for in-person visits but has since pivoted into a telemedicine platform offering consultations with physicians in Egypt, Kenya, Nigeria, Lebanon, Saudi Arabia, and Jordan. Unlike most telemedicine platforms providing broad primary care, Vezeeta focuses on specialties such as psychiatry, nutrition, dermatology, genecology and infertility, diabetes and endocrinology, and oncology and oncological surgery. The price of each virtual appointment is listed in US dollars and an appointment with a 4.5 star-rated oncologist in Cairo starts at $20, which is about what it costs to refuel a car in Egypt.
Investors are bullish on the African continent’s ability to churn out health tech companies that serve the needs of its population. African e-health start-ups operating across the continent raised over $90 million in 2020 alone. Indeed, more than half of health-tech investments made in Africa over the past five years happened in the first half of that year, according to Disrupt Africa, a source of investment news.
HANDS-OFF PHYSICAL EXAMINATION
Elsewhere, an Israeli-founded company is working to resolve one of the major missing links in telemedicine: the inability to perform a physical exam. TytoCare not only facilitates video visits but has also created a suite of tools that allow for a patient to be virtually examined by a doctor. The portfolio contains all the typical doctor’s tools, linked to a camera and Wi-Fi. Remotely, a doctor can look down a patient’s throat, in their ear, listen to their lungs, take their blood pressure and even listen to their heart. All these tools connect to an app and telemedicine portal.
With the evolution of TytoClinic, the company has created the means to turn any location into a telehealth examination centre. It is focused on increasing access to care in rural and under-served communities in the US and around the world. “We have some people in remote villages in Latin America that are having their first primary care visit,” says Dedi Gilad, CEO and co-founder of TytoCare.
As TytoCare bridges the gap between telemedicine and in-person care, attention is also turning to therapies and treatments for NCDs that have not only been difficult to address virtually, but for which in-person treatment aftercare has not been a great success either.
CARDIO REHAB REMOTE CARE SUCCESS
Cardiovascular disease (CVD) is the number one cause of death globally and in 2016, an estimated 17.9 million people died from CVDs representing 31% of all global deaths, according to the World Health Organization. While surgeries and interventional therapies are available—including stents and bypasses— patients do not spring off the operating table and go back to their nine-to-five job the next day. Recovering from a CVD event requires follow-up therapy known as cardiac rehabilitation that has to take place in a hospital and usually involves three sessions a week for 12 weeks. The time and flexibility needed to accommodate the treatment schedule is a luxury many patients do not have.
Only 20% of patients who need cardiac rehabilitation get it, according to Phas3, one of the companies in Startup Health’s portfolio. The biggest reason for the failure is that patients are getting back to full-time jobs, have families to care for and bills to pay, and little time or resources to make thrice-weekly trips to the hospital for several months.
Phas3, a Missouri-based start-up, focuses on pro- viding virtual care for those who have suffered a cardiac event. It offers a telemedicine platform allowing cardiologists to conduct cardiac rehab remotely, plus connected devices such as a bluetooth heart rate monitor, a blood pressure cuff, and a weight scale. The platform allows clinicians to assign specific care plans that allow patients to work through guided exercises and activities daily.
MOUNTAINS HAVE MOVED
Prior to the covid-19 pandemic, the inconvenience of missing half a day’s work and waiting what could be months to see a doctor for just 15 minutes had not been enough to push any significant adoption of telemedicine. Post-pandemic, however, it is a different story. Experience with IT-delivered health care that a rampant, deadly and highly infectious virus necessitated has created a new trust in its ability to deliver. Over the past year, start-ups in the virtual care space have pushed boundaries and innovated more quickly than ever.
Patients, especially those who were less tech-savvy, found themselves learning to use healthcare IT, which steadily developed to become more user-friendly. Although the shift has been less dramatic in LMICs, many of the newest start-ups in the sector are dedicated to helping more remote areas leapfrog over some of the resource barriers that currently exist. The covid-19 pandemic roared into the world and turned the healthcare industry on its head; now there is no going back. •
TEXT Marcella McCarthy — PHOTO Lars Just