digital health

Deployment of telemedicine: what are the obstacles in France today?

The limits of telemedicine seem to have remained the same for the past seven years, in spite of the decree n°2010-1229 of 19 October 2010 defining its acts as well as its conditions of implementation and financial support. However, today, there are no longer any technological obstacles, since functional and secure platforms have been created, but institutional and economic obstacles. If France does not resolve these problems quickly, the risk of foreign solutions taking over and distancing themselves from French solutions becomes increasingly real. It is important to provide solutions to the many limitations encountered by telemedicine players in France. What are they and what solutions exist to address them?
Juanita lives in Formentera, an island in the Balearic archipelago. Although Formentera attracts five times its population as tourists every summer, access to urgent specialist care is a problem there, as there are too few year-round residents to justify staffing the local hospital with the highly specialised staff and equipment it needs. So when her husband suffered a stroke, Juanita feared the worst.
When a stroke occurs, every minute counts, and a patient's survival depends on accessing neurological care as soon as possible after the first symptoms appear. Like many other patients, Juanita's husband was successfully treated in the remote stroke treatment programme set up in the Balearic Islands in 2006. Thanks to the use of advanced video-imaging techniques, broadband and electronic medical records, neurologists in the capital, Palma, can now save lives remotely, with a quality of care comparable to that enjoyed by their patients in Palma.
As a Swedish pharmacist, Jens has long had to struggle to decipher handwritten prescriptions, the customary hieroglyphics of the medical profession. Jens now has direct access to an electronic prescription system. Since Apoteket, a state-owned pharmaceutical company, decided in 2001 to extend electronic prescribing to the whole country, prescription processing has become safer, faster and easier in Sweden. The system has virtually eliminated the errors associated with reading handwritten prescriptions. It offers further security guarantees by preventing over-prescription of drugs, automatically reporting potential drug interactions and dispensing generic drugs where possible. Overall, consumer satisfaction has increased, and physicians and pharmacists save up to 30 minutes a day with the system, allowing staff to provide new services that help diversify pharmacy revenues.
These situations are reported by the OECD's Information Service, the OECD Observer, to illustrate how the wider use of information and communication technologies can improve the quality of care and reduce costs.
But the implementation of information technology in the health field is only the first step in a long and difficult process. Indeed, it is true that while the potential gains from wider use of these technologies have been evident for several years, most countries still face significant implementation challenges, and their use is much less developed in the health sector than in many other areas.

As a reminder, telemedicine encompasses five types of medical acts:
- Teleconsultation to allow a medical professional to give a remote consultation to a patient. The presence of a medical professional may assist the patient during this consultation.
- Tele-expertise to enable a medical professional to seek the opinion of one or more expert medical professionals on the basis of elements in the patient's medical file.
- Remote medical monitoring: to enable a medical professional to remotely interpret the data necessary for medical monitoring of the patient in order to make decisions on his or her care.
- Tele-medical assistance to enable a medical professional to remotely assist another professional during the performance of a procedure.
- The medical response provided within the framework of medical regulation (SAMU). 

Brake n°1: leaving the experimentation phases to move on (at last) to the creation of uses.

It's a fact: the market is not taking off in France, even though the need is identified and exists.
Since 2010, few "telemedicine" projects have been able to emerge: most of the initiatives can be summarised as pilot projects. Indeed, in 2013, 331 telemedicine devices were identified (1), most under the aegis of the Regional Health Agencies (RHAs).
To date, few projects have passed the test of experimentation. If one wants to be able to talk to a doctor online and obtain - if necessary a medical prescription - there are fewer than a small handful of players with the necessary authorisations for this large-scale activity.

Brake n°2: liberalize access to teleconsultation 

If the experiments have not yet given rise to telemedicine champions in France, it is mainly because of the wide disparities in the way in which the various projects are authorized. Pilot projects are not coordinated and developed at the national level: each Regional Health Agency decides on the orientation of the projects on its territory. For example, the Ile de France region has supported most of the viable projects, while other LRAs have not yet started their experiments... The latter are cautious and are not keen to see the arrival of private companies in the sector. They have blocked access to a license to practice telemedicine rather than supporting its development by supervising it and taking advantage of the medico-economic studies that could have been carried out by these companies publishing technological solutions.
In order to give all French players a chance, it is the government's responsibility to define a set of specifications common to all, regardless of their geographical location. How can this be done? By putting an end to the obligation to contract with a Regional Health Agency. However, these agencies will be able to be involved in the monitoring of projects and ensure that patients' rights are respected, that sensitive data is protected and that professionals work remotely in the best possible conditions.

Brake n°3: the problem of the payer, an economic model to be found

Today, we are facing three problems:
- the French are used to having their health expenses reimbursed,
- SRAs contract only if there are no outstanding charges for patients,
- and finally, the mutuals are not in favour of reimbursing acts in full and do not see what advantages they would have in financing the development of telemedicine in France.
These constitute an almost insurmountable barrier to the emergence of telemedicine projects. Indeed, it would be necessary to be able to pay for expensive infrastructure (development of platforms on secure environments and approved hosting for health data) and health professionals who respond to calls. What can be done? Wait for the results of the votes on the social security financing bill and also the outcome of negotiations between the various players for a generalised takeover of teleconsultations.
All e-health stakeholders therefore hope that these negotiations will be quick and lead to a reimbursement of online procedures in 2018!
The obligation on emerging projects not to leave any leftovers for the patient makes it difficult to understand their offer. Unless they have entered into care agreements with third party payers (mutual insurance companies, employers) in order to be able to send a prescription, they can only offer telecounselling services. Telemedicine players receive requests from patients who do not understand the reasons for these blockages and would like to be able to talk to a doctor in a very short time and receive a prescription when necessary. A simple request to which an incomplete and often misunderstood answer is given.

Brake No. 4: professionals who are not ready?

The digital transformation of medicine is developing rapidly abroad but is struggling to spread in France.
Health professionals have long been seeing the emergence of these digital practices, but they are unable to project themselves into a remote medical practice. While they sometimes doubt their ability to practice their art without a clinical examination, they do see the value of teleconsultation in certain specific cases. By making suitable tools and training available to them, and by taking responsibility for the financing of these acts, doctors could adhere more and more quickly to telemedicine.
In order for telemedicine to be truly deployed in France, current projects that address the problems of access to primary care by facilitating teleconsultation should be translated into action. Two things are therefore urgently needed: to set up a single regulatory framework applicable to all, and to reimburse teleconsultations outside the current experimental frameworks.
Mathilde Le Rouzicco-founder of Hellocare

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