The Boom of Telemedicine – Dr. Google Will Not Write You a Sick Note and Confirmation, a Virtual Doctor Can

The imposed social distance due to the coronavirus pandemic has drawn significant attention to virtual healthcare – telemedicine, currently one of the most important trends in healthcare, enabling interactive remote communication between patients and healthcare providers in real-time. Although it has been on the rise for the past decade, many have only now realized the power of telemedicine, and according to some estimates, telehealth could be one of the few winners in the anticipated prolonged slowdown of economic growth, which is why it is experiencing strong investment growth.

E-sick notes and e-certificates

Telemedicine is an integral part of the Croatian healthcare system, and the corona crisis prompted the Croatian Health Insurance Fund (HZZO) to upgrade the eHealth information system with eSick Notes at the end of March, through which employers have access to a digitized report on employee sick leave and data necessary for salary payment. Data related to maternity and parental benefits for employed and self-employed individuals will also be available.

Employers have access to the eSick Note through the eHealth business portal, and users can obtain such information through the eCitizens system. This means that patients no longer need to carry paper sick notes around, as their doctors report all data related to the opening and closing of sick leave to the Central Health Information System (CEZIH). Patients can more easily and quickly obtain prescribed medical aids with the help of e-certificates, without the need to visit their family doctor’s office.

In the pandemic crisis, the A5 referral, which has existed for several years, is also of great help, through which the family medicine doctor contacts the specialist instead of the patient and determines the further course of treatment.

Mature System

Telemedicine was first applied in Croatia in 2000 at the private cardiology Clinic Magdalena, which launched the first telemedicine center in this part of Europe. Patients wear an ECG device that allows for the recording of a 12-lead ECG and reads results in real-time, providing expert opinions with recommendations for further treatment. Approximately 12,000 telecardiology consultations are conducted annually.

Clinic Magdalena also has a virtual clinic and a digital assistant Megi who communicates with cardiovascular patients. Megi is a product of the Croatian technology company Mindsmiths, which also created the digital assistant Andrija, and for remote ECG readings, the clinic uses Israeli technology, the most advanced in the world.

However, the foundation for the development of telemedicine in Croatian public health was laid eighteen years ago by Ericsson Nikola Tesla in collaboration with the Ministry of Health and the Croatian Health Insurance Fund. This refers to the eHealth system and CEZIH, but ePrescription, eReferral, eOrdering, and eFile are not telemedicine, although digitized healthcare includes the provision of remote healthcare services.

The most commonly used telemedicine services in Croatia are from radiology and cardiology: the exchange of radiological images and the diagnosis of continuous arterial blood pressure monitoring and Holter ECG. The telemedicine service is an integral part of the Croatian Institute of Emergency Medicine (HZHM), and the network of telemedicine centers covers 68 healthcare institutions and has 141 active telemedicine centers.

– Telemedicine services are provided at the primary, secondary, and tertiary levels of healthcare, and recipients and providers of services include various healthcare institutions, from clinical hospital centers in larger cities to health centers. Medical services included in the digital exchange of findings, images, readings, diagnosis, remote treatment, and second opinions are from the fields of radiology, cardiology, neurology, hemodialysis, and transfusion medicine, and we also provide e-education services. Consultations between primary healthcare physicians and specialists and subspecialists enable quicker recognition of acute conditions, timely initiation of appropriate treatment, advance assessment of the need for surgical intervention and/or hospitalization, and decisions about transporting the patient to the institution where they will receive the best healthcare – says Prim. Dr. Maja Grba-Bujević, director of the Croatian Institute of Emergency Medicine and head of the Ministry of Health’s Crisis Staff.

In Real-Time

The telemedicine service of HZHM uses two telemedicine technologies, real-time and store-and-forward, and in some cases, both are used. Grba-Bujević emphasizes that telemedicine has become a necessary tool of the modern healthcare system that ensures access to top specialist healthcare services for all patients, even those in hard-to-reach locations and islands.

– Among the many advantages it brings, patients and doctors most often highlight timely diagnosis and therapy, improved health outcomes, less travel, and savings in time and costs – notes Grba-Bujević.

The telemedicine service of HZHM has been collecting data on the number of services provided since 2011; for example, last year, 38,106 telemedicine services were performed, and 9,987 in the first three months of this year.

– This epidemiological situation best illustrates the need for further strengthening and expanding the spectrum of telemedicine services to increase the availability of healthcare to all patients – says Grba-Bujević, highlighting cooperation with neighboring countries.

Croatia, in cooperation with the ministries of health of Bosnia and Herzegovina and Montenegro, is implementing the IPA project NeurNet – Network for the Care of Patients with Pharmacoresistant Epilepsy and Advanced Stage Parkinson’s Disease. As part of the project, a network between the reference center and hospitals is being developed to improve the quality and availability of services to patients. A total of ten hospitals from three partner countries will be networked with the Neurology Institute of the Clinical Hospital Dubrava as the reference center, and audiovisual communication, consultations, accurate diagnosis, and transfer of medical data between hospitals and the reference center will be enabled through information and communication technology.

Assistance from Applications

The telemedicine system is applied in several different activities at four locations of the Health Center Zagreb – Center (DZZC). Director Doc. Dr. Antonija Balenović explains that telemedicine is also used for consultations with other specialists outside DZZC; family medicine doctors collaborate with cardiology specialists from Clinic Magdalena regarding the interpretation of cardiological tests (ECG results). They also collaborate with experts from the Lipid Disorder Clinic at KBC Zagreb through eConsultations for the primary prevention of cardiovascular incidents in patients with hypercholesterolemia, and further collaborate with pharmacists in the Pharmacotherapy Counseling project at DZZC, within which a new pharmacy service for aligning pharmacotherapy is implemented to improve adherence and treatment outcomes for patients also using eConsultations.

Balenović emphasizes that new digital technologies enable the collection, processing, and exchange of reliable health data without unnecessary wandering of patients in the system and waiting at counters.

– Patients of DZZC have access to the mobile application Health Diary, which serves to collect and exchange data that they measure themselves (blood pressure, pulse, sugar, weight), which is transmitted directly to the medical eFile via the mobile application. Another functionality that has been developed and implemented in our health center is direct communication between primary healthcare physicians and specialists in secondary and tertiary healthcare through the aforementioned eConsultations. The project ‘Information Exchange between PZZ-SKZZ Doctors’ is being implemented, in which protected two-way communication among primary and secondary healthcare physicians is enabled through the A5 electronic referral and the newly developed Zdravlje.net in the CEZIH system for obtaining specialist opinions without physically referring the patient, according to the principle: ‘information travels, the patient stays’, of course in cases where such a type of consultation is appropriate – explains Balenović, emphasizing that telemedicine, or the processes of digitizing healthcare, leads to cost reduction, more efficient spending of money, generally contributes to all resources in healthcare, and especially to more rational and transparent management of human resources.

Personalized Healthcare

The information system on which DZZC, polyclinics, and hospitals operate is the work of the MCS group. Nikola Juranić, head of sales and marketing at the company, emphasizes that more than 60 percent of public health institutions in primary and specialist-consultative healthcare in Croatia use MCS group solutions.

Some of these solutions include Medicus.Net, intended for medical offices, specialist offices, polyclinics, health centers, hospitals, clinics, and other healthcare institutions; Zdravlje.Net serves communication between doctors and patients; and eConsultations enable communication between healthcare professionals in primary and specialist-consultative healthcare.

Although the number of telemedicine services in Croatia is significantly increasing, and healthcare institutions that practice them highlight time and cost savings as advantages of using telemedicine, HZZO still does not have data on how much money has been saved in this way. Regardless, telemedicine is one of the important steps towards personalized medicine, and the corona crisis has shown that remote communication between patients and healthcare workers significantly increases their safety.

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