A Quantitative Analysis of Barriers to International Telemedicine

Education: The Case of the Philippines

Toru Oga

, Katherine Panganiban

, Kuriko Kudo

, Jocelyn Celero

, Shintaro Ueda

Shunta Tomimatsu

, Jeffrey Domino

and Tomohiko Moriyama

Faculty of Law, Kyushu University, Motooka 744, Nishi-ku, Fukuoka-Shi, Fukuoka, Japan

Institute of Surgery, St. Luke’s Medical Center, 279 E Rodriguez Sr. Ave. Quezon City, 1112, Philippines

Telemedicine Development Center of Asia, Kyushu University Hospital, Maidashi 3-1-1, Higashi-Ku, Fukuoka-Shi,

Fukuoka, Japan

Asian Center, University of the Philippines, Diliman, Quezon City, 1101, Philippines

Keywords: Telemedicine, International Telemedicine Education, Communication, Collaboration, The Philippines.

Abstract: A multitude of studies have investigated the opportunities and limitations of telemedicine pre- and post-

COVID-19 pandemic. However, most of the research has focused on telemedicine's constraints in the context

of international, regional, and developed nations, with few studies examining the specific challenges that may

affect telemedicine's progress in developing countries where the pandemic may have exacerbated existing

technological and geographical difficulties. This study takes the Philippines as a case study due to its

archipelagic location, use of English as an official language, and other factors that influence its adaptability

to international telemedicine. We assessed the barriers and challenges to the advancement of telemedicine

from four viewpoints: policy, organization, individual, and collaboration between organizations. Therefore,

the significance of this study is twofold: (a) to concentrate on international telemedicine education by

contrasting domestic and international practices, and (b) to newly reveal connections between each

component, as prior research highlighted barriers and difficulties but did not clarify relationships among

different elements. We surveyed and interviewed 38 physicians, technicians, coordinators, and staff involved

in telemedicine education in the Philippines. The study found that (1) public support yields favourable results,

(2) a strong correlation exists between domestic and international telemedicine, (3) communication and

technical obstacles are interconnected, (4) unity and cooperation in intra-hospital collaboration are critical,

and (5) comprehending the "significance of work" has a positive impact. This study underscores the

intersectionality of several barriers to telemedicine development. It also recommends providing greater

support for telemedicine education in developing nations and promoting collaboration between developing

and developed nations.

1 INTRODUCTION

Since the global outbreak of COVID-19, telemedicine

has gained momentum as an increasingly popular

approach to the delivery of primary health care

conducted at a distance. While telemedicine has been

the subject of numerous studies in the past, focusing

on its limitations and possibilities for delivering

https://orcid.org/0000-0002-4909-383X

https://orcid.org/0000-0001-5391-4648

https://orcid.org/0000-0003-3652-6031

https://orcid.org/0000-0001-7692-1517

https://orcid.org/0000-0002-3200-9494

https://orcid.org/0000-0002-9868-4206

https://orcid.org/0000-0002-0682-8971

healthcare across space and scale, the pandemic has

magnified the challenges to the conduct of

telemedicine and telemedicine education among

practitioners. This study focuses on international

telemedicine education and identifies its barriers and

challenges, with particular attention to the

relationships among factors, which has not been

explored in previous studies.

Oga, T., Panganiban, K., Kudo, K., Celero, J., Ueda, S., Tomimatsu, S., Domino, J. and Moriyama, T.

A Quantitative Analysis of Barriers to International Telemedicine Education: The Case of the Philippines.

DOI: 10.5220/0011997600003476

In Proceedings of the 9th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2023), pages 75-80

ISBN: 978-989-758-645-3; ISSN: 2184-4984

 2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)

International telemedicine education, as defined in

this paper, is an international video conference

connection between hospitals for training and

exchange of ideas. Through international telemedicine

education, healthcare professionals can consult with

medical experts from around the world, acquire

knowledge and skills, and see live demonstrations of

advanced surgical techniques performed by world-

class experts. This study aims to compare domestic and

international telemedicine practices and newly uncover

relationships between each element. While previous

studies pointed out barriers and difficulties, relation-

ships among different elements are not clear.

The survey covered in this paper includes both

domestic and international telemedicine, with the aim

of comparing the two to identify issues in the latter.

The impact of the COVID-19 pandemic has increased

the growing need to examine how telemedicine can

be effectively implemented in local contexts, be it in

rural or urban areas, global or national, developed,

and developing countries.

This case study is focused on the Philippines, a

developing state with a high demand for international

and domestic telemedicine due to geographical and

technological factors. The conduct of telemedicine

becomes a challenge to provide health care to far-

flung areas that may have limited access to medical

and communication technologies, given its

archipelagic status. However, as English is an official

language in the country, international telemedicine

education is highly adaptable, allowing for

international cooperation among telemedicine

practitioners. This research explores the connection

between these barriers and further explores other

difficulties associated with creating a network

environment, especially during COVID-19, where

remote work has also progressed.

2 RELATED STUDIES

The existing literature has extensively explored the

challenges and barriers to the implementation of

telemedicine before the pandemic. Kruse et al. (2016)

identified organizational barriers such as cost,

liability, and efficiency, patient barriers such as

technological literacy, and staff barriers such as staff

shortages, aversion to change, and interoperability

that hinder telemedicine delivery. Weigel et al. (2020)

examined the development and evolution of

telemedicine policies by federal, state, and private

insurance companies. Kudo et al. (2022) found that

physicians and technicians face different barriers to

care in their study at a national university hospital in

Japan. Legler et al. (2021) discussed hospital-to-

hospital telemedicine collaboration in detail.

However, the relationship between these multiple

constraints has not been adequately explained.

During the COVID-19 pandemic, several studies

have assessed how the global health crisis has

exacerbated the existing challenges to telemedicine

delivery. However, these studies have mainly focused

on barriers specific to international/global (Bhaskar et

al. 2020; Legler et al. 2021), regional (Sabrina and

Defi 2021; David et al. 2021; Chu et al. 2022), and

developed country (Weigel et al. 2020; Kudo et al.

2022) contexts. Only a few studies have examined the

challenges specific to developing countries, notably

South Asian countries, during the pandemic, such as

Pakistan (Farooqi et al. 2022), Bangladesh, and India

(Agarwal et al. 2020; Das et al. 2020).

Considering the gaps in the existing literature, the

present research aims to explore the challenges that

hinder the implementation of telemedicine in the

Philippines during the pandemic.

3 RESEARCH DESIGN

The COVID-19 pandemic has highlighted the need

for telemedicine as a crucial tool for delivering

healthcare services remotely. However,

implementing telemedicine in developing countries

such as the Philippines comes with its own set of

challenges. The limited access to technology and

internet connectivity, inadequate infrastructure, and a

shortage of trained healthcare professionals are some

of the challenges that need to be overcome to

implement telemedicine successfully.

The study aims to identify these challenges and

prospects of implementing telemedicine in the

Philippines. The research will employ a mixed-

method approach, using surveys, interviews, and

statistical methods to collect and analyse data from

telemedicine professionals in the country. The study's

participants will include medical staff, technical staff,

and secretaries/coordinators involved in

telemedicine. The study will identify the specific

challenges that these professionals face based on their

professional characteristics and the level of policy,

organizational, and individual factors that contribute

to these challenges.

One of the critical areas that the study will focus

on is telemedicine education in the Philippines. The

study will assess the current status and issues related

to telemedicine education and examine how medical

staff, technical staff, and secretaries/coordinators

acquire the necessary skills for telemedicine through

ICT4AWE 2023 - 9th International Conference on Information and Communication Technologies for Ageing Well and e-Health

activities such as medical conferences.

The study's findings will be used to develop

tailored policy recommendations and problem-

solving strategies for different professional categories

in telemedicine. By identifying and addressing these

challenges, the study aims to contribute to the

successful implementation of telemedicine in the

Philippines. This, in turn, will improve access to

healthcare services for the country's underserved

communities and help bridge the gap in healthcare

delivery between urban and rural areas.

In conclusion, this mixed-method study is critical

to identifying the challenges and prospects of

implementing telemedicine in the Philippines. By

collecting and analysing data from telemedicine

professionals, the study will provide insights into the

specific challenges faced by different professional

categories in telemedicine. The study's findings will

help develop tailored policy recommendations and

problem-solving strategies that can contribute to the

successful implementation of telemedicine in the

Philippines, ultimately improving access to healthcare

services for the country's underserved communities.

4 METHODOLOGY

4.1 Survey Methods

To gather data for this research, an online survey was

conducted using Google Forms between July 17 and

August 7, 2022. The survey was targeted at medical

staff, technical staff, and secretaries/coordinators

who were involved in telemedicine education in

Japan and the Philippines. A total of 38 participants

were included in the survey and subsequent follow-

up interviews, consisting of 26 medical staff, four

technical staff, two secretaries/coordinators, and six

others.

The survey was conducted in two stages.

(1) Respondents completed an online survey via

Google Forms.

(2) A follow-up interview was conducted with the

same respondents via Zoom to obtain more in-

depth information on the reasons and

background behind their answers in the

survey. During the interview, participants

were asked to elaborate on their survey

responses and provide additional insights into

their experiences with telemedicine education

in the Philippines.

Overall, the data collected from the survey and

interviews will be analysed using a combination of

statistical and qualitative methods to identify the

challenges and prospects of implementing

telemedicine in the Philippines. The findings of this

research will provide valuable insights into how

telemedicine education can be improved.

4.2 Analytical Methods

The data collected from surveys and interviews with

telemedicine professionals in the Philippines have

been analysed using statistical methods such as

regression analysis, factor analysis, and

correspondence analysis. These methods have been

employed to identify differences in the awareness of

problems related to telemedicine based on the

occupational attributes of the respondents, including

medical staff, technical staff, and

secretaries/coordinators. The results of the analysis

will provide insights into the specific challenges

faced by different professionals in the telemedicine

industry in the Philippines. This information can

inform the development of tailored policy

recommendations and problem-solving strategies to

address and overcome these challenges.

5 RESULTS

In this study, questions were categorized into three

levels: policy, organizational, and individual.

Respondents were asked to provide their opinions on

government support for telemedicine and public-

private partnerships, which were assessed using a

seven-point Likert scale to gauge their level of

agreement or disagreement. The results at the policy

level indicated that greater satisfaction with

international telemedicine education was associated

with more favorable evaluations of government

support for telemedicine. Additionally, positive

evaluations of domestic telemedicine education were

found to be correlated with positive evaluations of

international telemedicine education.

Variables= public support

disparity_world -.056

disparity_country -.107

Telemd_solution .237

info_disparity_world -.028

info_disparity_domestic .066

private_solution .251

education_cooperation_international .581*

education_cooperation_domestic .001

.421**

** p < .01, * p < .05, + p < .10

A Quantitative Analysis of Barriers to International Telemedicine Education: The Case of the Philippines

Variables=education_cooperation_international

disparity_world .254

disparity_country -.414

Telemd_solution -.094

info_disparity_world .095

info_disparity_domestic -.079

private_solution -.160

public_support .271*

education_cooperation_domestic .564**

.730**

** p < .01, * p < .05, + p < .10

Organizational-level surveys illuminate the

relationship between individual and organizational

effort, as well as the connection between

collaboration and performance. Individuals who

appreciate organizational efforts are more likely to

value personal contributions. Respondents tend to

rate both individual and organizational performance

more positively when they value interdepartmental

collaboration or teamwork.

Variables=Organization

knowhow .239+

cost -.061

individual .580**

performance .139

collaboration -.188

collabo_hospital -.214

communication .369

.581**

** p < .01, * p < .05, + p < .10

Variables=Performance

knowhow .117

cost -.169

organization .098

individual .247

collaboration .559*

collabo_hospital -.078

communication .159

.704**

** p < .01, * p < .05, + p < .10

Participants experience similar communication

difficulties in international telemedicine as they do in

domestic telemedicine education. Communication

challenges in international telemedicine education are

also attributed to technical difficulties. Domestic

technological issues align with international

technological challenges. To establish cooperative

relationships within hospitals, unity and consultation

are crucial. However, collaboration within teams may

negatively impact cooperation at the hospital level.

Variables=communication_difficulty_international

communication_difficulty_domestic .376*

tec_diff_international .456*

tec_diff_domestic -.159

Overtime_international .300

Overtime_domestic -.270

Maintain .175

.507**

** p < .01, * p < .05, + p < .10

Variables=tec_difficulty_international

communication_difficulty_domestic .322*

tec_diff_international .111

tec_diff_domestic .528**

Overtime_international .150

Overtime_domestic -.124

Maintain -.147

.652**

** p < .01, * p < .05, + p < .10

Variables=collabo_hospital

Respect -.068

Unity .815*

Collaborate -1.215**

Consultation .638*

Voice .333+

.490**

** p < .01, * p < .05, + p < .10

Lastly, there are relationships with external

organizations. In order to build cooperative

relationships with other organizations, it is essential

to comprehend the importance of the work being

done, rather than focusing solely on responsibilities,

objectives, or the division of roles.

Variables=collaborate_other

responsibility_other .056

importance_other .833**

goal_other -.203

role_other .096

.628**

** p < .01, * p < .05, + p < .10

6 DISCUSSION

This study, based on data analysis, emphasizes

several key points.

First, at the policy level, domestic and

international telemedicine education practices are

interconnected, and positive domestic telemedicine

practices impact international telemedicine practices.

Enhancing government support and promoting both

international and domestic telemedicine practices

ICT4AWE 2023 - 9th International Conference on Information and Communication Technologies for Ageing Well and e-Health

will consequently increase satisfaction with

telemedicine at the policy level. Telemedicine

education aims to identify issues within various

professional categories to address problems and

develop policy recommendations.

Second, the organizational-level survey reveals a

correlation between individual-level efforts and

organizational-level initiatives. Collaboration and

teamwork lead to positive evaluations of both

individual and organizational performance.

Telemedicine education must emphasize the

importance of organizational collaboration and

individual effort.

Third, communication and technological

difficulties are evident at the individual level.

International communication challenges are similar

to domestic communication challenges, and technical

difficulties contribute to communication issues.

National and international telemedicine education, as

well as technical and communication aspects, are

evidently interconnected.

Fourth, to build cooperation within hospitals,

unity and consultation were found to be crucial.

However, intra-team cooperation was found to

negatively impact the development of cooperative

relationships at the hospital level. Consequently,

cooperation within small teams and larger groups

may have different contexts and adverse effects.

Lastly, the results highlight the importance of

forging relationships between organizations. The

significance of "the importance of the work" is

emphasized in this context. In telemedicine, where

collaboration with other organizations is essential,

sharing a macro-level understanding of the work

within the team is more important than focusing on

technical tasks alone.

7 CONCLUSION

Moving beyond previous studies that focus on

specific barriers to telemedicine delivery from global,

regional, and developed country perspectives, this

study investigates the interconnections between four

types of barriers affecting telemedicine in the

Philippines: policy, organizational, individual, and

inter-organizational collaboration. A questionnaire

and interviews were conducted with 38 physicians,

technicians, coordinators, and others involved in

telemedicine in the country. The results revealed that:

(1) public support generates positive feedback, (2) a

strong connection exists between domestic and

international telemedicine, (3) communication

barriers and technical barriers are linked, (4) unity

and cooperation are crucial for hospital collaboration,

and (5) the significance of the work is important.

Previous studies identified barriers and challenges to

telemedicine, but the relationships between factors

remained unclear. This study elucidates how multiple

barriers intertwine and suggests directions for

advancing telemedicine education in developing

countries. Future research should examine

comparisons or connections between developed and

developing countries and explore potential areas for

collaboration between them.

REFERENCES

Agarwal, N., Jain, P., Pathak, R., & Gupta, R. (2020).

Telemedicine in India: A tool for transforming health

care in the era of the COVID-19 pandemic. Journal of

Education and Health Promotion, 9.

Bhaskar, S., Bradley, S., Chattu, V. K., Adisesh, A.,

Nurtazina, A., Kyrykbayeva, S., & Ray, D. (2020).

Telemedicine across the globe-position paper from the

COVID-19 pandemic health system resilience

PROGRAM (REPROGRAM) international consortium

(Part 1). Frontiers in public health, 8, 556720.

Chu, M., Dalwadi, S., Profit, R., Searle, B., & Williams, H.

(2022). How Should Medical Education Support

Increasing Telemedicine Use Following COVID-19?

An Asian Perspective Focused on Teleconsultation.

International Journal of Digital Health, 2(1).

Das, N., Narnoli, S., Kaur, A., Sarkar, S., & Balhara, Y. P.

S. (2020). Attitude to telemedicine in the times of

COVID19 pandemic: Opinion of medical

practitioners from India. Psychiatry and clinical

neurosciences, 74(10), 560.

Farooqi, M., Ullah, I., Irfan, M., Taseer, A. R., Almas, T.,

Hasan, M. M., et al. (2022). The revival of telemedicine

in the age of COVID-19: benefits and impediments for

Pakistan. Royal College of Surgeons in Ireland.

https://hdl.handle.net/10779/rcsi.19115234.v1

Gudi, N., Konapur, R., John, O., Sarbadhikari, S., &

Landry, M. (2021). Telemedicine supported

strengthening of primary care in WHO South East Asia

region: lessons from the COVID-19 pandemic

experiences. BMJ Innovations, 7(3).

Kruse, C., Karem, P., Shifflet, K. et al. (2018). Evaluating

barriers to adopting telemedicine worldwide: A

systematic review. J Telemed Telecare. 2018 Jan;

24(1): 4–12. doi:10.1177/1357633X16674087

Kudo K, Kudo N, Isobe, et al. (2022). Barriers to

International Telemedicine Conferencing: A Survey of

the National University Hospital Council of Japan,

Telemedicine and e-Health 28(3) 433-439.

Legler, S., Diehl, M., Hillard, B. et al. (2021) Evaluation of

an Intrahospital Telemedicine Program for Patients

Admitted With COVID-19: Mixed Methods Study. J

Med Internet Res 2021;23(4):e25987. doi:10.2196/

25987.

A Quantitative Analysis of Barriers to International Telemedicine Education: The Case of the Philippines

Sabrina, M. I., & Defi, I. R. (2021). Telemedicine

Guidelines in South East Asia—A Scoping Review.

Frontiers in Neurology, vol. 11. – 2020.

https://doi.org/10.3389/fneur.2020.581649

Weigel G, Ramaswamy A, Sobel L, et al. Opportunities and

barriers for telemedicine in the U.S. during the COVID-

19 emergency and beyond. Women’s Health Policy.

Accessed 8 Dec 2022. https://www.kff.org/womens-

health-policy/issue-brief/opportunities-and-barriers-

for-telemedicine-in-the-u-s-during-the-covid-19-

emergency-and-beyond/

Zhai, Y. (2021). A call for addressing barriers to

telemedicine: health disparities during the COVID-19

pandemic. Psychotherapy and psychosomatics, 1.

ICT4AWE 2023 - 9th International Conference on Information and Communication Technologies for Ageing Well and e-Health