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 Healthc Inform Res > Volume 21(4); 2015 > Article
Kim, Ahn, Choi, Choi, Kim, Shin, Park, and Han: Fifteen-year Experience with Telemedicine Services in Gangwon Province in Korea

### Objectives

This study attempted to identify the factors that contribute to successful telemedicine service. This was done by analyzing the operational state of successful telemedicine services offered in Gangwon Province of Korea and their outcome for the last fifteen years.

### Methods

A comparative analysis was made based on reports and a thesis on the satisfaction rate of patients and providers, patient compliance to treatment, and economic assessment of Gangwon telemedicine service, which were carried out in three periods: the years 2006, 2010, and 2012.

### 2. Characteristics of Service Providers

Telemedicine services are provided through bilateral communication between a HCP in the field and a physician in a distant location. In 2015, currently, there are a total of 57 physicians, of which all are males except one doctor. Except three doctors, they are all public health doctors with a mean age of 30.4 years old. Fifty-four physicians, except three, largely have 3-year experience or less, considering the fact that they carry out their duties in place of regular military service. These HCPs are in their 40's and 50's with 20-year experience or more. The investigation regarding service hours of face-to-face and telemedicine medical services provided by 12 physicians and 38 HCPs revealed that 71.4% of physicians replied that the service hours for both were about the same. On the contrary, 81.6% of HCPs responded that the service hours had increased due to increased time needed for biophysical information input and management (50.0%), increased preparation (18.4%), and increased duration of medical and telemedicine services (10.5%) in decreasing order.

### 3. Extent of Satisfaction [3,4,5]

The Korea Institute for Health and Social Affairs first conducted a satisfaction survey targeting patients with hypertension and diabetes mellitus who received telemedicine services from public health clinics in 24 regions in 2006. In 2010, the Korea Health Industry Development Institute investigated the extent of satisfaction targeting patients with hypertension and diabetes mellitus who received telemedicine services from public health clinics in six regions. In addition, Hallym University conducted a satisfaction study in 2012. The investigation focused on changes in satisfaction rates in comparison to those obtained in studies conducted in 2006 and 2010 (Table 4).
The 2006' inquiry on satisfaction rates and intention of utilization, conducted one year after the commencement of telemedicine services, showed high satisfaction rates for both patients and providers. In particular, the patients who received telemedicine services showed the highest satisfaction rates with 3.85 and 3.67 out of the full score of 5, respectively. The physicians who were telemedicine service providers showed relatively low satisfaction rates of 3.03 and 3.67, respectively. The satisfaction rates in the 2010 and 2012 surveys showed a similar tendency. The HCPs' scores for the necessity of telemedicine services were 4.07 and 3.88 in 2006 and 2012, respectively. However, the physicians showed a result of relatively lower scores of 3.33 and 3.22, respectively. The telemedicine services of Gangwon Province are provided by the transmission of patient care guidelines, provided by a physician to an HCP, on the basis of shared information between these two parties. Accordingly, studies were conducted to inquire into satisfaction rates on quality of information and the application system. Investigations on the completeness, accuracy and timeliness of information were conducted in 2006 and 2012. HCPs showed a satisfaction rate of 3 points for both years, but physicians expressed a satisfaction rate of 3 points or more in accuracy but less than 3 points for both completeness and timeliness. A survey of satisfaction rates for the application system was conducted in 2010 and 2012. The results showed an overall satisfaction rate of 3.0 points or more for both HCPs and physicians. With respect to transmission of accurate information and network stability, the satisfaction rate of physicians was higher than that of HCPs. Both parties showed a similar satisfaction rate of 3.5 points regarding the program's convenience. However, the satisfaction rate of physicians was relatively rather low regarding quality of communication and convenience of equipment utilization.

### 4. Patient Compliance to Treatment

The most important goal of telemedicine services would be to increase the compliance of patients who have chronic diseases. In the 2006' study, changes in drug administration days, lifestyle, and behavior were measured on a five-point scale before and after the commencement of telemedicine services. It was confirmed that patients' compliance with treatment with respect to drug administration days, lifestyle, and level of adjustment (behavior), increased after the telemedicine services were introduced [3] (Table 5). In 2007, 111 telemedicine service patients and 71 face-to-face medical service patients, among those patients under drug management at the public health clinics for one year or longer, were examined for HbA1c measurement rates and funduscopic examination rates. The rates for the telemedicine service group were 64% and 35.1%, respectively, while the rates for the face-to-face medical service group in the corresponding regions were 1.6% and 3.2%, respectively. The rates for the former group were higher than the rates of the latter group. Also, the mean rates (30.4%, 6.1%) of HbA1c measurement and funduscopic examination of the telemedicine service group were higher than those of hospital patients nationwide [6]. A study on the drug compliance rates of face-to-face and telemedicine service patients conducted in 2012, revealed that patients who received telemedicine services with drug administration and lifestyle education once or twice a month for 3 years or improved more in compliance with drug administration than non-users of the telemedicine services did. Also, the levels of HbA1c at the time of registration for telemedicine and face-to-face services and the levels at the time of investigation were compared. Among 167 patients with diabetes mellitus who received telemedicine services, 106 patients regularly checked and managed their HbA1c levels. The mean level of HbA1c at the time of registration was 7.1% but the level decreased to 6.87% at the time of investigation, showing a statistically significant decrease. Only 9 out of 59 diabetes mellitus patients who did not receive telemedicine services were regularly managing their HbA1c levels, and there was no significant difference [6]. In the comparative analysis of the levels of HbA1c changes between 148 telemedicine service users and 29 non-users in Hoengseong county in 2012, 44.6% of telemedicine service users and 24.1% non-users were managing their HbA1c levels below the level of 6.5%, showing a similar result [3] (Table 6).
A study investigated the drug administration compliance rates and blood pressure adjustment rates of 1,048 patients with hypertension who had been registered from 2004 through 2006. There were 941 patients (89.8%) in the treatment group among registered patients. Of these 941 subjects, 699 patients (74.3%) belonged to the drug compliance group-which required 80% or more drug administration days for patients to be included in this group. Of these 941 patients, 841 (89.4%) were managed with respect to blood pressure adjustment rate (at normal and pre-hypertensive levels) (Figure 1). The results showed that the treatment rate of hypertensive patients in Korea was 30% to 50% during the same period, while the adjustment rate was merely 20% to 30%. In comparison with these national data, it is clear that telemedicine services would improve a patient's drug compliance and facilitate adjustment of the patient's blood pressure [7]. Furthermore, the effects of telemedicine services were compared by comparative analysis of the state of blood pressure initially at the time of patient registration and that at the time of investigation. The proportion of patients whose blood pressure could be adjusted to a normal blood pressure level increased from 7.4% to 23.9% at the early registration stage. The ratio of patients who could achieve blood pressure levels of the pre-hypertensive stage also increased from 37.9% to 65.5%. The proportion of patients belonging to Stage 1 hypertension decreased from 29.9% to 8.8%; and that of patients belonging to Stage 2 hypertension decreased from 24.8% to 1.8%. Overall, the proportion of hypertension-adjusted patients increased from 45.3% to 89.4% at the initial registration, while the ratio of patients in Stage 1 to 2 hypertension decreased from 54.7% to 10.6% [7] (Table 7). A 2012' study involving 435 patients whose hypertension was managed through telemedicine services and 122 patients whose hypertension was managed through face-to-face clinical care reported that there was no significant difference between these two groups. The initial mean blood pressure of patients in the telemedicine service group was 148/88 at the time of patient registration. The mean blood pressure decreased to 121/74 three months after commencement of the investigation. The mean blood pressure of face-to-face clinical care patients changed from 158/93 at the registration time to 122/74 three months after initiation of the investigation. Statistically, no significant difference between telemedicine service group and face to face clinical care group was found. While this data might be statistically insignificant, the percentage of patients whose blood pressure was managed under 140/90 was 97.1% for the telemedicine service group. This is 4.8% higher than 92.9% of the face-to-face clinical care group [3] (Table 8).

### 5. Economic Assessment

An analysis of monthly expenses one year after the provision of telemedicine services revealed that the average monthly wage for a telemedicine physician was $172; the network usage fee,$26; the administrative expenses, $5.7; and other expenses,$11.5. It showed a total average expenditure of 250,300 Korean won. The estimated average monthly expenses for each public health clinic were $215.2. These expenses did not include the system development fee, maintenance and repair cost or the HCP wage [3]. The same study, recently conducted in 2015, showed the expense of$1.8 per patient. This is a reduction of expenses by half (Table 9). Telemedicine service duties have been established as duties of public health clinics. Hence, it has reduced the cost of additional drugs, and the numbers of public health clinics and their patients have increased.
In 2007, a presumptive survey was conducted to find out whether 451 patients who received telemedicine services through 20 public health clinics would have an intention to pay for telemedicine services. The survey found that these patients were willing to pay about $3.4 for the telemedicine services they received [8] (Table 10). When the results are applied to the entire user group of the telemedicine services in Gangwon Province, the benefits of time savings, transportation, and other expense reduction, in addition to the benefit arising from reduction of medical service costs, are estimated to be$835,127-$1,007,318. In 2009, the Korea Health Industry Development Institute conducted an investigation on the benefits of time and clinic cost savings as well as transportation cost and other additional cost savings by the users of telemedicine services in Yongyang county, Gangneung, and Boryeong cities. The pilot project was carried out in preparation to build a ubiquitous sensor network (USN)-based remote health monitoring system for the regions in 2008. The full benefit of users in Gangneung city was estimated to be about$172 for 85 patients annually [9]. The reason for the rather low benefit is that Gangneung is an urban-agricultural complex region that includes patients (subjects) in the urban district, since the cost of transportation is lower than in other regions. The mean benefit for a patient in the entire Gangwon Province is estimated to be $387, which can be calculated with the number of patients (1,300) as above. The total estimate for all telemedicine patients in the Gangwon Province is about$542,402.

### IV. Discussion

In an attempt to overcome deficiencies in medical service availability and to secure medical equity, Gangwon Province has introduced and successfully operated telemedicine services for the last fifteen years. First, in Gangwon Province, one factor that has enabled the successful operation of telemedicine services for fifteen years has been the adaptation of appropriate technologies that can be implemented, rather than preferentially applying appropriate technologies on the cutting edge. Second, the adoption of telemedicine systems has focused on patients with chronic diseases, such as hypertension, diabetes mellitus, or dementia, which require continuous management. Thus, a collaborative system between HCPs in the field and local physicians has been developed; and this is another important factor of successful operation. Furthermore, enthusiastic support from each municipal government was obtained by mediating the preferential order of public health policies of local municipal governments. The matter of harmonious tuning with regional public health planning in Gangwon Province is of paramount importance for the telemedicine services of Gangwon Province to progress and be maintained continuously in the days ahead. Furthermore, it is necessary to secure a basis for the assessment of scientific and medical-care-focused performance and to continuously develop and offer services that can appropriately assist residents.

### Notes

Conflict of Interest: No potential conflict of interest relevant to this article was reported.

### References

1. Gangwon Province. 6th Gangwon regional health plan. Gangwon, Korea: Gangwon Province; 2014.

2. Ahn ME, Park KS, Han JH, Shin SG. The guide of Gangwon Telemedicine System. Gangwon, Korea: Health Policy Department; 2015.

3. Ahn ME, Han JH. The operational performance of the Gangwon u-health service. Gangwon, Korea: Hallym University Telemedicine Center; 2013.

4. Ryu SW, Rhee HS, Lee KH, Yoon JY. The evaluation of situation and performance of Gangwon Telemedicine System. Seoul, Korea: Korea Institute for Health and Social Affairs; 2006.

5. Lee YT, Park JS, Kwak MS, Kim JY, Park SB, Lee KI. A pilot project comprehensive assessment for the application of the u-Health service in 2010. Seoul, Korea: Korea Health Industry Development Institute; 2010.

6. Jang MH. The influence of telemedicine service system on diabetes care [dissertation]. Chuncheon, Korea: Hallym University; 2008.

7. Kim KH, Lee MO, Lee JK, Ryu SW. Compliance of hypertensive patients registered in primary health care posts implementing the Gangwon telemedicine service system. J Korean Soc Health Inf Health Stat 2008;33:59-76.

8. Kim SJ, Moon OR, Ahn ME, Ryu SW. Estimating the willingness-to-pay for telehealth services of chronic disease in rural area. J Korean Soc Health Inf Health Stat 2007;32(1):17-31.

9. Lee YT, Park JS, Kang DW, Kim SY, Ryu SW, Park DK, et al. A pilot project comprehensive assessment for the application of the u-Health service. Seoul, Korea: Korea Health Industry Development Institute; 2009.

### Operational processes and the outcome summaries of u-health service in Gangwon Province

ADSL: asymmetric digital subscriber line, ECG: electrocardiogram, POCT: point of care testing.

### Current situation in terms of the number of patients, prescriptions, and drug administration days

aNumber of remote centers: the number of public health clinics that perform telemedicine services. bStatistical data from January 2015 to May 2015.

### General characteristics of subjects (patients)

Values are presented as number (%) or mean ± standard deviation.

aComplex disease: hypertension, diabetes mellitus, dementia, etc.

### Satisfaction rate with telemedicine services

HCP: healthcare practitioner.

### Compliance scores before and after the telemedicine service

aDrug prescription days score = total prescription days / required prescription days × 100. bLifestyle score = (1/16) (compliance on smoking + compliance on alcohol drinking + dietary compliance + compliance on exercise) × 100.

### Comparative analysis of HbA1c levels based on the HbA1c level of 6.5% in patients with DM in the region of Hoengseong county in 2012

Values are presented as number (%).

HbA1c: glycated hemoglobin, DM: diabetes mellitus.

### Control effect after telemedicine service in hypertension (n = 941)

Values are presented as number (%).

### Comparisons of blood pressure control for hypertensive patients with telemedicine service group and face-to-face service groups (unit: mmHg)

Values are presented as mean ± standard deviation or number (%).

### Willingness to pay estimators (survival analysis)

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