Guidelines on the Monitoring and Evaluation (M&E) of the Use of Telemedicine in COVID-19 Response (Joint Memorandum Circular No. 2020-0003)

Issuance Text

May 6, 2020

MEMORANDUM CIRCULAR
No. 2020 - 0024

TO : ALL UNDERSECRETARIES, ASSISTANT SECRETARIES, DIRECTORS OF BUREAUS, REGIONAL OFFICES AND SERVICES; EXECUTIVE DIRECTORS OF SPECIALTY HOSPITALS, AND NATIONAL NUTRITION COUNCIL; CHIEFS OF MEDICAL CENTERS, HOSPITALS, SANITARIA AND INSTITUTES; PRESIDENT OF THE PHILIPPINE HEALTH INSURANCE CORPORATION; DIRECTORS OF PHILIPPINE NATIONAL AIDS COUNCIL AND TREATMENT AND REHABILITATION CENTERS; AND OTHERS CONCERNED

SUBJECT : Department of Health – National Privacy Commission (DOH-NPC) Joint Memorandum Circular No. 2020-0003 entitled “Guidelines on the Monitoring and Evaluation (M&E) of the Use of Telemedicine in COVID-19 Response”

Attached for your information and guidance is a copy of the DOH-NPC Joint Memorandum Circular No. 2020-0003 dated April 14, 2020 entitled “Guidelines on the Monitoring and Evaluation (M&E) of the Use of Telemedicine i COVID-19 Response”

Dissemination of the information to all concerned is requested.

By Authority of the Secretary of Health:

LILIBETH C. DAVID, MD, MPH, MPM, CESO III
Undersecretary of Health
Health Facilities and Infrastructure Development Team

DEPARTMENT OF HEALTH
NATIONAL PRIVACY COMMISSION

April 14, 2020

JOINT MEMORANDUM CIRCULAR
No. 2020- 0003

SUBJECT: Guidelines on the Monitoring and Evaluation (M&E) of the Use of Telemedicine in COVID-19 Response

I. BACKGROUND

Due to the rise of COVID-19 cases in the country and pursuant to Republic Act No. 11332, the President issued Proclamation No. 922, s. 2020 declaring a State of Public Health Emergency throughout the Philippines, and consequently, Proclamation No. 929 s. 2020 placing the entire Luzon under enhanced community quarantine. Simultaneously, a number of local government units (LGUs) have implemented Community Quarantine in their respective jurisdiction.

In the implementation of the Enhanced Community Quarantine, one of the critical measures identified to curb the spread of COVID-19 is the suspension of public transportation. This, however, resulted in missed appointments, missed filling prescriptions, and poor disease management, particularly among individuals with chronic illnesses that require ongoing active care, even when care is readily available.

To help address this gap, under the Joint Memorandum Circular (JMC) # 2020-0001, the Department of Health (DOH) and the National Privacy Commission (NPC) have institutionalized the use of telemedicine as a supplemental and complementary method to enable patients to still receive health services even while staying at home except for serious conditions, emergencies, or to avail of COVID-19-related health services as per standing protocols.

II. OBJECTIVES

The objectives of this Joint Memorandum Circular are to provide actionable information for accountability and performance improvement for telemedicine services, and create evidence for informed decision-making for the DOH and NPC at policy level on the possible long-term use of telemedicine for service delivery.

III. SCOPE AND COVERAGE

This Joint Memorandum Circular shall apply to the program implementation of telemedicine services during the period of Enhanced Community Quarantine; and shall cover all public and private, national and local healthcare providers regulated by DOH and Philippine Health Insurance Corporation (PhilHealth) providing telemedicine services; DOH-engaged telemedicine partners; the Department of Health; and the National Privacy Commission.

IV. DEFINITION OF TERMS

For the purpose of this Joint Memorandum Circular, the following terms are defined:

1. Evaluation refers to an objective and systematic assessment of an ongoing or completed program to determine its effectiveness, outcomes, impact and sustainability.
2. Healthcare Providers refer to any of the following:
   • a. Physician refers to all individuals authorized by law to practice medicine pursuant to Republic Act No. 2382, or the “Medical Act of 1959,” as amended;
   • b. Health facility refers to a public or private facility or institution devoted primarily to the provision of services for health promotion, prevention, diagnosis, treatment, rehabilitation and palliation of individuals suffering from illness, disease, injury, disability, or deformity, or in need of medical and nursing care;
3. Monitoring refers to regular and routine collection and analysis of information to track progress of implementation of telemedicine services. It is conducted to ensure that this interim initiative is being implemented in accordance with its intent and to make informed decisions for policy and strategic management.
4. Processing refers to any operation or any set of operations performed upon patient’s data including, but not limited to, the collection, recording, organization, storage, updating or modification, extraction, retrieval, consultation, use, consolidation, blocking, submission, erasure or destruction of data; and
5. Telemedicine refers to the practice of medicine by means of electronic and telecommunications technologies such as phone call, chat or short messaging service (SMS), audio- and video-conferencing, among others, to deliver healthcare at a distance between a patient at an originating site, and a physician at a distant site.
6. Telemedicine partner refers to a telemedicine company that has registered with the DOH telemedicine program in COVID-19 response and met the requirements for engagement as set forth under JMC 2020-0001 and its offshoot policies.

V. DECLARATION OF PRINCIPLES

The following principles shall govern the implementation of this Joint Memorandum Circular:

1. Results-based. Program management of telemedicine services shall have defined and measurable results that indicate the success of implementation. This contributes to better performance and accountability. It shall focus on activities, outputs, and short-term outcomes.
2. Effectiveness. Evidence of effectiveness, equity and sustainability shall be the basis for long-term use/implementation.
3. Alignment. The results of the monitoring and evaluation shall be interpreted together with existing agency management tools such as the Performance Governance System, and other relevant monitoring and evaluation tools or solutions to ensure strategic alignment and performance improvement.

VI. GUIDELINES

• A. Implementation Governance

  1. The interagency National eHealth Technical Working Group (NEHTWG) shall set policy directions and program oversight for the implementation of telemedicine services across the country.
  2. The NEHTWG shall organize the Sub-Committee on Telemedicine that will: (a) review and monitor the progress of implementation of telemedicine services; (b) conduct the necessary consultations and coordination with concerned stakeholders; and (c) submit monthly assessment and accomplishment reports to the NEHTWG for performance monitoring and evaluation.
     • The Sub-Committee on Telemedicine shall be composed of policy and technical experts on telemedicine from relevant agencies and organizations as defined by the NEHTWG.
  3. The National eHealth Program Management Office (NEHPMO) in KMITS of the DOH shall act as the overall technical and administrative secretariat for all activities related to the program implementation of telemedicine services.

• B. Situational Analysis, Goal-Setting and Planning

  1. The Sub-Committee on Telemedicine shall prepare strategic and operational plans, and endorse them to the NEHTWG for review and approval.
  2. These plans shall include a monitoring and evaluation framework. Initial dimensions for monitoring and evaluation shall be as follows:
     • a. Outcome measures (safety, effectiveness, efficiency, and quality of care);
     • b. Performance measures (access, functionality, quality and cost of service);
     • c. Summary measures (cost comparison); and
     • d. Operational measures (access, acceptability, provider satisfaction, patient satisfaction, data privacy and cybersecurity).
  4. A list of indicators and corresponding targets shall guide implementers to improve performance and results. (Annex 1.0.)

• C. Monitoring

  1. Healthcare Providers
     • a. All healthcare providers who have registered with a DOH telemedicine partner shall provide relevant information that will enable the telemedicine partners to provide timely reports to DOH.
     • b. Any other healthcare providers in telemedicine are encouraged to use secure non-public-facing platforms for the conduct of the teleconsultation while inputting consult data using the DOH data entry platform which can be accessed at telemed.doh.gov.ph. Reports will be extracted by DOH from the platform.
       • Required documentation for submission to DOH shall be the signed performance commitment (Annex 2.0).
  2. Telemedicine Partners
     • a. All telemedicine partners shall submit: (1) signed performance commitments; and (2) required documentations and reports to DOH through nationalehealthprogram@gmail.com in a timely manner. (Annex 3.0)
     • b. Telemedicine partners can adopt their own monitoring tools and solutions apart from the DOH requirements.
  3. NEHPMO
     • a. The NEHPMO shall: (i) receive and consolidate all submitted documentations and reports from telemedicine providers and those submitted from the DOH data entry platform; and (ii) provide the Sub-Committee on Telemedicine a summary result of findings and recommendations.
     • b. Feedback from the Sub-Committee on Telemedicine shall result in appropriate and timely action to address issues in program implementation.
  4. Sub-Committee on Telemedicine
     • a. The Sub-Committee shall provide guidance on monitoring and evaluation, and recommend relevant policies to the NEHTWG as necessary.
     • b. Random audits to verify compliance with applicable DOH and NPC guidelines on the implementation of telemedicine services shall be decided by the Sub-Committee.

• D. Evaluation

  1. A formative evaluation shall be conducted at an appropriate time.
  2. The results of the formative evaluation shall be used to determine if the program is effective in attaining its goals and objectives for COVID-19 response, and consequently, at the policy level on the possible long-term use of telemedicine for service delivery.

VII. REPEALING CLAUSE

All previous issuances that are inconsistent with any provisions of this Joint Memorandum Circular are hereby amended, modified, or repealed accordingly.

VIII. SEPARABILITY CLAUSE

In the event that any provision or part of this Joint Memorandum Circular is declared unauthorized or rendered invalid by any court of law, those provisions not affected by such declaration shall remain valid and in effect.

IX. EFFECTIVITY

This Joint Memorandum Circular shall take effect immediately for the duration of the declared Enhanced Community Quarantine for the management of COVID-19 health situation, and the effectivity of this Order shall likewise be automatically lifted once the imposed quarantine is lifted.

FRANCISCO T. DUQUE III, MD, MSc
Secretary
Department of Health

RAYMUND E. LIBORO
Privacy Commissioner and Chairman
National Privacy Commission

Annex 1.0. Monitoring and Evaluation Indicators

Dimensions	Indicators for Monitoring	Source/Method	Frequency of Collection	Unit Responsible for Monitoring
Outcome & Summary Measures	Output
	Average patient satisfaction rating of the telemedicine services provided by the healthcare provider	Submitted telemedicine reports	Monthly	NEHPMO, KMITS
Performance Measures	Input
	# of physicians engaged as providers of telemedicine services	Submitted telemedicine reports	Weekly	NEHPMO, KMITS
	# of unique individual patients who sought health services through telemedicine per healthcare provider (disaggregation: individual health facility vs individual physician; daily vs weekly)	Submitted telemedicine reports	Weekly	NEHPMO, KMITS
	Output
	# of telemedicine consultations received per healthcare provider (disaggregation: companion-assisted patient consultation vs non-companion-assisted/individual patient consultation; individual health facility vs individual physician; daily vs weekly)	Submitted telemedicine reports	Weekly	NEHPMO, KMITS
	Type of telemedicine consultations received per healthcare provider (disaggregation: COVID-19 vs non-COVID-19 health concerns; individual health facility vs individual physician; daily vs weekly)	Submitted telemedicine reports	Weekly	NEHPMO, KMITS
	Reasons for consultations (disaggregation: COVID-19 vs non-COVID-19 health concerns; individual health facility vs individual physician; daily vs weekly)	Submitted telemedicine reports	Weekly	NEHPMO, KMITS
	Clinical classification (disaggregation: COVID-19 vs non-COVID-19 health concerns; individual health facility vs individual physician)	Submitted telemedicine reports	Weekly	NEHPMO, KMITS
	Type of disposition per telemedicine consultation received (disaggregation: COVID-19 vs non-COVID-19 health concerns; individual health facility vs individual physician)	Submitted telemedicine reports	Weekly	NEHPMO, KMITS
Operational Measures	Input
	# of telemedicine providers engaged by DOH	Signed performance commitment & MOA	Weekly	NEHPMO, KMITS
	# of LGUs with engaged telemedicine providers	Signed MOA	Weekly	NEHPMO, KMITS
	# of health facilities engaged per telemedicine provider	Signed performance commitment & MOA	Weekly	NEHPMO, KMITS
	Presence of a Data Protection Officer	Submitted telemedicine reports	One time/as updated	NEHPMO, KMITS
	Privacy policy for telemedicine providers	Telemedicine privacy policy	One time/as updated	NEHPMO, KMITS
	Privacy management program in place for telemedicine providers	Privacy management program implementation plan or privacy manual	One time/as updated	NEHPMO, KMITS
	Activities
	Telemedicine program implementation plan in place for telemedicine providers	Telemedicine program implementation plan	One time/as updated	NEHPMO, KMITS
	Output
	# of patient complaints received by healthcare providers	Submitted telemedicine reports	Weekly	NEHPMO, KMITS
	# of patient complaints closed by healthcare providers	Submitted telemedicine reports	Weekly	NEHPMO, KMITS
	Types of complaints (i.e. privacy and security breach, medical errors, cost for access, provider disengagement, etc.) - built in monitoring and feedback mechanism in the platform for customer service	Submitted telemedicine reports	Weekly	NEHPMO, KMITS
	# of security incidents and personal data breaches reported within NPC protocols (incident reporting mechanism)	Submitted telemedicine reports	Weekly	NEHPMO, KMITS

Annex 2.0. Performance Commitment for Healthcare Providers who are Unable to Register with a DOH Telemedicine Partner

(Date)
DEPARTMENT OF HEALTH
San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila

SUBJECT: Performance Commitment

Sir/Madam:

To guarantee our commitment to support the fight against COVID-19, I respectfully submit this Performance Commitment. And for the purposes of this Performance Commitment, I hereby warrant the following representations:

1. That I agree to be enrolled in a sandbox implementation program for the utilization of telemedicine in response to COVID-19. The overall goal is to use telemedicine as a medium to deliver health services to patients in a safe environment following established treatment algorithms and guidelines while utilizing current technology capabilities.

2. That I shall only use a secure platform for medical consultation and referral of patients to the nearest health facility, if necessary.

3. That I shall ensure that the privacy settings of the platform being used is compliant with the minimum legal and regulatory laws and frameworks in the Philippines.

4. That I shall not use public-facing platforms like Youtube or Facebook Live, and such other similar public-facing platforms, for telemedicine consultations.

5. That I shall first obtain the informed consent of the patient prior to the collection of any personal data and the offering of any telemedicine service.

6. That I shall uphold the data privacy rights of patients using the platform, and shall provide mechanisms for the effective exercise of these rights. Patients should be: (a) informed that the platform being used entails privacy risks and that a telehealth consultation may not be equivalent to a face-to-face consult; (b) allowed to discuss their privacy and other related concerns, if any; and (c) be given the option not to proceed with the consult.

7. That I shall ensure that reasonable and appropriate security measures are implemented to safeguard the patients’ data collected, used, stored, or otherwise processed using the platform, against any accidental or unlawful destruction, alteration or disclosure as well as unlawful access, fraudulent misuse, or any other unauthorized processing.

   • 7.1. Patients should be informed that any personal data obtained in the course of the consult shall be used for medical treatment, kept confidential, and only those involved in patient’s care shall have access.
   • 7.2. That I shall choose a place to conduct the telemedicine consultation beforehand, i.e. conducive to communicating with the patient, and where interruptions or potential unwarranted disclosures are avoided.

8. That I shall comply with all pertinent DOH COVID-19 and non-COVID-19 treatment algorithms and guidelines, including patient surveillance.

9. That I recognize that DOH and I shall be the controller of patients’ data, which remains to be owned by the individual patients.

10. That I shall comply with the necessary protocols for data sharing, monitoring and evaluation activities.

11. That I shall render telemedicine services without cost either to the DOH or to the patients receiving the services.

12. That I shall be held liable for any security incident, or privacy violation, or personal data breaches, and other related issues and concerns arising from the conduct of telemedicine consultation, and which are attributable to me or my acts.

13. Nothing in this document shall be interpreted or construed as creating or establishing an Employer-Employee relationship between the DOH and the healthcare provider.

We commit to extending our full support in order to effectively and appropriately deliver primary care teleconsultations to those who are in need.

Very Truly Yours,

______________________________
Name of Healthcare Provider

______________________________
License Number

______________________________
Contact Details (i.e. address, phone number & email)

______________________________
Telemedicine platform being used

Reference: Patdu, Ivy D. (19 March 2020). Privacy should not be an obstacle to telemedicine. Newsbytes.PH. Retrieved from http://newsbytes.ph/2020/03/patdu-privacy-should-not-be-an-obstacle-to-telemedicine/.

Annex 3.0. Program Documentations and Reports for Submission by Telemedicine Partners

3.1. Telemedicine Program Implementation Document

Minimum Content Requirements

Frequency of Submission

1. Signed performance commitment (telemedicine company) 2. Signed performance commitment (for engaged healthcare providers) 3. Accomplished ICT service provider request form 4. Accomplished telemedicine program profile 5. Certified true copy of signed MOA with LGU (if applicable) 6. Telemedicine platform, including data and solutions architecture 7. Health human resource recruitment and management protocol 8. Telemedicine consultation protocol 9. Data privacy and cybersecurity measures 10. Risk and issue management protocol 11. Marketing protocol

One-time/As updated

3.2. Telemedicine Privacy Management Program Document

Minimum Content Requirements	Frequency of Submission
1. Contact details of data protection officer 2. Privacy policy 3. Documentation of privacy impact assessment 4. Privacy management program implementation plan or privacy manual	One-time/As updated

3.3. Weekly Status Reports (to be submitted every Monday of the following week)

• a. Demographics

  • Name of telemedicine provider
  • Total #, names, and contact details of LGUs engaged
  • Total #, names and addresses of health facilities engaged as providers of telemedicine services
  • Total #, names and contact details of physicians engaged as providers of telemedicine services

• b. Summary of telemedicine consultations

  • Total # of unique individual patients who sought health services through telemedicine per healthcare provider per day (disaggregation: individual health facility vs individual physician)
  • Total # of telemedicine consultations received per healthcare provider per day (disaggregation: companion-assisted patient consultation vs non-companion-assisted/individual patient consultation; individual health facility vs individual physician)
  • Type of telemedicine consultations received per healthcare provider (disaggregation: COVID-19 vs non-COVID-19 health concerns; individual health facility vs individual physician)
  • Reasons for consultations received per healthcare provider (disaggregation: COVID-19 vs non-COVID-19 health concerns; individual health facility vs individual physician)
  • Clinical classification (disaggregation: COVID-19 vs non-COVID-19 health concerns; individual health facility vs individual physician)
  • Type of disposition per telemedicine consultation received (disaggregation: COVID-19 vs non-COVID-19 health concerns; individual health facility vs individual physician)

  Name of Telemedicine Provider:
  Name and Address of Health Facility
  Name of Physician

  Case #	Age	Residence	Date of Consultation	Patient was accompanied by a companion during consultation (Y/N)	Reason for Consultation	COVID-19 Health Concern (Y/N)	Non-COVID-19 Health Concern (Y/N)	Diagnosis	Plan of Management	Issued ePrescription (Y/N)	Issued Referral to Health Facility (Y/N)	Clinical Classification	Disposition

• c. Feedback

  • Average patient satisfaction rating of the telemedicine services provided by the healthcare provider
  • # of patient complaints received by healthcare providers
  • # of patient complaints closed by healthcare providers
  • Types of complaints (i.e. privacy and security breach, medical errors, etc.)

  Name of Telemedicine Provider:
  Name and Address of Health Facility
  Name of Physician

  Case #	Patient Satisfaction Rating	Complaints/Issues (Y/N)	If yes, nature of complaint.	Action Taken	Closed (Y/N)	If no, indicate reason.

  • # of telemedicine provider complaints received from healthcare providers
  • # of telemedicine provider complaints from healthcare providers closed
  • Types of telemedicine provider complaints (i.e. disengagement, etc.)
  • # of security incidents and personal data breaches reported within NPC protocols (incident reporting mechanism)

  Name of Telemedicine Provider:
  Total # of LGUs engaged
  Total # of health facilities engaged
  Total # of physicians engaged

  Name of Health Facility	Address	Complaints/Issues (Y/N)	If yes, nature of complaint.	Action Taken	Closed (Y/N)	If no, indicate reason

  Name of Physician	Complaints/Issues (Y/N)	If yes, nature of complaint.	Action	Closed (Y/N)	If no, indicate reason

3.4. Performance Commitment for DOH Telemedicine Partners

(Letterhead of Telemedicine Company)

(Date)
DEPARTMENT OF HEALTH
San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila

SUBJECT: Performance Commitment

Sir/Madam:

To guarantee our commitment to support the fight against COVID-19, we respectfully submit this Performance Commitment. And for the purposes of this Performance Commitment, we hereby warrant the following representations:

1. That we agree to be enrolled in a sandbox implementation program for the utilization of telemedicine in response to COVID-19 where telemedicine companies are enjoined to conform to a minimum set of standard regulation for the practice of telemedicine. The overall goal is to test telemedicine as a medium to deliver care to individuals in a safe environment, utilizing current technology capabilities.

2. That we are a duly recognized telemedicine company abiding by the legal and regulatory framework of the country.

3. That all professional health care providers in our company possess proper credentials and given appropriate privileges in accordance with our policies and procedures.

4. That we shall render telemedicine services without cost either to the Department of Health or to the patients receiving the services.

5. That we shall ensure that all operations are compliant with all appropriate legal and regulatory frameworks in the Philippines.

6. That we shall provide a mechanism for physicians or medical doctors to sign up for this initiative and in the interim, for the latter to volunteer their medical services to the public at no charge to the patient.

7. That we shall provide a form of safety assurance for physicians to operate Telemedicine services to the patients or individuals.

8. That we shall provide a secure and user-friendly platform which shall be made available for medical consultation. The physicians or medical doctors will be able to make use of the process of this platform to record and maintain patient data and refer the patient to the nearest health facility, if necessary.

9. That we shall ensure that reasonable and appropriate security measures are implemented to safeguard the patients’ and doctors’ data collected, used, stored, or otherwise processed using the platform, against any accidental or unlawful destruction, alteration or disclosure as well as unlawful access, fraudulent misuse, or any other unauthorized processing.

10. That we shall train volunteer physicians to handle telemedicine consultations.

11. That we shall first obtain the informed consent of the patient prior to the collection of any personal data and the offering of any telemedicine service.

12. That we shall uphold the data privacy rights of patients and physicians or medical doctors using the platform, and shall provide mechanisms for the effective exercise of these rights.

13. That we shall comply with all pertinent DOH guidelines on COVID-19 responses and patient surveillance.

14. That we recognize that the DOH shall be the controller of patients’ data, which remains to be owned by the individual patients.

15. That we shall comply with the necessary protocols for data sharing, monitoring and evaluation activities.

16. That we shall act as the processor of patient data for and on behalf of the DOH.

17. That we shall be held liable for any security incident, or privacy violations, or personal data breaches, and other related issues and concerns arising from the use of our platform, and which are attributable to our platform or our company.

18. Nothing in this document shall be interpreted or construed as creating or establishing an Employer-Employee relationship between the DOH and telemedicine partner.

We commit to extending our full support in order to effectively and appropriately deliver primary care teleconsultations to those who are in need.

Very Truly Yours,

______________________________
Authorized Representative of the Telemedicine Company

3.5. Performance Commitment for Engaged Healthcare Providers by DOH Telemedicine Partners

(Date)
DEPARTMENT OF HEALTH
San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila

SUBJECT: Performance Commitment

Sir/Madam:

To guarantee our commitment to support the fight against COVID-19, I respectfully submit this Performance Commitment. And for the purposes of this Performance Commitment, I hereby warrant the following representations:

1. That I agree to be enrolled in a sandbox implementation program for the utilization of telemedicine in response to COVID-19. The overall goal is to use telemedicine as a medium to deliver health services to patients in a safe environment following established treatment algorithms and guidelines while utilizing current technology capabilities.

2. That I shall only use a secure platform for medical consultation and referral of patients to the nearest health facility, if necessary.

3. That I shall ensure that the privacy settings of the platform being used is compliant with the minimum legal and regulatory laws and frameworks in the Philippines.

4. That I shall not use public-facing platforms like Youtube or Facebook Live, and such other similar public-facing platforms, for telemedicine consultations.

5. That I shall first obtain the informed consent of the patient prior to the collection of any personal data and the offering of any telemedicine service.

6. That I shall uphold the data privacy rights of patients using the platform, and shall provide mechanisms for the effective exercise of these rights. Patients should be: (a) informed that the platform being used entails privacy risks and that a telehealth consultation may not be equivalent to a face-to-face consult; (b) allowed to discuss their privacy and other related concerns, if any; and (c) be given the option not to proceed with the consult.

7. That I shall ensure that reasonable and appropriate security measures are implemented to safeguard the patients’ data collected, used, stored, or otherwise processed using the platform, against any accidental or unlawful destruction, alteration or disclosure as well as unlawful access, fraudulent misuse, or any other unauthorized processing.

   • 7.1. Patients should be informed that any personal data obtained in the course of the consult shall be used for medical treatment, kept confidential, and only those involved in patient’s care shall have access.
   • 7.2. That I shall choose a place to conduct the telemedicine consultation beforehand, i.e. conducive to communicating with the patient, and where interruptions or potential unwarranted disclosures are avoided.

8. That I shall comply with all pertinent DOH COVID-19 and non-COVID-19 treatment algorithms and guidelines, including patient surveillance.

9. That I recognize that DOH and I shall be the controller of patients’ data, which remains to be owned by the individual patients.

10. That I shall comply with the necessary protocols for data sharing, monitoring and evaluation activities.

11. That I shall render telemedicine services without cost either to the DOH or to the patients receiving the services.

12. That I shall be held liable for any security incident, or privacy violation, or personal data breaches, and other related issues and concerns arising from the conduct of telemedicine consultation, and which are attributable to me or my acts.

13. Nothing in this document shall be interpreted or construed as creating or establishing an Employer-Employee relationship between the telemedicine partner and healthcare provider, and between the DOH and the healthcare provider.

We commit to extending our full support in order to effectively and appropriately deliver primary care teleconsultations to those who are in need.

Very Truly Yours,

______________________________
Name of Healthcare Provider

______________________________
License Number

______________________________
Contact Details (i.e. address, phone number & email)

Reference: Patdu, Ivy D. (19 March 2020). Privacy should not be an obstacle to telemedicine. Newsbytes.PH. Retrieved from http://newsbytes.ph/2020/03/patdu-privacy-should-not-be-an-obstacle-to-telemedicine/.

3.6. ICT Solutions Provider Request Form

Republic of the Philippines
Department of Health
KNOWLEDGE MANAGEMENT AND INFORMATION TECHNOLOGY SERVICE

ICT Solutions Provider Request Form

Date Submitted: ____________________

Company Details
Name of Provider
Main Office Address	Address: ____________________ City: __________ Region: __________ Zip Code: ______
Website (if none, attach company/business profile)
Years of Operation	☐ Please check if start-up (pending business registration)
Company Ownership	☐ Sole Proprietorship (Company) ☐ Partnership ☐ Sole Proprietorship (Consultant) ☐ Corporation ☐ Government agency or GOCC ☐ Non-Profit Organization ☐ Others (please specify): ____________________
Type of Provider	☐ Manufacturer ☐ Systems Integrator ☐ Distributor ☐ Reseller
Details of ICT Solution
Commercial Name/s of ICT Solution (if applicable)
Category	☐ Service/ICT Consultancy ☐ Mobile Health Applications ☐ Electronic Health/Medical Record System ☐ Telehealth Applications ☐ Hospital Information System ☐ ICT-based Biomedical Device ☐ Systems Software ☐ Other Software Application ☐ Cybersecurity Solutions ☐ Hardware, including computer peripherals and telephony ☐ Others (please specify): ____________________
Health System Dimensions that the ICT Solution aims to address/support (select whichever is appropriate)	☐ Data warehousing and business intelligence. ☐ Disease prevention and control, and health protection. ☐ Epidemiological surveillance and response. ☐ Supply chain management. ☐ Procurement and financial management. ☐ Health promotion and communications. ☐ Data privacy and cybersecurity. ☐ Alternative models of service delivery (e.g. telehealth) ☐ Electronic medical/health records management. ☐ Interoperability, electronic health information exchange, and service referral. ☐ ICT capacity building and management. ☐ Corporate ICT infrastructure.
Brief Description of ICT Solution
Request Details
Nature of Partnership Requested	☐ For government procurement under RA 9184 (GPRA) ☐ For public-private partnership for health under RA 7718 (BOT Law) or JV Guidelines ☐ For pilot implementation ☐ For health technology assessment ☐ Others (please specify): ____________________
Indicative Cost of Partnership (in PHP) (Indicate “0” if none)	Government (DOH) Indicative Cost Upfront Cost: __________ Subscription Cost: __________ Maintenance Cost: __________ Provider Indicative Cost Upfront Cost: __________ Subscription Cost: __________ Maintenance Cost: __________
Nature of Presentation (if applicable)	☐ N/A ☐ Company Profile Presentation ☐ ICT Solutions Demonstration ☐ Proof of Concept ☐ Others:
Contact Details
Primary Contact Person	Name: __________ Position: __________ Mobile No.: __________ Email: __________
Visiting Party Details (Name & Position)	1. 2. 3.
Other Details	☐ Yes ☐ No - Is this your first time to send this request form? ☐ Yes ☐ No - Do you have any government procurement experience? ☐ Yes ☐ No - Is your organization a past or current DOH contractor? ☐ Yes ☐ No - Does your organization have a Data Protection Officer? If yes, please indicate name and contact details: __________ ☐ Yes ☐ No - Any conflict of interest? If yes, please indicate: __________
(For Knowledge Management and Information Technology Service use only)
Reference Number
Date Received
KMITS Focal Person/s
Actions Taken	☐ Presentation date Date: __________ ☐ Officially relayed recommendation Date: __________ ☐ Endorsed to __________ Date: __________
Findings and Recommendations	☐ For proof of concept study ☐ For pilot demonstration ☐ For health technology assessment ☐ For participation in an ongoing DOH procurement ☐ For endorsement to PPPH-Program Management Unit ☐ For endorsement to another DOH Office/Agency: __________ ☐ Duplication with an existing DOH solution ☐ With conflict of interest ☐ Others: __________
Noted by	____________________ DR. ENRIQUE A. TAYAG, PHSAE, FPSMID, CESO III Director IV

Instructions:
E-mail a scanned copy of this form and presentation to nationalehealthprogram@doh.gov.ph
For more information, you may access FAQ’s for ICT Solutions Provider: bit.ly/DOHictspFAQ

3.7. Telemedicine Program Profile Template

TELEMEDICINE PROGRAM PROFILE

[Telemedicine Company]
SHORT PROFILE OF COMPANY
INSTRUCTION FOR PUBLIC TO ACCESS THE PLATFORM (e.g. hotline, mobile app, etc).
OPERATING HOURS
DESCRIPTION OF TELEMEDICINE SYSTEM FUNCTIONALITIES
PATIENT FLOW (ALGORITHM INTEGRATING DOH COVID-19 PROCESS FLOWS)
DESCRIPTION OF MANPOWER OR REQUIREMENTS FOR VOLUNTEER PHYSICIANS
AUTHORIZED REPRESENTATIVE AND CONTACT INFORMATION
MONITORING AND EVALUATION MECHANISMS FOR PERFORMANCE/QUALITY

Annex 4.0 Recommended Templates

4.1. Clinical Abstract/Consultation Summary Template

Name of Physician:	Date & Time of Teleconsultation:
Name and Address of Health Facility (if applicable):	Name of Telemedicine Partner (if applicable): If none, indicate telemedicine platform being used:

Prior to teleconsultation proper, obtain patient consent: ( ) Yes ( ) No
Is patient accompanied/assisted by another person during the consultation: ( ) Yes ( ) No

A. DEMOGRAPHIC PROFILE

1. Patient Profile			Case #
Last Name	First Name	Middle Name	Birthdate (yyyy-mm-dd)	Age	Sex
Occupation	Civil Status	Nationality	PhilHealth No.	Passport No.
Name of Companion: (if patient is assisted/accompanied during the teleconsultation)			Relationship:	Phone No.

2. Philippine Residence
House No./Lot/Bldg.	Street	Municipality/City	Province
Region	Home Phone No.	Cellphone No.	Email address

B. CLINICAL HISTORY AND PHYSICAL EXAMINATION

3. Clinical History
Reason for Consultation
Date of Onset of Illness	Name of Referral Health Facility (if applicable)	Date of Referral (if applicable)
Known Medical Condition/s and Medical History
Current Medications		Blood Type

4. Physical Examination (Inspection)
Clinical Status at the time of Consult
Specific Findings

C. COVID-19 SCREENING

5. Overseas Employment Address (for Overseas Filipino Workers)
Employer’s Name:			Place of Work:
House #/Bldg. Name	Street	City/Municipality	Province/State
Country	Office Phone No.		Cellphone No.

6. Travel History
History of travel/visit/work in other countries with known COVID-19 transmission14 days prior to onset of signs and symptoms: ( ) Yes ( ) No		Port of exit:
Airline/Sea vessel:	Flight/Vessel Number	Date of Departure	Date of Arrival in Philippines:

7. Exposure History
Known COVID-19 Case: ( ) Yes ( ) No ( ) Unknown	If yes: Date of Contact with Known COVID-19 Case:
Accommodation ( ) Yes ( ) No ( ) Unknown Specify type: Address:	Date of Last Exposure: Name: ( ) Guest ( ) Hotel worker
Food Establishment ( ) Yes ( ) No ( ) Unknown Specify type: Address:	Date of Last Exposure: Name: ( ) Diner ( ) Crew
Store ( ) Yes ( ) No ( ) Unknown Specify type: Address:	Date of Last Exposure: Name: ( ) Customer ( ) Worker
Health Facility ( ) Yes ( ) No ( ) Unknown Specify type: Address: Significant Other	Date of Last Exposure: Name: ( ) Patient ( ) Health Worker ( )
Event ( ) Yes ( ) No ( ) Unknown Specify type:	Date of Last Exposure: Event Place:
Workplace ( ) Yes ( ) No ( ) Unknown Company Name:	Date of Last Exposure: Address:
List of names of persons in contact with during any of this occasion, and their contact numbers:

8. Clinical Assessment
Symptomatic: A. 14 days PRIOR to first date of exposure ( ) Yes ( ) No B. Anytime during date of exposure ( ) Yes ( ) No	If yes, date of onset of illness: Name of referral health facility: Date of referral:	If no, place of quarantine: ( ) Home ( ) Quarantine Facility: __________
Fever _____ °C Cough ( ) Colds ( ) Sore throat ( ) Diarrhea ( ) Shortness/ difficulty of breathing ( )
Other symptoms, specify	Is there any history of other illness? ( ) Yes ( ) No If YES, specify: __________
Chest X-Ray done? ( ) Yes ( ) No If yes, when? __________	Are you pregnant? ( ) Yes LMP __________ ( ) No
CXR Results: Pneumonia ( ) Yes ( ) No ( ) Pending	Other Radiologic Findings:

9. Specimen Information
Specimen Collected	If YES, Date Collected	Date sent to RITM or any accredited laboratory	Date received in RITM or any accredited laboratory	Virus Isolation Result	RT-PCR Result
( ) Serum	___/___/___	___/___/___	___/___/___
( ) Oropharyngeal/ Nasopharyngeal swab	___/___/___	___/___/___	___/___/___
( ) Others	___/___/___	___/___/___	___/___/___

10. Classification
☐ Suspect Case ☐ Probable Case ☐ Confirmed Case

11. Outcome
Date of Discharge:	Condition on Discharge: ( ) Died ( ) Improved ( ) Recovered ( ) Transferred ( ) Absconded

D. DIAGNOSIS/ASSESSMENT
Summary of Assessment Findings
Diagnosis Clinical Classification: ( ) COVID-19 Case ( ) Non-COVID-19 Case If COVID-19 Case, ( ) Suspected Case ( ) Probable Case ( ) Confirmed Case

E. PLAN OF MANAGEMENT
Plan of Management: Prescription: Referral:
Disposition:

Name & Digital Signature of Physician:	License #	Professional Tax Receipt (if applicable):

COVID-19 Case Classification

1. Suspect case – is a person who is presenting with any of the conditions below.
   • a. All Severe Acute Respiratory Infection (SARI) cases where NO other etiology fully explains the clinical presentation.
   • b. Influenza-Like Illness (ILI) cases with any one of the following:
     • i. with no other etiology that fully explains the clinical presentation AND a history of travel to or residence in an area that reported local transmission of COVID-19 disease during the 14 days prior to symptom onset OR
     • ii. with contact to a confirmed or probable case of COVID-19 in the two days prior to onset of illness of the probable/confirmed COVID-19 case until the time the probable/confirmed COVID-19 case became negative on repeat testing.
   • c. Individuals with fever or cough or shortness of breath or other respiratory signs or symptoms fulfilling any one of the following conditions:
     • i. Aged 60 years and above
     • ii. With a comorbidity
     • iii. Assessed as having a high-risk pregnancy
     • iv. Health worker
2. Probable case – a suspect case who fulfills anyone of the following listed below.
   • a. Suspect case whom testing for COVID-19 is inconclusive
   • b. Suspect who tested positive for COVID-19 but whose test was not conducted in a national or subnational reference laboratory or officially accredited laboratory for COVID-19 confirmatory testing
3. Confirmed case – any individual, irrespective of presence or absence of clinical signs and symptoms, who was laboratory confirmed for COVID-19 in a test conducted at the national reference laboratory, a subnational reference laboratory, and/or DOH-certified laboratory testing facility.

4.2. Patient Satisfaction Survey Form

Name of Patient: ____________________
Case # ____________________
Name of Provider: ____________________
Date of Consultation: ____________________

Questions	Rating					Remarks
1. How comfortable did you feel?	1 (not at all comfortable)	2	3	4	5 (very comfortable)
2. How convenient was the encounter?	1 (not at all convenient)	2	3	4	5 (very convenient)
3. Was the lack of physical contact acceptable?	1 (not acceptable)	2	3	4	5 (very acceptable)
4. Concerns about privacy?	1 (no concerns)	2	3	4	5 (very concerned)
5. Overall satisfaction?	1 (not at all satisfied)	2	3	4	5 (very satisfied)
6. Would you do a teleconsultation again?	Yes			No
7. Suggestions and recommendations

4.3. Sample Informed Consent

AUTHORIZATION AND CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION
PAGPAPAHINTULOT AT PAGSANG-AYON NA LUMAHOK SA KONSULTASYONG TELEMEDICINE (SAMPLE CONSENT)

The purpose of this form is to obtain your consent to participate in a telemedicine consultation with the following physician: __________________
Ang layunin ng form na ito ay makuha ang inyong pahintulot upang lumahok sa isang konsultasyong telemedicine ni Dr. __________________.

Purpose and Benefits. The purpose of this service is to use telemedicine to enable patients to still receive health services even while staying at home during the enhanced community quarantine, except for serious conditions, emergencies, or to avail of COVID-19-related health services as per standing protocols.
Layunin at Benepisyo. Ang layunin ng serbisyong ito ay gumamit ng telemedicine para mabigyan ng pagkakataon ang mga pasyenteng apektado ng enhanced community quarantine na nasa bahay na patuloy na makapagkonsulta at makatanggap ng serbisyong medical, maliban na lamang kapag ang pasyente ay may malubhang sakit o may medical emergencies na nangangailangan ng agarang atensyong medical, or makakuha ng COVID-19-related na serbisyong medical alinsunod sa mga umiiral na protocol.

Nature of Telemedicine Consultation: During the telemedicine consultation:
Anyo ng Konsultasyong Telemedicine: Sa inyong konsultasyong telemedicine:

• a) Details of you and/or the patient’s medical history, examinations, x-rays, and tests will be collected and discussed with other health professionals through the use of interactive video, audio and telecommunications technology if needed.
  Ang mga detalye mo at/o ng pasyente tungkol sa kasaysayang pang-medikal, mga ginawang pagsusuri at x-ray ay kokolektahin at tatalakayin kasama ng ibang mga eksperto sa pamamagitan ng interactive video, audio, at telecommunications technology kung kinakailangan.
• b) Physical examination of you or the patient may take place.
  Ang pisikal na pagsusuri sa iyo o ng pasyente ay maaaring gawin.
• c) Nonmedical technical personnel may be present in the telemedicine studio to aid in video transmission, if needed.
  Maaaring may makasamang mga kawani sa telemedicine studio upang magbigay ng serbisyong teknikal at umagapay sa video transmission kung kakailanganin.
• d) Video, audio, and/or digital photo may be recorded during the telemedicine consultation visit.
  Maaaring i-record ang video, audio, at/o kumuha ng larawan habang isinisagawa ang konsultasyong telemedicine.

Medical Information and Records. All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Additionally, dissemination of any patient-identifiable images or information from this telemedicine interaction to researchers or other entities shall not occur without your consent, unless authorized by existing law, policies and guidelines on privacy and data protection.
Impormasyong Pang-medikal at Mga Talaan. Lahat ng mga umiiral na batas tungkol sa inyong pagkuha ng impormasyong pang-medikal at ng inyong mga talaang pang-medikal ay naaangkop sa konsultasyong telemedicine na ito. Bukod dito, ang pagpapakalat ng mga larawan ng pasyente at impormasyon sa pakikipag-ugnayang telemedicine na ito sa mga mananaliksik at ibang tao ay hindi mangyayari nang wala ang inyong pagsang-ayon, maliban na lamang kung ito ay pinahihintulutan ng mga umiiral na batas, polisiya at alintuntunin tungkol sa privacy and data protection.

Confidentiality. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation. All existing law, policies and guidelines on privacy and data protection apply to information disclosed during this telemedicine consultation.
Confidentiality. Isinagawa ang mga makatwiran at naaangkop na hakbang upang alisin ang anumang panganib sa confidentiality ng gagawing konsultasyong telemedicine. Lahat ng umiiral na batas, polisiya at alintuntunin tungkol sa privacy and data protection ay nakapaloob at naaangkop sa mga ibibigay na impormasyon sa konsultasyong telemedicine na ito.

Risks and Consequences. The telemedicine consultation will be similar to a routine medical office visit, except interactive video technology will allow you to communicate with a physician at a distance. At first you may find it difficult or uncomfortable to communicate using video images. The use of video technology to deliver healthcare and educational services is a new technology and may not be equivalent to direct patient to physician contact. Following the telemedicine consultation, your physician may recommend a visit to a health facility for further evaluation.

Nakaambang Panganib at Kahihinatnan. Ang konsultasyong telemedicine na ito ay kahalintulad ng isang tipikal na konsultasyon sa isang opisinang pang-medikal, maliban sa may gagamitin ditong interactive video technology na magagamit upang makipag-usap sa isang doctor mula sa malayo. Sa simula ay maaaring mahirapan ka o maging hindi ka komportable na makipag-usap gamit ang video images. Ang paggamit ng video technology upang ibigay ang mga serbisyong pang-medikal at pang-edukasyon ay isang makabagong teknolohiya at maaaring hindi matumbasan ang direktang pakikipag-ugnayan ng isang pasyente sa kaniyang doktor. Gamit ang isang konsultasyong telemedicine, ang inyong doktor ay maaaring irekomenda ang pagpunta sa isang pasilidad na pangkalusugan gaya ng RHU o ospital upang masuri nang mas maigi.

Rights. You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right of future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. You have the option to consult with the physician in person if you travel to his or her location.
Mga Karapatan. Maaari mong itigil o bawiin ang iyong pagsang-ayon sa konsultasyong telemedicine sa anumang oras nang hindi naaapektuhan ang iyong karapatan sa pangangalaga o magamot sa hinaharap, o malagay sa panganib o pagbawi ang anumang benepisyo na maaari mong makamtan. Ikaw ay may karapatang kumonsulta sa doktor nang harapan kung ikaw ay pupunta sa kaniyang klinika.

Financial Agreement. You and/or your insurance company will not be billed for this visit.
Kasunduang Pinansyal. Ikaw at/o ang iyong insurance company ay hindi sisingilin sa konsultasyong ito.

I have been advised of all the potential risks, consequences and benefits of telemedicine. The physician of this telemedicine consultation has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above.
Ako ay pinayuhan sa lahat ng maaaring panganib, kahihinatnan, at benepisyo ng telemedicine. Ang doctor sa konsultasyong telemedicine na ito ay tinalakay sa akin ang mga impormasyong inilahad sa itaas. Ako ay binigyan ng pagkakataong magtanong tungkol sa impormasyong ito at lahat ng aking mga tanong ay nasagot. Nauunawaan ko ang mga impormasyong nakasulat sa itaas.

Signature:
Lagda

______________________________
Patient (or person authorized to give consent)
Pasyente (o taong itinalaga upang magbigay ng pagsang-ayon)

Date: __________
Petsa: __________

If signed by person other than patient, provide relationship to patient: __________________
Kung nilagdaan ng ibang tao bukod sa pasyente, ibigay ang kaugnayan sa pasyente: __________________

Witness: ______________________________
Saksi: ______________________________

Date: __________
Petsa: __________

Official PDF

OCR used during extraction: no