Enabling telehealth lessons for the gulf cooperation council

Enabling telehealth:
Lessons for the Gulf
A report by The Economist Intelligence Unit

Commissioned by


Enabling telehealth: Lessons for the Gulf

Contents

1

About this report

2

Executive summary

3

A note on definitions

4

Chapter 1 – New policies for the ‘connected care’ era

5

Case study: Mayo Clinic

6

Chapter 2 – Communications infrastructure

8

Chapter 3 - Skilling up

10

Map graphic: “Telehealth associations and user groups, global”

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Chapter 4 – Lessons for the Gulf

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© The Economist Intelligence Unit Limited 2015


Enabling telehealth: Lessons for the Gulf

About this
report

Enabling telehealth: Lessons for the Gulf is an Economist
Intelligence Unit report about the enabling environment
for telehealth, with a focus on policy, infrastructure, skills
and institutional user groups. The findings are based on

desk research and interviews with experts, conducted by
the Economist Intelligence Unit. It draws from case study
experience in North America, Europe, Australia and New
Zealand, and identifies principles and practices relevant
to the Gulf Cooperation Council region. This research was
commissioned by Philips. The author was Frieda Klotz. The
editor was Adam Green.
The Economist Intelligence Unit would like to thank the
following experts for insights shared during the research of
this report:

l Steve Ommen, a cardiologist and associate dean of the Mayo
Clinic’s Center for Connected Care
l Stephan Schug, chief medical officer of the European Health
Telematics Association
l Verina Waights, a senior lecturer in professional healthcare
education at the Open University
l Kawaldip Sehmi, CEO, International Alliance of Patients’
Organisations
The Economist Intelligence Unit bears sole responsibility for
the content of this report. The findings and views expressed in
the report do not necessarily reflect the views of the sponsor.

l Mario Gutierrez, executive director of the Center for
Connected Health Policy

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© The Economist Intelligence Unit Limited 2015

Enabling telehealth: Lessons for the Gulf

Executive
summary

The technologies of telehealth are advancing
quickly as part of the ‘connected care’ revolution.
Patients and health providers are ever more
closely linked through real-time electronic tools.
From digital imaging to allow remote viewing
of CT scans, through to patient diagnosis,
videoconferencing and monitoring, these tools
could touch all aspects of the patient-provider
relationship.
Much of the promise of telehealth is predicated
on its ‘access’ benefits: the improved access
of the patient to medical expertise regardless
of location, and improved access of health
providers to their patients, for the purpose
of diagnosis, consultation and monitoring.
Yet access to telehealth depends not only on
telehealth technology. Policy frameworks
must be modernised, communications
infrastructures such as broadband and mobile
network coverage must be improved, and
skillsets – both of clinicians and patients
– need to be strengthened. This briefing
paper outlines three factors shaping the
telehealth access environment: government

readiness (e.g. legal and regulatory clarity and
harmonisation, especially across states and
borders), communications infrastructure, and
skills.

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© The Economist Intelligence Unit Limited 2015

Key findings
l Ensuring access to telehealth depends
not just on the technologies, but on the
broader enabling environment, especially
policy harmonisation, communications
infrastructure, and skills. The telehealth
innovation frontier is advancing rapidly. But to
fully realise its potential – and strengthen access
to healthcare services – telehealth requires the
right support. Health policy needs to adapt to
the technological frontier, communications
infrastructure needs to reach vulnerable citizens,
and skills programs must be in place to maximise
the utility of the new technologies.
l Governments should consider more efficient
licensing if telehealth is to enable patients
to access medical expertise outside of their
state, province or country. Where governance
standards converge, regulatory bodies should
trust more in the licensing decisions of
neighbouring authorities to create ‘portable’

medical licenses that allow health providers to
interact with patients in other regions.
l Telehealth provision must go hand-in-hand
with Internet infrastructure rollout, since
vulnerable populations are the lowest users
of the Internet. The digital divide stubbornly


Enabling telehealth: Lessons for the Gulf

persists even in more advanced economies. Some
regions and populations, such as the disabled
and elderly, cannot be assumed to be Internet
users; to benefit from telehealth they need
communications infrastructure and training.
l Focus on systems integration: Telehealth can
enable a wider cast of actors to collaborate in
patient care, from doctors to social workers and
nutritionists. However, there is a challenge in
balancing more users on the one hand, with the
need to build usable systems with the requisite
security and privacy. Careful planning is also
needed to ensure new telehealth systems work

seamlessly with those already in place, to avoid
medical specialties having ‘one-off’ solutions.
l Health providers may need support in
working with new technologies. Medical
providers vary considerably in their support
for, and adoption of, telehealth. Hospitals and

providers may wish to develop training programs
to show relevance and usage, as well as to
impart etiquette and best practice codes such
as upholding the same standards of patientdoctor interaction that holds in face-to-face
consultations.

A note on definitions
Telehealth has a range of definitions depending
on jurisdiction; a linguistic divergence that
reflects the patchwork nature of the policies
and structures that govern it. At its most basic
level, it refers to the delivery of health services
and information through telecommunications
technologies, most often mobile and internetbased. For the World Health Organization
(WHO) telehealth involves ‘computer assisted
communications’ to ‘support management,
surveillance and access to medical knowledge,’
as opposed to telemedicine, which is more
narrowly defined by the WHO as ‘the use
of telecommunications to diagnose and
treat disease.’ The Australian government
also distinguishes between telehealth and
telemedicine, with the former focusing on the
use of telecommunications that provide medical
and health education and services, the latter
incorporating exchange of health information

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© The Economist Intelligence Unit Limited 2015

to provide care. Scotland, meanwhile, has
coined the term ‘tele-healthcare,’ which it
defines as “the convergence of tele-care and
telehealth to provide a technology-enabled
and integrated approach to the delivery of
effective, high quality health and care services,”
and which “can be used to describe a range of
care options available remotely by telephone,
mobile, broadband and videoconferencing.”
In the US, each state characterises telehealth
differently, some excluding email, phone or fax
communications; and two states, Rhode Island
and New Jersey, lack any definition at all.
For the purposes of this paper, we use a
broad definition of telehealth that includes
telemedicine and incorporates the full spectrum
of health care services, covering a wide range
of fields such as education, management and
diagnosis.


Enabling telehealth: Lessons for the Gulf

1

Chapter I: New policies for connected
care era

The US is the world’s largest healthcare market

and a testing ground for how telehealth access
plays out in a developed economy setting.
The private sector is already pushing into the
telehealth space. “Given the fact that we’re such
an entrepreneurial society, virtual healthcare
is becoming one of the most, if not the most,
attractive areas for investments from venture
capital,” says Mario Gutierrez, executive director
of the Center for Connected Health Policy, a nonprofit research organisation in California. “There
are billions of dollars rapidly being invested both
in technology and in companies that provide care
virtually.”
Companies such as Teladoc provide anytimeanywhere medical consultations, which are
helpful for people on the lowest level of
‘Obamacare’ insurance plans. To avoid paying
the high deductibles common to such plans,
such patients can contact Teladoc on an episodic
basis and pay out of pocket. “So in one sense
the country is moving very quickly to make care
available,” Gutierrez explains. “At a price—it’s
not free, so people pay in cash.”
But these tools will work best when the right
policy adaptations are made. The Centers for
Medicare & Medicaid Services (CMS) is the agency
that administers Medicare, the federal program
for seniors of 65 and over, and Medicaid in the
US. States tend to follow the lead of the CMS and
private payers look to the states for guidance.
“It really has been a challenge because the
federal government has not moved very quickly

to change the laws related to telehealth in the
Medicare program,” Gutierrez says. “The laws
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© The Economist Intelligence Unit Limited 2015

were written at a time when telehealth was in
its nascent form in terms of the technology,” he
explains. “They are basically stuck in the 70s.”
In health, as in so many other areas, technology
moves faster than the policy frameworks. No two
US states are alike in how telehealth is defined,
regulated and practised. California, for instance,
is considered one of the leaders currently for
having shifted financial incentives away from
fee-for-service and towards value. “California
tends to be a leader in healthcare improvements
and changes, there’s much more openness here
to doing that from the state government,” Mario
Gutierrez says. Other states, like Texas, seem to
be more cautious about the new technologies.
Diverse regulation creates a complex
environment for stakeholders, particularly
companies wanting to provide services in
multiple states. And although legislation is
advancing—in 2015, 42 states introduced
more than 200 telehealth-related pieces of
legislation—many of these changes are not
yet in effect. Incentives are one area in need
of attention. Currently many systems work

on a fee-for-service model which rewards
providers for individual services rendered. This
structure dissuades practitioners, clinics and
hospitals from making efficiencies and adopting
telehealth, because that would reduce their
payments. Better models are those of the Mayo
Clinic or Kaiser Permanente which have planned
an orientation on maintaining health (rather
than curing illness) by paying providers a fixed
salary and emphasising a value-based care
model.


Enabling telehealth: Lessons for the Gulf

Case study: Mayo Clinic’s connected care
The Mayo Clinic has main campuses in
Minnesota, Florida and Arizona, and operates
a broader system with more than 70 clinics and
hospitals across four states. It offers telehealth
to patients, physicians, and even employers—
via portals through which patients can; access
their electronic health records or where external
physicians can upload information on patients
and monitor those whom they have referred
to the clinic; asynchronous services allowing
secure communications between patients and
their team; and e-consultations with external
physicians. In addition, Mayo engages in
“synchronous,” real-time activities such as

video medicine and emergency video services
for tele-stroke, partnering with smaller or
rural hospitals in the region. “As a medical
community in the US and abroad, we see a grand
potential for mobile-enabled care,” says Dr
Steve Ommen, a cardiologist and associate dean
of the Mayo Clinic’s Center for Connected Care.
“We just don’t know how it’s going to play out at
this point because it’s a change in paradigm for
most practices.”

of location, but licensing and certification rules
differ by country, state or province. In the US,
doctors’ licensing is regulated by states, with
slightly different requirements for licensure
in each state. The Mayo Clinic’s asynchronous
services are available to a national audience
because such communications are not
categorised as practising across state lines.
For synchronous services though, such as
video-consultations, the situation is different.
A doctor is not permitted to offer direct-topatient care to a person in another state. Thus,
if the Mayo Clinic in Minnesota treats a New
Yorker and that patient has questions after
he or she returns home, the Minnesota-based
physician who treated the patient can conduct a
follow-up video visit only if he or she is licensed
to practice in New York. “If the physician isn’t
licensed in New York then we would need to say
the patient either needs to do their follow-up

care with someone in New York who is licensed
there—their local team who referred them,”
Ommen explains, “or they need to come back
here for their follow-up visit.”

A key issue is license portability. Telehealth
means patients can access doctors regardless

Time for portable licenses?
Recently, several states developed an InterState Medical Licensure Compact in which a
growing number of states agreed to recognise the
diligence their peers have conducted in awarding
a license to a doctor. One of the driving factors
was telehealth. “Proponents of telemedicine
have often cited the time-consuming stateby-state licensure process for multiple-license
holders as a key barrier to overcome in order for
telemedicine to continue to grow and thrive,”
the program’s website states. “The Compact
would make it easier and faster for physicians to
obtain a license to practice in multiple states,
thus helping extend the impact and availability
of their care at a time when demand is expected
to grow significantly.” Dr Ommen notes that
the compact eases the barrier to providing
telemedicine in another state and creates
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© The Economist Intelligence Unit Limited 2015

momentum that could lead to a system of mutual

recognition across the country. “It starts a
conversation around breaking down those stateby-state barriers so that in the future perhaps we
will move to a broader licensing arrangement.”
Such effort to reduce state-by-state barriers
is relevant for Europe, which has experienced
many years of regulatory harmonisation efforts
through the European Union, and is also an
instructive model for other regions around
the world who may benefit from harmonising
licenses across provinces and sub-regions
or even between neighbouring countries.
The world is made up of many advanced and
fledgling economic and regulatory unions
between countries, which provide a foundation
for collaboration on telehealth license
portability and broader telehealth regulatory
harmonisation.


Enabling telehealth: Lessons for the Gulf

The centre and the satellites: Telehealth
access in Europe
As the world’s most advanced regional economic
and political union, Europe provides a useful
case study in telehealth harmonisation and
integration. Telehealth in the European Union
is regulated largely by the health systems of
individual EU member states, but the European
Commission also plays a part. “In this particular

field we always have these two elements, where
the EU has a role and where the member states
come in,” explains Dr Stephan Schug, chief
medical officer of the European Health Telematics
Association. “Telehealth and e-health are just
in the middle because it’s always a little bit ICT
and a little bit health and social care. So it’s
always a little bit ‘European regulation’ and
some elements which are reserved for national
regulations.”
The European Commission has included
telehealth as a key element in its “Digital
Agenda for Europe” towards 2020, with Action
75 promising to “give Europeans secure online
access to their medical health data and achieve

widespread telemedicine deployment.” The
Commission drafted a green paper outlining
stakeholder views about m-health, and is
developing a code of conduct for m-health
services to foster public trust in the fast-growing
health app industry. Covering topics such as
privacy and security, the code aims to raise
awareness among app developers of EU data
protection rules and to facilitate compliance.
It has funded a number of projects including
European Patients Smart Open Services (epSOS),
in which 25 countries agreed on specific
formats for electronic patient data to make
them interoperable, so doctors in different

jurisdictions could process them meaningfully.
This is encouraging progress but there will always
be limits to how far the European Commission can
go. “[It] can help to remove any roadblocks on
the way and encourage member states to jointly
agree on goals and on measures and so on. But
I would not expect that there could be anything
like a telemedicine directive or a telemedicine
regulation. This would be against the European
constitution,” says Dr Schug.

Telehealth policies in Australia and Canada
Other OECD countries are also showing
political will to develop the policy frameworks
to support telemedicine. Australia launched
an electronic health record system in 2012
accessible to all citizens providing a summary
of each individual’s important health
information. The Australian government has
funded pilot programs across multiple aspects
of telehealth to explore whether it makes
health services more accessible in remote
areas, reduces unnecessary hospitalisations,
improves communication between patients
and carers and offers better communication

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during health emergencies. Canada, another
country with large swathes of rural terrain, has
invested heavily in telehealth. Since 2001 the
Canadian government has poured $2.1bn into
more than 400 projects across the provinces
and territories. In March 2015, availability of
electronic health records was at 91% in Canada.
In 2014, more than 500,000 clinician-patient
consultations took place, according to the
annual report of Canada Health Infoway, a
government-funded think-tank charged with
increasing the use of digital health solutions.


Enabling telehealth: Lessons for the Gulf

2

Chapter 2 - Communications
infrastructure

For telehealth to promote access to care, the
communications infrastructure, especially
broadband and mobile network coverage,
needs to function effectively. According to Dr
Verina Waights, a senior lecturer in professional
healthcare education at the Open University, UK,
such infrastructural issues are relevant even in
developed regions. “For America, Eurasia and
ourselves the issues are remarkably similar,” she

says. “At the moment some countries have much
better infrastructures than others but even they
have black spots where you cannot get good
broadband. We feel that’s going to create major
issues and probably create more diversity among
people being able to access services.”
The promise of telehealth is that it will cater
to hard-to-reach patients, but rural areas are
those most poorly served by broadband access.
According to Kawaldip Sehmi, CEO of the
International Alliance of Patients’ Organisations,
poor broadband access perpetuates inequalities
between rural and urban areas, creating a
digital divide, even within individual countries.
“Broadband services in rural areas are so bad that
most patients living in rural areas cannot access
or enjoy the benefits of online products and
services.”
Even in a developed nation like the UK, pockets of
the country have insufficient broadband strength
to facilitate telehealth. The British government
has invested £1bn in mobile and broadband
infrastructure and promises to deliver high speed
broadband across the country by 2018. Waights
recommends that internet access is built in to
new housing projects. The strategy has been
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trialled in pilot form in Birmingham, where a
community housing association teamed up with
a wireless provider and the city council to give
free Wi-Fi to 200 residents along with internet
training. “Change has got to come from both
sides, both improving the infrastructure and
making it affordable so that people see it as a
necessity,” says Waights.
Joining up telehealth systems with broader
communications investment is also in play
elsewhere in the OECD. New Zealand has
established a National Telehealth Forum,
supported by the National Health IT Board,
which is part of the Ministry of Health, and a
government-funded high speed broadband
initiative is underway in parallel. This
integration of internet accessibility and broader
healthcare access strategy helps, suggests Dr
Robyn Whittaker, an m-health expert and lead
investigator in an SMS-based smoking cessation
randomised trial. “I think the m-health initiatives
are more likely to be successful if closely tied into
health services.”
Disparities in access are also relevant in the US,
where some people still use dial-up to connect
to the Internet. According to Mario Gutierrez,
this includes individuals and facilities offering
healthcare services. “There are rural hospitals
out there that would really benefit from those
services but are still operating on dial-up,”

Gutierrez says. Using mobile connectivity instead
of broadband may be the answer - the model
has been adopted to cater to rural communities
in Spain, where broadband access is weak but
mobile phone coverage can compensate. Dr


Enabling telehealth: Lessons for the Gulf

Schug notes that some telehealth services work
successfully through SMS messages. “You do
not need broadband everywhere,” he says. It is
also well-known in parts of Africa: “Emerging
nations that do not have the infrastructure have
been able to leapfrog and move very quickly to
using technologies for communication between
providers and consumers,” says Dr Schug.

Balancing interoperability with data
security
Infrastructure is only partly a question for
governments to address. For health providers,
careful planning goes into the delivery
of telehealth systems and ‘information
architectures’. It may be unique for each system,
depending on its specialisation, other systems
they use, and their size, explains the Mayo
Clinic’s Dr Ommen. New tools must integrate
seamlessly with those already in place. “You
don’t want each specialty having its own ‘oneoff’ solution. So you do have to spend some time

planning that,” he says.
Investment is needed to join a main hospital
with smaller, satellite partners, or to support
people outside the hospital firewall who will be
connecting with those inside it. If the Mayo Clinic
partners with a smaller hospital to provide telestroke care, for instance, it also trains staff at
the partner hospital so that they understand the
software and hardware and know where to access
customer support if necessary. For all these
systems, cyber security becomes paramount.
The Mayo Clinic’s Office of Information Security
rigorously vets any new technology system to
ensure it meets a high security standard. “I would
guess that most big systems have teams in place
that are worried about information security just

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© The Economist Intelligence Unit Limited 2015

to protect the patient’s health records,” Ommen
says.
Interoperability between provider tools is a key
infrastructure consideration when systems are
complex. In the US, the Affordable Care Act
promoted the use of electronic health records,
but the systems in use are proprietary and do
not connect with each other. CVS, the nation’s
second largest pharmacy chain, installed virtual
health advisory systems that provide access

to mid-level physicians. In August 2015, it
announced a partnership with several online
doctor forums: American Well, Doctor on Demand
and Teladoc. This represented a big step forward
for telehealth. But providers of these services will
have no access to the records of the patients who
visit them, leading to potentially hazardous care
inconsistencies. Moreover, it is likely that over
time providers will interact with a broader care
team perhaps comprising nutritionists, social
workers and mental health counsellors. The
potential of telehealth to bring together such a
wide cast of actors is clearly exciting - but also
raises questions about how data and information
systems can be built which are both usable by
such a large range of stakeholders, whilst not
being vulnerable to data security compromises
and integration problems.
This challenge will fade over time, Dr Ommen
suggests. “In the history of our lifetimes, at
one point Microsoft software products were
incompatible with Apple computers and now if
you’re heavily leveraged with the Microsoft Office
product suite you can use it on any computer
you want and it works fairly seamlessly. That will
happen in this solution as well.”


Enabling telehealth: Lessons for the Gulf

3

Chapter 3: Skilling up

Using communications technologies to deliver
healthcare may seem intuitive. After all, many
people today are comfortable using mobile
and Internet tools to manage important tasks
such as personal banking. But precisely for that
reason, tailored training is required to remind
practitioners that standard privacy procedures
still hold sway in the telehealth arena. The Center
for Connected Health Policy provides etiquette
training for physicians, covering how to talk to
patients with whom they engage virtually. “There
are some misconceptions,” Gutierrez observes.
“I’m sitting here with my laptop and am speaking
with a client and I have my door open. Well, I
should be thinking about that in the context of
that person being there in-person. A lot of the
issues related to privacy and security need to
be addressed,” he says. Telehealth changes the
dynamic of physician-patient interactions, and
doctors may need training to adapt effectively.

EU statistics database
Available at http://
ec.europa.eu/eurostat

1

10

A second skills issue concerns hesitation within
the medical community about telehealth itself.
In part this involves a simple change in attitudes,
habits and expectations; many doctors still feel
more comfortable seeing a patient in person.
Doctors will need to ask themselves whether they
really need to see a patient in person or are just
following a routine. Some physicians may feel
threatened, worried that large hospitals with
extensive telemedicine systems will encroach
on their business. When the Texas Medical Board
introduced new rules governing and restricting
telemedicine in the state, Teladoc brought a
lawsuit arguing that the board was blocking
competition and trying to shut down Teladoc’s
business in the state. “Doctors are trying
© The Economist Intelligence Unit Limited 2015

to protect their practice from telemedicine,
basically,” a Dallas-based healthcare attorney,
Brenda Tso told National Public Radio at the time.
Teladoc won the case.

Skilled patients…and carers
Skills and behaviour change are not only relevant
on the provider side. Patients and carers are also
affected. Being able to join a video conference

requires a certain minimum level of digital skill
or IT support that must not be assumed. In
some European countries, such as Bulgaria and
Romania, around 40% of households do not have
internet access, according to Eurostat, the EU’s
statistics agency.1 This cohort of non-internet
users largely comprises elderly and disabled
people, says Dr Verina Waights, who conducts
research into helping elderly and disabled people
access and use telehealth. In a recent project,
she took the approach of letting the patients
engage with technologies through interaction
rather than instruction. She worked with elderly
people, and with informal or family carers
and professionals. “Not in a formal way,” she
emphasises, “but helping them learn the way that
children explore, where you give it a go and see
what happens.”

Confidence for carers
Similar issues can affect the confidence of carers,
Waights notes. When her team offered training,
carers were reluctant to take what they saw
as a course in computers or IT, seeing it as too
advanced for their everyday needs. But when
telehealth was seen as more integral to their lives
— learning more about the health condition of


Enabling telehealth: Lessons for the Gulf

the person they supported – they became more
enthusiastic. Both professional and informal
carers describe themselves as time poor, says
Waights, whose research spanned the UK, Greece,
the Netherlands and Spain. “Across all four
countries, nobody wanted a computing course,”
she says. “We embedded the skills through the
things they did want to know about.”
Professional carers are beginning to receive
digital training as a matter of routine. For
example, Skills for Care, an organisation for
workforce development in adult social care in
the UK, offers a module on digital working and
incorporates digital learning and information
sharing in its overall strategy. About 80% of

carers and older people are unaware of the
services and devices that could help them, says
Waights. Her team raises awareness among those
who might benefit. Co-design, involving senior
citizens in solutions, could help. “We need [to
be] working together with the people who will
be using these devices and the solutions, right
from the beginning,” she says. Through faceto-face training, her team helped older people
with preliminary decisions, such as which types
of computers to buy, how to send email, and how
to broaden their online social engagement. “It’s
looking at it in the round, rather than focusing on
just one angle,” Waights says.

International telehealth organisations and user groups

American Telemedicine Association
(ATA) is a mission-driven non-profit organisation.
Membership is open, and its leadership comprises
industry and academia

European Health Telematics Association
(EHTEL) is a European forum for telehealth
stakeholders providing a platform for
companies, institutions and individual actors

National telehealth-related organisations
exist in Algeria, Brazil, Finland, Germany,
Ghana, India, Indonesia, Iran, Japan, Morocco,
Nigeria, Poland, Russia, South Africa, Tunisia,
Uganda, Ukraine, UK, United Arab Emirates,
Saudi Arabia, Qatar among others

International Society for Telemedicine and e-health
NGO with WHO recognition that aims to promote
telemedicine and e-health worldwide. It has 31
national telehealth members along with
institutional and corporate members

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HIMSS is a global, cause-based, not-for-profit
organization focused on better health through

information technology

© The Economist Intelligence Unit Limited 2015

Australasian Telehealth Society
Founded in 2008, it aims to create a forum
for practitioners, clinicians and industry
partners involved in telehealth in Australia
and New Zealand


Enabling telehealth: Lessons for the Gulf

“GE and Gulf Capital to
tap health market”, The
National, January 30th
2010

2

Kingdom of Saudi Arabia
Ministry of Health portal.
Available at: http://www.
moh.gov.sa/en/Ministry/
nehs/Pages/Overview-ofeHealth.aspx

3

National E-Health and
Data Management Strategy

Draft for Stakeholder
Consultation, PwC 2015.
Available at: http://www.
nhsq.info/app/media/3125
4

“Abu Dhabi Healthcare
Strategic Plan Announced”,
Abu Dhabi Health Authority
press document. Available
at: d.
ae/haad/tabid/58/
ctl/Details/Mid/417/
ItemID/463/Default.aspx

5

“GCC smart card steering
committee commends UAE’s
‘Digital Authentication’
project”. United Arab
Emirates media centre,
2014. Available at: http://
www.id.gov.ae/en/mediacentre/news/2014/10/31/
gcc-smart-cardsteering-committeecommends-uaes-digitalauthentication-project.aspx

6

“The Social Impact of
eHealth Integrated Health

Innovations Conference
Dubai, United Arab Emirates”
presentation, Deputy Minister
of Health for Planning &
Health Economics. Available
at: ssme.
org/innovations13/
docs/HIMSSME_IHIC13_
SpeakersPresentation_
MohammadAlyemeni.pdf

7

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4

Chapter 4: Lessons for the GCC

The total healthcare spending in the Gulf
Cooperation Council (GCC) region is forecast
to reach $60 billion by 2025, as a result of
population growth and a rise in chronic, noncommunicable diseases.2 Non-communicable
disease are among the most complex and costly
to manage, suggesting that a well-designed and
flexible health system is vital to ensure the GCC
region can provide standards of care needed in a
tough new era. The region’s abilities to harness
telehealth and provide the enabling framework
hang in the balance: it has a generally high

income level with strong rates of ICT penetration
and infrastructure. At the same time, it has
limited experience of regional healthcare
regulation and harmonisation, and a skills
shortage in healthcare.
The member states within the GCC, an economic
and political union, are relatively well-integrated
from an economic perspective.  Intra-GCC trade
has increased seven-fold since 2000, a year
before the formation of the customs union, to
just under $100bn in 2013. Plans to develop a
GCC-wide rail network are underway, expected to
further facilitate trade. Components are being
developed independently, such as the Etihad Rail
in the UAE, designed to connect to the larger GCC
network. Through an interconnected power grid,
the countries are also set up to share surplus
electricity between member states, which could
save governments up to $6bn in surplus power
capacity. Through the Gulf Cooperation Council
Interconnection Authority, they are able to
monitor electricity consumption in real-time and
assess potential gaps. Co-developed regulation
under the Gulf Standards Organisation includes
the Gulf Conformity Marking, the regional
© The Economist Intelligence Unit Limited 2015

equivalent to the European CE marking. Such
integration suggests a reasonable track-record
to be utilised in a new areas such as telehealth

although so far, there is limited concrete
evidence of a joined-up approach.

Policy momentum
Led by Saudi Arabia, Qatar and the UAE, there is
evidence that GCC countries are keen adopters of
telehealth. The GCC leads the Middle East in terms
of telehealth enabling environments. E-health
and telehealth strategies have government
support in Saudi Arabia,3 Qatar4 and the United
Arab Emirates,5 who have invested in initiatives
to integrate telehealth with wider reforms.
The GCC countries are developing regional
harmonisation initiatives, evident in discussions
about a “smart card” digital ID that would include
people’s health information, which proponents
hope will be interoperable across the region.6
There is a centralised GCC drug registration
system currently, and GCC members have stated
their aim to increase broader integration through
a recommended “Unified Gulf Plan for Prevention
and Control of Non Communicable Diseases 20142025”.
Each country in the region has its own policy
stance. A rich nation with a growing population
and increasing demands on its healthcare system,
Saudi Arabia made telehealth a central part of
its healthcare policy. In a public presentation in
December 2013, the deputy minister for health,
Mohammed Al Yemeni, stressed that Saudi Arabia
“has allocated a huge budget for e-health, since

access to healthcare services in remote and rural
areas is of prime importance.”7


Enabling telehealth: Lessons for the Gulf

Kingdom of Saudi Arabia
Ministry of Health portal, ibid.

8

“KSA ‘fastest growing’ eHealth
market in the Middle East”,
Saudi Gazette. Available at:
.
sa/index.cfm?method=home.
regcon&contentid=
20141119224908

9

IDC Middle East and Africa
Healthcare Provider 2013 IT
Spending and 2014–2018
Forecast. Available at: https://
www.idc.com/getdoc.
jsp?containerId=prAE25365015
10

National E-Health and Data

Management Strategy Draft
for Stakeholder Consultation.
Available at: q.
info/app/media/3125

11

“Telemedicine - the high tech
answer to the UAE’s burgeoning
health needs?”, “Albawaba
Business”, May 10th 2015.
Available at:
/>business/telemedicine-hightech-answer-uaes-burgeoninghealth-needs-692360

12

Technology, Media &
Telecommunications
Predictions 2015 Middle East,
Deloitte.
13

“Bridging the digital divide
through ICT: A comparative
study of countries of the Gulf
Cooperation Council, ASEAN
and other Arab countries”,
Kaba and Said. “Information
Development”, November
2014 vol. 30 no. 4 358-365

14

13

Saudi Arabia has created an eHealth Strategy and
Change Management Office that has developed
an evaluation framework to “define, quantify
and track the eHealth strategy performance
in addition to social and financial benefits of
the eHealth investments” and the government
portal lays out 1, 3 and 5 year commitments.8 This
combination of political will and investment has
led to Saudi Arabia being characterised as the
“fastest growing health IT market in the Middle
East,”9 by the Saudi Gazette, growing at 13.4%
per year.10

The first is license portability and regional
harmonisation to allow users to benefit from the
‘borderless’ promise of telehealth. Countries must
find the right balance between national versus
supra-national rules. In the case of the UAE, there
is the added complexity of a country comprised
of seven individual Emirates, with different
regulatory structures. Most medical expertise
is clustered in Abu Dhabi and Dubai, but such
knowledge need not be limited to these markets
if patients in other Emirates can interact with
medical specialists there.

Spending on IT services and products is
also forecast to grow quickly in the United
Arab Emirates, where Mubadala Healthcare,
established by the Abu Dhabi government,
recently joined forces with the Swiss firm Medgate
to launch the Abu Dhabi Telemedicine Centre,
which will offer around-the-clock consultations in
Arabic and English. The Centre is covered by some
national health insurance plans and provides
eligible patients located across the country direct
access to medical advice, thereby “increasing
access to healthcare particularly for patients
living in areas of the Emirates which may not have
providers nearby,” Hasan Al Attas, its general
manager, told Middle East Health Magazine.
Abu Dhabi’s engagement with telehealth is also
evident in key upcoming milestones such as
hosting the World Telemedicine and e-Health
Forum, sponsored by the International Society
for Telemedicine and eHealth (ISfTeH), in March
2016.

Policy harmonisation may focus on efficient
licensing structures first if telehealth is to enable
patients to access medical expertise outside of
their country, region or province. Where general
governance standards converge, regulatory
bodies in the GCC could build on the licensing
decisions of neighbouring authorities to create
‘portable’ licenses that allow clinicians and

medical providers to interact with patients in
other regions. Governments and regions can
look to initiatives such as the Inter-State Medical
Licensure Compact as a valid model, although
it requires significant trust in the decisions of
other authorities. A more technical measure to
support integration could be the linking up of
existing digitisation programs – of health systems
and patient health records – which is a priority
in some nations who wish to build a unified
electronic health records system. Such systems
support the transmission of information across
borders, although privacy and security related
factors need to be borne in mind as the user base
expands. A number of areas will need to be unified
if a regional telehealth market is to emerge, such
as definitions of telehealth and consistent data
privacy and information protection.12

Nearby, Qatar launched a national e-health
strategy in June 2015, aiming to define national
policies and regulations, establish standards for
interoperability and data-sharing, and encourage
the use of e-health.11 Authorities are also looking
more broadly at technologies to support care
delivery, such as Dubai Health Authority’s plans
to deploy Android tablets as part of an effort to
build ‘smart hospitals’ that will improve customer
experience.
Looking to the OECD nations explored in this

report, several trends are pertinent to the Gulf.
© The Economist Intelligence Unit Limited 2015

Infrastructure backdrop
Mobile penetration across the Middle East rose
rapidly from 3% in 2000 to 100% in 2012.13
Gulf countries have superior ICT infrastructure
than their neighbours in Arab states,14 and
governments’ commitment places the UAE,
Qatar and Saudi Arabia, as well as Bahrain, at


Enabling telehealth: Lessons for the Gulf

the forefront of ‘network readiness’ in the MENA
region.15 The Saudi market stands out, with 16m
internet users representing over 50% of the
population.
A 2014 report by GSMA, the mobile industry
association, notes that Arab states were relatively
late to launch higher speed networks but are now
catching up. In the UAE, Saudi Arabia and Qatar,
as much as 60% of internet connections now
operate through 3G and 4G. Despite this, there
are still broadband blind spots and portions of the
population, especially the elderly and the disabled,
who may not use the Internet. Mobile broadband
rather than fixed broadband communication links
may be the way forward for telehealth, especially in
Saudi Arabia, where rural villages punctuate large

areas of desert and fixed-line infrastructure is weak.
Engagement with the telecommunications players
can be helpful, especially given the dominance
of indigenous multinational telecommunications
companies who provide a more efficient route to
reach large populations than would be the case in
more fragmented telecommunications markets. The
UAE sought to bridge connectivity with telehealth
tools through a 2012 agreement between Etisalat
and du, large local telecommunications providers,
to become directly involved in e-health. In January
this year, the UAE government signed a deal with
Etisalat and du to develop mobile health products.
Etisalat has also deployed GE’s cloud-based Muse
Cardiology Information System.
World Economic Forum,
The Global Information
Technology Report 2015

15

Skills and knowledge flows

New skills, among patients and providers,
are critical to enabling telehealth in the Gulf.
16
“Successes and Challenges
Partnerships, such as that between Mubadala
in the Implementation and
Application of Telemedicine Healthcare in the UAE and Medgate, are one way to

in the Eastern Province of
foster knowledge exchange. Strong international
Saudi Arabia”, El-Mahalli
linkages can have benefits. In the UAE, Johns
et al., Perspect Health Inf
Hopkins has constructed a centre of healthcare
Manag. 2012 Fall; 9(Fall)
excellence, and Harvard University has its own
under way, which brings expertise and research
17
The Social Impact of
capabilities.
eHealth Integrated Health
Innovations Conference
Dubai, United Arab Emirates
presentation, ibid.

14

However, the success of telehealth will rely not
only on skills but also attitudes. A 2012 survey into
© The Economist Intelligence Unit Limited 2015

the use of telemedicine technologies in eastern
Saudi Arabia found that “although telemedicine
is promising and the Ministry of Health in Saudi
Arabia has allocated a huge budget for e-health,
the telemedicine modalities used were very
limited.” Interest among health professionals
was high but adoption was low, and those who

did deploy it found it less easy to use than hoped.
The study recommended more information
about telemedicine and better training of health
professionals.16 Governments also need to invest
in training to ensure the neediest populations are
comfortable with telehealth.
While the rapid rise on mobile phone usage,
particularly among younger people, indicates
a market ripe for telehealth adoption, there
continues to be some reluctance among the
public. Research into the use of tele-dermatology
conducted by King Faisal University, Saudi Arabia,
found that 14% of patients declined to send
photographs of skin blemishes to doctors, citing
social or religious reasons.17 Such cultural or social
considerations must be kept in mind as policies and
infrastructure around telehealth are developed.
Telehealth cannot be seen as fully substitutable
with conventional, in-person patient-doctor
interactions.
The Gulf experience is some ways mimics that of
the OECD nations explored earlier in this report.
Ensuring access to telehealth depends here, as
elsewhere, not just on the technologies, but on
the broader enabling environment, especially
infrastructure, policy and skills training. The
innovation frontier is moving forward with
increasing speed, capturing the interest of
healthcare companies and venture capital. But to
fully realise its potential – and to achieve its goal

of strengthening access to health – telehealth
requires the right enabling environments. The
Gulf has an enormous healthcare challenge due
to demographic shifts, affluence and the rise of
‘Western’ diseases. Watching from the experiences
of North America, Europe, Australia and New
Zealand could provide valuable experiences and
lessons to guide decision-making in the Gulf.


While every effort has been taken to verify the
accuracy of this information, The Economist
Intelligence Unit Ltd. cannot accept any
responsibility or liability for reliance by any person
on this report or any of the information, opinions
or conclusions set out in this report.

Cover image - © Graphicworld/Shutterstock


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