Expansion of Telemedicine in the Wake of the COVID-19
Pandemic
Seigo HaraCEOMICIN, Inc.

In September 2020, with the resignation of former Prime
Minister Shinzo Abe, he was succeeded by Cabinet Minister
Yoshihide Suga. One of Cabinet Minister Suga’s platform policies
was to make telemedicine permanent, and with considerable
discussion among experts in the field, a cabinet decision in June
2021 made telemedicine a permanent policy in Japan beginningin FY 2022. The demand for telemedicine care increased with thespread of the COVID-19 pandemic, so virtual clinics are finallytaking shape and systems are getting organized. Here, we describe
how telemedicine has developed since before the COVID-19
pandemic.

1. Telemedicine care before the COVID-19
pandemic

Telemedicine care is a form of remote medicine that graduallybegan spreading throughout Japan in around 2015. In 2018,
remuneration for clinical work was reformed; establishing new fees
for telemedicine care and setting guidelines regarding appropriate

Yoko Kiriyama

RA Specialist
MICIN, Inc.

operation of online care (Telemedicine care guidelines). However,
although this was an opportunity to establish systems fortelemedicine care, the conditions were severely limited (Table 1),and did not lead to significant spread of telemedicine care.
According to documented statistics＊1 of actual medical andclinical behavior in society from an investigation in June 2018,
fees for telemedicine care were charged a total of 65 times, 15times for telemedicine treatment, and 4 times for online homemanagement, so it was not even one millionth of the number ofclaims for medical services per month: approximately 100 million.
Examining results over time, the trend is not increasing＊2, andthere continue to be almost no insured telemedicine treatments.
There are several possible reasons for this, but the four major issues
are summarized in Table 1. They are: (1) constraints on medical
conditions covered, (2) low profitability for insured treatment,(3) strict conditions on provision of services, and (4) guidance for
medications can only be given in-person.

■ Table 1: S ystematic regulations for treatment under health insurance and effects on clinical work

＊1 Central Social Insurance Medical Council General Meeting Document (Sept. 2019), “Calculation of fees, etc. after FY 2018 medical fee reforms”＊2 Central Social Insurance Medical Council General Meeting Document (Nov. 2019), “Regarding online medical management fees.”

10New Breeze Autumn 2021

■ Table 2: C hanges in virtual clinics due to temporary mitigation measures

2. C hanging conditions due to expansion ofthe COVID-19 pandemic

However, with the expansion of the COVID-19 pandemic,
these conditions changed completely. In February, 2020, aspecialist session of the government issued a declaration thattelemedicine care would be used as a measure to control further
spread, the Ministry of Health, Labour and Welfare issued
successive notices regarding telemedicine care, and temporary
measures were taken to relax regulations. The main changes
are summarized in Table 2. The change that attracted the mostattention in the media was lifting the ban on performing initial
examinations online, but perhaps more important was therelaxation of restrictions on the medical conditions covered, whichwere extremely limiting previously.
MICIN Inc. has been providing a telemedicine care service
called “curon” since 2016. In March 2020, the environmentchanged, and approximately 5,000 medical institutions are
currently using our product (as of February, 2021). The number ofexaminations being done with the system also increased by morethan a factor of ten at that time. Considering that in December,
2019, the number of medical facilities using the system wasapproximately 1,800, it is easy to imagine that the needs of both
medical facilities and patients changed suddenly with the spreadof the pandemic. Other providers of telemedicine care systems
are also experiencing this increase in users, and according toMinistry of Health, Labour and Welfare documents＊3, over
16,000 medical facilities were performing telephone or online
examinations as of August, 2020. New enterprises also continue
to enter the market providing telemedicine care systems, andconsidering current conditions in society, we expect the numberof medical facilities using telemedicine care systems will continue
to increase. On the other hand, the report from a Ministry ofHealth, Labour and Welfare review meeting on May 31, 2021,
indicated that the number of medical facilities using such systems
had begun to level off＊4. Based on the current systems andtechnology platforms, telemedicine care platforms and use cases
are beginning to stabilize to some extent.
In the next sections, we introduce the “curon” virtual clinic
service that we provide, and also a new service called “curonmedication support,” providing online guidance for taking
medications.

3. System provided by MICIN(1) The “curon” telemedicine care service
MICIN’s telemedicine care service, called “curon,” has been
providing comprehensive, end-to-end systems mainly to medical
clinics since 2016, including appointments, medical history taking,video examinations, billing, payment and prescription filling anddelivery. The virtual clinic systems from other providers each havetheir strengths, but a major difference between curon and systems
from other providers is that installation and operation is free-ofcharge for medical facilities, and patients are required to pay fee(330 yen tax incl.) to use the application. We considered that oneof the major benefits of telemedicine care is improving access to
medical care for patients, so we decided to collect revenue fromthe patients, who receive this benefit, rather than from the medicalfacility. As of February, 2021, over 5,000 medical facilities had
introduced our system.

＊3 Ministry of Health, Labour and Welfare, 10th Review of Appropriate Online Medical Care Operation document, “Trends in medical facilities (Overall, initial examinations)” (August, 2020)＊4 Ministry of Health, Labour and Welfare, 15th Review of Appropriate Online Medical Care Operation document, “Numbers of medical facilities (May, 2021)

New Breeze Autumn 2021

11(2) curon medication support
Following the telemedicine care system that has beenestablished since 2018, there was a plan to lift restrictions ononline medication guidance in September, 2020, according torevisions made in November 2019 to the Pharma and MedicalDevices Act. However, with the spread of the COVID-19
pandemic, the Ministry of Health, Labour and Welfare issued
temporary special mitigation measures, which included lifting
this ban early and giving approval for medical facilities to sendprescriptions to pharmacies by FAX. We had been developing
our online medication guidance service with the intention ofreleasing it in September, 2020, but with this mitigation measure,
we developed and began providing additional functions in ourcuron telemedicine care service, to upload prescription data andto send prescriptions to pharmacies. Thus, before launching ouronline medication guidance service, we were able to equip curon
with functions to send prescriptions to pharmacies by FAX. Since
the number of patients requested to stay home was expected toincrease greatly, our development team worked day-and-night, andwas able to develop and publish the new features in only three days
from when the measures were announced.
Later, α and β versions of our online medication guidanceservice for pharmacies (“curon Medication Support”) were releasedin May and July respectively, and the first official version wasreleased in August. The process for curon Medication Support isshown in Figure 1. We had determined to have curon Medication
Support installed and in use at more than 2,500 pharmacies by theend of 2020, and we continue to work to have it used in even morepharmacies. Note that curon Medication Support is not limited to■ Figure 1: Medication support process with curon

12New Breeze Autumn 2021

curon and can be used with other telemedicine care systems.

4. Telemedicine care and information security

We are sometimes asked whether using a comprehensive
telemedicine care system like the one we provide is necessary
when offering telemedicine care. Not necessarily, and use ofgeneral-purpose video conferencing systems is not prohibited.
However, information security must be considered when doing
so, and medical facilities performing online examinations have aduty to take adequate measures. The differences between using acomprehensive telemedicine care system and system using generalpurpose services are summarized in Table 3.
Here, taking adequate measures to guarantee security meansthat the organization must create systems and operate following
the guidelines for telemedicine care issued by the Ministry ofHealth, Labour and Welfare. A comprehensive telemedicine caresystem like the one we provide has already been designed andbuilt confirming to these guidelines (Figure 2), but if general
purpose services are used, the medical facility must prepare theenvironment and operate with consideration for security to ensure
that, for example, video calls are not intercepted, and informationregarding ailments or prescriptions is not leaked, falsified ordestroyed.
There were quite a few medical facilities that began providing
telemedicine care using general-purpose services, which wereimmediately available during the first wave of the COVID-19
pandemic, but considering the above issues, we expect that manyof these will migrate to a comprehensive telemedicine care systemin the future.

■ Table 3: C omparing comprehensive online medical care systems with generalpurpose systems■ Figure 2: Use of curon with system design conforming to guidelines

5. Future of telemedicine care

Use of telemedicine care began to spread, prompted by theCOVID-19 pandemic, but there is discussion of making it
permanent, so we expect it will become established. However,
it is still difficult to escape the image of “medical examination
by video conference.” This is due to technical issues with online
examinations, which do not allow doctors to obtain all of theinformation that is available in a conventional, face-to-faceexamination, using all five senses. However, there have beenvarious developments in digital health in the past few years, andin the future, we expect developments integrating telemedicine
care with compatible digital therapeutics (DTx). We are alreadyworking with pharmaceutical enterprises to establish patient
support programs that aim to improve treatment continuity andadherence for patients, in our efforts to increase convenience forpatients and add new value to telemedicine care.
DTx is a field that is currently seeing vigorous development,
both domestically and internationally. In the USA, many products
are entering the market, starting with the Bluestar smartphone
diabetes treatment application from Welldoc Inc., which wasapproved by the FDA in 2010. Japan is several years behindsome other countries, but in August, 2020, CureApp SC, fromCureApp Co. Inc., was the first digital treatment device to receive
Pharmaceutical Affairs Act approval in Japan, and in November it
attained insurance coverage. We expect various other products tobe developed in Japan in the future.
With progress in system design to make telemedicine
treatment permanent, we look forward to seeing it take root as one
form of medical treatment, and something that can contribute tosociety as the technology develops in the future.

New Breeze Autumn 2021

13