Abstract
Introduction:
Health care disparities are severe across Asia. To bridge gaps in professional knowledge and skills, Doctor-to-Doctor (DtoD) telemedicine shows promise. However, the specific technical skills required for effective DtoD conferences and consultations, particularly those involving advanced technologies, remain undefined. This study aimed to establish a consensus on these essential skills.
Methods:
We used the Delphi method, engaging 30 participants from Asia-Pacific Advanced Network Medical Working Group DtoD training programs. Investigators and an expert panel developed an initial list of technical skills for both synchronous and asynchronous DtoD teleconferences and consultations, which participants evaluated in Round 1. Following an in-depth workshop, a revised questionnaire incorporating new skills and feedback was assessed in Round 2, yielding the final list.
Results:
The study included 30 hospital IT staff, doctors, and nurses from 11 Asian countries, 57% of whom were affiliated with university hospitals. All participants completed both rounds. After integrating 46 written comments, 10 new skills were added, resulting in a final list of 43 technical skills. These encompassed conceptual understanding, technical execution, coordination, and security policy. Notably, “Extracting images from medical devices” and “Maintaining audio quality” were identified as key skills.
Discussion:
This study is the first to delineate the technical skills necessary for DtoD telemedicine conferences and consultations in Asia. The identified skills can guide future training, assessment, and development initiatives to strengthen the telemedicine workforce across the region.
Keywords
Introduction
While medical innovations contribute to advancing health services, noticeable disparities exist in health and medical services worldwide. 1 In Asia, disparities in health care services have been consistently reported.2–5 One significant factor contributing to these disparities is lack of a skilled health workforce.6–9 Traditionally, to learn the latest techniques, skills, and approaches to technology use, medical professionals visit overseas medical facilities. However, considerable time and costs are associated with physical travel. To overcome this limitation, doctor-to-doctor (DtoD) telemedicine conferences and consultations using information and communication technology are used to provide training at a distance. Evidence suggests that DtoD telemedicine can effectively bridge current gaps in health care by equipping health care professionals with diagnostic and therapeutic knowledge and skills.10–13 The Coronavirus disease-2019 (COVID-19) pandemic further engendered the use of teleconferencing systems, with DtoD telemedicine conferences and consultations having been held on diverse topics, including COVID-19 control measures.14–18 DtoD telemedicine includes remote imaging support such as teleradiology and telepathology, supporting remote consultation, tele-ICU, information sharing, and educational activities. 19 These activities are based on video/audio communication and image output from medical devices, while some involve direct connection between medical devices such as microscopes in telepathology and robotic surgical equipment in teleoperation.
Routine adoption of DtoD telemedicine began in the 1990s, overcoming earlier cost and technical barriers since its inception in the 1960s. 20 In Asia, early initiatives included activities using Integrated Services Digital Network (ISDN) and satellite communications to link medical centers within Asia and globally.21–24 Around 2000, the adoption of internet-based platforms expanded these activities to include case conferences and live demonstrations.25,26 Live demonstrations, an educational method delivering procedures in real time, have become a popular instructional method in fields such as gastrointestinal surgery, cardiac surgery, endoscopy, and dentistry.27–30 In Asia, uncompressed, high-resolution communication systems were adopted for DtoD conferences/consultations.31,32 These systems required close collaboration between physicians and technical experts. To institutionalize this interdisciplinary cooperation across the region, the Asia-Pacific Advanced Network Medical Working Group (APAN-MWG) was established in 2005. 33 This working group consists of physicians from Asian countries who regularly use telemedicine in their clinical practice. The members of the working group include network engineers and hospital IT staff who are part of the telemedicine teams. These teams conduct not only one-on-one remote consultations and conferences but also case conferences and live demonstrations between multiple domestic and international hospitals. Their activities range from routine telemedicine consultations to large-scale events such as academic conferences and research meetings.
Recent innovations in virtual reality (VR) and immersive communication have enhanced this mode of communication.34,35 For instance, 360° videos display images in all directions from the camera’s position, allowing viewers to explore the scene and focus on specific areas.36,37 These videos are applied in fields such as surgery, trauma, dental radiology, and emergency medicine,38–41 contributing to improved learner satisfaction and self-efficacy, and supporting better learning outcomes. 41 Another innovative modality is the metaverse,42–46 which enables users to interact, socialize, work, and learn online through digital avatars in immersive environments. From VR interventions for chronic pain management 47 to medical training, 44 the metaverse can be applied in various scenarios.
The expansion of telemedicine has increased interest in education and training. Indeed, telemedicine education occurs in clinical settings and educational institutions in the United States, Brazil, Australia, the United Kingdom, and Japan.
48
Training programs are embedded in medical school curricula.49,50 Recently, integrated guidelines for doctor-to-patient video consultation etiquette have been developed, and e-learning programs to enhance health care professionals’ knowledge and confidence in virtual care have been proposed.51,52 DtoD telemedicine conferences and consultations require implementing and adjusting networks, video and audio equipment, and videoconferencing systems. Within the APAN-MWG, training and Train-the-Trainer programs for IT staff and physicians have been conducted since 2015.53–55 Training has been provided to enable domestic and international telemedicine conferences and consultations using academic research and commercial networks, using the latest technologies.
56
Technological advances have enabled doctors and administrative staff to perform tasks previously handled by hospital IT staff.53,57,58 Increased use of DtoD conferences after the COVID-19 outbreak has created demand for specific technical skills among staff members. Yet, limited attention has been paid to understanding the technical skills required for DtoD telemedicine led by interdisciplinary teams in Asia. Addressing this gap, the current study collaborated with the APAN-MWG to identify the technical skills necessary for DtoD telemedicine in Asia,55,59,60 to provide technical skills relating to:
setting up technology to conduct domestic and international DtoD telemedicine; training to install and use various technologies and equipment relevant to different medical subspecialties; familiarizing trainees with recent advanced technologies emerging in the field.
Methods
This study employed the e-Delphi method to solicit individual opinions of experts within the APAN-MWG interdisciplinary team regarding technical skills needed for DtoD telemedicine conferences and consultations, including emerging technologies by distributing an online questionnaire via email.61–63 First, a team was organized consisting of investigators, an expert panel, and Delphi participants. The investigators included five members from Japan, Indonesia, and India: three telemedicine researchers and two IT directors at medical facilities. The expert panel comprised five members recruited from Malaysia, Japan, Indonesia, and Australia, including four IT directors in health care facilities (three physicians and one technologist) and one medical education specialist affiliated with a telemedicine center. Thirty participants were recruited from the trainers of the APAN-MWG DtoD training program and the Train-the-Trainer program. All participants were engaged in telemedicine, and the majority (80%) were affiliated with university hospitals or nonuniversity hospitals, followed by government agencies (17%). The aggregated opinions were evaluated, refined, and ultimately consensus was reached.64–66
In Phase 1, an expert panel was established to formulate a list of DtoD-related technical skills. It identified technical themes and formats; both synchronous and asynchronous models were considered. Live demonstrations and 360° video content were targeted for specific medical fields to identify particular skills. Live demonstrations were often conducted at endoscopy and laparoscopic surgery conferences; thus, the study focused on live demonstrations of endoscopy. Meanwhile, 360° video content was often used to present the operating room environment involving staff from multiple professions; the same was set up accordingly. Five themes and formats were identified:
Overview of DtoD telemedicine and videoconferencing basics Setting up a large venue for hybrid medical conferences Live medical demonstration: endoscopy demonstration 360° video on-demand transmission of the operating room Medical case conferences using the metaverse
In Phase 2, the Round 1 questionnaire was administered on December 1, 2023, to assess the listed items with respect to technical skills. Phase 3 involved organizing and conducting a workshop with the participants to further discuss the items identified by the expert panel, held on December 15, 2023. The workshop was conducted in a hybrid format, allowing both on-site and online participation. In total, 27 participants from 24 institutions in 14 countries attended the workshop. During the workshop, experts presented and discussed their implementation experiences and related problems, as well as the technical skills required, for each of the five themes and formats. After the workshop, the revised Round 2 questionnaire was sent to participants for review on January 25, 2024. Respondents were asked to rate the appropriateness of each item on a 1–9 scale (1: Inappropriate; 9: Appropriate). Questionnaire responses were categorized into three levels: 1–3 (inappropriate), 4–6 (unknown), and 7–9 (appropriate). The recommended consensus rate of the Delphi method ranges from 51% to 70%, with 70% indicating a more cautious threshold. 67 Therefore, responses of 70% or greater were treated as signifying consensus. The investigators revised the list of skills based on all consensus results, comments, and input from the workshop. Consequently, in the analysis, the number and percentage of respondents who answered 7–9 were calculated.
Ethical considerations
This study was conducted according to the principles of the Declaration of Helsinki and was approved by the Ethics Committee of Kyushu University Hospital (No. 23235-00). All participants signed an informed consent statement prior to participation.
Results
Thirty participants took part in the study. Table 1 shows participants’ characteristics. The majority were hospital IT staff. A doctor and a nurse also took part in the study. Over half (57%) were affiliated with university hospitals, followed by nonuniversity hospitals (23%). Five worked in government sectors. The highest number of participants were from Indonesia and Vietnam (7/30, 23%), followed by Nepal (6/30, 20%), and Japan (3/30, 10%). All 30 participants from 11 countries completed the Round 1 questionnaire, and all drafts were evaluated as appropriate, with 46 comments. After the workshop, 10 skills were added such as “Set up a system for one-to-one consultations/meetings (Topic 1),” “Manage multiple audiovisual signals (Topic 2),” and “Obtain approval from the appropriate management department (Topic 4).” Participants also completed the second survey, and all drafts were evaluated as appropriate, with 44 comments. In total, 43 technical skills were identified by consensus among the participants. The list included skills related to conceptual understanding, technical execution, coordination, operational management, and security policy considerations. Skills needed for hybrid medical conferences received the highest scores (Round 1: 94%, Round 2: 91%), while those for 360° video on-demand transmission received the lowest (Round 1: 85%, Round 2: 81%). The results for each of the five topics are presented in detail below.
Characteristics of the Participants
Information technology.
Topic 1: Overview of DtoD telemedicine and videoconferencing basics
The workshop discussion resulted in additional four topics. In Round 2, all nine items were agreed upon, with an average agreement rate of 89% (Table 2). A hospital IT staff from Nepal noted:
Consensus on Skills: Topic 1—Overview of DtoD Telemedicine and Videoconferencing Basics
In developing countries like Nepal, where internet facilities in rural hospitals are minimal, they have budgetary constraints for procuring dedicated internet services. In addition, technical IT human resources are limited for maintaining the IT system.
Topic 2: Setting up a large venue for hybrid medical conferences
A participant from Malaysia described the challenges of large venue setups: A large venue setup is very challenging. Thus, higher skills are required for the IT staff to handle this, especially for sound and video.
A nurse from Nepal highlighted infrastructure and power issues: Most of the things depend on the computer and hospital infrastructure. Dedicated internet connectivity may be required which is costly. In addition to this, frequent power cuts can be another issue in operating telemedicine.
At the workshop, feedback indicated that staff management and controlling multiple audiovisual signals were important aspects of preparing a large venue. Therefore, the theme “Setup local venue from scratch” was revised to “Setup local venue from scratch for a large audience.” Two items, “Organize staffing for a large venue” and “Manage multiple audiovisual signals” were added. In Round 2, all 11 items were agreed upon, with an average agreement rate of 91% (Table 3).
Consensus on Skills: Topic 2—Setting up a Large Venue for Hybrid Medical Conferences
Topic 3. Live medical demonstration: endoscopy demonstration
A hospital IT staff member from Bhutan emphasized the importance of skills for extracting and distributing images from medical devices. Practical sessions are very important to improve capacity to extract endoscopy images, and to able to provide live demonstration.
Workshop participants thought the theme “Handling live demonstrations” was too abstract. They suggested it should be more specific; for example, switching video sources according to the situation (e.g., picture-in-picture) and monitoring the quality of streaming video. Thus, two items were added: “Managing multiple video signals for live demonstrations” and “Monitoring the quality of streaming video.” In Round 2, all nine items were agreed upon, with an average agreement rate of 89% (Table 4).
Consensus on Skills: Topic 3—Live Medical Demonstration: endoscopy Demonstration
Topic 4. 360° video on-demand transmission of the operating room
In Round 1, two participants noted little experience using a 360° camera. Additional comments included: Need more reviews ∼360° image quality such as the real image ratio… (Hospital IT staff, Indonesia) Ethical clearance and administrative approval-related issues were not included! (Hospital IT staff, Sri Lanka)
In response, “Obtain approval from the appropriate management department” was added to the existing theme “Predict and address security risks, such as inappropriate exposure of patient information and viewer age restrictions.” In Round 2, all eight items were agreed upon, with an average agreement rate of 81% (Table 5).
Consensus on Skills: Topic 4—360° Video on-Demand Transmission of the Operating Room
Topic 5. Medical case conferences using the metaverse
In Round 1, two participants noted limited experience using the metaverse. The hospital IT staff from Bhutan stated: Trainees should be exposed to the latest equipment and technologies. They should keep abreast with the technologies, applications, and sound and video systems so that they know the right thing to do when they are exposed to the situation/equipment they are not familiar with… .
The hospital IT staff from Indonesia raised privacy concerns: Talking about the metaverse means also talking about privacy protection. It needs more study ahead.
At the workshop, participants agreed to add new technical elements despite some having little experience with the metaverse. Skills such as simultaneous distribution (e.g., YouTube) were deemed necessary to enable spectators who had not installed the system to view the sessions. Accordingly, the item “Livestreaming settings” was added. In Round 2, all five items were agreed upon, with an average agreement rate of 84% (Table 6).
Consensus on Skills: Topic 5—Medical Case Conferences Using the Metaverse
Discussion
This study aimed to identify the technical skills needed for conducting DtoD telemedicine conferences/consultations. Thirty technicians and medical staff from medical and government facilities in 11 Asian countries were recruited. Based on the results, 43 technical skills were identified across five categories. Skills for using recent innovations, such as 360° video streaming and the metaverse, were also considered important. Despite our cautious target of 70% for the agreement rate, we exceeded 90% agreement in Round 2 (22 out of 42). The average agreement rate for each category was high, exceeding 84%. The category with the highest agreement rate was Topic 2, “Setting up a large venue for hybrid medical conferences,” which may reflect the greater number of implementation opportunities available for this topic compared with the other four. The lowest agreement rate (81%) occurred for Topic 4, “A 360° video on-demand transmission of the operating room,” likely because it is a relatively new technology. Similarly, Topic 5, “Medical case conferences using the metaverse,” involving another new technology, had an agreement rate of 84%, slightly lower than other items. Comments indicated that further research is needed on privacy issues related to using these technologies. During workshop discussions, participants agreed that these new technologies are being applied in DtoD telemedicine and should be included, but the technical skills acquired may require updating as the technologies become more widely adopted. The opinions of the 30 experts converged, and they agreed on the capabilities identified in this study. Although originally planned to continue until consensus was reached on all items, the final consensus rate of 70% was exceeded for all items in Round 2. In past studies, the Delphi method has often been conducted in two to three rounds.64,68 After analyzing the second-round results, the final findings were provided to all respondents during the Round 2 group feedback session.
The list of technical skills had the following characteristics. In Topic 1, in addition to understanding the concept of DtoD, “basics of video conferencing” was added in Round 2. The item “Prepare for efficient conferences/consultations,” added in Round 2, is necessary to ensure efficiency, a major benefit of telemedicine.69,70 To minimize the time commitment of the doctor in charge on the day of the consultation or conference, sharing relevant information in advance with the participants and thoroughly checking the operation of equipment to avoid wasting time is necessary. Regarding Topic 2, focusing on a hybrid setup in a large venue, the operation of video and audio equipment and network devices, quality control, and skills related to management of multiple audiovisual signals and staff—unique to large venues—were identified as important. Hospital IT staff from Nepal repeatedly emphasized the need to address limitations in technical infrastructure and IT staff at hospitals in rural areas. Geographically, Nepal has a large mountainous area and has been implementing telemedicine; thus, the ability to manage communication problems in resource-limited rural areas is essential.71,72 Accordingly, video, audio, and network maintenance items were included in this topic. Regarding Topic 3, the hospital IT staff from Bhutan highlighted the importance of extracting images from medical devices. Live demonstrations are often used in endoscopic diagnosis, treatment, and surgery, and smoothly switching between images from medical equipment and those held by the demonstrator is important. Extraction and switching skills are required to present the images that the receiver needs. Furthermore, during live demonstrations, distribution personnel were previously satisfied with merely sending video and did not monitor how it appeared online, making monitoring at their own facilities necessary. Topic 4 focused on the distribution of 360° videos. As these videos present content in all directions, important aspects included obtaining permission from the medical facility that owns the videos, predicting security risks, and taking measures to address them. Regarding Topic 5, which involved the metaverse, as with other new systems, it is deemed necessary to prepare for streaming distribution for participants unable to join due to technical constraints. The metaverse is a promising yet nascent technology. While its potential to transform industries is significant, it remains in the early stages of development. Key challenges include high costs of VR and AR devices, limited infrastructure in many regions, and fragmented platforms lacking interoperability. 44 Public adoption is also uneven, with concerns regarding privacy, data security, and mental health affecting user confidence. 73 Despite these hurdles, the metaverse is steadily growing, with companies and developers exploring innovative applications, from virtual classrooms to collaborative workspaces. 74 Its evolution mirrors that of the internet—initially met with skepticism but gradually becoming integral to daily life. As technology advances and societal adaptation improves, the metaverse can potentially redefine how people connect, create, and collaborate in a digital-first world. Therefore, keeping abreast of the most recent technology through related experiences and training is crucial. In DtoD, it is possible to change discussion partners depending on the topic, explore complex three-dimensional structures such as organs collaboratively, and communicate with others using gestures or maintaining a distance.43,75,76 These differences in communication formats have the potential to expand and deepen telemedicine activities.
Limitations and strengths
The participants were members of the APAN-MWG, which implements DtoD; therefore, there is a possibility that skills are limited toward technical content. While this study did not restrict activities to specific medical fields, the live demonstration for Topic 3 targeted a case in endoscopy, and the 360-degree video for Topic 4 targeted a case in surgery. Therefore, different skills may be required for activities in other medical fields. This study targeted relatively new technologies such as VR, which were covered in the APAN-MWG training program. However, several participants reported limited experience with these technologies, which may have affected their evaluations. Nonetheless, the study incorporated opinions from participants in 11 Asian countries, including respondents from facilities with limited equipment and human resources, allowing the creation of a highly versatile list. Few prior studies have clarified the technical skills needed for DtoD telemedicine, which this study identified across conditions and contexts, including synchronous and asynchronous models, domestic and international settings, and multiple medical departments. As new technologies continue to be developed and are likely to be introduced in the future, this study can serve as a foundation for improving technical skills needed for DtoD telemedicine.
Conclusions
To our knowledge, this study is the first to identify the technical skills needed for DtoD telemedicine conferences and consultations in the Asian context. In total, 43 technical skills were identified across five categories, including basic knowledge, currently popular modes of livestreaming and large-scale hybrid setups, as well as 360° video streaming and the metaverse. These skills can inform the development of future training programs and evaluation criteria. Building and disseminating such programs will enable DtoD activities to be implemented more efficiently and support further development.
Authors’ Contributions
K.K.: Conceptualization, investigation, formal analysis, and writing—original draft. S.U.: Investigation, formal analysis, and writing—original draft. Y.H.: Investigation, formal analysis, and writing—original draft. S.E.: Investigation and supervision. A.K.: Conceptualization and investigation. T.M.: Conceptualization, investigation, writing—reviewing and editing and supervision.
Footnotes
Acknowledgments
The authors are grateful to the members of the APAN-MWG.
Author Disclosure Statement
None declared.
Funding Information
This work was supported by JSPS KAKENHI [Grant Numbers JP23K25702, JP23K17621, JP24K06306, JP24K06247, 22K02858, 24K06306].