A LITERATURE REVIEW OF TELEMEDICINE IN INDONESIA: PAST, PRESENT, AND FUTURE PROSPECTIVE

Background: Indonesia has a great potential in the development of digital health technologies. However, several challenges might also arise in hand with the development of telemedicine. Aims: We aimed to conduct a literature review of the use of telemedicine in Indonesia in order to know how the start is, the development, and future considerations of its usage. Methods: From the digital databases of PubMed, Google Scholar, and Neliti (Indonesia's Research Repository), each author completed literature searches of telemedicine in Indonesia from 1985 to 2021. Results: A total of 8 studies were included in current literature review. In 1985-1987, Indonesia undertook the first satellite-based telemedicine. During the early twenty-first century, rapid improvements in information technology have expanded to other industries, including health care through telemedicine. Covid-19 dilemma compels physicians to adopt. Through telemedicine, many is experienced the benefit during the pandemic. However, in developing telemedicine system for the future, the use of telemedicine has several challenges, namely related to human resources, infrastructure and ethical regulations. Conclusion: When telehealth is successfully implemented in Indonesia, it will benefit both the developer and the consumer. Despite the benefits, the challenge of implementing and developing a comprehensive eHealth environment in Indonesia might be seen as tremendous, given that the country is currently developing its infrastructure.


Introduction
Indonesia as the world's fourthlargest population has a great potential in the development of digital health technologies.The technology may assist Indonesia citizens in accessing healthcare way easier than ever before (Tuckson, Edmunds and Hodgkins, 2017) This will benefit the country's more than 260 million individuals across the country (Population, total -Indonesia | Data, 2018) The development and innovation of eHealth, which enables users to share and search for the most recent information, longdistance consultations with doctors, including e-prescribing, and exchange of patient health records, is what's driving the digital revolution in the health industry.(Tuckson, Edmunds and Hodgkins, 2017).
Telemedicine has the potential to shift care from a practice-cantered model to a patient-cantered model, reducing travel time or requesting for a school or work leave.However, there is no universally accepted definition of telemedicine at this time.Telemedicine, telehealth, and eHealth are all concepts that are frequently used interchangeably (Hilty et al., 2013).These are the terminology used to describe how information technology systems are utilized in the healthcare industry to improve communication between patients and healthcare professionals, especially those who live in remote locations.Telemedicine, according to the World Health Organization (WHO), is the use of information and communication technology to provide health care, particularly in areas where access to medical services is limited.(WHO Telemedicine, 2010) Telemedicine is traditionally defined as the delivery of medical treatment through the internet using audio-visual technology.(Grossman et al., 2020) Telehealth is the use of medical devices, activity trackers, automated reminders, blood glucose monitors, and other tools to collect and send health information, frequently with the aim of monitoring or managing chronic illnesses.It also includes telemedicine technologies.Telehealth can also aid in the development and improvement of healthrelated education, health management, and general public health (Edirippulige and Armfield, 2017).
The term 'eHealth' is also used in several European countries to designate digital health and technology-driven remote health care.Before 1999, this term was little in use; it now appears to serve as a general buzzword, describing not only internet medicine, but also nearly everything related to computers and medicine.They coined this term, along with others like ecommerce, e-business, e-solutions.The word eHealth is often used to refer to a broader range of digital information tools, such as electronic health records, which makes it easier for health care practitioners to share patient data.Computerized physician order entry systems, eprescribing, and clinical decision support technologies are examples of eHealth, which offer physicians with electronic information on protocols and standards for diagnosing and treating patients.(Edirippulige and Armfield, 2017).
However, due of the limitation of small number of published literatures, little is known about the development and the effectiveness of telemedicine use in Indonesia.Doctors are also less familiar with telemedicine since they are unaware of the implications of its use in any medical practice.During the COVID-19 pandemic, clinicians will attempt to use this technology for outpatient care in order to facilitate access and convenience of care.Several challenges might also arise in hand with the development of telemedicine in Indonesia, such as human resources, infrastructure and ethical regulations (Kawaji et al., 1990).Thereby, we aimed to conduct a literature Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p- ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v10i2.2022.261-272Literature Review review of the use of telemedicine in Indonesia in order to know how the start is, the development, and future considerations of its usage.

Method
From the digital databases of PubMed, Google Scholar, and Neliti (Indonesia's Research Repository), each author (G.S, L.R, and J.H) completed literature searches of telemedicine in Indonesia from 1985 to 2021 on 17 September 2021.As far as the available documentation, telemedicine practice was initially trialled back in 1985.As such, we included studies in 1985 afterward.We used the terms "telemedicine", "telemedika", "telenursing", "remote consultation", "telehealthcare", "telemonitoring", "remote monitoring", "teleeducation", "health messages", "remote diagnosis", "telediagnosis", "teleconsult", "mobile health", "mHealth", "eHealth", and "Indonesia".We conducted literature searches from 1 January 1985 until 17 September 2021.From 1347 published scientific articles, 337 studies were deleted due to duplicates.Following title and abstract screening, we selected 35 articles for full text screening.The authors excluded 18 studies for not reporting the key interests, 3 meeting abstracts, 4 studies conducted not in Indonesia, and 2 studies duplicate.We deemed 8 studies to be eligible for current literature review.We collected all reports on telemedicine use in Indonesia with restrictions to English and Indonesian language.Telemedicine refers to the use of electronic communications channels or mediums and information technology to deliver clinical services.As the primary endpoint of our study, articles were required to give original data on telemedicine use in Indonesia.We exclude narrative, conference abstracts, commentary, perspective, and opinion.
Nonprimary literature was excluded due to lacking credibility.However, we still retrieved studies from a systematic review, abstracts, and other nonprimary literature references to ensure literature saturation.The approach we used for current review is traditional review.
Initially, each author (G.S, L.R, and J.H) screened the title or abstracts for extracted articles from each electronic source.After that, we read the remaining pieces in full paper format and decided which papers were eligible for our study.Any discrepancies were resolved through discussion by the authors.We critically appraised the quality of included studies using the Joanna Briggs Institute (JBI) for case report or Newcastle-Ottawa Scale (NOS) as appropriate.
For data extraction, we collected the demographic characteristics (total patients, age, and sex), publication year, medical fields (e.g., neurology, cardiology, or other), study design, and results from each study.(Suksmono et al., 2014) We aimed to conduct a literature review of the use of telemedicine in Indonesia in order to know how the start is, the development, and future considerations of its usage.

Historical start of telemedicine in Indonesia
In 1985-1987, Indonesia undertook the first satellite-based telemedicine trial and other academic activities as part of the SHARE (Satellite for Health and Rural Education) project supported by Intelsat to honour its their anniversary.(Abdulrachman and Abdulrachman, 1991) Practice of teleconference was reported to be first used in Indonesia in the 1985, between an Indonesian National University and the World Health Organization (WHO).The data that was transferred was in text format (Suksmono et al., 2014) Telemedicine applications were first launched in 2010 as part of a biomedical technique that included a simple block diagram and multiple disciplines.E-health applications were developing to provide real-time connections between medical stations and terminals for teleconsultations between general practitioners and specialists.That store-and-forward can be used to distribute a short report about patient recapitalization at a community health centre.In 2011, short message service technology for streamed audio and video data in a mobile setting was used to develop e-health applications for disease detection (Shimizu et al., 2010).To assist with patient and pharmaceutical data, an eprescription system with a mobile e-health system for child and mother therapy was built in the same year.The SMS module in this system can transmit short messages in various operation modes.An SMS software module and a modem connected to a PC-based e-health system constitute an eprescription for mobile e-health, in essence.(Nugraha and Aknuranda, 2017) Telemedicine vastly developed the focus on mobile-based health systems.As of 2018, the government manages seven network-based health care applications and 18 private online health service applications.Although various platforms provide online health information and services, many Indonesians have yet to use this app.According to a poll performed between May and July 2018, 67.6% of 102 respondents have never used an online health service application (Husni et al., 2006).

Before the pandemic
Health service innovations in the digital era help patients use their time more efficiently, such as reduction in hospital traveling time and health facilities for consultations.There are 7 network-based health service applications managed by the government and 18 private online health service applications which can be seen from Table 1    Literature Review

During the pandemic
The Covid-19 epidemic has triggered a global crisis that is putting an unprecedented strain on the healthcare system.Hospitals with a high number of Covid-19 patients that require immediate care influence medical personnel's health and the necessity for personal protective equipment.Surgeries, technology, and expertise can all provide challenges for doctors when performing medical treatments.Because doctors are unfamiliar with the current conditions, the current Covid-19 dilemma compels physicians to adopt technology that they do not understand.Additionally, in order to scale up the healthcare systems and modernize healthcare delivery as healthcare systems across the nation get ready for an inflow of Covid-19 cases, quick action is required.(Ventura, Gibson and Collier, 2020).
Patients with chronic conditions are treated at home according to their physician's instructions and directions during the current Covid-19 pandemic.By utilizing the digital technologies, physicians can monitor the patient's progress without having to visit the patient.Patients with chronic conditions may have comorbidities that increase the chance of Covid-19 infection worsening; thus, healthcare providers must make efforts to limit Covid-19 patients with chronic disease comorbidities from hospitalization (Bendelin et al., 2020).On the other hand, the use of telemedicine in the treatment of chronic diseases makes it easier to control patient medication (Orozco-Beltran et al., 2017).Additionally, telemedicine is beneficial in reducing the number of visits to the hospital and arrivals to the emergency department (Eccleston et al., 2020).Telemedicine can support patient self-management starting from medication prescription, lifestyle modification, and patient emotional management effectively, which then improve the quality of patient outcomes (Hanlon et al., 2017).Through telemedicine, patients with chronic diseases can be avoided from Covid-19 infection that are at risk of increasing the risk of patient death (Guan et al., 2020).

Future prospect of telemedicine in Indonesia
Although telemedicine can improve the quality of medical practice during a pandemic, the use of telemedicine has several challenges, namely related to human resources, infrastructure and ethical regulations (Tedeschi, 2020).Doctors and health policymakers are currently still paying less attention to the use of telemedicine to integrate it into the national health system (Omboni, 2020).Due to the need for doctors to master new and complicated consultation techniques, the use of telemedicine by medical professionals is still restricted during the present Covid-19 epidemic (Smith et al., 2020).In addition, health policy-making factors regarding telemedicine depend on the geographical conditions of the application of the technology, which limit Wijaya, Octavius, Hwei Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v10i2.2022.261-272 .261-272Literature Review the use of telemedicine in urban areas due to the ease of access to health care facilities compared to remote locations (Smith et al., 2020).The majority of existing telemedicine policies use telemedicine in rural and remote areas to make it easier for rural communities to consult doctors without travelling long distances.In the context of Covid-19, telemedicine is needed in dense populations that have a high risk of transmission, such as in urban areas.Therefore, promotions related to the use of telemedicine can be a priority in pandemic conditions to minimize the risk of transmission through person-to-person contact (Kichloo et al., 2020).Procurement of telemedicine facilities requires infrastructure that can support telemedicine applications.However, it is undoubted that a significant challenge in developing countries is the basic infrastructure such as electricity, electronic hardware, communication equipment, and software applications to support telemedicine activities (Combi, Pozzani and Pozzi, 2016).Deloitte has suggested a framework called "Five Yearly Developmental Goal" in which infrastructure, data storage, and eHealth actualization (Smart hospital using Integrated Management Information System) are comprehensively planned (Deloitte 2019).In addition, the financial difficulties of using telemedicine in medical procedures are due to the unclear return on investment due to unclear income measures and complex insurance reimbursement (Iribarren et al., 2017).The financial challenges associated with procurement of telemedicine infrastructure hinder in the necessary technologies development and thus limit the application of telemedicine in medical practice (Kim and Zuckerman, 2019).
The accessibility of medical records via telemedicine during doctor-patient consultations is one of the problems in promoting the field of telemedicine (Orozco-Beltran et al., 2017;Bendelin et al., 2020).Privacy of data and medical records is a concern when using telemedicine in every practice of doctors.This condition results from telemedicine's use of unregulated medicine.Problems in ethical aspects related to patient information for treatment can cost a lot of money in solving these problems (Tedeschi, 2020).To address these moral dilemmas, medical professionals must inform patients about the restrictions placed on their use of telemedicine so that they can consent to it or decline.To guarantee patients of the confidentiality of patient data and information, clinicians using telemedicine must also follow specific rules and laws (Ventura, Gibson and Collier, 2020).Figure 1 depicts an overview of development of telemedicine in Indonesia.

Conclusion
When telehealth is successfully implemented in Indonesia, it will benefit both the developer and the consumer in many aspects.Despite the benefits, the challenge of implementing and developing a comprehensive eHealth environment in Indonesia might be seen as tremendous, given that the country is currently developing its infrastructure.This literature review provides the government's and private companies' effort in developing and strengthening the telemedicine infrastructure in the country.Also, promising future of telemedicine should be balanced with some ethical and human resources issue.

Indonesian Journal of Health Administration
. Wijaya, Octavius, Hwei Indonesian Journal of Health Administration(Jurnal Administrasi Kesehatan Indonesia)    p-ISSN 2303-3592, e-ISSN 2540-9301  10.20473/jaki.v10i2.2022.261-272Literature ReviewIndonesia completed a low-cost "Still Picture Transmission by Narrowband Technique" for educational and medical services in the early 1990s, followed by a series of image processing studies on a laboratory scale.Pan Asia-Pacific Region Telecommunication Network for Tests and Research by Satellite (PARTNERS), a cooperation financed by Japan's Myanmar Posts and Telecommunications and managed by the Association of Radio Industries and Businesses, was established to undertake experiments on Engineering Test Satellite-Five L-Band transmission and related applications(Suksmono et al., 2014).Slow scan video lectures were held among our PARTNERS members(1992( -1997( ) (Nakajima et al.,  2001)).Educational and medical messaging can utilize this type of application conducted by Tokai University's School of Medicine, which is one of the partners for ITB (Institut Teknologi Bandung) school of engineering.In 1997, a satellite-based telemedicine experiment was conducted between the UNJANI (Universitas Achmad Yani) Faculty of Medicine and Engineering in Bandung as the centre/control station, the Central Hospital of Mataram, and the Harapan Kita Hospital in Jakarta(Nakajima  et al., 2001).The trial was on maternal care using a television in order to conduct the trial in Indonesia's eastern territory.Another post-PARTNERS telemedicine experiment was a wireless-based telemedicine system that connected one university hospital and one university in Bandung, Hasan Sadikin Hospital and UNJANI via JCSAT 3 satellitelinked between ITB and Ohkura National Hospital in Japan (Tedeschi, 2020).Another telemedicine activity was carried out in the ITB's Biomedical Laboratory.The research team created an internet-based telemedicine system for the country's Primary Community Health Centre (Puskesmas).Tele-consultation, basic telediagnostic, tele-coordination, tele-education, and medical databases are among the services provided (Suksmono et al., 2014).During the early twenty-first century, rapid improvements in information technology have expanded to other industries, including health care through telemedicine.Despite the governmental decree on initiating telemedicine practice (tele-ECG) in 2011, (Menteri Kesehatan Republik Indonesia, 2020) there have been several medical researches of telemedicine in 2004.Telemedicine via an internet connection was developed for the Community Health Centres (Puskesmas) which supported teleconsultation, telediagnosis, simple tele coordination, tele-education, and drug databases, among other applications (Suksmono et al., 2014).In the same year, a telebiomicroscopy was developed by the Research Group of Padjajaran University's Faculty of Health (Suksmono et al., 2014).A wireless communication channel in this system was used to transmit a microscopic description of an eye condition.As a result of the findings, it was determined that an eye illness diagnosis might be performed remotely utilizing a telemedicine system.Another experiment was carried out in a compromised hemodynamic state, with vital patient data provided over a communication link.The outcome of the experiment was also encouraging (Suksmono et al., 2014).A web-based medical information system for broad communities has been created by PT Telkom (Indonesia's national telecommunications corporation).Teleconsultation and tele-education were implemented as part of another trial called MediFa, which uses a videophone to connect primary care clinics and referral hospitals.This technology was expanded over the next few years to include video streaming, Short Message Service, and Wireless Application Protocol for usage by Wijaya, Octavius, Hwei Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v10i2.2022.261-272Literature Review family doctors.(Nugraha and Aknuranda, 2017) Telemedicine continued developing until 2005, and until then, Indonesian engineering established an ICT-based ehealth system designed for epidemic management.For a web-based epidemic management system and a mobile phonebased system with multiple communication links, many e-health prototypes have been developed.A mobile communications system was created by teams from the hospital, various health service units, and the ambulance in order to determine what equipment was easily available (Soegijoko et al., 2011).Mobile telemedicine was created up until 2007 as a component of a tele-emergency effort to provide medical care in remote areas.A mobile telemedicine system prototype that consists of both hardware and software could be swiftly set up in rural locations or at disaster sites where the communications infrastructure has collapsed (Shimizu et al., 2010).

(
Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v10i2.2022.261-272Literature Review system that has been established for both public and private hospitals.It is based on the patient's disease and the technique of paying for patient treatment based on cases or diagnoses that are generally comparable.In addition, JKN tariff revisions are being discussed to include telemedicine financing.In the current JKN era, 1,227 hospitals have implemented the INA-CBG.(Deloitte 2019, 2019).The number of supporting health centres for telemedicine programs in five years is developed according to the road map of the Indonesian Ministry of Health.The Ministry of Health's 5-year (2015-2019) telemedicine program roadmap is prioritized for poot regions and islands or called as Daerah Tertinggal Perbatasan dan Kepulauan (DTPK) where health facilities are very difficult to be accessed by the community.The target of telehealth facilities by the Ministry of Health is prioritized at 120 tertiary healthcare facilities in the DTPK or also known as "Puskesmas".The target of the referral hospital programmed in 2015 is around 3 supporting hospitals.The target for 2019 is to reach 42 referral hospitals.The telehealth program in this study was started in 2016, with a target of eight supporting hospitals.If it is assumed that the number of health centres supported by each supporting hospital is 10 health centres.The number of puskesmas trained in the first year (2016) was 80 puskesmas.The number of densely packed health centres in 2020 will reach 680 health centres.The target of this telehealth program is for areas outside the border and underdeveloped.This program will be successful if the area has access to electricity and is affordable by data services at least third generation (3G) technology.(Indonesia Ministry of Health, 2018a).

(Figure 1 .
Figure 1.An overview of development of telemedicine in Indonesia.

Table 1 .
Online health service applications managed by the government and private.