The Far-Reaching Telehealth and Telemedicine on Pharmacy, Rehabilitation and Surgery

#### **Chapter 4**

## Stakeholders of the Online Pharmaceutical Market

*András Fittler, Márton Fittler and Róbert György Vida*

#### **Abstract**

During the past two decades, the pharmacy supply chain has developed a new segment besides traditional "brick and mortar" pharmacies. The expansion of the internet, consumer experience in online purchases, the ease of mail order trade, and distance selling have facilitated the growth of the internet pharmacy landscape. Changes in health-seeking behavior, patient empowerment, and openness to selfdiagnosis and self-treatment have also contributed to the phenomenon and were further facilitated by the pandemic. Various types of online medicinal product sellers have been published previously, however, authors have classified online pharmacies mainly according to legality and patient safety considerations. As online pharmacies show great diversity, no distinct categories can be specified, rather pharmacies on the web can be categorized by multiple aspects. Admittedly, consumer preferences, regulatory environment, and legitimacy of operation are key influencing factors. In this chapter, key aspects of categorization and nomenclature are discussed to profile different vendors on the internet.

**Keywords:** internet pharmacies, illegal online pharmacies, drug supply chain, patient safety

#### **1. Introduction**

Internet today is not only a resource for health information but a real opportunity to obtain medical services and pharmaceuticals due to changes in health-seeking behavior, patient empowerment, and openness to self-diagnosis and self-treatment. During the past decades, the internet has become an accepted means to procure various products, especially during the pandemic, and the pharmacy supply chain has developed a new segment beside traditional brick-and-mortar pharmacies. The main motivation lurking behind internet procurement of medications is convenience, the potential to save money, and assure client privacy. The pandemic has caused changes regarding the demand and access to medications and has facilitated self-care and selfmedication behaviors among the public worldwide. Likely the experience in online purchases, the ease of mail-order trade, and distance selling has further facilitated the growing market of online pharmacies. Recent reports and a representative sample of Hungarian outpatients suggest the use of internet pharmacies and the number of individuals obtaining medications and various health products online is increasing [1], international literature data indicate the prevalence of buying prescription drugs

online in the population ranges from 1 to 32% [2]. Admittedly, the COVID-19 pandemic has impacted consumer behavior and changed consumer preferences, further integrating pharmacy e-commerce in healthcare delivery [3].

Internet pharmacy is an umbrella term, while online pharmacy, e-pharmacy, e-commerce pharmacy, or cyber pharmacy often being used as synonyms. Although there is no internationally accepted definition, internet pharmacies are entities that offer and dispense nonprescription and prescription medicines direct to patients and offer products and services through an internet website [3, 4]. Distant selling of medicinal products by mail-order pharmacies has existed in the United States for more than a century [5] and during the past decades, it has extended its services online, becoming online retail mail-order pharmacies. The first legitimate internet pharmacy started its operation in 1999, however, during the past two decades rapid proliferation has been observed with the penetration of e-commerce, digital service offerings, and direct-to-consumer healthcare [3, 6].

Due to the intangible nature of the internet, the actual size of the online pharmacy market is yet relatively unknown. Thousands of internet pharmacies are accessible on the web; and as the internet is an immeasurable and low-controlled environment, a vast number of illegitimate vendors overwhelm the market of online pharmaceuticals [7, 8]. It is difficult and nearly impossible to determine the total number of active internet pharmacies, the volume of medicines sold or the actual public health impact [9], as data is not aggregated, and insights are difficult to derive from this channel [10]. This is mainly because the illegal market segment is an uncontrolled environment, with practically no restrictions regarding vendors, consumers, or products. Nearly anyone can purchase any type of medication without a prescription, medical supervision, or appropriate diagnosis, consequently compromising patient and medication safety. Hence, the globalization regarding e-commerce has enabled the creation of a "digital pharmaceutical gray market" separate and far beyond the legitimate supply chain [6]. In addition to the benefits perceived by patients, several patient safety risks are linked to the procurement of medicines outside the traditional supply chain, including questionable sourcing, poor product quality, improper storage, and transportation [11], while cybercrime including consumer fraud and data privacy issues can be noted as potential nonhealth-related risks [12]. Illegitimate online pharmacy

#### **Figure 1.**

*Elements of evaluating internet pharmacy websites.*

#### *DOI: http://dx.doi.org/10.5772/intechopen.108485 Stakeholders of the Online Pharmaceutical Market*

websites are considered the major source of substandard and falsified medications in developed countries [6, 13, 14]. Illegal actors have been using the internet as a channel of distribution and the problem of online prescription drug sales has been escalating since the mid-1990s [15]. Although, probably, it would be better to reserve the term "internet pharmacy" only for licensed legitimate websites providing legitimate professional pharmacy services, in our current chapter for simplicity, we will refer to online vendors of medicinal products as internet pharmacies.

Cyberspace is global and not local, websites can be viewed globally, and e-commerce crosses jurisdictional boundaries, consequently, internet pharmacies and purchasing of medications via the internet make regulation and governance problematic [16]. In the case of trans-border trade, the country of operation determines the licensing regulations and the quality assurance standards. Concurrently, delivery must be performed in accordance with the destination country's regulations on distance sale of pharmaceuticals. As many, likely illegal, websites are reluctant to reveal their real-world location, consumers cannot bear the responsibility of illegitimate purchases as they cannot be sure of the regulatory framework under which the website is operating [17].

Due to the lack of internationally standardized regulations the control and law enforcement of medications moving across the border is an issue, often making national authorities powerless outside their own borders. Safety issues related to online pharmacies originate from a lack of regulation. According to the FIP global survey on online pharmacy operations and distribution of medicines, more than half (n = 37, 51%) of the responding countries indicated that they had no regulations for online pharmacies, while nearly all in Africa and South-East Asia were lacking laws regulating online pharmacy operations [3].

Despite the national legal differences, there are a few internationally accepted norms. These include that prescription-only medicines cannot be dispensed without a valid physician order, and that pharmacies shall adhere to the regulations on the distant sale of medications in the destination country. Further, controlled substances (narcotics, psychotropics) and unauthorized medicines or ones not approved for sale by the national drug authority cannot be distributed, meanwhile, the sale of substandard and falsified medicines is considered a crime.

As internet pharmacy websites show great diversity, online medicine vendors can be categorized by multiple aspects. In the above, simplified process scheme, the most influential aspects of internet pharmacies are illustrated. The method of how consumers contact vendors and online availability, further regulatory framework regarding the distant sale of medicinal products are important elements of accessibility of internet pharmacy websites. The degree of interaction with customers and patients impacts the services provided by operators of the website. Finally, treatment outcome and patient safety are the primary outcome parameters of internet pharmacies (see **Figure 1**).

#### **2. Categorization aspects of internet pharmacies and online vendors of medicinal product**

#### **2.1 Legitimacy and verification**

Although sometimes used synonymously, the distinction between legal-illegal and legitimate-illegitimate online sales and purchases of pharmaceuticals must be discussed. Legitimate internet pharmacies are *registered* and possess a pharmacy license to dispense medications, further these websites are monitored and adhere to national regulations. These websites comply with the regulations of the country of operation and the country of destination where the products are shipped [7]. Websites adhering to their national jurisdictions may trade medications transborder to consumers in countries with different domestic laws. It may occur that in the destination country where a consumer is located, the online pharmacy is not registered and/or the medication is not legally sold. In these circumstances, the consumer is engaged in unauthorized or illegitimate online purchase. Even though the selling prescription drugs without valid prescription violates regulations consumers may not be aware they are obtaining drugs illegally [16]. According to LegitScript's data on a global scale, approximately 5% of online pharmacies operate in full compliance with applicable jurisdictions [18].

Illegal/rogue online pharmacies intentionally fail to comply with national or international standards and regulations. The most common and noticeable indicator of these online vendors is the sale of prescription-only medication without a valid prescription, not to say controlled (addictive) prescription drugs. These websites account for approximately 92% of all online vendors, and operators do not have legally required pharmacy licenses and sell unapproved and unregulated medications [18].

Verification is of key importance, however, may not necessarily correlate with patient- and/or medication safety issues. Unfortunately, in a relatively large proportion (n = 21, 38%) of the countries participating in a global survey, there is no established method to verify the authenticity of online pharmacies [3]. At once, verification systems are not mutually recognized internationally. The main issue related to verification systems is that they require consumer awareness, without consumer knowledge of the dangers of illegal medicines sales and the existence of verification systems, their impact on protecting patients is relatively low. Additionally, nonprofessional and unofficial verification systems may exist and the seals used to differentiate legitimate websites from illegal ones can be faked.

However, there are numerous web-based verification/accreditation/certification systems worldwide. Unfortunately, verification systems are generally not accepted internationally. Further, parallel to national and international systems approved or maintained by drug authorities, private agencies also certify that drug-selling websites and nonreputable verification services may also exist. These services differ in certification standard, coverage, business model, and certification outcome [19]. Website seals or logos provided by certificate agencies, commercially available verification services, and top-level domain names are currently available solutions for providing reliable information for consumers regarding the legal status of an online pharmacy. These methods rely on and require consumer awareness and participation at the point-of-sale [8].

Accredited or legitimate vendors display website seals as images and links acquired from national or regional agencies or authorities. The National Association of Boards of Pharmacy (NABP) initiated the Verified Internet Pharmacy Practice Site (VIPPS) program in 1999, the program is voluntary and requires payment verification. This rigorous inspection program expects mainly US-based online pharmacies to comply with relevant regulations, right to privacy, authenticate and secure prescription orders, adhere to quality assurance policy, and provide meaningful consultation with pharmacists. The majority of accredited websites (currently less than 100) in the NABP's database are open to all customers, including chain pharmacies and pure

#### *DOI: http://dx.doi.org/10.5772/intechopen.108485 Stakeholders of the Online Pharmaceutical Market*

online pharmacies. The remaining are membership-only sites that belong to pharmacy benefit managers. The NABP reviews fraudulent operators and publishes a not recommended sites list as well. A European regulation applicable to the legal sale of medications via the internet was implemented in the Falsified Medicines Directive 2011/62/EU (FMD) and all EU states follow the model described by the regulation. Since 2015 internet pharmacies in the EU must be registered by national authorities and display the common recognizable security logo [16]. Additional European voluntary registers of online medicine retailers officially authorized for the mail order trade were available before the FMD for example the DIMDI logo in Germany or the Registered Pharmacy in the UK. The common EU online seal verification requires visitors to click on the image, the logo takes the visitors to registers on the authority's website where the retailers' details are displayed.

LegitScript.com is the commercial leader private company for website verification services partnering with search engines, e-commerce platforms, payment companies, and regulatory agencies. In addition to internet pharmacies, telemedicine providers, and other healthcare merchants can get certified in the healthcare merchant certification program. The website permits free public searches for consumers to check online pharmacy legitimacy. PharmacyChecker is a verification agency established in 2003, requiring voluntary application and certification fees for Canadian and international online pharmacies. The website allows price comparison among verified members that meet the standards and guidelines for pharmacy accreditation. However, a complete list of searchable database of approved members or unapproved illegal sites is not available on the company's website. It has been published that the private agency has less stringent requirements and has certified suspect online drug sellers previously [20].

The ".pharmacy" generic top-level domain was launched by NABP in the USA as an ultimate identification for safe, legal, and ethical internet pharmacy websites. As the highest level of the internet namespace, it is a built-in verification tool for credible and safe websites, and as opposed to verification/certification logos, there is no possibility to fake the pharmacy extension. Evidently, the benefits are limited if consumers are not aware of this top-level domain while navigating in the online space [8].

#### **2.2 Online and offline presence**

The click-and-brick pharmacies offer online and offline services, these websites are the virtual representation of an individual pharmacy store, chain, or grouping, for example, Boots in the UK or CVS in the USA. Meanwhile, internet-only internet pharmacies do not have a physical store that patients can enter thus websites are not linked to brick-and-mortar pharmacies. Such pure-play online pharmacies include DocMorris in Germany. Regardless of the type of operation, it is a mandatory requirement for a legitimate online pharmacy to have a physical address and the contact information must be clearly presented on the websites.

#### **2.3 Prescription requirement**

Prescription-only pharmacies request valid prescriptions, including e-prescriptions, faxed or scanned versions, written by independent medical doctor to be submitted. There are two forms of online health status evaluation methods. Prescribing/ online consultation pharmacies require individuals to consult with health professionals (physician or pharmacist) employed by or affiliated to the online pharmacy

to obtain prescription drugs. Some internet pharmacy websites supply medications following the completion of an online questionnaire; however, this method appears to give consumers a false sense of health assurance than providing an actual health status assessment. Although online patient questionnaires can identify certain contraindications or prevent medication errors, these instruments can be bypassed by consumers, filled with inappropriate data, or include pre-selected answers [2]. No-records online pharmacies dispense prescription drugs without any prior documentation necessary [9]. Electronic prescriptions, implemented in the jurisdictions of many countries according to a recent FIP survey [3] will further facilitate the growth of the legitimate online market.

#### **2.4 Operator and business model**

Stakeholders of the pharmaceutical e-commerce market can be further classified according to the operator of the website. Legitimate internet pharmacies (e-pharmacies) are directly linked to and operated by a licensed pharmacy business. Depending on national regulations the operator may be a local independent community pharmacy, a pharmacy/drugstore chain, or a mail-order pharmacy (USA) extending its service online. Central pharmacy portals are operated by a trade association, distributor, or franchise partner involving independent pharmacies that offer orders online and collect in-local store service.

Affiliate and aggregator websites are often listed in search engine results and can be considered dominant players in promotion of medicinal and consumer health products. These sites are operated by individuals or companies and do not deal with products listed on their websites, rather than only market another company's products by diverting customers to the merchant's site for an agreed commission fee. Aggregator websites provide the opportunity to compare products from multiple merchants and direct users to the selected page. Websites engaged in an affiliate internet pharmacy program act as influencers and receive a commission for sending traffic and sales to online merchant websites. Interestingly, only a minority of the websites in the illegal internet marketplace operate independently as 97% of rogue websites are part of an affiliate network or other grouping indicating common control [18].

#### **2.5 Product categories offered**

Distant selling of medicinal products may be limited to consumer healthcare products including nonprescription or over-the-counter (OTC) medicines, dietary supplements, and patient- and personal-care products. By default, legitimate online pharmacies offer these products without medical prescription in several countries (e.g., Hungary and Russia) [21]. However, online sale of nonprescription medications is not allowed in 19% of countries participating in a survey published by the FIP in 2021 [3]. Subject to national regulations remote retail trade of prescription-only (Rx) medicines is also available from verified internet pharmacies in numerous countries (e.g., China, Germany, India, Lithuania, USA, Sweden) [10]. Although restrictions apply to selling certain Rx pharmaceuticals remotely, such as controlled drugs (narcotics, psychotropic medicines). The development and acceptance of online sales of medicines are illustrated by the fact that high-cost specialty medicines requiring special handling and/or clinical assessment are also supplied by online outlets linked to brick-and-mortar pharmacies in most regions of the world [3].

#### *DOI: http://dx.doi.org/10.5772/intechopen.108485 Stakeholders of the Online Pharmaceutical Market*

Due to complicated global differences in medicine regulations, nonprescription medications can be further classified as pharmacist-only medicines sold by licensed outlets and requiring consultation with a pharmacist, and general sales list medicines also available from nonpharmacy outlets [16]. The majority of countries limit the supply of pharmacist-only medicines if the website is linked to a brick-and-mortar pharmacy [3]. Accordingly, the majority of the internet pharmacies can be categorized as nonprescription-only e-pharmacies or extended product portfolio OTC + Rx e-pharmacy websites. Additional stakeholders selling consumer healthcare products with no direct connection to licensed pharmacies are present on the internet. These nonpharmacy webshops include general outlets (e.g., supermarkets) and parapharmacies (e.g., druggists) offering healthcare products including nutrients, herbal products, patient- and personal-care goods. Although in some countries consumers can purchase non-prescription medicines from non-pharmacy retailers, in most instances no authorized or licensed medicines are offered by operators not holding a pharmacy license.

Some online medicinal product vendors may not sell a vast range of products and brands, but rather specialize in a single specific brand or therapeutic area. Such dedicated websites may deal only with vitamins, lifestyle and embarrassment drugs (erectile dysfunction, hair loss, obesity, etc.), dental or veterinary products, controlled drugs (e.g., alprazolam, oxycodone), and steroids.

#### **2.6 Delivery of products**

Online pharmacies may offer in-pharmacy pick-up or cooperate with nonpharmacy pick-up points (e.g., retail druggist chains). For distance sales, the logistical function can be provided by mail or courier delivery. Delivery time and cost are important aspects of online purchases and distant sales of medicinal products. In general, purchasing medications from internet pharmacies can be lengthy as the delivery may require several days or even weeks depending on the county of origin. Additional implicit or explicit expenses should be considered, as shipping costs can have a significant impact on the total expenses for low-cost item purchases. Further, in the case of transborder trade, customs fees or taxes may also apply.

#### **2.7 Geographical service orientation and language of operation**

Pharmacies can provide their services to the local community to domestic customers within a country, or trans-border to reach international markets. Websites focusing on domestic customers are monolingual, while others serving international markets can be multilingual. Legitimate internet pharmacies typically offer their services and target their sales in the national and regional jurisdiction where they are licensed [18]. Disclosure of the website operator's geographical location and contact information is an essential element of transparency and legitimacy. However, such information may be biased as several studies have demonstrated the declared physical location may not correspond to the area of domain registration [9].

Numerous websites modify the language of operation based on the geolocation of the visitor or enable international visitors to select the language of operation. As illegal online vendors are willing to ship to locations where they are not licensed and/or where they are not allowed to sell prescription drugs, multilingualism and global market orientation may be linked to illegal activity.

#### **2.8 Pharmacist and pharmacy services**

Although in most countries pharmacists are not able to access shared patient health records [3], as the level of access (e.g., medication history, laboratory results) and rights (reading or writing) increase the complexity of pharmacy services offered offline and online will further develop. The minimum "service" available on websites is basic information about the product offered, including instructions, composition, price, etc.

#### **3. Issues related to illegitimate online vendors**

The risks to humankind require a global approach and international multidisciplinary cooperation. Most importantly, (a) national regulatory frameworks are heterogeneous regarding the distance sale and online marketing of medicines, (b) national authorities are typically powerless beyond their continental borders, (c) the effectiveness of public campaigns is limited, and (d) uninformed consumers are unlikely to be able to differentiate legitimate websites from illegitimate perpetrators. Consequently, illegitimate operators provide fraudulent online services and disregard safe pharmacy standards without legal or commercial consequences worldwide [6, 9].

A comprehensive risk assessment and test purchase methodology have been developed and published by our research group culminating in a decade of robust research (Vida et al., 2020). Our findings usher beneficial, descriptive evidence regarding issues related to the uncontrolled online market, including (a) unsubstantiated health claims lacking scientific evidence and missing warnings on contraindicated conditions and drug-interactions, (b) wide availability and easy access to biological and oncological medications, and (c) quality issues due to unprofessional distribution and handling [11, 22, 23]. Several review articles (Mackey and Nayyar, 2016; Nayyar et al., 2019) support that uncontrolled perils associated with the illicit online pharmaceutical market are persistent and current legislation and law enforcement actions seemly are ineffective to battle the complex globalized illicit online pharmaceutical market. In particular, vendors of the illegal internet market utilize abusive "underground" marketing techniques including e-mail spam, manipulation of search engine results, and development of large affiliate networks [18, 24, 25].

In the case of counterfeiting and online marketing, the traditional quality assurance measures supporting medications in the legal supply chain (e.g., audits and analytical measurements), leave gaps between the manufacturing and the product use, as it is not possible to assess the quality of a drug sold online until purchased. Furthermore, normal consumers (patients) do not own laboratory instruments and professional knowledge to determine the safety and efficacy of a specific medication. Product quality issues are likely recognized later as the unwanted effects occur or the lack of desired pharmaceutical effects becomes obvious [26].

Patient safety harm associated with counterfeit or illegal medicine use can be categorized based on the quality issue and content of the products. These products may contain toxic doses of a component (e.g., glibenclamide, metformin) or a dangerous component (e.g., diethylene glycol and/or chromium) and can result in poisoning. Additionally, the poor quality of these medicines may compromise the treatment of chronic and infectious diseases (e.g., β-lactam antibiotics), causing disease progression and drug resistance. Falsified medicines may also carry

#### *DOI: http://dx.doi.org/10.5772/intechopen.108485 Stakeholders of the Online Pharmaceutical Market*

microbes from other geographical locations in the world and lead to unexpected infectious diseases [14, 26].

In consideration of the manufacturing and distribution of drugs becoming more complex, modern technology-based solutions are needed to protect patients. Emerging technologies focusing on supply chain elements are under development (e.g., radio frequency identification, blockchain technologies, and edible noncloneable functions) or being implemented during the past years (e.g., serialization and the Falsified Medicines Directive in Europe and mobile-based verification of products in developing countries) [8]. However, as described in our recent research paper their efficacy outside the legitimate supply chains, such as the illegal online pharmacy market, is questionable even in developed countries [27]. Numerous publications emphasize the interdiction of internet sales of falsified and substandard medicine requires strategies yet to be developed [28]. It must be noted that several attempts to regulate the online pharmacy market (website verification databases, online logos, top generic domain name) have been introduced during the past decade, both in the USA and throughout the EU, but with limited effect upon the globalized illicit e-market of pharmaceuticals [29, 30].

Accordingly, due to the limitations of previously applied or generally used methodologies, novel approaches and methods are necessary and further research is required to develop standardized protocols to address the intrusion techniques, the prevalence, health consequences, and economic burden of substandard and falsified medicines distributed via the internet [28]. Developing technologies, such as the use of machine learning and competitive intelligence tools for market research, show a great promise in detecting and preventing the sale and distribution of substandard and falsified medicines, especially via online platforms [6].

#### **4. Multistakeholder approach in the online pharmaceutical market**

Stakeholders who can contribute to the integrity of the supply chain include organizations representing health professionals, patients and consumers, manufacturers, distributors, authorities, prevention and enforcement services (police, customs, justice), media and governments, and medicines providers (community and hospitals pharmacies). Further, search engine providers have a decisive role in evaluating and moderating search engine result pages, for example, by excluding unfair online marketing practices of illegitimate vendor sites [31]. All parties would benefit from a safe and regulated internet pharmacy market segment. Consumers and patients could take advantage of the benefits of e-commerce without evident dangers associated with illegal sellers and dubious products sold online. Pharmaceutical supply chain participants would also benefit from a safe internet pharmacy market, as infiltrated supply chains, illegal manufacturers, and distributors displace sales from legitimate pharmaceutical companies and retailers. In addition to loss of revenue, illegal and counterfeit products damage the reputation of brands, firms, and in general the perception of safety and efficacy attributed to medicines. An uncontrolled environment impacts governments and healthcare systems by diverting resources from limited health budgets due to direct and indirect health costs associated with patient harm, regulatory and enforcement actions, and patients' loss of confidence in healthcare systems.

As we aim to envision the online pharmaceutical market as a safer place for consumers and patients, multiple stakeholders should be kept in mind. This chapter gives an opportunity to the readers to familiarize themselves with the complexity of the online market segment of the pharmaceutical supply chain, a continuously developing segment with significant potential threats to healthcare systems and individuals as well. The multistakeholder aspect and various participants and services utilized by the legal and illicit actors give an uneven, rugged nature to this market that seems to be difficult to control. Admittedly, we have described and evaluated the characteristics of the surface web, however, one should not forget the additional threat associated with the uncontrolled and illegal sale of medicinal products on the deep and dark web. In this ecosystem transnational organized crime syndicates use legal services like Internet Service Providers (e.g., search engines, social media platforms, payment procedures, transportation services, and domain name registries), highlighted by the 2016 review from Mackey and Liang [6].

Seemingly, there's no golden bullet or ultimate measure that will solve the international issues related to uncontrolled online medicine sales. National regulatory approaches can decrease patient safety risks by providing an opportunity for the legal sector to grow and fighting against illegal actors. Although there are multistakeholder approaches and initiatives like Operation Pangea including law enforcement, pharmaceutical and wholesales industries, internet service sector, credit card companies, health regulators, and customs agencies; however, their regular and continuous operation would be required to increase the efficacy of their actions. Active participation of healthcare workers, including pharmacists, general practitioners, nurses, and the patients' organizations is required in this field, as the point of care interventions can easily and efficiently increase consumer awareness [7, 32, 33].

#### **5. Conclusions**

Internet pharmacies are trending in most countries and have become popular participants in the pharmaceutical supply chain, especially for consumer healthcare products. The global market size is estimated to be more than US\$50 billion and is growing at an impressive rate [10]. Depending on national regulations majority of legitimate and verified websites offer non-prescription, herbal products, dietary supplements, cosmetics, etc., meanwhile, in some countries, prescription-only medicines are also available via distant selling. Unfortunately, benefits are hindered by patient safety concerns due to illegal vendors overwhelming the online pharmacy landscape.

Preferably, internet pharmacy websites should adhere to regulations set by the country of operation and the country where the products are shipped to. Internationally harmonized legal frameworks and a global internet pharmacy verification system would facilitate quality assurance and law enforcement of the transborder trade of pharmaceutical products. Physical location and contact information of the seller must be clearly stated on the website, and consultation with a licensed healthcare professional should be available for customers. If the regulatory environment permits, online vendors must require a valid medical prescription from a licensed prescriber for prescription-only medicines. Similarly, to offline interactions between the patient and the pharmacists, online vendors shall evaluate the health status of consumers prior to purchase. Website content must contain all essential information (indication and effects, dosage, contraindications, storage, etc.) required for the safe use of the products.

*Stakeholders of the Online Pharmaceutical Market DOI: http://dx.doi.org/10.5772/intechopen.108485*

Although the internet pharmacy landscape is constantly developing, a better understanding of online vendors and e-pharmacy shoppers is required to maximize benefits and limit potential harms associated with online medicinal product purchases.

#### **Funding**

The research has been supported by the ÚNKP-21-5-PTE-1349, ÚNKP-21- 2-I-PTE-1259, ÚNKP-21-4-PTE-1118, and ÚNKP-22-5-PTE-1730 New National Excellence Programs of The Ministry for Innovation and Technology from the source of the National Research, Development and Innovation Fund, further supported by the János Bolyai Research Scholarship of the Hungarian Academy of Sciences (BO/00238/20/5).

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Notes and other declarations**

None.

#### **Author details**

András Fittler\*, Márton Fittler and Róbert György Vida Faculty of Pharmacy, Department of Pharmaceutics, University of Pécs, Hungary

\*Address all correspondence to: fittler.andras@pte.hu

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Fittler A, Vida RG, Káplár M, Botz L. Consumers turning to the internet pharmacy market: Cross-sectional study on the frequency and attitudes of hungarian patients purchasing medications online. Journal of Medical Internet Research. 2018;**20**(8):e11115

[2] Long CS, Kumaran H, Goh KW, Bakrin FS, Ming LC, Rehman IU, et al. Online pharmacies selling prescription drugs: Systematic review. Pharmacy. 2022;**10**(2):42

[3] International Pharmaceutical Federation. Online Pharmacy Operations and Distribution of Medicines. The Hague: The Netherlands; 2021

[4] Orizio G, Schulz P, Domenighini S, Caimi L, Rosati C, Rubinelli S, et al. Cyberdrugs: A cross-sectional study of online pharmacies characteristics. The European Journal of Public Health. 2009;**19**(4):375-377

[5] Khandelwal N, Duncan I, Rubinstein E, Ahmed T, Pegus C. Community pharmacy and mail order cost and utilization for 90-day maintenance medication prescriptions. Journal of Managed Care Pharmacy. 2012;**18**(3):247-255

[6] Mackey TK, Nayyar G. Digital danger: A review of the global public health, patient safety and cybersecurity threats posed by illicit online pharmacies. British Medical Bulletin. 2016;**118**(1):110-126

[7] Fittler A, Bosze G, Botz L. Evaluating aspects of online medication safety in long-term follow-up of 136 internet pharmacies: Illegal rogue online pharmacies flourish and are long-lived. Journal of Medical Internet Research. 2013;**15**(9):e199

[8] Mackey TK, Nayyar G. A review of existing and emerging digital technologies to combat the global trade in fake medicines. Expert Opinion on Drug Safety. 2017;**16**(5):587-602

[9] Orizio G, Merla A, Schulz PJ, Gelatti U. Quality of online pharmacies and websites selling prescription drugs: A systematic review. Journal of Medical Internet Research. 2011;**13**(3):e74

[10] IQVIA Consumer Health. e-Pharmacy and the New Consumer Whitepaper. 2020 https://www.iqvia. com/library/white-papers/e-pharmacyand-the-new-consumer-whitepaper

[11] Fittler A, Vida RG, Rádics V, Botz L. A challenge for healthcare but just another opportunity for illegitimate online sellers: Dubious market of shortage oncology drugs. PLoS One. 2018;**13**(8):e0203185

[12] Miller R, Wafula F, Onoka CA, Saligram P, Musiega A, Ogira D, et al. When technology precedes regulation: The challenges and opportunities of e-pharmacy in low-income and middleincome countries. BMJ Global Health. 2021;**6**(5):e005405

[13] Gaudiano MC, Manna L, Bartolomei M, Rodomonte AL, Bertocchi P, Antoniella E, et al. Health risks related to illegal and on-line sale of drugs and food supplements: Results of a survey on marketed products in Italy from 2011 to 2013. Annali dell'Istituto Superiore di Sanità. 2016;**52**(1):128-132

[14] Blackstone EA, Fuhr JP, Pociask S. The health and economic effects of counterfeit drugs. Am Health Drug Benefits. 2014;**7**(4):216-224

*Stakeholders of the Online Pharmaceutical Market DOI: http://dx.doi.org/10.5772/intechopen.108485*

[15] Inciardi JA, Surratt HL, Cicero TJ, Rosenblum A, Ahwah C, Bailey JE, et al. Prescription drugs purchased through the internet: Who are the end users? Drug and Alcohol Dependence. 2010;**110**(1-2):21-29

[16] Sugiura L. Respectable Deviance and Purchasing Medicine Online. Cham: Springer International Publishing; 2018

[17] Alwon BM, Solomon G, Hussain F, Wright DJ. A detailed analysis of online pharmacy characteristics to inform safe usage by patients. International Journal of Clinical Pharmacy. 2015;**37**(1):148-158

[18] The Center for Safe Internet Pharmacies. The Internet Pharmacy Market in 2016: Trends, Challenges and Opportunities [Internet]. He Center for Safe Internet Pharmacies (CSIP). 2016 [cited 2022 Mar 30]. Available from: https://safemedsonline.org/wp-content/ uploads/2016/01/The-Internet-Pharmacy-Market-in-2016.pdf

[19] Bate R, Jin GZ, Mathur A. In whom we trust: The role of certification agencies in online drug markets. B E Journal of Economic Analysis & Policy 2014;**14**(1):111-150

[20] Liang BA, MacKey T. Searching for safety: Addressing search engine, website, and provider accountability for illicit online drug sales. American Journal of Law & Medicine. 2009;**35**(1):125-184

[21] Lobuteva L, Lobuteva A, Zakharova O, Kartashova O, Kocheva N. The modern Russian pharmaceutical market: Consumer attitudes towards distance retailing of medicines. BMC Health Services Research. 2022;**22**(1):582

[22] Vida RG, Fittler A, Mikulka I, Ábrahám E, Sándor V, Kilár F, et al. Availability and quality of illegitimate somatropin products obtained from the internet. International Journal of Clinical Pharmacy. 2017;**39**(1):78-87

[23] Vida RG, Fittler A, Somogyi-Végh A, Poór M. Dietary quercetin supplements: Assessment of online product informations and quantitation of quercetin in the products by highperformance liquid chromatography. Phytotherapy Research. 2019;**33**(7):1912-1920

[24] McCoy D, Pitsillidis A, Jordan G, Weaver N, Kreibich C, Krebs B, et al. PharmaLeaks: Understanding the business of online pharmaceutical affiliate programs. In: Proceedings of the 21st USENIX Security Symposium. 2012. pp. 1-16

[25] Leontiadis N, Moore T, Christin N. A nearly four-year longitudinal study of search-engine poisoning. In: Proceedings of the 2014 ACM SIGSAC Conference on Computer and Communications Security. New York, NY, USA: ACM; 2014. pp. 930-941

[26] Rahman MS, Yoshida N, Tsuboi H, Tomizu N, Endo J, Miyu O, et al. The health consequences of falsified medicinesa study of the published literature. Tropical Medicine and International Health. 2018;**23**(12):1294-1303

[27] Vajda P, Richter K, Bodrogi Z, Vida RG, Botz L, Kovács S, et al. Survey of workflow and cost implications of decommissioning regarding the falsified medicines directive in Hungarian hospital pharmacies. BMJ Open. 2021;**11**(11):e047193

[28] Nayyar GML, Breman JG, Mackey TK, Clark JP, Hajjou M, Littrell M, et al. Falsified and substandard drugs: Stopping the pandemic. The American Journal of Tropical Medicine and Hygiene. 2019;**100**(5):1058-1065

[29] Fadlallah R, El-Jardali F, Annan F, Azzam H, Akl EA. Strategies and systems-level interventions to combat or prevent drug counterfeiting: A systematic review of evidence beyond effectiveness. Pharmaceutical Medicine. 2016;**30**(5):263-276

[30] Hamilton WL, Doyle C, Halliwell-Ewen M, Lambert G. Public health interventions to protect against falsified medicines: A systematic review of international, national and local policies. Health Policy and Planning. 2016;**31**(10):1448-1466

[31] Fittler A, Paczolai P, Ashraf AR, Pourhashemi A, Iványi P. Prevalence of poisoned google search results of erectile dysfunction medications redirecting to illegal internet pharmacies: Data analysis Study. Journal of Medical Internet Research. 2022;**24**(11):e38957. DOI: 10.2196/38957. PMID: 36346655

[32] Fittler A, Bosze G, Botz L. Attitude of patients and customers regarding online drug purchase - a Hungarian community pharmacy survey. Orvosi Hetilap. 2010;**151**(48):1983-1990

[33] Fittler A, Lankó E, Brachmann B, Botz L. Behaviour analysis of patients who purchase medicines on the internet: Can hospital pharmacists facilitate online medication safety? European Journal of Hospital Pharmacy. 2013;**20**(1):8-12

#### **Chapter 5**

## Telerehabilitation in Low- and Middle-income Countries

*Intan Sabrina Mohamad and Irma Ruslina Defi*

#### **Abstract**

Telemedicine is the delivery of healthcare services using information and communication technologies (ICT) to its users. Mobile communications in telemedicine or Mobile health (mHealth) is the most commonly accepted mode of telemedicine in lowand middle-income countries (LMICs) due to its affordability and user-friendly features. Telemedicine may be used to treat, prevent and monitor health conditions; as well as to promote health and educate clients. Access to medical and rehabilitation services in LMICs may be limited due to the lack of expertise, geographical locations, and sociocultural issues. Telerehabilitation (TR) may be a practical solution to circumvent these barriers in LMICs. TR providers must possess the necessary knowledge, skills, and expertise to deliver quality TR services to clients while ensuring patient safety and adhering to medical ethics and regulations. Policymakers and administrators should ensure vulnerable groups are included when making policies on healthcare services. Changes must be made to existing policies on telemedicine, in order to include all stakeholders in TR and overcome human, organizational, and technical challenges in LMICs.

**Keywords:** telerehabilitation, telemedicine, low- and middle-income countries, LMIC

#### **1. Introduction**

Telemedicine, also known as telehealth, eHealth, telepractice, online medicine, virtual consultation [1], or distant medicine [2] is the delivery of healthcare services using information and communication technologies (ICT) to its users. The use of mobile communications is called Mobile health (mHealth), which is the most commonly accepted mode of telemedicine in low- and middle-income (LMIC) [3, 4]. In 2020, upper-middle income countries (UMIC) like Malaysia had 40.69 million mobile subscriptions and 27 million (83.1%) internet users [4].

Telemedicine may be used to treat, prevent and monitor health conditions, as well as to promote health and educate clients [5]. Although the list is not exhaustive, applications of telemedicine have expanded beyond teleconsultations to telerehabilitation, telesurgery, telerobotics, telereferrals, telepharmacy, teletherapy, telediagnostics (telepathology, teleradiology); teleassessments, telemonitoring, telementoring, teleeducation, and telecounseling [6, 7].

Telemedicine provides faster access and communication between healthcare providers (HCPs) and patients [8, 9]. The COVID-19 pandemic has accelerated the uptake of telemedicine as it avoids direct exposure to infections, reduces traveling

time and cost [8–10], and reduces time away from work or caregiving. Sub-acute cases requiring rehabilitation and monitoring can no longer be managed in acute or rehabilitation hospitals due to competing health priorities and shortened length of stay (LOS). Telerehabilitation (TR) may be a key innovation to ensure continuity of care post-hospital discharge and reduce the global burden of disability [11–13].

The scope of TR services depends on 4Ps namely the patient, provider, policymaker, and payer. The needs of its people and healthcare system will steer the direction of telemedicine in LMIC [13]. The success or failure of TR will depend on the dynamic relationships between human, organizational, and technical factors [10, 11]. Vulnerable groups such as people with disabilities (PWDs) and the elderly in LMIC face additional challenges in accessing TR.

Sociocultural issues such as unemployment, homelessness, overcrowding, language barrier, cultural and religious beliefs; and literacy will influence the delivery and uptake of TR. Literacy does not only mean the basic ability to read and write, but also the ability to navigate ICT and contextualize information obtained from healthcare professionals (HCPs) and the media. Non-English speakers may face additional literacy disparity, as 63.2% of the information on the internet is in English [14]. TR services should be available in foreign languages so as not to exclude a significant proportion of people who are only proficient in their native language [13]. Policymakers and HCPs must ensure vulnerable groups are included when making policies on healthcare services. Existing policies and guidelines on telemedicine in LMIC are mostly physiciancentric [15–17] and do not have clear policies on fee structure, insurance coverage, and financial incentives for allied health professionals (AHPs) [17]. Changes must be made to existing policies on telemedicine, in order to include all stakeholders in TR and overcome human, organizational and technical challenges in LMIC.

#### **2. Telerehabilitation in low- and middle-income countries**

#### **2.1 Telerehabilitation requirements**

TR services depend on the needs of its people and healthcare systems and are differentiated by their ecosystem and convenience. Low cost and technology, easy-touse features, and quick responses are key to the adoption of TR in LMIC. **Figure 1**

#### **Figure 1.**

*Hub-and-spoke model on telerehabilitation stakeholders. (Source: Adapted from Malaysian Telemedicine Flagship Application, 2013; page 12) [7].*

shows a Hub-and-spoke model and illustrates the inter-relationships among TR stakeholders.


#### *2.1.1 Telerehabilitation providers*

Although the list is not exhaustive, TR providers may include:

• Healthcare Professionals (HCPs)

Treat patients, instead of going to health centers, these services can be accessed through ICT they give consultation, examine patients and devise a treatment plan which includes prescribing medications, therapies, and rehabilitation equipment for patients. HCP also requests laboratory tests.

• Policymakers

Write regulations for health care providers to protect patient's rights and safety,

• Organizations, hospitals, or health centers

Look into the runnings of TR

• Laboratories

Process patient's samples for health care providers to access, but this can also be accessed by the patients themselves without the health care providers.

• Pharmacies

Dispense medicine prescribed by HCPs

• Researchers

Conduct research and studies of evidence-based practice and review policies

• Data analyzer

Analyze data, from all of the above, such as policies, laboratories, and the information stored and transmitted in the TR process

• Hardware or software developers

Develop technology to be used in the TR process

• Telecommunication and internet providers

Provide connectivity between TR providers and the clients

• Artificial intelligence (AI)

The three major components of TR are clinicians, IT, and TR services. A clinical provider's role is to deliver TR services [18]. They may either be physicians, AHPs [17] such as nurses, therapists, counselors, social workers, dietitians, pharmacists or traditional and complementary practitioners, or even caregivers [11]. TR providers may be stationed at hospitals, clinics, health centers, homes [5], or online.

There should be good leadership in TR. TR providers are regarded as leaders or brand ambassadors in telemedicine; promoting and building relationships among stakeholders such as HCPs, policymakers, and hardware or software developers [18]. TR providers need to embrace new technologies such as AI (Chatbot or robots) to meet clients' exponential demand for an immediate and constant response beyond office hours. The high cost and lack of human resources to deliver TR may be substituted with pre-programmed Chatbot responses, and prerecorded audio or text messaging systems.

#### **2.2 Telerehabilitation clients**

Telerehabilitation clients may include:


PWDs and those with chronic diseases in LMIC often undergo a vicious cycle of disability, unemployment, and poverty. Family members usually become informal caregivers, since paid caregivers are costly and not sustainable. Caregivers in LMIC often have to work several jobs to support PWD in the family or give up their jobs to be full-time caregivers. Family-based rehabilitation (FBR) and community-based rehabilitation (CBR) may be realistic models of care in LMIC [11, 12]. TR facilitates FBR and CBR by empowering caregivers and HCPs in the community.

Not all PWDs can be TR clients. Patients with acute emergencies, with severe communicative disorders and no access to ICT, may need additional considerations and in-person assistance [11, 19]. TR providers must adhere to the Code of Ethics and have a duty of care to ensure patient safety prior to selecting patients as TR clients [1, 10] (see case history 1).

#### **2.3 Case history 1**

*Mrs. Y* is an elderly lady who lives with her elderly husband, *Mr. Y* who has hearing impairment, in a village with no internet access. She has sudden left knee pain and cannot travel to the hospital on her own. *Mr. Y* informed *Nurse LN* to assess *Mrs. Y*. *Nurse LN* made a diagnosis of acute septic arthritis and called for an ambulance to transfer *Mrs. Y* to the local hospital. *Dr. HQ* (TR provider) discharged *Mrs. Y* a week later with a home exercise program, to be supervised by *Nurse LN*. *Nurse LN* (TR client) visited *Mrs. Y* weekly and taught *Mr.* and *Mrs Y* the prescribed exercises. Two months later, *Miss SN* (TR client) sent pictures and videos of *Mrs. Y* cooking and walking to *Dr. HQ* and the rehabilitation team at the hospital (TR providers) via WhatsApp.

#### *2.3.1 Information and communication technologies*

ICT is a major component of TR as it links TR providers to its users (**Figure 1**). ICT may be broadly classified into:


Information can be transmitted through the following methods:


#### *2.3.1.1 Synchronous telerehabilitation*

Synchronous communication is also known as sync, real-time, face-to-face (F2F) or live interaction between TR provide and its users. Synchronous TR provides immediate responses and exchange of information between two or more parties. Body language, tone of voice and better rapport can be established via live video. Illiterate and visually impaired TR clients can interact with TR providers without having to read written information, as in asynchronous TR. Any doubts, misunderstanding, and feedback can be obtained immediately via verbal communication.

Fast internet speed, adequate data capacity, and technical expertise are required in order to provide synchronous TR. The minimum broadband speed for satisfactory synchronous teleconsultation or teleeducation in Vietnam (LMIC) is 2 Mbps, whereas diagnostic images such as those transmitted in teleradiology would require a minimum of 4 Mbps2. Upper middle-income countries (UMIC) such as Malaysia, have an average download speed of wireless broadband of 15.6 Mbps to 27.6 Mbps20; which is slow compared with the average fixed internet connection speed worldwide (78.0 Mbps).

A survey conducted in 2020 revealed internet users in Malaysia used smartphones (96%), laptops/notebook/netbook (41%), and tablets (18%) for Chat Apps (97%),

social networking Apps (70%), and entertainment or video Apps (55%) [4]. Some examples of apps which can be downloaded for free and have synchronous features are WhatsApp, Facebook live, FB messenger, Instagram, WeChat, GoogleMeet, Zoom, and Skype. Video conferencing and live chats can also be conducted on Chatbots and telephone. ICT user habits and trend may project how synchronous TR can be delivered in LMIC and UMIC [4, 23–25].

#### *2.3.1.2 Asynchronous telerehabilitation*

Asynchronous communication is also known as async or store-and-forward communication [7]. Information can be exchanged between two or more parties without the involvement of live or immediate responses. Asynchronous information can be stored and edited beforehand and viewed later. There is no time-pressure and it does not require everyone to be present at the same time. Caregivers in LMIC often have to juggle between work commitments and providing care for PWDs. Asynchronous TR may be more acceptable to caregivers and patients who cannot commit to appointment scheduled within office hours or when there are ICT limitations for synchronous TR. Clients who are introverts, shy or not well-versed in F2F communication may also find asynchronous TR more appealing.

Some examples of asynchronous communication are SMS, email, and voice or video recordings. Prerecorded lectures, webinars, and YouTube videos are popular modes of asynchronous information, which can be useful in LMIC.

#### *2.3.1.3 Hybrid telerehabilitation*

At times, TR clients may require a hybrid of synchronous and asynchronous telerehabilitation in order to fulfil their needs. Most smartphones contain apps with hybrid features, such as WhatsApp, Facebook live, FB messenger, Instagram, WeChat, Google Meet, Zoom, and Skype [4]. These apps are popular in LMIC as they can be downloaded for free, easy to use, and can be accessed on multiple ICT devices such as smartphones, desktops, laptops, and tablets.

#### *2.3.1.4 Mobile health*

Mobile health (mHealth) is the most commonly accepted telemedicine method among patients with chronic diseases in LMIC [3], because of its affordability and easy access in rural and poor communities [2, 8–13, 20, 21, 27]. Systematic reviews on mHealth interventions in rehabilitation [23, 24] showed positive outcomes in the following domains:


TR clients can receive reminders via SMS, access information and services; monitor biochemical markers, physiological readings, and behaviors from their mobile

phones [23, 24]. The most commonly used mobile phone Apps in LMIC are Facebook, WhatsApp, Viber, Skype, Zoom, and GoogleMeet [4, 22–25], mainly due to its free and user-friendly features.

Some examples of free mHealth Apps in South East Asia are MySejahtera, MorChana, Vietnam Health Declaration, PeduliLindungi, and StaySafe PH26. These apps are used to monitor public health, disseminate information and provide health education to the public. Mobile Apps such as Doc2us and Halodoc from Malaysia and Indonesia respectively, provide teleconsultation, teleprescription, and medication delivery to its user at an affordable fee. Such telemedicine services are not only timely during the COVID-19 pandemic but also help reduce the workload on governmentfunded health centers [26].

A critical factor that must be considered in LMIC is data affordability. In Malaysia, a prepaid mobile phone plan of 2.5 Gb data costs RM 26 (USD 6.22) per month, while a postpaid Plan with unlimited data costs RM68 (USD 16.28) per month [27]. The main difference between a Pre-paid and a postpaid mobile plan is the payment schedule. The former only provides mobile service based on the load of the purchase (payas-you-use), while the latter is billed at the end of the monthly subscription and is based on data consumption. Prepaid plans are more affordable for users in the lower economic group (B40) such as in Malaysia, a country where the minimum wage is RM 1200 per month or USD 9.57 per day. Similar observations have been reported in other LMIC [11–13, 25, 28, 37–44].

#### *2.3.1.5 Assistive technology*

Assistive technology (AT) is any item, place of equipment, software program, or product system that may be used in rehabilitation to increase, maintain, or improve the functional capabilities of persons with disabilities (PWDs) [23, 24]. AT features may be built into smartphones such as switch and voice controls for PWDs with limited limb and verbal functions. Other accessibility features include magnifying or bolding fonts and texts for visually impaired people.

Some wearable devices have AT features that use wireless or Bluetooth technologies. PWDs with limited limb functions such as tetraplegics or amputees may use a wearable device such as the *GlassOuse* and *Bite Switch* (mouse) to connect and operate their mobile phones, computers, tablets, and smart television using Bluetooth technology [29] (**Figure 2**). TR providers in LMIC require training and funding for AT to be useful in their practice.

#### *2.3.1.6 Robotic technologies*

Although robotic technologies may be useful in rehabilitation, their affordability makes them neither feasible nor sustainable in low-resource settings. Evidence-based reviews comparing robotic technologies with standard care interventions did not show long-term significant differences in locomotor training for walking after spinal cord injury and stroke or upper limb function after stroke [30]. TR providers in LMIC may have to consider other affordable alternatives to robotic technologies.

#### *2.3.2 Training*

Delivering TR services requires specific competencies, which may not necessarily be taught to HCPs in their profession [11]. In addition, there is a big shortage of AHPs

**Figure 2.**

GlassOuse *is worn like a pair of glasses and connects to mobile phones, computers, tablets, and smart TVs via Bluetooth. The user moves her head from side to side to navigate the cursor on the screen and bites on the* Bite Switch *(in cyan) to click items on the computer similar to a computer mouse. (*Photo by Intan Sabrina*).*

such as physiotherapists (PTs), occupational therapists (OTs), speech and language pathologists (SLPs) and audiologists in LMIC, especially in rural areas [11, 12]. There should be a TR coordinator for every TR activity in order for TR program(s) to succeed and be sustainable.

Guidelines on telepractice by AHPs are few [5, 11, 17, 30]. For example, only 10– 20% of SLPs tend to use telepractice in India and only 3% of SLPs in Croatia had completed formal training related to telepractice in SLP services [11]. Organizations in LMIC should provide training and credentialing procedures for TR providers on a regular basis to suit the evolving needs of TR clients [31]. The IFNR Task Force (2021) cautioned that not everyone with a smartphone can deliver teleneurorehabilitation (TNR). They also noted that standardizing functional assessments through teleassessments may prove to be a challenge.

Training in TR can be divided into three main groups:


HCPs must be trained to obtain informed consent from patients and caregivers and how to document TR activities [6]. Telemedicine service is voluntary and should allow clients to opt out at any point of the telemedicine service. Patients and caregivers in LMIC and rural areas usually require guidance, training, and on-site assistance before TR services can be delivered. The level of assistance should be determined beforehand, such as the need for interpreting language(s) or dialects, setting up ICT devices such as keeping their mobile phones charged [28] and ensuring clients have adequate mobile data and network coverage. TR clients in LMIC need to be briefed on the prerequisites of a conducive telemedicine environment [19, 28, 32]. Ideally, the latter should be a quiet room or corner, with minimal distractions from other family members and good network coverage. Any fees and costs involved in the TR service must be declared at the outset by the TR provider.

IT support and infrastructure are critical components of TR service(s), but may be limited in LMIC. Quick solutions such as on-the-job (OTJ) training among HCPs or

appointing IT representatives in each unit or department may be useful to bridge gaps in IT support. HCPs who are not trained in ICT may have to switch roles from becoming TR providers to TR clients. ICT training and technology-transfer in TR may be conducted via teleeducation and telementoring.

#### *2.3.3 Policies and guidelines*

Since the COVID-19 pandemic, many countries around the world have updated their policies on telemedicine. Telemedicine guidelines should not be physiciancentric and must cater for the needs of AHP, patients, and their caregivers. These guidelines must cover points of service such as healthcare settings, homes, or community-based worksites [5].

A scoping review of telemedicine guidelines in South East Asia (SEA) revealed most countries had guidelines on clinical governance, confidentiality, ICT infrastructure, data security, record keeping, and licensing [6]. However, only Singapore and Indonesia have policies on telemedicine fee structure, insurance coverage, or reimbursement for medical practitioners. Policymakers and organizations should have clear billing and coding processes designated for TR so that payers can reimburse costs to TR providers [5], especially those offered by AHPs.

Most guidelines on telemedicine tend to regulate HCPs, rather than the technologies, platforms, or types of telemedicine services [1, 6, 33]. Telemedicine guidelines should have clear credentialing, privileging and regulatory requirements for licensure, certification, and use of telemedicine and its applications [5, 6, 11]. Mobile apps and internet of things (IoTs) are usually regulated by Medical Device Acts in the country they are registered (MDA) [34–36]. TR providers should adhere to their respective organizations and regulating bodies to ensure the safe and effective delivery of TR services to their clients [1, 5, 6, 15–17].

#### **3. Setting up telerehabilitation services in low- and middle-income countries**

TR providers must identify the service(s) which can be converted to TR exclusively or as a hybrid model. Clear inclusion and exclusion criteria for patient selection must be outlined in the TR Standard Operating Procedure (SOP) [5, 32, 33]. A feasibility study should be conducted to familiarise every stakeholder prior to the rollout of the TR service [19]. Any hiccups should be addressed accordingly.

There are four main phases in telerehabilitation [32, 33]:


Pre-C activities comprise calling the TR client and introducing the purpose of TR, obtaining verbal and/or written consent, clarifying contact details of the TR client and determining the medical or rehabilitation requirements. Details on the date, time,

platform of AC and fee should also be conveyed clearly to the TR clients during the Pre-C phase. Technical assistance (TA) such as ICT literacy, translation, or physical assistance should also be pre-determined in the Pre-C phase. TA may comprise any family member, neighbor or the local HCPs closest to the TR client's home.

Pre-C activities may be simplified by using questionnaires or assessment tools, which may be sent via email, text message and/or Google Doc formats. For example, in a tele home visit, TR clients can send measurements, pictures and videos of their home environment to their Occupational Therapist (OT) via email or WhatsApp messages or videos. The OT can then make the necessary recommendations for home modifications, prescribe rehabilitation equipment and arrange for a F2F assessment if required. Another example is when TR clients send audio recordings of their vocal exercises to their Speech Therapist or Audiologist prior to AC sessions.

A standard script, template, and checklist [32] would be useful to standardize communication between both parties. All communications and interventions involving TR clients should be documented clearly in the client's medical records [5, 6, 19, 25, 32, 33].

AC activities may range from teleconsultation to teleassessment, teletherapy, telemonitoring and teleeducation. Details such as patient identification, diagnoses, medications, investigation results, progress report, rehabilitation equipment, funding options and treatment needs should be addressed in the AC phase and documented in the clients' medical records. TR providers should determine the outcome measures, assessment tools and equipment involved in the AC activities. Several trials of Pre-C and AC activities should be conducted prior to the roll-out of TR services to address pitfalls and additional TR requirements.

Post-C activities may include documenting and storing data collected in the Pre-C and AC phases, referrals to other parties, teleprescriptions of medications, information and/or home-based programs to TR clients, issuing medical certificates, and other activities similar to F2F consultations. All TR activities must be documented clearly and securely stored to ensure patient confidentiality, data security, and storage.

Finally, TR providers must be trained in data collection on TR activities and compare them with those in the standard-care pathway(s). The TR coordinator should review all TR services periodically and provide feedback to all stakeholders for quality assurance (QA) and improvements [32].

#### **Figure 3.**

*Challenges in telerehabilitation in low- and middle-income countries (Source: Adapted from Leochico et al. 2020. Telerehabilitation Challenges in Developing Country; Table 2, page 10 [12]; and IFNR Research Task Force et al. 2021. TeleNeurorehabilitation During COVID-19 in LMICs, 2021; Table 2, page 4 [11]).*


*Telerehabilitation in Low- and Middle-income Countries DOI: http://dx.doi.org/10.5772/intechopen.107449*


*NB: This summary is based on a scoping review on Telemedicine*

 *Guidelines in South East Asia by the authors and published in Front. Neurol. 11:581649. doi:* 

**Table 1.** *Challenges to deliver telerehabilitation in low-and middle-income countries.*

*10.3389/fneur.2020.581649*

#### **4. Challenges to deliver telerehabilitation in low- and middle-income countries**

Challenges to deliver telerehabilitation in LMIC [11, 12, 37–44] can be categorized into human, organizational, and technical factors (**Figure 3**). These factors usually overlap with one another, such as guidelines and laws on telemedicine (human and organizational); lack of digital knowledge and skills (human and technical); and lack of technical support and training (organizational, and technical). **Table 1** is a summary comparing challenges to delivering TR in five LMIC. The recurring themes in LMIC are lack of ICT training and infrastructure, lack of political will, and timeconstraint. TR providers should review these challenges regularly and provide solutions so that TR services can be improved and be sustainable. A scoping review on telemedicine guidelines in South East Asia by Sabrina and Defi suggested that there should be a comprehensive and universal telemedicine guideline for any country to adopt based on the local context [6].



**Table 2.**

*Recommendations to overcome barriers and challenges to telerehabilitation in low- and middle-income countries.*

#### **5. Recommendations and future threats**

Telerehabilitation will continue to be an integral component of health services in LMIC across the world. Digital health is the new norm. It is projected that mHealth will be a key player in complementing and adding value to healthcare services globally, particularly in LMIC [4, 10, 11, 25, 41]. Current trends in digital technologies indicate that mHealth is the go-to option in LMIC. Advances in AI, algorithms, and mobile apps may replace human-to-human interactions. Thus, HCPs should be equipped with the necessary skills to embrace the changing trends in healthcare delivery, especially those which do not require physical presence or touch.

In conclusion, TR in LMIC is challenging. However, affordable and quick solutions such as free mobile apps may overcome barriers in TR.

*Telerehabilitation in Low- and Middle-income Countries DOI: http://dx.doi.org/10.5772/intechopen.107449*

### **Author details**

Intan Sabrina Mohamad1,2,3\* and Irma Ruslina Defi4

1 Department of Rehabilitation Medicine, Hospital Serdang, Selangor, Malaysia

2 Regen Rehab Hospital, Petaling Jaya, Selangor, Malaysia

3 Rehabilitation Medical Unit, Tung Shin Hospital, Kuala Lumpur, Malaysia

4 Department of Physical Medicine and Rehabilitation, Padjadjaran University, Bandung, Indonesia

\*Address all correspondence to: drintansabrina@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Malaysian Medical Council Advisory on Virtual Consultation (During The Covid19 Pandemic). Available from: https://mmc.gov.my/wp-content/ uploads/2020/04/MMC\_virtualconsulta tionADVISORY.pdf

[2] Regulating the Management of Distant Medicine (Circular 49) Circular No. 49/2017/TT-BYT. Ministry of Health, Vietnam. Available from: https:// hethongphapluat.com/circular-no-49-2017-tt-byt-dated-december-28-2017on-telemedicine.html

[3] Sahu M, Grover A, Joshi A. Role of mobile phone technology in health education in Asian and African countries: A systematic review. International Journal of Electronic Healthcare. 2014;**7**:269. DOI: 10.1504/ IJEH.2014.0.64327

[4] Malaysia Digital Marketing Statistics. General Internet Statistics. 2021. Available from: https://digitalinfluence. com/malaysia-digital-marketingstatistics-2020-2021/

[5] Brennan D, Tindall L, Theodoros D, Brown J, Campbell M, Christiana D, et al. Blueprint for telerehabilitation guidelines. International Journal of Telerehabilitation. 2010;**2**(2):31-34. DOI: 10.5195/ijt.2010.6063

[6] Intan Sabrina M, Defi IR. Telemedicine guidelines in South East Asia – A scoping review. Frontiers in Neurology. 2021;**11**:581649. DOI: 10.3389/fneur.2020.581649

[7] HIMS. Blueprint – Towards excellence in health information management. In: Health Informatics Center, Planning Division, Ministry of Health. Malaysia; 2013. Available from: https://www.who.int/ goe/policies/malaysia\_hims\_blueprint\_ 2013\_b.pdf

[8] Buabbas AJ, Albahrouh SE, Alrowayeh HN, Alshawaf H. Telerehabilitation during the COVID-19 pandemic: Patients and physicial therapists' experiences. Medical Principles and Practice. 2022;**31**(2): 156-164. DOI: 10.1159/000523775

[9] Wotton R, Bonnardot L. Telemedicine in low-resource settings. Frontiers in Public Health. 2015;**3**:5-6. DOI: 10.3389/fpubh.2015.00003

[10] Istepanian RSH, Woodward B, Richards CI. Advances in telemedicine using mobile communications. Engineering in Medicine and Biology Society, 2001. Proceedings of the 23rd Annual International Conference of the IEEE. Volume 4. DOI: 10.1109/ IEBS.2001.1019600. Available from: https://www.researchgate.net/publica tion/3958008

[11] Srivastava A, Swaminathan A, Chockalingam M, Srinivasan MK, Surya N, Ray P, et al. Teleneurorehabilitation During the COVID-19 pandemic: Implications for practice in low- and middle-income countries. Frontiers in Neurology. 2021; **12**:667925. DOI: 10.3389/ fneur.2021.667925

[12] Leochico CFD, Espiritu AI, Ignacio SD, Mojica JAP. Challenges to emergence of telerehabilitation in a developing country: A systematic review. Frontiers in Neurology. 2020;**11**: 1007. DOI: 10.3389/fneur.2020.01007

[13] Babatunde AO, Abdulazeez AO, Adeyemo EA, Uche-Orji CI, Saliyu AA. Telemedicine in low and middle income countries: Closing or widening the health *Telerehabilitation in Low- and Middle-income Countries DOI: http://dx.doi.org/10.5772/intechopen.107449*

inequalities gap? European Journal of Environment and Public Health. 2021; **5**(2):em0075. DOI: 10.21601/ejeph/1077

[14] Usage statistics of content language for websites. UNESCO Institute for Statistics. 2021. Available from: https:// w3techs.com/technologies/overview/ content\_language

[15] Laws of Malaysia Act 564. Telemedicine Act. 1997. Available from: https://www.google.com/search?q=tele medicine+act+1997&rlz=1C1CHBF\_e nMY1000MY1000&oq=telemedicine +&aqs=chrome.1.69i57j35i39l2j0i512l4j 69i61.4054j0j4&sourceid=chrome&ie= UTF-8

[16] Law of the Republic of Indonesia Number 11 of 2008 Concerning Electronic Information and Transactions. Undangundang Republik Indonesia Nomor 11 Tahun 2008 Tentang Informasi Dan Transaksi Elektronik. 2008. Available from: https://zaico.nl/files/RUU-ITE\_english.pdf

[17] Laws of Malaysia Act 774. Allied health professions Act. 2016. Available from: https://nutrition.moh.gov.my/wpcontent/uploads/2019/10/Akta\_AHP\_ Akta-774.pdf

[18] Alghatani KM. Telemedicine implementation: Barriers and recommendations. Journal of Scientific Research and Studies. 2016;**3**(7):140-145

[19] Agence d'évaluation des technologies et des modes d'intervention en santé (AETMIS). Telehealth: Clinical Guidelines and Technological Standards for Telerehabilitation. Report prepared by Gilles Pineau, Khalil Moqadem, Carole St-Hilaire, Robert Perreault, Éric Levac, and Bruno Hamel, with the collaboration of Hélène Bergeron, Alexandra Obadia and Lorraine Caron (AETMIS 06-03). Montréal: AETMIS. 2006. p. x

[20] Average download speed of broadband wireless in Malaysia in 2020, by mobile service provider. Available from: https://www.statista.com/statistic s/1051857/malaysia-average-wirelessdownload-speed-of-internet-provider/ {Accessed: 9 March 202]

[21] Sianipar BH. Kebijakan pengembangan telemedisin di Indonesia. Kajian Kebijakan dan Hukum Kedirgantaraan. 2015:42-62. DOI: 10.30536/9786023181339.3

[22] Suksmono AB, Sastrokusumo U, Mengko. J TLR, Pramudito T, Oktowaty S. Overview of telemedicine activities in Indonesia: Progress and Constraints. Proceedings. 6th International Workshop on Enterprise Networking and Computing in Healthcare Industry – Healthcom 2004 (IEEE Cat. No.04EX842). 2004

[23] Marcolino MS, Oliveira JAQ, Novillo-Ortiz D. The impact of mHealth interventions: Systematic review of systematic reviews. 2018. DOI: 10.2196/ mhealth.8873. Available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ PMC5792697/

[24] Dicianno BE, Parmanto B, Fairman AD, Crytzer TM, Yu DX, Pramana G, et al. Perspectives on the evolution of mobile (mHealth) technologies and application to rehabilitation. 2015. DOI: 10.2522/ ptj.20130534. Available from: https:// pubmed.ncbi.nlm.nih.gov/24925075/

[25] Mar M, Morris C, Scott RE. WhatsApp guidelines – what guidelines? A literature review. Journal of Telemedicine and Telecare. 2019;**25**(9): 524-529

[26] Lee B, Ibrahim SA, Zhang T. Mobile Apps leveraged in the COVID-19 pandemic in East and South-East Asia:

Review and content analysis. JMIR mHealth and uHealth. 2021;**9**(11):e32093. DOI: 10.2196/32093. Available from: https://mhealth.jmir.org/2021/11/e32093

[27] The 5 best post-paid plan in Malaysia. Available from: https://www.trustedmala ysia.com/best-postpaid-palns-malaysia/

[28] Jack CL, Mars M. Ethical considerations of mobile phone use by patients in Kwazulu-Natal: Obstacles for mHealth? African Journal of Primary Health Care & Family Medicine. 2014; **6**(1);607-613. DOI: 10.4102/phcfm. v6i1.607

[29] GlassOuse – Head Mouse. Spectronics inclusive learning technologies, Australia. Available from: https://www.spectronics. com.au/product/glassouse-head-mouse)

[30] Engkasan JP. Cochrane evidence on rehabilitation using robotic technology [Internet]. 2019. Available from: CochraneRobotics\_201https://rehabilita tion.cochrane.org/sites/rehabilitation.coch rane.org/files/uploads/cochrane\_robotics\_ 2019\_2.pdf9\_2 [Accessed: 2022-07-05]

[31] Anil K, Freeman JA, Buckingham S, et al. Scope, context and quality of telerehabilitation guidelines for physical disabilities: A scoping review. BMJ Open. 2021;**11**:e049603. DOI: 10.1136/ bmjopen-2021-049603

[32] Canadian stroke best practice recommendations telestroke implementation toolkit. 2020. Available from: https://www.heartandstroke.ca/-/ media/1-stroke-best-practices/csbpr7 virtualcaretools-13may2020

[33] Garis Panduan Pelaksanaan Klinik Virtual (Virtual Clinic) di Hospital. Available from: file:///C:/users/ intansabrina/downloads/garispanduan\_ pelaksanaan\_klinik\_virtual\_(virtual\_ clinic)\_di\_hospital.pdf

[34] Laws of Malaysia Act 737 Medical Device Act. 2012. Available from: http:// www.agc.gov.my/agcportal/uploads/ files/Akta%20737%20-%20kelulusan% 20TP.pdf

[35] Laws of Malaysia Act 738. Medical Device Authority Act. 2012. Available from: http://www.agc.gov.my/agcportal/ index.php?r=portal2/lom&menu\_id=b 21XYmExVUhFOE4wempZd E1vNUVKdz09&page=15

[36] Regulatory Guidelines for Telehealth Products. Medical devices branch; health sciences authority. 2019. Available from: https://www.hsagov.sg/docs/defaultsource/hprg-mdb/regulatory-guidelinesfor-telehealth-products-rev-2-1.pdf

[37] Hamad WB. Current position and challenges of e-health in Tanzania: A review of literature. Global Scientific Journals. 2019;**7**(9):364-376

[38] James O, Felix C, Ngozi I, Tonia O, Ekwueme CO, Agwuna KK. Telemedicine and biomedical care in Africa: Prospects and challenges. Nigerian Journal of Clinical Practice. 2016;**20**(1):1-5. DOI: 10.4103/ 1119-3077.180065

[39] Chifamba N. A scoping review on the challenges of Telemedicine implementation the Southern Africa. 2018. DOI: 10.13140/ RG.2.2.32011.23842.

[40] Arthur G, Erika K-M, Nagla R, Isaac R, de Beer J. Artificial intelligence (AI) deployments in Africa: Benefits, challenges and policy dimensions. The African Journal of Information and Communication. 2020;**26**:1-28. DOI: 10.23962/10539/30361

[41] Moeloek NF, Ekatjahjana W. Permenkes No. 20 Tahun 2019 tentang Penyelenggaraan Telemedicine antar

*Telerehabilitation in Low- and Middle-income Countries DOI: http://dx.doi.org/10.5772/intechopen.107449*

Fasilitas Pelayanan Kesehatan. Ministry of Health. 2019. Available from: https:// www.researchgate.net/publication/ 338428993

[42] Ariyanti S, Kautsarina K. Technoeconomic study on telehealth in Indonesia. Buletin Pos dan Telekomunikasi. 2017;**15**:43-54. DOI: 10.17933/bpostel.2017.150104

[43] Bali S. Barriers to Development of telemedicine in developing countries. In: Heston TF, editor. Telehealth. London: IntechOpen; 2018. Available from: https://www.intechopen.com/chapters/ 64650. DOI: 10.5772/intechopen.81723

[44] Purwaamijaya BM,Wijaya A, Shadani SB. Perceptions and prospective analysis of artificial intelligence and its impact on human resources in the Indonesian industry 4.0. In: Proceedings of The 1st International Conference on Sustainable Management and Innovation, ICoSMI 2020, 14-16 September 2020, Bogor, West Java, Indonesia; 14-16 September 2020; Bogor. Belgium: EUDL; 2021

#### **Chapter 6**

## Telesurgery and Robotics: Current Status and Future Perspectives

*Sudhir Kumar Singh, Jyoti Sharma, Lokavarapu Manoj Joshua, Farhanul Huda, Navin Kumar and Somprakas Basu*

#### **Abstract**

The concept of telehealth has revolutionized the healthcare delivery system. Based on this concept, telesurgery has emerged as a promising and feasible option, providing surgical care to remotely located patients. This has become possible by advancements in the robotic system combined with the cutting-edge technology of telecommunication. Since the ability to perform telepresence surgery was hypothesized, consistent development and research in this novel area have led to the beginning of telesurgical care, which can fulfill the demand for surgical care in remote locations. In addition to the benefits of robotic-assisted minimally invasive surgery, telesurgery eliminates geographical barriers, which helps patients have better access to quality surgical care. It may reduce the overall financial burden by eliminating the travel expense of the patients, providing expertise through the telepresence of experienced surgeons, and reducing the operating room personnel. The telesurgical approach is also being utilized for telementoring, i.e., real-time guidance and technical assistance in surgical procedures by highly skilled surgeons. Despite the numerous technological improvements in telesurgery, its widespread implementation in clinical setting still lags, mandating the identification of the offending factors that limit its clinical translation.

**Keywords:** telesurgery, robotic surgery, medical robotics, telemedicine, remote surgery

#### **1. Introduction**

Telehealth and telemedicine involve transferring expertise, through which patients can be examined, monitored, and treated without transporting the patient. Telemedicine is based on data acquisition, storage, transfer, processing, and display. This breakthrough came after the revolution in communication technology, such as high-speed data connections and management information systems [1, 2]. Patients can communicate with doctors from their homes using technology or a telehealth kiosk. Nowadays, telemedicine is an integral part of health services in many countries, and upcoming hospitals will attract patients from all over the world without geographical restrictions.

#### **2. Telesurgery**

The concept of telemedicine has been applied to provide surgical care to remotely located patients and is termed "Telesurgery" or "Telepresence Surgery" or "Remote Surgery" [3]. Initially considered as a "science fiction," it has now been materialized and will continue to be the reality in today's era. This revolutionized surgical care delivery has become possible by advancements in the robotic system. Since the establishment of the robotic surgery, the surgeon typically controls these robots by staying by the patient's side. In telesurgery, the robotic system still remains in direct contact with the patient, whereas the surgeon sits on a console at a remote location and performs the surgical task. As a backup, a surgical team remains in the operating room to proceed with the surgery as and when required [4]. Here, the advanced communication technology enables the surgeon to control the endoscopic camera and manipulate the robotic arm attached to the patient cart with real-time feedback. This emerging surgical system requires advanced wireless networking and robotic technology to perform the surgery [5]. The main objective of telesurgery is to eliminate unnecessary travel for patients and accompanying persons, apart from providing high-quality surgical care from expertise worldwide.

#### **3. Evolution of telesurgery**

The concept of telesurgery came into existence since U.S. National Aeronautics and Space Administration (NASA) started exploring the possibility of providing treatment to the astronauts in space long back in 1970 [6]. The invention of the endoscope, followed by the development of a video computer chip that allowed the magnification and projection of images onto television screens, was a breakthrough in introducing laparoscopic surgery [7]. This minimally invasive approach changed the era of surgery and created a possibility for evolution of telesurgery.

In the late 1980s, Scot Fisher and Joseph Rosen hypothesized the ability to perform telepresence surgery using a robotic system. Computer-assisted surgical tools have emerged after constant advancement in surgical instruments and techniques, followed by a gradual evolution from automated biopsy robots to high-end modern robotic surgical systems for visceral surgery (like the ZEUS Surgical System and the da Vinci System). The development of AESOP (automated endoscopic system for optimal positioning) followed by the ZEUS operating system from computer motion was an outstanding achievement in the development of robotic surgery. A parallel innovation of SRI green telepresence, which was refined further by Intuitive Surgical, conferred in the revolutionary development of the current da Vinci System [8]. Implementation of the telesurgery concept in a broader way could be possible after introducing mainly two robotic systems, i.e., the ZEUS Surgical System by Computer Motion and the da Vinci Surgical System by Intuitive Surgical. These modern robotic systems work on a master-slave technology where the surgeon sits at a console kept a few feet away from the patient cart, enabling the surgeon to view real-time threedimensional imaging of the operative site. Complex software translates the surgeon's hand movement and manipulates the robotic arm accordingly, attached to the articulating surgical instruments and endoscope [9].

After merging with Computer Motion in 2003, Intuitive Surgical dominated the robotic surgical market and discontinued the Zeus platform as the da Vinci robot had several advantages over it. As in laparoscopic surgery, depth perception was a

significant problem resolved substantially by the da Vinci system using a 3D immersive camera, while the Zeus system has a 2D screen display. Furthermore, the da Vinci system controls the surgical instrument using an "Endowrist," which mimics wrist


#### **Table 1.**

*Historical timeline of the evolution of robotic system and telesurgery.*

movement with natural movement with seven-degree freedom. The da Vinci Xi™ (Intuitive Surgical, 2014) is the most recent iteration of da Vinci systems, which has been redesigned to be more ergonomic and thinner and have well-arranged robotic arms to conserve space. Moreover, it has been upgraded with fluorescence imaging and near-infrared technology to better visualize vessels, tissue perfusion, and bile duct. Still, there is a lack of haptic feedback, which needs further improvement.

In usual robotic surgeries, where both console and robotic arms are directly connected to several meters of cable wire, there is no time lag in communication because data transmission from the console to the surgical device and back to the console is almost instantaneous. Thus, the surgeon sees his movements on the computer interface as he performs the surgery. When robotic telesurgery was conceptualized, the primary concern was the time delay in communication between the surgeon console and surgical robot due to moving the surgical system to a more remote location. Thus, the surgeon's real-time interventions could be milliseconds or even seconds behind the visualization of the operating field, which can lead to catastrophic outcomes during surgery. As proved in studies, a time lag of more than 150–200 milliseconds is harmful [10]. So seamless robotic telesurgery requires robust communication media between console and robot with negligible latency. To provide safe telesurgery services, collaborating with the telecommunications sector to build a secure, dependable, high-speed data transmission across enormous distances with unnoticeable delays is of utmost importance.

The world's first telesurgery was the "Lindbergh Operation," a transatlantic cholecystectomy on a 68-year-old female patient in Strasbourg, France, performed on September 7, 2001 by Professor Jacques Marescaux in New York City. ZEUS system was used for this landmark surgery, and France telecom provided the spare fiber optic ATM (automated teller machine) lines to minimize the latency and optimize connectivity. The average time delay during surgery was 135 milliseconds, which is impressive considering the data traveled over 8600 miles (14,000 kilometers) from the surgeon's console to the surgical system and back [11]. This milestone in surgery was a big inspiration for establishing the first dedicated telerobotic surgical service in Canada. Since then, various robotic telesurgeries have been performed worldwide.

The timeline of evolution of the robotic system and telesurgery has been summarized in **Table 1**.

#### **4. Benefits of telesurgery**

Telesurgery is an extension of the telemedicine/telehealth concept that has become possible with the advancement of the surgical robot and sophisticated telecommunication technology. So the benefits of telesurgery encompass the inherent advantage of telehealthcare as well as robotic-assisted minimally invasive surgery, which are mentioned below:

	- a.Delivery of high-quality surgery to remote settings, such as underserved rural areas, battlefields, and space stations.
	- b.Provides an opportunity for patients to receive surgical care by surgical experts from all over the world without going outside of their local hospitals. It is beneficial for patients for whom medical travel is not feasible due to financial constraints, travel-related health risks, travel restrictions, or time delays.
	- c.Real-time collaborations between surgical professionals from various healthcare facilities can benefit patients who require complicated microsurgical techniques and other complex surgeries.
	- d.Telesurgery may be a potential solution to the global shortage of competent surgeons.
	- e.During the COVID-19 era, apart from the benefit related to the need of lesser number of operating room staff in robotic surgery, the main benefit of telesurgery was the physical separation of the surgeon from the patients, thus reducing the interpersonal contact and spread of infection [15]. Telesurgery could also provide care when travel restrictions during a pandemic are the main reasons limiting medical care.

#### **5. Limitations of telesurgery**

Being a novel concept for delivering surgical care, telesurgery is still in its nascent phase and needs continuous upgrading. At present, the following factors pertinent to telesurgery are a major hindrance to the widespread use of this technology:

1.Time lag or latency: This vital issue is related to telecommunication and is mainly due to data transmission over a network and video coding and decoding. This time delay is directly proportional to the distance between two far-reaching locations. It has a propensity for surgical error and puts the patient's safety in danger.

A time lag of fewer than 100 milliseconds is considered an ideal latency time that a dedicated telecommunication system can achieve. A latency time greater than 300 milliseconds produces significant inaccuracies in instrument handling. Research suggests that a simple telesurgical procedure can be safely performed without any significant surgical inaccuracy with a time lag of up to 700 milliseconds [16].


### **6. Scope of advancement in telesurgery**

Innovation of robotic platforms opened up the path for clinical translation of the concept of telesurgery and went side by side with the advancement in the robotic system. Further advancement in telesurgery needs the incorporation of various emerging technologies.

#### **6.1 Haptic feedback**

Tactile feedback has been a big concern since the advent of laparoscopic surgery and continues to be the Achilles heel in Robotic surgery. Here the surgeon touches the tissue with a long instrument having a hinge that goes inside the patient's body through the ports. This series of interfaces of contact with instruments at various levels leads to degradation in the haptic feedback, which is necessary for precise and delicate tissue manipulation. This can be achieved by upgrading the technology of the human-machine interface (HMI) and sensor-based robotic instruments, reflecting the force of instruments on surgeons' hands [18]. There is ongoing research for making a perfect haptic-enabled telesurgical system. It also requires a seamless networkbased communication that can send the data of hand motion and instrument-tissue contact from the surgeon to the patient and the other way around. An alternative to overcome this feedback problem is haptic-assisted training, which requires shared control of two master HMIs and one slave robot [19].

#### **6.2 A 3-D visual feedback system**

Although it appears that haptic feedback is vital in manipulating delicate tissues, today's upgraded versions of robotic systems are still inefficient in providing this tactile input appropriately. In addition, the relevance of haptic feedback in robot-assisted performances of surgical tasks is yet to be proved. It has been hypothesized that visual feedback of local tissue deformation caused by tension, retraction, or needle insertion can compensate for the lack of sensory force feedback [20]. The 3-D display system can provide this high-definition visual feedback, but further improvement is required in this aspect.

#### **6.3 High speed and quality telecommunication**

The quality of telesurgery depends on the quality of presentation of the information transmitted in the form of digitized data from one center to another. The quality of shared data and latency depends upon the bandwidth (i.e., the capacity of data flow) of the network used to relay the processed data. It can be accomplished by a telecommunication network having wide bandwidth, minor delay, slight jitter, and minimal data loss. The network-level quality of service (QoS) control is also required, ensuring bandwidth reservation for telesurgery [21]. The integration of recently available high-speed 5G internet could meet the required bandwidth and reduce the time lag issue that plagues telesurgery.

#### **6.4 Internet of things (IoT)**

Remote monitoring in the healthcare industry is now feasible owing to IoTenabled devices, which can keep patients safe and healthy while allowing clinicians to provide superior care. As sensor technology is improving gradually, IoT devices can also be incorporated into surgical devices, which can enable the recording of intraoperative events and the movement of instruments [22]. By analyzing the data created by these devices by artificial intelligence technology, procedures can be standardized by identifying the most appropriate use of surgical devices, which will help in ensuring the safety of surgery but requires proper validation before incorporation into telesurgery.

#### **6.5 Concept of "one-to-many" remote surgery**

This concept can be perceived as an expert surgeon seated in the master control room remotely, performing surgeries on multiple patients simultaneously. It is helpful for surgeries that require a combined approach, i.e., robotic-assisted minimal invasive and an open approach during different steps of the procedure. For example, the expert sitting in master control will perform specific steps requiring robotic assistance in patient A present at one hospital and then switch to take control of another surgical robot attached to patient B at a different hospital. Meanwhile, the rest of the steps requiring an open approach for patient A will be completed by the onsite local surgical team [23]. By using this concept, further attempts can be made to plan complex surgeries, mimicking the production line of car manufacturers, by transferring the control of robotic arms in a predestined sequence to a group of surgeons sitting in their master control room far from each other and skilled in specific steps of surgery.

#### **6.6 Artificial intelligence in telesurgery**

Artificial intelligence (AI) has transformed various industries in the past decade. The incorporation of AI into telesurgery is a brand-new concept that has sparked a lot of interest as a part of the surgical procedure that can be automated. Thus, AI reduces the cognitive and physical burdens of the surgical team and can increase the efficiency of surgery by reducing the operative time and increasing accuracy [24]. Simultaneously, it can also decrease the required number of staff in the surgical team. The utilization of AI in other industries has led to a substantial increase in efficiency, but its role in surgical procedures has not yet been proven. A significant amount of adaptation and further research is required to prove its performance and build up confidence in its use in surgical care.

#### **7. Clinical application of telesurgery**

Several projects researching the feasibility and practicability of telesurgery on human patients were completed at the beginning of the twenty-first century. Because of various obstacles in the clinical utilization of telesurgery, it has not picked up its pace and is still in the developmental phase. The first dedicated telesurgery center was established in Canada, and at present, North America is leading the market in telesurgery [25]. Globally, every human being has the right to access all the recent surgical facilities present worldwide, and telesurgery is the critical innovation fulfilling these promises. But such facilities are not readily available in the developing countries and the rural parts of developed countries. It is a paradox that the secluded population worldwide that can benefit from telesurgery is also the one that cannot afford it due to high cost or lack of essential telecommunication facilities. But it is expected that in the near future, this problem will be alleviated as the internet access is rapidly expanding and various new manufacturers of affordable robotic systems are emerging.

Patients' perspective about telesurgery is pretty promising as most of them are very enthusiastic about the concept of using the robot for surgeries. This inclination toward new technology results from the projected benefits of smaller incisions with better cosmetic outcomes, shorter hospital stays, faster recovery, and fewer complications because of the precise movement of the robotic instrument during surgery. Still, this technology needs further advancement and scrutiny by noble clinical trials with a higher evidence level.

Telesurgery has opened up the opportunity of treating patients who require immediate medical attention regardless of their location. This could prove lifesaving in extreme conditions such as space and battlefields where getting a usual hospital is impossible. However, many obstacles stand in accomplishing this vision, such as installing the robotic system in such places and providing a robust connection to run the telesurgery proficiently with negligible latency. Various research studies are going on to test the feasibility and clinical implication at such extreme locations.

For astronauts on the deep-space mission, many surgical emergencies such as fatal injuries, appendicitis, intracranial hematoma, or kidney stones can occur, which mandate urgent operations then and there. So for such space missions, telesurgical assistance should be considered. But again, the signal delay will be a detrimental factor due to the vast distance between the earth and the space station. An added problem is the feasibility of robotic surgery in a zero-gravity environment. NASA is carrying out a series of missions in an undersea laboratory, Aquarius, simulating the

extreme environmental condition found in space. Some substantial progress has been achieved in teleoperation, control of the surgical robot, and other challenges related to space surgery, such as the behavior of the organs and bodily fluids in zero gravity, but it's still a long road ahead of us [26].

Similarly, on the battlefield or in a natural disaster situation, telesurgery can offer a solution to provide surgical care at the site of injury and can save many lives. A semiautomated telerobotic device known as "Trauma Pod" has been created for such scenarios, which may conduct lifesaving surgeries and stabilize wounded soldiers on the battlefield. These are designed to be deployed rapidly in such unfavorable situations. These robots can also act as assistants, like a scrub nurse, in the operating room. These scrub nurse robots are automated to do different tasks such as changing tools, dispensing equipment, and tracking supplies. Various trials are going on to see the feasibility and further advancement in these trauma pods. Though these are currently being tested for first aid treatment such as putting intravenous lines, performing hemostasis, protecting airways, and placing monitor devices, we are hopeful, that the robot will be able to move beyond the current first-aid procedures [27].

#### **8. Telementoring and telestration: a new domain for surgical training**

The concept of telesurgery has opened up a new way of real-time teaching and training of surgical fellows. With this sophisticated communication technology, an expert surgeon present remotely mentors a trainee surgeon sitting in the operating room by controlling the endoscope to control the field of view throughout the entire procedure, as and when required. This unique way of training is known as "telementoring," which is considered an ideal method of skill-sharing and training [28]. An associated but slightly different method of real-time teaching is termed "telestration," in which the expert guides the trainees by freehand sketching or pointing out the structure by marking it over the trainees' video monitor. The remote surgeon and the surgeon with the patient will both have identical views of the surgical field [29]. At present, the Canadian Surgical Technologies & Advanced Robotics (CSTAR) is the leading facility globally, providing training via surgical telementoring and telestration. Some telesurgeons are also developing computer-based training modules that can be shared over the Internet.

Although robotic telesurgeries have been adopted since the beginning of the twenty-first century, telesurgery is not commonly used worldwide due to a lack of facility or proper training. So a robust training program is mandatory to make it available worldwide, which simultaneously ensures the patient's safety. It not only includes the training of the surgeon, but the whole surgical team, including nursing staff, OR technicians, anesthetists, and information technology technicians. Team training is necessary to attain the best clinical results. Even after a few successful robotic or telemanipulation surgeries, most surgeons will revert to traditional methods if they do not have qualified assistance from nurses and anesthesiologists. Comparative to conventional operations, these telesurgeries are technically demanding and need a well-trained surgical team, with each member an expert in their domain.

The training program's goal for robotic and telesurgery procedures should be focused on stepwise training of the surgeon. Like the traditional basic surgical skill program, this includes system training by didactic lectures, dry and wet laboratory training, and advanced procedure-specific training. After proficiently learning each step, the trainee should move on to the next level of surgical telemanipulation. Simultaneously, each step should undergo evaluation for the quality and clinical

safety of the patient. Many training centers have developed and suggested adopting an objective-based curriculum for the training of surgical teams. Apart from providing training to young surgeons, these robotic and telesurgical training programs will promote academic writing and scientific publication.

#### **9. Cost: benefit analysis**

From a hospital-centric healthcare delivery model to a more sustainable and effective patient-centric model has been made possible with the introduction of telesurgery. It has revolutionized healthcare delivery by expanding it into a global patient base. However, cost remains a significant challenge hindering its global acceptance, especially in low and middle-income countries. The total expenses can be categorized into the initial investment and maintenance costs. Initial investment includes the cost of the robotic system, infrastructure development, and the cost of procurement of equipment and disposables.

Until now, Intuitive Surgical company's da Vinci system has been the best known and most used system. The estimated cost of a top-of-the-line robotic system ranges from \$ 1 to 2.5 million. According to Intuitive Announces First Quarter Earnings, 6920 da Vinci Surgical Systems have been installed worldwide as of March 31, 2022 [30].

#### *Telesurgery and Robotics: Current Status and Future Perspectives DOI: http://dx.doi.org/10.5772/intechopen.107465*

The annual maintenance cost of these robotic systems is also very high. US hospitals spend \$ 1000–4000 more per robot-assisted case than in endoscopic or minimal access and open procedures [31, 32]. Apart from the recently launched "Senhance" surgical system, companies such as Stryker Corporation, Hansen Medical, Verb Surgical, and Mazor Robotics are the leading companies in the robotic-assisted telesurgery market, which challenges the monopoly of Intuitive Surgical. It is believed that this competition will significantly decrease the cost of robotic systems, equipment, disposables, and maintenance in the near future.

Despite the high cost, it has been assumed that robotic surgery would be costeffective in the long term by reducing postoperative recovery and hospital stays. Until now, most studies evaluating the cost-benefit analysis of robotic surgery are only observational studies. Concrete evidence from well-designed randomized clinical trials is needed in confirming the cost-effectiveness of robotic surgery vis-a-vis laparoscopic or open surgery.

Establishing a high-speed and quality telecommunication service is another area of high investment in telesurgery. It will be determined by the distance between the telelinked centers. In Operation Lindbergh, the estimated cost for 1-year availability of the ATM lines ranged between \$100,000 and \$200,000 [33]. With advancements in communication technology, its cost is also expected to decrease with time, making telesurgery and robotics available to a larger population.

Apart from the technological expenses, there is an added expense for training the surgical staff. Procedural cost, cost of additional supplies, anesthesia, and medicines required for surgery are the additional costs. It is not easy to justify these costs based only on the clinical outcome and shorter recovery time. Currently, on an objective assessment, the cost factor overwhelms the benefits associated with telesurgery. But if analyzed based on healthcare and patient outcomes, the benefits certainly outweigh the costs. The future looks promising in terms of overall cost reduction, which will make telesurgery acceptable throughout the world (**Figure 1**).

#### **10. Conclusion**

In the coming era, the goal of providing health facilities to all will be fulfilled by incorporating telemedicine and telesurgery facility into the health care system. In providing telehealthcare, setting up the facility for telesurgery requires a comparatively more robust network channel and affordable surgical robots. Apart from taking care of the scarcity of expert surgeons in remote places, it will also give freedom to choose the desired surgeon for the patient. Telesurgery may save time and money of patients and their families while improving health outcomes. Treating injured soldiers in the combat zone and astronauts in space are the added benefits of telesurgery. This technology would also allow trainee surgeons to perform surgery under the supervision of expert surgeons without jeopardizing the patient's safety. With future advancements in robotic technology, including haptic and visual feedback coupled with a 5G network, telesurgery could revolutionize health care and surgical treatment around the globe.

#### **Acknowledgements**

The authors would like to acknowledge the Department of General Surgery.

### **Conflict of interest**

The authors report no conflict of interest.

### **Author details**

Sudhir Kumar Singh, Jyoti Sharma, Lokavarapu Manoj Joshua, Farhanul Huda, Navin Kumar and Somprakas Basu\* All India Institute of Medical Sciences, Rishikesh, India

\*Address all correspondence to: somprakas.surg@aiimsrishikesh.edu.in

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Becevic M, Sheets LR, Wallach E, McEowen A, Bass A, Mutrux ER, et al. Telehealth and telemedicine in Missouri. Missouri Medicine. 2020;**117**(3):228-234

[2] Nelson R. Telemedicine and telehealth: The potential to improve rural access to care. The American Journal of Nursing. 2017;**117**(6):17-18. DOI: 10.1097/01.NAJ.0000520244.60138.1c

[3] Bashshur R, Shannon G, Krupinski E, Grigsby J. The taxonomy of telemedicine. Telemedicine Journal and E-Health. 2011;**17**(6):484-494. DOI: 10.1089/ tmj.2011.0103. Epub 2011 Jun 30

[4] Choi PJ, Oskouian RJ, Tubbs RS. Telesurgery: Past, present, and future. Cureus. 2018;**10**(5):e2716. DOI: 10.7759/ cureus.2716

[5] Xia SB, Lu QS. Development status of telesurgery robotic system. Chinese Journal of Traumatology. 2021;**24**(3):144-147. DOI: 10.1016/j. cjtee.2021.03.001 Epub 2021 Mar 13

[6] Arora S, Allahbadia GN. Telesurgery: Windows of opportunity. International Journal of Health Sciences (Qassim). 2007;**1**(1):81-88

[7] Lane T. A short history of robotic surgery. Annals of the Royal College of Surgeons of England. 2018;**100**(6\_sup):5- 7. DOI: 10.1308/rcsann.supp1.5

[8] George EI, Brand TC, LaPorta A, Marescaux J, Satava RM. Origins of robotic surgery: From skepticism to standard of care. JSLS. 2018;**22**(4):e2018.00039. DOI: 10.4293/ JSLS.2018.00039

[9] Antoniou GA, Riga CV, Mayer EK, Cheshire NJ, Bicknell CD. Clinical

applications of robotic technology in vascular and endovascular surgery. Journal of Vascular Surgery. 2011;**53**(2):493-499. DOI: 10.1016/j. jvs.2010.06.154

[10] Mohan A, Wara UU, Arshad Shaikh MT, Rahman RM, Zaidi ZA. Telesurgery and robotics: An improved and efficient era. Cureus. 2021;**13**(3):e14124. DOI: 10.7759/ cureus.14124

[11] Brower V. The cutting edge in surgery. Telesurgery has been shown to be feasible--now it has to be made economically viable. EMBO Reports. 2002;**3**(4):300-301. DOI: 10.1093/ embo-reports/kvf083

[12] Roy S, Evans C. Overview of robotic colorectal surgery: Current and future practical developments. World Journal of Gastrointestinal Surgery. 2016;**8**(2):143- 150. DOI: 10.4240/wjgs.v8.i2.143

[13] Carpenter BT, Sundaram CP. Training the next generation of surgeons in robotic surgery. Robotic Surgery: Research and Reviews. 2017;**4**:39-44. DOI: 10.2147/RSRR.S70552

[14] Palep JH. Robotic assisted minimally invasive surgery. Journal of Minimal Access Surgery. 2009;**5**(1):1-7. DOI: 10.4103/0972-9941.51313

[15] Bailo P, Gibelli F, Blandino A, Piccinini A, Ricci G, Sirignano A, et al. Telemedicine applications in the era of COVID-19: Telesurgery issues. International Journal of Environmental Research and Public Health. 2021;**19**(1):323. DOI: 10.3390/ijerph19010323

[16] Xu S, Perez M, Yang K, Perrenot C, Felblinger J, Hubert J. Determination of the latency effects on surgical

performance and the acceptable latency levels in telesurgery using the dVTrainer((R)) simulator. Surgical Endoscopy. 2014;**28**:2569-2576. DOI: 10.1007/s00464-014-3504-z

[17] Stanberry B. Telemedicine: Barriers and opportunities in the 21st century. Journal of Internal Medicine. 2000;**247**(6):615-628. DOI: 10.1046/j. 1365-2796.2000.00699.x

[18] Schleer P, Kaiser P, Drobinsky S, Radermacher K. Augmentation of haptic feedback for teleoperated robotic surgery. International Journal of Computer Assisted Radiology and Surgery. 2020;**15**(3):515-529. DOI: 10.1007/s11548- 020-02118-x. Epub 2020 Jan 30

[19] Butt A, K, Augestad KM. Educational value of surgical telementoring. Journal of Surgical Oncology. 2021;**124**(2):231- 240. DOI: 10.1002/jso.26524

[20] Jourdes F, Valentin B, Allard J, Duriez C, Seeliger B. Visual haptic feedback fortraining of robotic suturing. Front Robot AI. 2 Feb 2022;**9**:800232. DOI: 10.3389/ frobt.2022.800232

[21] Parsaei MR, Mohammadi R, Javidan R. A new adaptive traffic engineering method for telesurgery using ACO algorithm over software defined networks. European Research in Telemedicine/La Recherche Europeenne en Telemedecine. 2017;**6**(3-4):173-180

[22] Abujassar RS, Yaseen H, Al-Adwan AS. A highly effective route for real-time traffic using an IoT smart algorithm for tele-surgery using 5G networks. Journal of Sensor and Actuator Networks. 2021;**10**:30. DOI: 10.3390/ jsan10020030

[23] Tian W, Fan M, Zeng C, Liu Y, He D, Zhang Q. Telerobotic spinal surgery

based on 5G network: The first 12 cases. Neurospine. 2020;**17**(1):114-120. DOI: 10.14245/ns.1938454.227. Epub 2020 Mar 31

[24] Feizi N, Tavakoli M, Patel RV, Atashzar SF. Robotics and AI for teleoperation, tele-assessment, and tele-training for surgery in the era of COVID-19: Existing challenges, and future vision. Frontiers in Robotics and AI. 2021;**8**:610677. DOI: 10.3389/ frobt.2021.610677

[25] Telesurgery Market – Top Key Players Competitive Scenario Study Report with Forecast by 2025 [Internet]. 2020. Available from: https://www.biospace. com/article/telesurgery-market-topkey-players-competitive-scenario-studyreport-with-forecast-by-2025/ [Accessed: 2022-08-12]

[26] Haidegger T, Sándor J, Benyó Z. Surgery in space: The future of robotic telesurgery. Surgical Endoscopy. 2010;**25**(3):681-690

[27] Garcia P, Rosen J, Kapoor C, Noakes M, Elbert G, Treat M, et al. Trauma pod: A semi-automated Telerobotic surgical system. The International Journal of Medical Robotics and Computer Assisted Surgery. 2009;**5**(2):136-146

[28] Shin DH, Dalag L, Azhar RA, Santomauro M, Satkunasivam R, Metcalfe C, et al. A novel interface for the telementoring of robotic surgery. BJU International. 2015;**116**(2):302-308. DOI: 10.1111/bju.12985. Epub 2015 Mar 17

[29] Erridge S, Yeung DKT, Patel HRH, Purkayastha S. Telementoring of surgeons: A systematic review. Surgical Innovation. 2019;**26**(1):95-111. DOI: 10.1177/1553350618813250. Epub 2018 Nov 22

*Telesurgery and Robotics: Current Status and Future Perspectives DOI: http://dx.doi.org/10.5772/intechopen.107465*

[30] Intuitive Announces First Quarter Earnings. Intuitive Surgical Available from: https://www.isrg.intuitive.com/ news-releases/news-release-details/ intuitive-announces-first-quarterearnings-2. [Accessed: August 28, 2022]

[31] Patel S, Rovers MM, Sedelaar MJP, et al. How can robot-assisted surgery provide value for money? BMJ Surgery, Interventions, & Health Technologies. 2021;**3**:e000042. DOI: 10.1136/ bmjsit-2020-000042

[32] Barbash GI, Glied SA. New technology and health care costs — The case of robot-assisted surgery. The New England Journal of Medicine Overseas Ed. 2010;**363**:701-704

[33] Marescaux J, Leroy J, Rubino F, Smith M, Vix M, Simone M, et al. Transcontinental robot-assisted remote telesurgery: Feasibility and potential applications. Annals of Surgery. 2002;**235**(4):487-492. DOI: 10.1097/ 00000658-200204000-00005

### Section 3
