Tian Junzhang: Internet-Enabled Primary Healthcare as the Foundation for Tiered Diagnosis and Treatment

Significant difficulties and dilemmas still remain in effectively implementing the state-advocated tiered diagnosis and treatment policy.

This Wednesday, the VB Group interview invited Tian Junzhang, President of Guangdong Second Provincial General Hospital, to share insights on tiered diagnosis and treatment based on “Internet + Public Healthcare.” The online hospital platform and the “Yangshan Model” may offer some new perspectives.

Disclaimer: The medical institutions mentioned in this discussion are those I have personally investigated. My descriptions of relevant policies apply solely to the locations I surveyed. Without investigation, one has no right to speak. Given China’s vast size and the significant regional variations, the impact of policies on specific localities does not imply any flaw in national policy.

Today, we will discuss the practice of tiered diagnosis and treatment based on “Internet + Healthcare.”

On September 8, 2015, the General Office of the State Council issued the “Guiding Opinions on Advancing the Construction of a Tiered Diagnosis and Treatment System,” requiring the establishment and improvement of six safeguard measures for tiered diagnosis and treatment, including rational allocation of resources, contracted primary care services, health insurance payment systems, medical service pricing, improved benefit distribution, and division of labor and collaboration among institutions. There are ten evaluation criteria, which will not be elaborated here individually. However, can the relevant requirements for tiered diagnosis and treatment proposed by the state be achieved?

As is well known, the state’s overarching concept of tiered diagnosis and treatment is sound. Tertiary hospitals are overcrowded, with appointments extremely difficult to secure. Without effective implementation of tiered diagnosis and treatment, this situation will worsen, making it difficult for healthcare reform to achieve substantive results.

The current tiered diagnosis and treatment system can be described as a pathway forced by desired outcomes; however, in some regions, without effective methods, it is difficult to achieve the favorable results we anticipate. For example, Yangshan County in Guangdong Province—one of the few poverty-stricken counties in the province—is among the institutions assisted by our hospital.

In June 2015, our hospital was assigned by the Guangdong Provincial Health and Family Planning Commission to provide assistance to Yangshan County People's Hospital. I personally led a team to conduct a ten-day field survey in Yangshan.

During this period, we conducted a survey at Yangshan County People’s Hospital and 13 township health centers, held symposiums with village doctors from all 159 village health stations, and visited selected village clinics. What were the findings? The state of primary healthcare is alarming, with no signs of improvement in sight.

Yangshan County has 159 administrative villages, each staffed by one village doctor, totaling 159 village doctors. The vast majority hold only a Village Doctor Certificate, with very few possessing qualifications as Licensed Physicians or Assistant Licensed Physicians. Their educational backgrounds are predominantly below the level of secondary specialized schooling. The county has 18 township health centers, including five branch clinics, employing over 200 clinical physicians. Most are Assistant Licensed Physicians, and a significant proportion lack certification. Ninety percent have an associate degree or lower. There are 24 laboratory technicians and five radiologists, all of whom have educational qualifications below the associate degree level.

It is well known that the professional competence of physicians in Yangshan County, particularly those at township health centers, remains at a very low level. Their diagnostic capabilities, in particular, basically fail to meet the requirements for primary healthcare institutions.

From our discussions with village doctors, we observed low morale, primarily due to a significant decline in their income following the implementation of zero-markup drug pricing. Previously, village doctors relied on a single source of income, mainly derived from drug markups. After the adoption of the zero-markup policy, their primary income became a monthly government subsidy of 800 yuan, necessitating side jobs to supplement household expenses; for some, these side ventures have even become their main occupation.

During our field research at the county people’s hospital and township health centers, we identified a severe shortage of medical personnel as the most pressing issue. While township hospitals previously employed university graduates with bachelor’s degrees, various factors have since made it difficult even for the county people’s hospital to recruit such candidates. Consequently, there is an acute scarcity of healthcare professionals across county, township, and village levels, resulting in limited medical capacity and suboptimal care quality. As a result, residents face significant challenges seeking medical treatment in major cities such as Guangzhou and Foshan. The county-level patient visitation rate currently stands at 70% and continues to decline.

Under the traditional assistance model, it is difficult to address the severe challenges currently faced, even with substantial investments of human and material resources. Following in-depth research and careful consideration, we believe that leveraging “Internet + Healthcare” is virtually the only viable option for resolving the current issues in Yangshan’s tiered diagnosis and treatment system. Accordingly, we have proposed the “Yangshan Model,” which utilizes “Internet + Healthcare” to achieve integrated and precise assistance across provincial, county, township, and village-level medical services in Yangshan.

This involves extending the service model of online hospitals to counties, towns, and villages. Specifically, a provincial-level online hospital and a provincial diagnostic center are established at the Second Provincial People's Hospital; a county-level online hospital and a regional diagnostic center are established at the Yangshan County People's Hospital; and online consultation points are set up in the 13 township health centers and 159 village clinics under the jurisdiction of Yangshan County.

First, in the analysis of services for village doctors, the Internet is applied to provide service support in four areas for 159 villages. The first is online physician services, the second is public health services, the third is patient referral, follow-up, and rehabilitation services, and the fourth is technical services.

• Online Doctor Services

We provide each village doctor with a telemedicine video consultation terminal, including necessary medical wearable devices such as thermometers, blood pressure monitors, and blood glucose meters. Some village doctors with the appropriate conditions are also equipped with electrocardiogram (ECG) machines. All terminal equipment is provided free of charge.

County- and provincial-level telemedicine physicians provide diagnostic support to village doctors when needed, including emergency care guidance, consultations on complex cases, and prescription services. This ensures that village doctors are not working in isolation but have backend support, thereby expanding the breadth and depth of their medical services. Conditions that were previously beyond their capacity or diagnostic accuracy can now be managed, enabling them to deliver more comprehensive and higher-quality healthcare to villagers.

Medications required by village doctors are delivered through a centralized distribution system. Previously, village doctors procured certain medications independently, resulting in higher costs. Now, they can request medication deliveries via the online hospital terminal, with partner pharmacies of the online hospital providing delivery from the nearest location. In addition, health products needed by villagers, such as healthcare supplements, wheelchairs, crutches, and various medical wearable devices, can also be delivered through this platform. In Guangdong Province, a total of 10,000 chain pharmacies associated with online hospitals have minimized related costs through centralized procurement and localized delivery.

As village doctors’ service capacity and quality improve and costs decrease, their average annual income can increase by more than RMB 10,000 compared with previous levels.

• Public Health Services (Village Doctor Component of the 12 Categories and 45 Items)

In Yangshan County, 159 village health stations provided virtually no public health services due to lack of internet connectivity and information systems. With support from the Yangshan County Government, internet access was established for each village health station last year.

We have customized a public health service system for village doctors on the provided online hospital consultation terminals, enabling them to deliver essential public health services to villagers, including establishing electronic health records, conducting health education, and managing chronic diseases.

Under Guangdong Province’s policy, the per capita annual funding for public health services is RMB 40, of which village doctors receive 40%, equivalent to RMB 16 per person per year. This service can increase a village doctor’s annual income by more than RMB 10,000 in a village with a population of 1,000.

• Hospital Transfer, Follow-up Care, and Rehabilitation Services

Management of patients requiring referral to higher-level hospitals and those returning to their villages for rehabilitation primarily involves the following two aspects. Pre-referral management includes monitoring and coordinating patient transfers. Post-discharge management involves follow-up visits and rehabilitation care in the village. Township health centers and county-level network hospitals provide green channels and transfer services for village doctors referring patients. The County People's Hospital assesses and allocates compensation based on work performance; through this performance evaluation, the service can increase village doctors' annual income by RMB 10,000.

• Appropriate Technology Training Services

Including first aid techniques; acupuncture, cupping, tuina, and massage.

To enable village doctors to quickly master the aforementioned service contents, in September 2015, the Provincial Internet Hospital organized relevant experts to conduct the first phase of training for 159 village doctors in Yangshan County in three batches, which was warmly welcomed by the participants. In November 2015, the Internet Hospital launched the second phase of training. Although only 50 village doctors were notified, more than 100 attended, demonstrating an unprecedented level of self-motivation and initiative in their learning.

Through training, nearly half of the village doctors have gained a preliminary mastery of appropriate Traditional Chinese Medicine (TCM) techniques. This has not only ensured their service capacity but also enabled them to increase their annual income by more than 10,000 yuan over their previous levels.

With the aforementioned four support services, village doctors’ morale has been boosted and their enthusiasm significantly increased, laying a solid foundation for further improving health protection for villagers.

We leverage internet-based applications to provide four types of technical support to 13 township health centers. The first is telemedicine services. Recognizing that the service capacity and proficiency of physicians in township hospitals require improvement, we have established telemedicine consultation points at these 13 township health centers. Through these points, county-level and provincial-level online hospitals provide support to township hospitals, primarily focusing on case discussions for complex and difficult conditions and guidance for emergency patient care.

Next is the provision of auxiliary diagnostic services. To address the shortage of professionals in radiology, electrocardiography (ECG), ultrasonography, and laboratory analysis at township health centers, regional diagnostic centers have been established at county-level people’s hospitals, and a remote diagnostic center has been set up at the Second Provincial Hospital. These centers provide services such as remote radiological image interpretation and remote ECG diagnosis. Relevant data are transmitted via the internet from township hospitals to either the county-level regional network diagnostic center or the provincial network diagnostic center, with results returned to primary healthcare institutions and network physicians. This network-based diagnostic approach alleviates the severe shortage of diagnostic physicians at the grassroots level and significantly enhances diagnostic accuracy.

Taking the Remote ECG Diagnosis Center as an example, let us examine how we established such a center. It operates on a three-tier service structure. The tertiary diagnosis center is the Remote ECG Diagnosis Center of Guangdong Provincial Internet Hospital, which receives complex cases uploaded by lower-level diagnosis centers, as well as electrocardiograms (ECGs) submitted by some village doctors.

Level II Diagnostic Center refers to the county-level regional ECG diagnostic center established by the County People's Hospital. This center receives ECGs from affiliated community health centers and township health centers, including those transmitted via network as well as those from some village doctors, for centralized diagnosis within the region. Primary community hospitals and township health centers mainly generate data without performing diagnoses; their data are directly uploaded, and diagnostic reports can be downloaded and printed.

We have provided services to the county-level people’s hospital, implementing what we call the “Four Integrations”: integrated network information, integrated medical technology, integrated auxiliary diagnosis, and integrated professional training.

• Network Information Integration

We are establishing a branch of the Internet Hospital at Yangshan County People's Hospital. This initiative focuses on two key aspects: first, achieving integration between the provincial and county-level Internet Hospitals by ensuring their interconnectivity; second, enabling the county-level Internet Hospital to primarily provide guidance to doctors in townships and villages.

Furthermore, provincial and county-level hospitals have achieved interoperability of hospital information systems, including the establishment of doctor-to-doctor telemedicine platforms and a tiered referral system. Previously, our remote diagnostic systems operated through isolated hospital-based nodes. Now, we have fully opened up the system: the desktops of physicians in Yangshan County are directly connected to those of specialists at Guangdong Provincial People’s Hospital, effectively integrating them into a single unified system. This enables immediate consultation between providers whenever needed.

• Integrated Medical Technology

Provincial-level hospitals have provided robust support to county-level people’s hospitals in terms of talent, technology, management, and training. This includes supporting the development of three clinically distinctive and key specialties. Specifically, department directors from our hospital are appointed to concurrently serve as directors in Yangshan, leading teams to build these disciplines. Their performance is incorporated into the hospital’s performance evaluation system, with a particular emphasis on assessing their contributions to grassroots capacity building over the course of one year.

• Integrated Auxiliary Diagnosis

Establish county-level regional diagnostic centers, including radiology, electrocardiography, and clinical laboratory diagnostics, to provide technical support for resolving complex and challenging cases. Physicians from both provincial and county-level hospitals jointly participate in the diagnosis of difficult cases. Additionally, our internet hospital provides professional mobile medical examination vehicles equipped with digital radiography (DR), color Doppler ultrasound, and biochemical analyzers to assist county hospitals in regularly delivering medical services to the public. This approach has yielded excellent results and has played a positive role in communities across Guangdong Province.

• Integrated Professional Training

Provincial-level experts go down to the grassroots level, while grassroots doctors come up for training. This initiative primarily involves our experts being assigned long-term to specific departments at lower-tier facilities. For every grassroots doctor who comes up, one expert goes down, engaging in one-on-one mentorship. The grassroots doctors then study and conduct clinical rounds alongside physicians at our hospital, thereby enhancing the patient flow management and professional competence of our emergency department physicians.

By leveraging online platforms, we conduct professional training, trial teaching, and demonstrations, enabling joint ward rounds, image-based analysis, and diagnostic consultations. This approach integrates physicians from Yangshan County People's Hospital and our network hospitals into a unified professional training program.

Despite the short duration of the pilot program, it has achieved remarkable results. We rapidly enhanced the medical technical capabilities and management proficiency of Yangshan County People's Hospital. Through technical assistance, village doctors have improved their clinical skills and income levels, gaining both the competence and motivation to serve as family physicians for rural grassroots populations. Consequently, Yangshan County People's Hospital has seen a substantial increase in outpatient visits and operational revenue, while the county-wide patient retention rate has steadily risen.

The above outlines the basic situation of our Internet-based pilot program in Yangshan County. This model is currently being promoted in other counties and districts across Guangdong Province, including pilot projects in Zhuhai High-Tech Industrial Development Zone, Xinyi County (Maoming), Huazhou City, Heping County (Heyuan), and Gaoming District (Foshan), all of which have achieved initial success.

Leveraging the internet, medical expertise is effectively cascaded down through each tier of the healthcare system, while patients are appropriately referred up through the tiers, ensuring that initial consultations and rehabilitation are delivered at the primary care level, thereby truly implementing a tiered diagnosis and treatment system.

At every stage of the internet-based tiered diagnosis and treatment system, patients are the primary beneficiaries, gaining direct access to county- and provincial-level physicians in their local communities. Village doctors have significantly increased their service revenue due to enhanced professional capabilities, improved service quality, and an expanded scope of practice. Township health centers play a pivotal connecting role; they have experienced increased patient flow and expanded service volume by developing specialized rehabilitation techniques. The county people’s hospital has seen a substantial rise in service volume through patient referrals from village doctors. By leveraging internet-enabled tiered diagnosis and treatment, the county people’s hospital has effectively managed patient flow and ensured an increase in the hospitalization rate within the county.

Just now, I introduced the application of internet healthcare in county-level tiered diagnosis and treatment through the Yangshan case. You may wonder: how should it be implemented in urban communities?

In fact, the foundation of tiered diagnosis and treatment in online hospitals still lies in urban communities, with the only change being that consultation points have shifted from village health stations to pharmacies.

Many friends may ask, “Why not place them in community health service centers?” Currently, these centers operate under a management model where revenue and expenditures are handled separately, and they are assigned based on designated geographic zones. For instance, certain community health service centers are managed by one hospital, while others are managed by another. It is nearly impossible to integrate all community health service centers into such a system, whereas pharmacies do not face this issue.

The function of community pharmacy consultation points is essentially the same as that of village doctors. Of course, these pharmacy consultation points also offer additional services, such as medication delivery, providing convenient door-to-door pharmaceutical delivery for community residents.

By August this year, we will establish at least 5,000 standardized consultation sites among the more than 10,000 pharmacies already under contract in Guangdong Province. This initiative will create a foundational network for internet-based tiered diagnosis and treatment, with urban communities served by pharmacies and rural residents by village doctors. With this foundation in place, patient referral patterns can be established in an orderly manner.

Of course, this is a massive systemic engineering project that requires not only a robust internet healthcare platform but also the effective integration of hospital resources, physician resources, pharmacy resources, village doctor resources, and more, all working together to serve the general public.

We also look forward to physicians and physician groups interested in entering the digital health sector establishing studios on our internet hospital platform. We will directly channel various service demands to these studios and provide them with comprehensive support.

Finally, I would like to emphasize that the difficulties encountered in implementing tiered diagnosis and treatment through internet-based healthcare are difficult to imagine without firsthand experience. While many perceive that online hospitals are currently developing well, it is important to recognize the substantial groundwork laid in the early stages. This includes building out the extensive village doctor system and the vast pharmacy network in Guangdong Province, one by one. Furthermore, many village doctors initially lacked computer literacy or familiarity with digital systems; training them to become proficient users was a challenging endeavor. In short, we must remain down-to-earth and persevere relentlessly; otherwise, we will ultimately achieve nothing.

Q1. In our model, what are the primary barriers to implementing patient referrals? Are there any conflicts in benefit distribution, and how should they be addressed?

Throughout our tiered diagnosis and treatment system, each stakeholder—including provincial hospitals, county-level people’s hospitals, and village doctors—has its own interests. In the referral process, there are no significant barriers. If any difficulties exist, they primarily relate to medical insurance reimbursement rates.

Sometimes, villagers require referral to higher-level hospitals. Under the medical insurance reimbursement scheme, the reimbursement rate decreases as patients are referred up the healthcare hierarchy. Some patients still prefer to receive treatment locally; however, local healthcare infrastructure cannot be built overnight. Consequently, referrals often need to follow a stepwise, hierarchical process.

Furthermore, patients often refuse to be transferred to lower-level facilities during acute treatment, preferring to remain at the current hospital until their condition stabilizes. This necessitates that tertiary hospitals actively facilitate patient transfers back to primary care settings, ensuring that rehabilitation is initiated only after clinical stabilization, in accordance with established protocols. Therefore, it is imperative for hospitals and physicians across all tiers of the tiered diagnosis and treatment system to fulfill their respective responsibilities effectively.

Q2. Should the future ideal tiered diagnosis and treatment system be government-led or market-driven? From the previous discussion, it is evident that the government strongly supports “Internet+” tiered diagnosis and treatment. Is the key to the online hospital model the effective integration of government, hospitals, and social capital?

This is an excellent question. Online hospitals are not fully market-driven; rather, they constitute a tiered diagnosis and treatment system jointly established by public hospitals and platform companies under government guidance and support. In this process, both the government and social capital have played significant promotional roles, with a clear shared objective: to serve the general public.

Certainly, during the course of this service, platform companies may have their own requirements. In the process of serving such a large population, we are able to obtain many value-added services, which is something our platform company is willing to provide. As for hospitals, the ultimate patient referral flow will definitely be directed toward the highest-tier hospitals. Therefore, from our hospital’s perspective, we have achieved relatively good results.

Q3. How is medical data shared within your internet hospital system? Have electronic medical records, laboratory test results, and imaging data been integrated and shared with primary care hospitals?

From the perspective of data sharing, this is an excellent platform. All data from primary care providers, including village doctors, are fully interconnected with those from provincial hospitals, with no silos; the entire information system is shared.

Q4. As the president of a public hospital, what motivated you to establish Guangdong Provincial Internet Hospital at such an early stage in China?

Our hospital was originally a military hospital. In the fiercely competitive market environment of Guangdong Province, how to carve out our own path has been a question pondered by successive leaders. During my tenure, this issue has continued to challenge us: how can we achieve overtaking on a bend, enabling our hospital to rapidly advance into the ranks of medical institutions in Guangzhou that command respect for their status and caliber?

To be honest, for any hospital to move forward, it ultimately comes down to discipline development and talent cultivation. If we simply followed this conventional path, we would never be able to compete with many large hospitals. Therefore, the direct reason we began building our online hospital was to find a unique path forward given our current circumstances.

By establishing online hospitals, we have extended our reach into communities. As is well known, it is quite difficult for newer hospitals to secure medical resources; for instance, existing county-level hospitals already have their own designated supporting institutions, making it challenging for new entrants to compete with them. Therefore, we have directly extended our presence to the grassroots level, into rural areas and communities, thereby enabling hospitals to identify their own space for development.

Q5. Within the entire consultation and referral system, how are consultation fees charged, and is there a standard fee schedule? Are these fees paid online or offline?

Regarding the specific consultation fees, requirements vary depending on the circumstances. As Yangshan County primarily focuses on poverty alleviation, we generally provide our services there free of charge. For other areas with relatively better economic conditions, we apply a proportional fee structure; currently, there are no rigid regulations in place.

Regarding consultation fees, a combination of online and offline methods is generally employed. Payments are sometimes made online, while at other times, settlements are conducted offline between hospitals or between hospitals and various clinics.

Q6. In many parts of China, leveraging internet healthcare technology support is more suitable than directly allocating physician medical resources. Which internet healthcare companies do you believe could establish close collaborations with this system?

Currently, there are many internet healthcare companies that hope to provide a platform where everyone can gather, thereby creating a strong customer base and achieving significant effectiveness and profitability. In my opinion, truly excelling in internet healthcare requires an approach akin to “shedding a layer of skin”—without such profound commitment and transformation, it is difficult to succeed.

To enter this sector, I believe one must first have a clear strategy. Many companies aim solely to secure financing upon entry; however, without strong growth prospects, raising capital remains extremely difficult. This is also a primary reason why an increasing number of internet companies are struggling to sustain their operations—they lack sound top-level design.

We maintain a highly open mindset and are committed to providing active support. Specifically, for individuals in other provinces who have relevant ideas and approaches, we will extend the same level of support to help them successfully implement related initiatives.

Q7. What are the challenges regarding physician resources? How should training be conducted?

The development of online hospitals is currently progressing very well, with rapid growth and smooth implementation of service locations. The primary challenge at present is that the pace of expansion has been too fast, resulting in a significant shortage of qualified online physicians. We are actively working to address this issue.

Certainly, there are significant differences between online physicians and those providing in-person consultations. Inadequate training may lead to isolated issues. In this regard, we are actively exploring better approaches and methods to expand the capabilities of online physicians, ensuring that each physician is utilized effectively so that we can serve the public more extensively.