Biomedical ScienceCovid-19Medicine

Telemedicine: The Future of Health Care?

Introduction

The COVID-19 pandemic has resulted in several drastic changes in not only our everyday lifestyle but also healthcare. From school to social gatherings, almost everything has shifted to an online platform and medicine is no different. Telemedicine is the provision of healthcare services remotely with the help of modern telecommunication technology. To gain an in-depth understanding of the way in which the use of telemedicine has changed as a result of this pandemic, the following doctors were interviewed in July 2020 with regards to their views on telemedicine as a key modality in the future: Dr Vaibhav Bagaria, Director – Orthopaedics; Dr Aashish Contractor, Director – Rehab & Sports Medicine; and Dr Rajesh Parikh, Director – Psychiatry. Here are some of their views:

Use in the Past

Telemedicine has definitely “been around for a while”. Telegraph was used to report casualties and injuries during the Civil War and a 1879 Lancet Report discussed the plausible reduction in “unnecessary office visits.”[1] Yet, telemedicine as we recognize it today was first introduced in the 1950s when a few medical and healthcare systems attempted to find ways to share information via telephone. For instance, the use of video consultations for the provision of cancer care for primarily medical management first took place over two decades ago in 1994. However, until recently, the main application of telemedicine was for patients who were outside the city. This was mainly because the general understanding is that both patients and doctors prefer seeing each other in person.

Applications in different specialties

A wide range of responses exist in terms of applications; however, the one application of telemedicine commonly present within all three specialties was video consultations, which include “follow ups as well as the first consults.” Within the field of orthopaedics, Dr Bagaria mentioned “the main applications of telemedicine include following up on operative patients on the basis of some criteria including physical strength, pain and any milestones achieved in the recovery period”. A review performed by the Centre of Medicare and Medicaid services in terms of virtual orthopaedic examinations mentioned that although vital elements of an examination such as palpation and dynamic testing may be missing, the situation asks for optimum utilisation of available resources. For instance, a “web-based goniometer” is often used to measure range of movement at the joints.[2] Dr Contractor mentioned that the application of telemedicine in the Rehab & Sports Medicine is most prominent in the “cardiac rehab, cancer rehab and neurology rehab.” If you are struggling with addiction, you may be interested on a program like this to recover.

Through the use of tele-communication technologies, a patient can be “guided through an exercise in their own house.” Additionally, using certain equipment, such as those that monitor a patient’s ECG live, can be used to observe their vital signs. If the equipment is not available, patients can also be asked to manually check vitals such as “blood sugar and blood pressure.” With regards to Psychiatry, Dr Parikh stated that the main application is “psychometric tests and counselling.” Laboratory tests are also ordered with the help of telemedicine. Additionally, a review done by Europe PMC titled “Telemedicine Interventions for Mental Disorders” stated that after 25 weeks of combined pharmacotherapy and caregiver training provided by child psychiatrists via videoconferencing to children with ADHD, a significant improvement was seen in terms of “inattention, hyperactivity, and combined ADHD and caregiver performance.”[3]

The Benefits

The doctors that were interviewed agreed that telemedicine had “enormous benefits.” In general, telemedicine is considered to be more “cost and time efficient” since it cuts down on “commuting time as well as waiting time for patients.” It helps “decongest the hospital, particularly during the COVID-19 situation, when a majority of hospital resources are being used in the pandemic and social distancing has become the new way of life to stay safe.” In Orthopaedics, the use of telemedicine definitely helps prevent patients from coming to the hospital “with the help of a simple x-ray”, which can be done using a portable x-ray machine at home.

One major benefit in Rehab & Sports Medicine was the wide range of patients, in terms of their current health situation, that could be reached through telemedicine. Consultations with the very ill patients or those who are almost comatose can take place with a family member for instance who can be told to help the patient perform some movements such as leg and hip movements to assess the range of movement. These patients would otherwise not be able to physically come down to the hospital to meet the doctor.

In the Psychiatric department, Dr Parikh said that “a huge benefit is the increased privacy of a video consult. Since there are no interruptions, a consult can be structured and organised better”, which is imperative in this specialty. He also added that another major benefit is that “doctors can also consult with their colleagues from across the world and gain further insight.”

A study done by the British medical Journal (BMJ) stated that “10 sessions delivered via Skype were as effective as 10 face-to-face sessions at maintaining the working alliance.” Additionally, Skype proved to be effective when used for counselling and mental health consultations, especially for teenagers as a “medium for supporting independence and self-confidence.” These consultations were found to be “feasible and acceptable” in managing social anxiety disorders in “24 patients who each received 12 weekly sessions of behavioural therapy.”[4] As per a study done by the British Journal of General Practice (BJGP), a major benefit experienced by the participants (doctors, nurses and patients) was “access to remote consultation”, especially for those who worked commuted for several hours for a face-to-face consultation. The participants had generally “positive experiences” and most stated that they would “use VC (video consultation) again for a follow-up consultation.”[5] The same response was evident in a review done by the Canadian Centre Activities (CCA) wherein most patients seen by VC wanted to “receive these services in the future” with an average of 93% of all patient populations being satisfied by the VC. A “significant reduction in anxiety level” was also observed amongst these patients.[6]

The Challenges

Apart from the obvious inability to do a surgical procedure, one challenge that was common to all specialties was the loss of “human touch” which can result in the consult becoming impersonal. In Orthopaedics, Dr Bagaria mentioned that the inability to do a clinical examination results in an “increased dependence on diagnostic tools, images and history.” There is room for improvement in the “quality and availability” of special diagnostic aids such as X-rays. This is very important in orthopaedics because if diagnostics are being relied upon, great quality of the aids is required. In Psychiatry, “a certain degree of physical contact is needed” to establish a stronger connection with the patient. According to Dr Parikh, “both doctors and patients have been used to face-to-face interaction, so that paradigm shift is a challenge.” Another evident challenge is the “discomfort associated with new technology,” especially for older doctors and patients. This can often ruin the sanctity of an interaction since a lot of time goes into adjusting to the technology and understanding how it works and most importantly managing the wifi network at times. The patients included in the study done by the BJGP presented 1.5 problems, on average, in each consultation. A prominent challenge was “time lag” that can occur over the internet.[7] The review by CCA mentioned that common problems associated with technology included “voice echo, poor image, loss of sound and asynchrony of voice and sound.” [8]

In Rehab & Sports Medicine, Dr Contractor stated that “the biggest challenge is to convince the patient that the quality of care via this consult is no less than being done in person.” This is especially important in this field because several exercises and movements need to be carried out in an accurate manner and without the patient believing that the quality is the same through the use of telecommunication technologies, the consultation won’t be successful.

Dr Bagaria mentioned that language is also often a barrier since there are several local languages and so the use of in-built translation could help. Therefore, “improvements in both hardware and software” are required.

Ensuring the same standard and quality of healthcare as in person

In all specialties, the most imperative requirement to maintain the same standard and quality of healthcare provision is to build a “rapport” with the patients and a lot of that has to do with the personality of both the doctor and the patient. “It is fairly easy to build rapport with some patients. However, on the other hand, some are reticent.” While this factor remains true for physical consultations as well, “there is more opportunity in person to establish that human connect.” Comfort with technology is also an important factor to consider in this case because if the patient and doctor have used the online platform in that past, the consultation will take place more smoothly.

Although the above examples show that there are challenges when ensuring that the standard and quality of healthcare is the same as that in person, there is a flipside. It is possible that telemedicine may provide “better quality” consultations. “Today, a busy doctor in their consulting room in the middle of a consult will invariably have several interruptions such as a phone ring from a front desk or an assistant could come in with a report.” However, in the case of telemedicine, the doctor will typically ask people not to enter, resulting in fewer interruptions and possibly an improved quality of interaction.

It is vital to get “patient feedback” since the quality of the consultation is directly dependent on “patient experience.” One approach in this regard that is being implemented includes “short term and long term feedback forms.” The short term form would include basic questions about the actual experience of the video consultation while the long term form would include asking the patients “if the consultation benefitted them 3 months down the road.”

Security and Ethical Concerns

Since telemedicine uses telecommunication technologies, data privacy is a significant consideration. It is important to “choose the online platform wisely, look at their security systems and check if they’re encrypted.” The platform used should be reasonably secure but it shouldn’t be a deal breaker when using telemedicine. A doctor can take steps to protect the privacy of the patients such as using a code or their initials when storing patient data.

Conclusion: Is Telemedicine really the future of healthcare?

There was a unanimous response amongst the doctors that telemedicine would definitely be a significant part of the future of healthcare and is “here to stay simply because necessity is the mother of invention.” Having been put in this situation, doctors were “pleasantly surprised” to find that both them and the patients found the use of telemedicine enjoyable. A fair amount of consultations, approximately 80%, can be done through telemedicine. Today, there are plenty of instruments that allow a person to do an ultrasound and allow people to check their kidney, abdominal cavity or even the heart echo without physically being at the hospital. Furthermore, using telemedicine as a method to follow-up on patients, especially for “mental health, chronic illness management, blood test results and medication reviews” would be very useful.

Telemedicine will also “drastically increase the accessibility of healthcare since areas that are otherwise unreachable because of physical distance can be reached.” Additionally, with the accessibility there will also be a “better equity of healthcare” because a person in a village who has access to a doctor in the city also gets the same quality of healthcare as someone in the city. Even though, as reported by the BMJ, Video Consultations are the most preferred alternative to face-to-face consultations since both the doctor and patient can see each other, other telecommunication technologies including “telephone, text messaging and email consultations” are also available which further increases the accessibility of telemedicine. [9]

Furthermore, from a financial perspective, the total costs for VC is usually less than in-person consultations which will definitely help in the future use of telemedicine. According to the review done by CCA, “overtime as VC systems are used more frequently, operating costs can be reduced by as much as half or more.” [10]

Also, “incorporating AI (artificial intelligence) would be very useful”. Relevant questions can be asked and diagnostic information can be provided to the doctor which would make the process a lot more efficient. Improved technical infrastructure is required for telemedicine to be effectively practiced and become routine in several specialties.

Still, it is hard to develop faith in a doctor long term if the patient is only seen virtually. Once the connect has been established it is easier to transition into telemedicine.” As per the study done by BJGP, “face-to-face consulting was still perceived as the gold standard for emotionally charged or more challenging consultations.” A patient who participated in the study also said that the “initial relationship” that they had formed with the doctor before doing a follow-up video consultation made the interaction a lot more “comfortable.”[11] Therefore, the answer for the future will be a hybrid model: a combination of both telemedicine and traditional medicine wherein a few meetings will take place in person while the majority would be over video consultations because human connect is the one thing distance cannot represent, especially when it comes to health and medical care.

Acknowledgements

I would like to thank Dr Vaibhav Bagaria, Dr Aashish Contractor and Dr Rajesh Parikh for their time, guidance and invaluable inputs.

Bibliography

1: Guzman, Earl. “The Application of Technology to Health: The Evolution of Telephone to Telemedicine and Telepsychiatry.” Journal of Technology in Behavioral Science, 22 Mar. 2017.

2: Tanaka, Miho J. “Telemedicine in the Era of COVID-19.” CMS, 24 Apr. 2020.

3: Bashshur, Rashid L. “The Empirical Evidence for Telemedicine Interventions in Mental Disorders.” Telemedicine and e-Health, Feb. 2016.

4, 9: Greenhalgh, Trisha, et al. “Virtual Online Consultations: Advantages and Limitations (VOCAL) Study.” British Medical Journal, 2016, pp. 1–13.

5, 7, 11: Donaghy, Eddie, et al. “Acceptability, Benefits, and Challenges of Video Consulting: a Qualitative Study in Primary Care.” British Journal of General Practice, Sept. 2019, pp. e586–e594.

6, 8, 10: Kitamura, C., et al. “How Effective Is Video Consultation in Clinical Oncology? A Systematic Review.” Canadian Centre Activities, 2010, pp. 17–27.

Footnotes

  1. Guzman, Earl. “The Application of Technology to Health: The Evolution of Telephone to Telemedicine and Telepsychiatry.” Journal of Technology in Behavioral Science, 22 Mar. 2017.
  2. Tanaka, Miho J. “Telemedicine in the Era of COVID-19.” CMS, 24 Apr. 2020.
  3. Bashshur, Rashid L. “The Empirical Evidence for Telemedicine Interventions in Mental Disorders.” Telemedicine and e-Health, Feb. 2016.
  4. Greenhalgh, Trisha, et al. “Virtual Online Consultations: Advantages and Limitations (VOCAL) Study.” British Medical Journal, 2016, pp. 1–13.
  5. Donaghy, Eddie, et al. “Acceptability, Benefits, and Challenges of Video Consulting: a Qualitative Study in Primary Care.” British Journal of General Practice, Sept. 2019, pp. e586–e594.
  6. Kitamura, C., et al. “How Effective Is Video Consultation in Clinical Oncology? A Systematic Review.” Canadian Centre Activities, 2010, pp. 17–27.
  7. Donaghy, Eddie, et al. “Acceptability, Benefits, and Challenges of Video Consulting: a Qualitative Study in Primary Care.” British Journal of General Practice, Sept. 2019, pp. e586–e594.
  8. Kitamura, C., et al. “How Effective Is Video Consultation in Clinical Oncology? A Systematic Review.” Canadian Centre Activities, 2010, pp. 17–27.
  9. Greenhalgh, Trisha, et al. “Virtual Online Consultations: Advantages and Limitations (VOCAL) Study.” British Medical Journal, 2016, pp. 1–13.
  10. Kitamura, C., et al. “How Effective Is Video Consultation in Clinical Oncology? A Systematic Review.” Canadian Centre Activities, 2010, pp. 17–27.
  11. Donaghy, Eddie, et al. “Acceptability, Benefits, and Challenges of Video Consulting: a Qualitative Study in Primary Care.” British Journal of General Practice, Sept. 2019, pp. e586–e594.

Biography

Ayushi Gianchandani is a senior at Dhirubhai Ambani International School in Mumbai and a newsletter editor at YSJ. She is deeply interested in the field of medicine and plans to pursue it in the future. She’s also very passionate about math and playing the piano.

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