Telehealth accelerated due to the pandemic

14 Aug, 2020

The COVID-19 pandemic is the defining global health crisis of our time and one of the greatest challenges we have faced since the last century. Since its emergence in Asia late last year, the virus has spread to every continent, except Antarctica, causing not just a health crisis but also a socio-economic one that will leave deep and longstanding scars.

The rapid progression of the disease exceeded the capacity for citizen care, leading health professionals and governments to struggle. One of the strongest measures to reduce and mitigate the advance of the pandemic in recent month has been social distancing, specially to avoid contamination through close contact. This situation has reminded us the importance of telehealth, together with remote work and online education, to help and provide support to healthcare systems, particularly in public health, prevention and clinical systems.

Telehealth has a positive impact in patients with and without COVID-19. For those suffering the disease, or concerned that they might be infected, telehealth can help with remote assessment and provision of care. For those not infected, telehealth can provide access to routine care with no risk of exposure in hospital and medical facilities (especially if they are overwhelmed).

Thanks to current technologies, telehealth can provide healthcare information and services to people in multiple remote locations across the world, which is ideal in pandemics, to avoid person-to-person contamination. It has played a key role in the medical practice in recent years through the use of digital information and communication technologies to manage health care and to access health care services remotely. This approach connects practitioners and patients in different ways: online consultations, chatbots, reduced time to diagnosis, follow up from home, telemonitoring, etc.

Telehealth can help in the training of health professionals: for example, use of telementoring in surgery enriches the teaching capabilities of a remote surgeon. In telementoring a surgeon (mentor) can transfer information and knowledge to another surgeon (mentee) remotely, though audio and video. Current telecommunication systems allow for dramatically increased transmission speeds, which considerably decreases the time delay – something crucial in telementoring. However, this valuable technology can also be applied in other medical disciplines to help clinical teams rapidly learn new techniques and procedures required for the care of patients in emergency situations.

However, there are multiple modalities of “Telehealth” that must be understood. as they involve a number of clearly defined rules and limitations:

Telemedicine: 

The use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.

Teleconferencing: 

Interactive electronic communication between multiple users at two or more sites through voice, video and/or data transmission systems: audio, graphics, computer and video systems.

Telemonitoring: 

The process of using audio, video and other telecommunications and electronic information processing technologies to monitor the health status of a patient remotely.

Telepresence: 

The use of a number of technologies that allow individuals to feel as if they were present or to appear to be present, or which have an effect at a place other than the patient’s actual location.

Teleconsultation: 

Remote consultation between a provider and a specialist through either saved and forwarded telemedicine or through real-time videoconferencing.

Telementoring: 

Telementoring is a relationship, facilitated by telecommunication technology, in which an expert (Mentor) provides guidance to a less experienced learner (Mentee) from a remote location.Telestration: a technique for drawing freehand annotations on a still image or video.

The Mentor/telementor is an expert surgeon who undertakes to impart his/her clinical knowledge and skills in a defined setting to a mentee. The mentor must be appropriately privileged, skilled, and experienced in the procedure and or technique in question. The telementor, by definition, does not have the ability to physically intervene onsite in the primary activity without the telecommunications interface.

The Mentee/trainee is a surgeon with appropriate basic knowledge and experience seeking individual training in skills and/or procedures not previously learned in prior formal residency or fellowship training. The mentee must have appropriate background knowledge, basic skills, and clinical experience relevant to the proposed curriculum.

Telementoring differs from teleconsultation in three specific ways:

1. Telementoring requires an established relationship between mentor and mentee in which the skills and knowledge of both are understood through a relationship developed prior to the telementoring event.

2. Telementoring is performed with a competent mentee who can manage the patient’s disease, as if the mentor were not telepresent, although likely using a different technique or technology.

3. Telementoring occurs within an educational framework through which both mentor and mentee have worked to prepare for the mentoring experience.


Modern technology has allowed for numerous advances in the utilization of telementoring. 
Early telementoring systems were limited by low transmission rates, raising concerns about the harmful effects that a time delay may have on surgical performance.

Current telecommunication systems allow for dramatically increased transmission speeds, permitting a considerably decreased time delay. In addition, the high resolution associated with modern high definition cameras has enhanced remote surgeons’ ability to zoom in and visualize small anatomic details. 

Wearable technology, such as Virtual Reality Glasses, and augmented reality telementoring methods have also been implemented and have had some success. Specially designed telemedical robotic platforms have also been developed and may play a role in further increasing the remote surgeon’s presence in the operating room. But one of the most important advances in telementoring systems has been interactive additions such as laser pointing capabilities, telestration, and increased remote control of the visual field, which play a role in enriching the remote surgeon’s teaching capabilities.  

These different telementoring strategies have numerous advantages that have continued to increase. Telestration enables a trainer to point or draw freehand sketches on a video for the trainees to see. This method can improve trainees’ performance, in terms of economy of movement, after initial mastery has been attained. The improved use of laparoscopic video results in more direct instrument movement. The telestration system benefits trainees in the adoption of professional vision, which would further enhance trainees’ technical skills and understanding of the procedure.

Telestration reduces travel and time away from work for both surgeons involved in training – a major limiting factor in surgeon upskilling. In addition, the hospital benefits from performing more cases at their facility and ensuring that the surgeon has the expert support needed to deliver high-quality care early in their post-training learning curve. Furthermore, the patient has peace of mind from knowing that their surgeon will be supported by additional experts.

As the technology required to implement surgical telestration is now readily available to many physicians, its advancement depends on several other hurdles limiting its expansion.

Even though many studies have demonstrated the usefulness and safety of telementoring and telestration, the literature is limited by small sample sizes, variation in telementoring platforms, procedure, and the experience of the onsite surgeon. These limitations have given rise to some confusion regarding the optimal use of this technology. 

Future studies evaluating clinical and educational outcomes with large sample sizes spanning many procedures may be necessary to validate its usefulness and appropriate indications for use. The skill set and experience of the onsite surgeon likely has a large impact on the success the telementored procedure. However, some studies have started to investigate its potential for use “worst-case scenarios”, in which the mentored onsite healthcare professionals have very limited experience or training in the procedure they are required to perform.

Future studies are needed to determine the feasibility of telementoring in guiding inexperienced healthcare professionals. Determining a minimum set of qualifications and skillsets is another factor that may better define the best application of telementoring and its future success.

The main benefit is that telementoring has the potential to impart specialized surgical knowledge and guidance through a relatively convenient and low-cost method as compared to traditional mentoring. The development of platforms that optimize patient outcomes and the educational value of that training, while maintaining appropriate cost effectiveness, have great potential to mitigate the shortage of surgeons around the world.



Protecting the patient

Whilst the potential benefits of Telehealth are clear, its implementation is limited by legal aspects to protect the privacy and security of protected health information. Protecting patients’ health data and rights is a major concern for society, as medical records can include intimate details about a person’s life.

In the U.S. certain regulations are issued under the Health Insurance Portability and Accountability Act (HIPAA) law to protect personal health information. In the European Union its equivalent is the General Data Protection Regulation (GDPR) which includes everyone (including the USA).

During the COVID-19 emergency, health professionals have provided telehealth services through remote communication technologies that do not fully comply with the requirements of the HIPAA or GDPR rules. This practice goes against the good faith provision of telehealth by potentially introducing privacy risks. Health professionals are often unaware that they are using providers that do not have available encryption and privacy modes when using their applications, what can endanger their patients’ privacy. Video communication product providers who want to implement telehealth should be HIPAA and/or GDPR compliant, such as Skype for Business / Microsoft Teams, Zoom for Healthcare, and Google G Suite Hangouts Meet.

During this coronavirus COVID-19 epidemic, telehealth has become doctors’ first line of defense to slow down the spread of the disease. In many ways, this approach makes communication between health professionals and patients regarding care, diagnosis, treatment follow-up, and training easier and faster. Use of these simple available technologies should not stop when coronavirus is mitigated, as there are opportunities to for their use in daily clinical practice.

References:

https://aischannel.com/society/telementoring-future-surgical-training/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140977/

https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

https://www.elsevier.es/es-revista-atencion-primaria-27-avance-resumen-telemedicine-in-face-covid-19-pandemic-S0212656720301268#bib0315