Leadership Recovery: The Future of Telemedicine

October 27, 2020 by David Nitkin | Categories: Leadership Recovery | Tags: home care, telemedicine

The Issue:

Telemedicine use has exploded as the virus threatens patients and caregivers alike with the risk associated with interacting face-to-face in physician offices and group settings. The post-virus implications for sustainability however are open to contention in the opinion of experts. This blog updates an earlier EthicScan review of telemedicine and home-care change literature published in the period 15 March-30 June. What you are reading here deals with more recent professional literature published in the period 1 July-15 October.

COVID and Adaptations Influencing Telemedicine and Home Care

Photo by National Cancer Institute

Telemedicine refers to virtual health care; that is, non-face-to-face-contact health care. While Canada was an early pioneer in the development of virtual care in the 1970s, it has since been surpassed by other countries in the scale-up of virtual care. Prior to COVID-19, the only telemedicine service eligible for OHIP coverage came through the Ontario Telemedicine Network. But in March, the Ministry of Health introduced temporary billing codes, enabling health-care providers to bill for virtual care on whatever technology they chose to use. That sparked a “profound acceleration” in the adoption of digital-health technologies in Ontario, which provides 24/7 access to primary care through instant message, audio, or video.

At the start of wave one of the pandemic, about 4 per cent of Canadians had received virtual medical care, excluding phone service, prior to the pandemic. By June, a CMA survey showed that 47 per cent of Canadians had received virtual medical care since the start of the pandemic — by phone, text, video conference, e-mail, their provincial telehealth service, or a private virtual health provider.

The coronavirus pandemic has overwhelmed hospitals, physicians and the medical community. That’s pushed telemedicine into the hands of providers and patients as the first response for primary care. Telemedicine and home care isn’t new to the medical community. It just hasn’t been embraced widely before the pandemic.

There are plenty of case studies that back up the benefits of telehealth. In 2016, Frederick Memorial Hospital in Maryland trialled a remote patient monitoring platform for people with chronic conditions. Patients were given a tablet and Bluetooth health devices that collect biometric data so doctors could regularly monitor them and communicate in real-time. The hospital saw emergency room visits drop by half for patients using the platforms, while re-hospitalizations were reduced by 89% over a 30-day period.

The positive contributions and attributes of telemedicine and home care are numerous. They include:

reduces health-care personnel (in doctor’s offices and hospitals) exposure to ill persons
conserves and preserves personal protective equipment (PPE)
minimizes the impact of patient surges on health-care facilities
helps provide necessary care to patients while minimizing the transmission risk of the SARS-CoV-2 virus
offers patients better access to care, improved health outcomes and increased patient empowerment
allows high-risk patients to be monitored and treated more easily
helps health-care personnel (HCP), professional and otherwise, to improves their efficiency and work-life balance
increases access (through phone, video, device apps and e-mail) to primary care and urgent care
improves collaboration and efficiency of care with long-term care facilities, dialysis centers, clinics and other provider locations
improves access, triage and patient care management
provides better patient access for primary care and specialty visits
improves internal and external training.

Forecasts Addressing Sustainability

Recent literature from individuals and professional panels offers a number of ways to build upon and contribute to sustaining the growth of telemedicine:

1. Create more and better emergency room tools and apps: In order to combat the two biggest burdens to emergency rooms—chronic obstructive pulmonary disease (emphysema) and congestive heart failure—leaders will need to create versatile, dependable and timely preventative diagnosis apps that keep people out of hospital. These apps could measure a person’s weight, lung volume and strength to detect flare-ups. For example, staff at UHN have developed an app called Medly, which determines the likelihood of heart failure before it happens.

2. Introduce more pre-hospital admission assessment tools to coordinate and/or replace inpatient hospital treatment: Imagine if a patient could be triaged by a nurse or doctor online instead of waiting five to six hours in a waiting room. If they determine you need to come to the hospital, you would tell them how long it will take to get there, and they’d send you a text before the doctor can see you. Otherwise, they can just call in a prescription to a nearby drugstore.

A lot of health issues can be resolved via video, phone and photography. We can assess muscle or joint problems and look at skin rashes or spots. We can check on a patient’s diabetes or heart failure, help them stop smoking and provide care for mild to moderate mental-health issues. We can even use encrypted, secure programs—such as the Ontario Telemedicine Network, Doxy.me and Think Research Virtual Care—to ensure patient privacy.

3. Strategically locate advanced diagnostic centres (ambulatory clinics): It is important to invest in medically underserved or socially vulnerable neighbourhoods so people more at risk don’t have to travel great distances to get an MRI or CT scan. Eventually, some of these micro-technology diagnostics will become handheld—you could have your own ultrasound unit at home that attaches to your phone.

4. Invest in home care: People getting sick or forgoing their medical needs because they’re afraid to leave their homes. A shift toward home care could revolutionize family health care and lead to easy and efficient care for illnesses like emphysema and congestive heart failure, as well as chronic back pain and injury. Some experts predict that we could reduce the number of ER visits by as much as 30 per cent. By preventing emergencies before they even start, we can devote our existing hospital space to the people who really need it.

5. Build patient-centred criteria into health-system changes: Many experts call for a fundamental change in medicine, one where the patient’s time is better valued, factored into expenditure decisions, and used so they are more actively engaged in their own health. Examples include:

(a) Provide coaching and support for patients to self-manage chronic health conditions, including weight management and nutrition counseling;
(b) Allow more self-monitoring of clinical signs of certain chronic medical conditions (e.g., blood pressure, blood glucose, other remote assessments; and
(c) Deliver advance care planning and counseling to patients and caregivers to document preferences if a life-threatening event or medical crisis occurs

6. Collaboration with private companies: There is need for the provinces to increasingly and directly fund collaborative projects with private companies. This includes companies that:

(a) provide a tool as opposed to a service,
(b) provide a service; or
(c) collect and analyze data (with serious privacy consequences). For example, Toronto-based InputHealth has an online tool that allows patients to take a COVID-19 self-assessment, after which they can then be virtually connected with a primary care provider if they require follow-up. Trillium Health Partners in Mississauga allows long-term-care patients to access physicians using a specialized Maple platform, as well as provides on-call coverage for long-term-care residents, who previously would have had to go to the emergency room.

Outlooks for Low Person-To-Person-Contact Care

Supporters of sustainable telehealth or remote access services identify a range of positive capabilities such as:

Can help preserve the patient-provider relationship at times when an in-person visit is not practical or feasible
Screen patients who may have symptoms of COVID-19 and refer as appropriate
Provide low-risk, urgent care for non-COVID-19 conditions, identify those persons who may need additional medical consultation or assessment, and refer as appropriate
Facilitate access to appropriate primary-care providers and specialists, including mental and behavioral health, for chronic health conditions and medication management
Participate in physical therapy, occupational therapy, and other modalities as a hybrid approach to in-person care for optimal health
Engage in case management for patients who have difficulty accessing care (e.g., those who live in very rural settings, older adults, and those with limited mobility)
Enhances follow-up with patients after hospitalization
Enhance provision of non-emergency care to residents in long-term care facilities
Provide education and training for HCP through peer-to-peer professional medical consultations (inpatient or outpatient) that are not locally available, particularly in rural areas

A checklist of positive and desirable outlooks or outcomes for home care and telehealth include:

1. Ease the burden on hospitals

2. Enhance Integration of systems: In the current model, we have siloed systems—hospitals; primary care, or family medicine; and home care. In the future, industry experts think we’ll see those integrated. This means expanding the use of telehealth services in all parts of the health-care delivery system including community clinics, pharmacies, prisons, and school-based health centers.

3. improve digital literacy (education) for care givers and receivers both: Train providers and staff on policies, practices, and protocols for using telehealth services, including appointment scheduling, documentation and billing, referral processes for specialty care, urgent and emergent care, laboratory services, pharmacy prescriptions, medical equipment, and follow-up visits. Infometrics literacy will enhance health outcomes through digital access to cell connection, device apps, and high-speed Internet especially in rural, remote, underserved, medically-marginalized, and Indigenous communities.

4. Experiment with expanding telemedicine modality services: Use appropriate technologies to deal with prioritized challenges such as:

(a) health emergency services, including ventilation assistance,
(b) ophthalmological services,
(c) remote evaluation, and
(d) group psychotherapy.

There are modality technology choices here:

Modality	Platform	Application
Synchronous	Real-time telephone or live audio-video interaction typically with a patient using a smartphone, tablet, or computer	Peripheral medical equipment (e.g., digital stethoscopes, otoscopes, ultrasounds) can be used by another HCP (e.g., nurse, medical assistant) physically with the patient, while the consulting medical provider conducts a remote evaluation
Asynchronous	Store and forward technology where messages, images, or data are collected at one point in time and interpreted or responded to later	Patient portals can facilitate this type of communication between provider and patient through secure messaging.
Remote patient monitoring	Directly transmit a patient’s clinical measurements from a distance to their health-care provider	May or may not be in real time. Appropriate for language interpretation challenge issues

5. Expand telemedicine to long-term-care patients and facilities: Adapted remote-patient monitoring developed for in-patient use to out-patient management of individuals with chronic conditions. This includes developing programs to improve access to 24/7 care in those settings and create an infrastructure to deploy rapid access to care and telemedicine consulting to partner long-term care facilities.

Telemedicine has its real or potential limitations or barriers, however. According to experts, they include

In-person visits may be essential for things like immunizations, prenatal care and examinations for urgent problems

Interprovincial licensure challenges and other regulatory issues may exist
Situations exist where in-person visits are more appropriate for reasons of urgency, underlying health conditions, an inability to perform an adequate physical exam, or the need to address sensitive topics, especially if there is patient discomfort or concern for privacy
There may be limited connectivity or access to technological devices (e.g., smartphone, tablet, computer) needed for a telehealth visit
Patients and HCP staff may have different levels of comfort with technology
Cultural acceptance barriers may exist around conducting virtual visits in lieu of in-person visits
For the duration of the pandemic and likely long after it’s over, patients coming in for an appointment may have to bring their own mask and wait in their car or in the hall until the doctor can see them—no more crowded waiting rooms
Doctors’ offices will need to book extra time between appointments to clean all the surfaces patients might touch before they come into the room. Doctors will keep their distance more than before, and examinations may be brief.

Conclusion:

Telemedicine and home care may soon just be part of our health system. We won’t call it virtual health care — it will just be health care. However, there are important investment choices and planning decisions that can enhance or hurt virtual care for both patients and providers.

The Issue:

COVID and Adaptations Influencing Telemedicine and Home Care

Forecasts Addressing Sustainability

Outlooks for Low Person-To-Person-Contact Care

Conclusion:

Further Reading: