The pandemic has brought in a sea-change in the way we work. Work from home is the norm, so is a palpable need to get treated and stay healthy but without any travel, and without face-to-face interaction with a doctor. Let us not even mention going to hospitals, which are supposedly dens, where the dreaded corona virus is ready to pounce upon you. There is an explosion of apps as well as services which allow digital health interactions. A concomitant need for remote health care devices, is forthcoming.
Healthcare delivery is a service which depends on a set of interactions with in-depth assessment. Most interactions were done physically in the past, wherein the healthcare provider would hear the problem (History), examine, investigate further, make a diagnosis and treatment plan, and then deliver the care. Telemedicine is essentially medicine but using Information and Communication Technology (ICT) to facilitate the interaction allowing for the patient and care provider to not be face-to-face. In this a process of digitization is required, which means converting the verbal and physical interactions to a digital format. History taking would entail typing, or dictation along with use of a voice to text convertor, instead of writing by hand. Visual examination of say a lump or deformity is photographed, while movements – both of a patient or the viewers’ scope can be video-graphed. Sounds can easily be transmitted. Since the role of investigation reports becoming extremely high in the diagnostic tree. The process of digitization has accelerated, Most investigations are in a way digital ready. X-Ray, US.MR/CT Imaging etc., is nowadays crucial for most decision making and all of these use DICOM and can be viewed as well as reported remotely.
Many digitization devices exist. Commonest is a digital camera for images and videos and a microphone for sound with the tele-stethoscope as an example (Figure 1). Sophisticated systems for remote viewing and examination exist and do add value, which however, is not always commensurate to the cost. The simplest of these are autofocus cameras. There are also those, which follow a sound source and adjust the aperture to available light and focal length. The microphone can adjust of sound amplitude for better quality and also cut off background noise.
Inbuilt communication methods like Bluetooth, Infrared and WiFi capability allow for a truly mobile and allow hand-held usage. Though some would admit that a mobile with add on features would be far more useful and cheaper. Heavier objects like a microscope or an ultrasound machine can have wired connectivity ports like a USB or RJ45 for Ethernet. Previously used components of devices like ports for a printer or a VGA monitor are now considered archaic.
All the scopes used for the patient evaluation e.g., stethoscope, ophthalmoscope, otoscope, arthroscope, laproscope, hysteroscope, cystoscope, microscope, dermascope etc have a possibility of digital transmission. Having one or more of these makes a clinic to be tele-capable. Methods for storage and remote access of the information are important for the information to be available and put to use. There is a definite cost factor for these additional devices and the clinician has to think on how much of use would they be put to. Due to Corona and the fear of getting infected themselves has definitely given a push.
What is telemedicine!
Telemedicine has been portrayed as the next big change in medical care. It corrects health disparities related to socio -economic factors especially geography. Using ICT, Information travels seamlessly between patient and provider to facilitate medical diagnosis and care. Even though the term telemedicine is more popular, the author prefers the term Telehealth. The difference in brief is that telemedicine is restricted to provision of remote medical care. Telehealth not only subsumes telemedicine but also covers a whole range of health services wherein physical interaction is reduced or obviated through Information and Communication Technology or ICT. It includes preventive health services i.e., epidemiology along with online medical education, data analytics, and even decision- making support (CDSS) which requires artificial Intelligence
Telehealth has many definitions, the simplest is the “Use of ICT to deliver healthcare when the patient and the care provider are not face to face”. In other words, information travels rather than people. Information can travel through unlimited distances at electronic speeds using one or more concurrent and interchangeable cabled or wireless modes like 3G/4G, Broadband, telephone etc. Hence physical presence becomes irrelevant. While This technology has been with us since the start of the telephone – in fact the first such interaction was the Alexander Graham Bell, the inventor of the telephone calling his assistant for help after acid was spilt on his trousers!
Various processes which are called upon for telehealth adoption include
– Real-time or Synchronous – mostly in the form of telephone calls and video consults, as also viewing of ultrasound or pathology slides remotely. In the latter, a technician can manipulate the US probe or slide for immediate review by the concerned specialist. This is done without a time-lag. e.g., if the patient is in Dubai with local time 3 PM, the treating doctor in Mumbai is doing the consult at 4:30 PM. Real-time is data intensive. Even while storage needs are extensive, benefits of later search and reuse are limited.
– Store and Forward or Asynchronous – here information sharing allows for a time-lag. I.e. it is recorded either as text (history, examination findings, investigation reports prescription etc), sounds (heart, pulmonary), Images (Photos, X rays), video etc., and shared as files. Viewing and comments are made by the doctor to whom the patient has been referred too and then reshared as per convenience. An Electronic Health Record (EHR) system is the best way to ensure data-sharing on a long-term basis, and provide life-long continuity of care by a range of care providers.
– Tele-monitoring Here data production is ongoing, and is conducted through a device i.e., without human interference. The same can easily be linked to an EMR/EHR system.
However, in telehealth, there are limitations to a complete patient evaluation. It means making do without some assessment features like palpation altogether. The recently released Telemedicine Practice Guidelines has made tele-consultation legal even while the Indian Medical Association (IMA) continues to give contrary instructions. Many doctors in the past – this has changed somewhat – refused to do tele-consult. Some even making a far-fetched statement – “Till I have touched the patient, I am not satisfied and try to insist further neither is the patient”
Digitization also offers immediate secondary gains in the form of long-term memory storage, instant recall, and data analytics. This leads to predictions and adds to planning allowing better case management through a team of care providers e.g., a typical case of cancer will require joint decision making through a team. Surgeons – not only the onco-surgeon but also a gynaecologist, plastic surgeon etc., as the case may be. Medical and radiation oncologists are also required and these in turn require further help from the radiologist, pathologist as well as a physiotherapist. The wound care nurse and social worker do also need to be aware of the day-to-day progress. Long term team care was done through physical documentation in the past but now it is done electronically (Box 1).
The best part of EHRs and EMRs is that such record keeping is immediately telehealth capable, as once information is digitized access becomes easy from anywhere across the globe. Physical presence is immaterial. Neither are there any limitations to the exact time when the access was made.
Adopting telehealth is not an insignificant change. It requires not only costly equipment, but also much relearning. For a busy doctor, this relearning along with purchase of expensive equipment makes it daunting. A specific change management process needs to be understood to improve the adoption and gets reflected in the overall outcomes of the project. (Figure 2). Even while some components like a communication interphase is essential for it to be called telehealth.
Topics to be discussed in further issues
- Security Issues
- Implementation and adoption
- Devices for specific conditions and specialties.
Shashi Bhushan Gogia,
Fellow of International Academy of Health Science Informatics.