How does TeleMedicine work?

I recently posted this article in The British Society Contact Newsletter (October 2018 issue)
Dr Jorge C Stanham MBE (a Spanish version will follow shortly)

Those who dare follow me on LinkedIn and my blog are already aware that I’m all for TeleMedicine. In fact, for more than 20 years, I’ve practised it with the tools of informatics and the Internet, be it e-mail, electronic health record messaging, SMS, WhatsApp – and (to my despair) via Facebook messaging. Plus, for the time-being, it’s all for free!

Healthcare is notorious for being the latecomer to every bandwagon that has changed the way humans manage information and connect, especially when it comes to the physician part of providing the services. When doctors do get involved in a change, it has already happened in administration, accounting, marketing and even diagnostic services. I frequently refer to the Greek mythological character Procrustes, who had a lodge for visitors and travellers, but had only a one-size-fits all bed model. For those shorter than the bed, he’d stretch the poor host to reach the bed size and for those longer, he’d cut off whatever exceeded the bed’s limits. Medicine as practised, is enormously Procrustean: we rely on the one-on-one and face-to-face model, which means that we strive to fit a doctor and a patient in that time-space singularity called an office visit: never remote and always at the same time. Consequence: assembly-line-industrial-model medicine, leading to queues, waiting lists, unneeded emergency room visits and even, losing precious time. This single-tool model is the consequence of expanding what was possible in the middle of the 20th and forcing it on the multidimensional modes of relating people and professionals of the 21st century. A Continuous Quality Improvement (CQI) pioneer once said: “Every system is designed to produce the results that it gets.” Many cite Einstein’s ‘insanity trap’: you cannot get out of a problem using the same resources that got you into it.

So, back to TeleMedicine. The ‘tele’ part is the first (and defining) key: the service is provided from a distant location ie, the patient and the provider/doctor are not located in the same place. With this concept in mind, we enter the second key: the service can be provided at the same (synchronous) or at a different (asynchronous) time. Let’s remember the old-fashioned phone call to or from the doctor: this would be ‘tele’ (at a distance) and synchronous (at the same time). Expand this to Skype and we add video (sounds more like the present, doesn’t it?). Think about e-mail: its ‘tele’ and asynchronous. Interfacing the two models would be chatting (‘tele’ and nearly synchronous) as can happen with SMS or WhatsApp. (Why this isn’t happening in a generalised way will be explained later.) To start, there are three types of Telemedicine:

1.       Synchronous. Just like the good old phone call, the patient and the provider interact over the internet, usually in view of each other (like Skype). Recently, I’ve been aware that some psychiatrists and psychotherapists follow up on their patients using synchronous audio-video technology, with good results and a high degree of satisfaction. That this type of TeleMedicine is well-suited for mental health if probably a reflection that a physical exam is not needed, or that it has been performed previously by another doctor and not relevant to the problem at hand.

2.       Store-and-forward. This is, by definition, asynchronous. E-mails would be typical of this interaction: information is recorded, saved/stored and sent/forwarded to the doctor/provider, who’ll respond and give recommendations or requests for further info. Receiving results from a lab on a patient’s mobile phone app, which is then forwarded to the doctor, is just another form. Consultations, second opinions, sending images and lab test results to remotely (even across the globe) located professionals or clinics, is store-and-forward. Sending everyday diagnostic images from North America or Europe to highly trained radiologists in India for interpretation, shortens the turnaround time for reports, making use of the different day/night time zones.

3.       Remote patient monitoring. The world, both in developed and in developing countries, has to face the fact that providing services to remote locations, to a progressively ageing and home-bound population, plus the burden of chronic, non-communicable diseases, cannot be handled with the present tools of Procrustean medicine. Self-care and monitoring with wearables or trusted diagnostic home devices, produces information that can be managed remotely (tele) in asynchronous or synchronous modes and by non-physician healthcare professionals. Even the younger ‘worried well’ population will feel secure with this type of relationship with their healthcare providers.

So why isn’t TeleMedicine happening in a widespread way? Some point at doctors as the main bottleneck, as we (doctors) are already hard-worked and have our hands (and minds) already full with the Procrustean model of assembly-line medicine. Besides, most TeleMedicine services are not reimbursed (payed for) – so why offer it, having to work longer? – even if it’s maybe notoriously beneficial for some patients. Many cite confidentiality and cybersecurity issues (true) and the liability of a regulatory vacuum and how to document the doctor-patient interactions in the electronic health record. Although many cite that physical examination cannot be reliably performed over the internet (this may change), in fact many follow-ups, most medication refills and follow-up tests can be done safely, without forcing patients to book, wait and see their doctor personally, for every single issue.

In a nutshell: Telemedicine saves time, the need for displacement and can be as reliable as traditional one-on-one and face-to-face medical practice, or even better, when used flexibly and in addition – or in place of – what we’re doing now. We only need to start thinking outside of the box, like the CQI improvement author and Einstein said.

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