Introduction
In comparison to “in-person” medicine, telemedicine, i.e., “remote” or “over a distance” medicine, has another set of advantages and limitations. For example, in a teleconsultation with a patient on a sailboat, diagnostic systems and most medications are unavailable. The clinician has less information to rely on, and in the end has to rely more on intuition and innovation. However, in a telemedicine setting involving a general practitioner at an outpatient clinic remotely consulting an expert such as a pulmonologist, tele adds to the usual set of options. Another example of telemedicine could be a constant automated remote monitoring of a patient, with the observing clinician also working remotely at home. Other examples could include a clinician-guided group psychotherapy session over videoconferencing, or robots delivering medications on an isolation ward.
Living participants of a telemedicine setting may be patients, clinicians, family members, or other parties such as officials. A family member or a social worker may participate remotely in an in-person clinical visit. Automated participants may include software agents such as smartphone programs/apps connected to remote monitoring systems, artificial intelligence systems based on machine learning, or traditional expert systems based on descriptive logic programming. They may also include physical robots, which need no protection from aerosols, can be built self-disinfecting, and can work without breaks or rest.1
Amid pandemic-related societal closures and social distancing requirements, telemedicine has offered an opportunity to address the ongoing health care needs of patients. Telemedicine has been applied to the whole treatment process or parts of it, such as an initial diagnosis or a follow-up.
In these days, technological prerequisites for telemedicine are often easy to fulfill. Even low-end smartphones provide the necessary capabilities for videoconferencing. External diagnostic devices providing heart rate or oxygen level monitoring may be utilized through wireless connections provided by the phones. Many “smart” watches and rings have these features built in. There are also experiments with microscopic lenses to be overlaid on smartphone camera lenses to diagnose parasites in blood samples, for example.2
Depending on locally available mobile data plans, videoconferencing and remote data monitoring may have an affordable fixed cost or may be relatively expensive. These costs may be offset by reduced need for traveling, for example. A clinician only working remotely may save on office costs. Possibilities depend also on features of existing electronic medical record and prescribing systems.
The return on investment on telemedicine may be larger in developing countries due to less equal access to health care between rural areas and cities.3 However, also in Western countries, specialists are often concentrated in the cities. Telemedicine may thus equalize access to health care. Fields of medicine depending on touch may be unfeasible or at a disadvantage, although counterexamples such as telesurgery exist. By reducing person-to-person contact, robot-assisted surgery or telesurgery reduces risk of infections for both patients and medical professionals. Telesurgery could provide high-quality surgery in rural areas, battlefields, refugee camps, boats, etc.4 It allows collaboration among surgeons residing at different locations, reduces need to travel, and may allow more efficient use of surgeons’ time, helping to overcome the shortage of surgeons. Operator’s physiological tremor can be cancelled, improving accuracy and reducing damage to adjacent healthy tissues, thereby quickening recovery. With new innovations, methods applied in telesurgery could possibly be extended to other fields of medicine, for example, by building general-purpose remote-controlled robots that could utilize ultrasound and other diagnostic devices.
Although it has different set of advantages and disadvantages in comparison to conventional settings, on average the efficacy of telemedicine may not differ much from conventional clinical work. For example, a systematic review of eight randomized controlled trials and three cluster randomized trials about telemedicine in pediatrics revealed that telemedicine was comparable and occasionally more beneficial, compared to in-person visits, with regard to outcomes related to symptom management, quality of life, satisfaction, medication adherence, visit completion rates, and disease progression.5 Interventions were based on videoconferencing, smartphone-based solutions, and telephone counseling.
Telemedicine during the Pandemic
In the United States, telehealth-provided Medicare primary care visits increased dramatically, from 0.1% in February 2020 to 43.5% in April 2020.6 This was due to a significant relaxation of telehealth-related regulations during the public health emergency. Telehealth use increased dramatically also among specialists. The highest uptake of telehealth primary care visits occurred in cities, whereas the uptake was somewhat smaller in rural areas with lower incidences of COVID-19. It is estimated that an increased demand in telehealth visits will remain also in the postpandemic era. In a survey of 300 practitioners, the percentage of telehealth visits was 9% before pandemic, 51% amid the first wave, and was expected to remain at 21% postpandemic. With regard to access of care, in one local survey of telemedicine visits in the United States, black and Asian minorities used less telemedicine services than whites, and women used more services than men, indicating that some patient groups may have been less likely to use the services.7
The Smart Field Hospital of Wuhan
In March 2020, a field hospital for 20,000 patients was built in Wuhan, with the aim of relieving exhausted health care workers.8 Patients wore smart bracelets and rings that constantly monitored their vital signs. Autonomous robots screened patients’ temperatures, delivered food, drinks, medicines, information, and entertainment to patients. They also disinfected surfaces with UV-C light and cleaned the floors. Due to successful containment of the epidemic, the experiment was short-lived.
In June 2020, a Chinese research group proposed dual-arm robot for isolation wards, capable of remote auscultation and operation of bedside medical instrument touchscreens, equipped with ultrasound stethoscope and UV disinfection device.9
A Handheld Remote Physical Examination Platform in COVID-19
In April 2020, the University of Virginia organized a multidisciplinary response team for handling COVID-19 outbreaks in patients of a local postacute and long-term care facility.10 Using off-the-shelf FDA-approved equipment, the team built a handheld platform that allowed remote physical examination. It integrated videoconferencing with a stethoscope, an otoscope, an oral camera, and wireless vital sign monitoring.
Patients’ clinical statuses and vital sign data were reviewed daily in videoconferencing meetings of the facility teams and the university clinical, administrative, and technological experts. Predefined changes in oxygen saturation, respiratory or heart rate, blood pressure, temperature, mental status, or gastrointestinal distress triggered a consultation with university pulmonologist or geriatrician, leading to transfer to a hospital if needed.
Initially, 85% of the patients at the facility tested positive for COVID-19. Median age was 85 years and all had multiple chronic health conditions. Over a month, 27% received telemedicine consultation and 38% required hospitalization, and mortality rate was 12.5%. Other comparable facility outbreaks reported a hospitalization rate of 54% and a mortality rate of 34%. The authors attributed the difference to rapid identification of patients requiring escalation of care, provision of care plans for monitoring and treatment of patients remaining at the facility, confirmation and optimization of goals of care, and coordinated care efforts between the facility and hospital. After the initial experience, the approach has been replicated to other facilities.
Teleconsultation in COVID-19
As an example of COVID-19-related teleconsultation, between March 1 and April 30, 2020, the French medical maritime teleconsultation organization Tele-Medical Assistance Service (TMAS) consulted 51 suspected COVID-19 patients of 15 nationalities in passenger ships, ferries, ocean liners, merchant ships, fishing vessels, and pleasure crafts.11 In total, 88% presented with fever, 76% with cough, 15% with respiratory distress, 13% with headaches, 2% with diarrhea, 2% with loss of smell, and 2% with loss of taste. A total of 47% were prescribed paracetamol, 10% antibiotics, and 2% antitussive agents. However, 45% were not given a prescription by TMAS but approximately half of them were also attended to by a physician on board.
On closure, 2% were rerouted, 13% evacuated, 20% disembarked, and 65% received treatment on board. The evacuated tested COVID-19 positive in 92% of cases. In addition to the 51 patients, 10 more patients were classified as epidemic-related cases (30% of these were contacts of suspected COVID-19 patients, 10% suffering from isolation, and 60% had a shortage of previously prescribed medication). On average, treatment of one case involved four calls (standard deviation = 4; min = 1; max = 13).
After the National Institutes of Health (NIH) guideline change in early 2021 taking a neutral stance toward ivermectin but the continuing reluctance of most clinicians to prescribe it, several clinicians in the United States begun providing ivermectin prescriptions by teleconsultation.12
Tele-Intensive Care Units
In one example in the United States, an existing virtual telecritical care (TCC) system, which involved providing care to critically ill patients through synchronous, two-way audiovisual communication, was expanded with four goals.13 The first goal was to augment room capacity by equipping non–intensive care unit (non-ICU) rooms with mobile telehealth carts, to expand the pool of available teleintensivists (e.g., allow retired or self-quarantined clinicians to work from home), and to allow nonintensivists to provide bedside critical care with the help of remote guidance by intensivists. The second goal was to minimize exposure of workers to patients by allowing communication without direct exposure, and simultaneously verify that personal protective equipment was used properly. The third goal was to improve bedside team management by enabling instant communication with non-ICU specialists, allow virtual team-based rounding with remote members, and serve as a central point of coordination and communication for evolving clinical algorithms. The fourth goal was to optimize ICU bed utilization by creating a real-time capacity surveillance of confirmed and suspected cases, and centralizing ICU triage decisions. Global supply-chain shortages affected by the pandemic affected purchases of necessary equipment for the TCC system expansion. Use of extension tubing to move ventilators and intravenous pumps to outside the patient’s room impaired the ability for TCC intensivists to assess the patient and intervene. Use of personal protective equipment (PPE) by staff impaired bedside audiovisual communications. Language barriers further limited communications. There was a potential for conflicting medical decision making between bedside and virtual providers, and potential of service disruption related to technological issues. Regardless, TCC infrastructure allowed flexible up- and downregulation of capacity. The study also described the components and costs of the carts and home workstations.
A rapid guideline provided recommendations on the organizational management of ICUs during the pandemic.14 The guideline suggested, among other items, use of mathematical modeling to support surge capacity planning. They also recommended using available communication technology to enable family members to communicate with patients and staff, and engaging family members in rounds and patient care discussions. In addition, the guideline suggested engaging chaplains/spiritual care, social workers, ethics consultants, and patients advocates to provide support to patients and their families. The guideline also advised against using the sequential organ failure assessment (SOFA) score for triaging COVID-19 patients, due to its low performance in predicting outcomes.
In 2012, a centralized tele-ICU service center was established in India, later providing services to 50 hospitals in the United States.15 During the COVID-19 pandemic, tele-ICU was proposed for alleviating gross shortages of intensivists in India (India had approximately 70,000 ICU beds, and the largest society of critical care medicine in India had approximately 12,000 members, in contrast to a population of approximately 1,350,000,000). However, regulatory guidelines mostly addressed outpatient telemedicine, not inpatient telemedicine including tele-ICU. Also, there was a lack of training and funding. In addition, in India, intensivists provide consultation but are not fully empowered to direct care, creating ambiguities that may be exacerbated in a remote setting.
Patient–Family Communications
Telemedicine was also utilized for tablet-based communications between isolated patients and their family members in cases where patients did not own mobile phones.16 Tablets were restricted to disallow use of other apps. Privacy regulations required ensuring patient privacy by selecting apps in which only accounts on an allowed contact list could call the patient. Non-HIPAA-compliant apps without centralized administration capabilities added administrative overhead. User-friendliness and familiarity with the chosen app was important in order to reduce the need for support.
Telemedicine in Other Diseases during COVID-19
As an example, in March–May 2020, a buprenorphine clinic in New York assessed feasibility of telemedicine-based opioid treatment with buprenorphine–naloxone in 78 patients with 252 visits.17 At 8 weeks, 54% of patients remained in care, 27% were referred to community treatment program, and 19% were lost to follow-up. It was concluded that unobserved home induction on buprenorphine–naloxone was safe and feasible.
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