Telemedicine and teleconsultation in the era of COVID-19
Telemedicine has multiple definitions, with the key elements being distance as a critical factor, and usage of validated technologies for information exchange regarding prevention, diagnosis and treatment of disease. The imperative remains “the interests of advancing the health of individuals and their communities”.
Telemedicine has ancient roots, with elderly and infirm villagers sending verbally communicated symptoms over to remotely-located traditional healers or medicine men, and receiving empirically prescribed medications in turn. Modern telemedicine was discussed as early as 1879 in The Lancet. Instances of a doctor diagnosing a child over the phone, and using telephone consultations were discussed as a means to lower the caseload of house visits. The 21st century internet age has set a stage in which it may be used optimally, with rapid two-way transfer of audio-visual and textual data.
Telemedicine has typically worked best in settings where direct interaction with patients is usually not required, such as teleradiology and telepathology (a store-and-forward approach). There is good evidence that it works well for skin diseases, and more significantly, in psychiatry.
Direct interaction with patients is more challenging. A first step in this direction is telemonitoring of chronic controlled conditions (e.g. home-based recording of blood sugar and blood pressure in chronic diabetics and hypertensives) with adjustment of drug doses accordingly. Such interventions have indeed been seen to be safe and also improve adherence to and compliance with drug intake. Practising tele-medical consultations in this population in India has the added advantage of keeping high-risk groups (the elderly, diabetics, hypertensives) away from healthcare facilities and community spread of disease by minimizing their travel. Another important cohort is cancer survivors. Telehealth interventions can help minimize anxiety, provide reassurance, mitigate long-term side effects and engender independence.
The role of telemedicine in managing infectious diseases effectively is unclear. Overall, outcomes with telemedicine consultation seem comparable to in-person infectious diseases consultation. Importantly, treatment for viral diseases has been successfully administered and monitored in some studies.
In the wake of the COVID-19 pandemic, national bodies such as the Medical Council of India and foreign bodies such as the American Medical Association and American Association of Family Physicians have clearly espoused the role of telemedicine and laid down broad guidelines incorporating increased flexibility in the telehealth process. Importantly, the Indian guidelines include implied consent when the patient initiates the teleconsult. In addition, specific instructions have been given to preserve patient confidentiality and data integrity. Clear instructions have been given for first rapid counseling, and proper guidance and referral in case of emergencies.
Most importantly, clear guidelines have been provided as to what drugs can be prescribed in telemedical consults, with explicit prohibition on drugs listed in Schedule X of the Drugs and Cosmetics Act and Rules, or any narcotic and psychotropic substance listed in the Narcotic Drugs and Psychotropic Substances Act, 1985 (e.g. anticancer drugs, narcotic substances such as morphine and codeine). The guidelines have also laid down definitions of misconduct – these include insisting on teleconsult when the patient desires in-person consultation, misusing patient images and data, prescribing restricted drugs and solicitation of teleconsults through advertisement. Another notable feature is the exclusion of Artificial Intelligence (AI) based platforms for now from the teleconsulting process.
Telemedicine can enable us to prepare better for epidemics in the future. Telehealth portals with optimized algorithms can be used to screen patients, elicit travel histories and severity of symptoms, allow high-risk screening and segregation, and facilitate “forward triage” before patients arrive at the Emergency Department. Telehealth can also allow for effective monitoring of low-risk cases and contacts without the need for hospital visits.
Telemedicine at Tata Memorial Hospital (TMH) in the COVID-19 era
The COVID-19 crisis and the subsequent lockdown necessitated expedient strategies to address patient concerns, as the Tata Memorial Hospital is visited by thousands of patients from all corners of India and indeed from many other countries.
We have instituted a system where routine long-term follow-ups are carried out over the telephone to assess symptoms. Any red flags and alarm signs necessitate additional appropriate investigations (thereafter conveyed to patients via electronic media) and referral to a suitably equipped local oncology centre, while patients who appear stable have been advised deferred follow-ups at a date which has later been conveyed to them.
Patient satisfaction has also been assessed, and any patient who has been expressly desirous of a physical follow-up in TMH has not been refused the option. The long-term efficacy of this strategy, if objectively proved, can assist us in long-term use, and reduce the significant costs associated with travel and stay in Mumbai, without compromising the integrity of patient care.
The current pandemic is a warning for the future. Systems and logistics need to be maintained at a certain level of preparedness all year round, with allocated funds and personnel to allow seamless transition between telehealth and routine healthcare. The main lessons are that one must provide equivalent quality, adhere to institutionally-defined protocols, document data accurately, promptly report adverse events, minimize red tape, and avoid creation of parallel systems. Adherence to these principles and the fundamental tenet of “first do no harm” will allow us to use telemedicine as a potent weapon in trying times like these.
The authors are all affiliated with the Tata Memorial Hospital, Tata Memorial Centre & Homi Bhabha National Institute (HBNI).
Abhishek Chatterjee and Sarbani Ghosh Laskar are in the Department of Radiation Oncology, Priya Ranganathan is in the Department of Anesthesiology & Critical Care Medicine, Manju Sengar is in the Department of Medical Oncology, Girish Chinnaswamy is in the Department of Pediatric Oncology, and CS Pramesh is the Director of the Tata Memorial Hospital and is in the Department of Surgical Oncology.