Coronavirus disease COVID-19 and remote healthcare: telemedicine – virtually perfect

Today, scientists who recognize the importance patients place on appropriate, cost-free treatments have used an article in NEJM, the leading medical journal, to open up discussion about whether face-to-face consultations could be the second, third or even last option for meeting patients' needs. Previously, the potential use of telemedicine (remote healthcare) specifically in disaster and public health emergencies was discussed, and in health systems that have successfully implemented this innovation, telemedicine technology against COVID-19 is being prepared for use through further development.

Telemedicine applications in emergency medicine and other fields

Triage, that is, prioritizing patients for appropriate treatments, is vital in meeting the excessive demand expected of healthcare services. Telemedicine / telehealth services are thought to offer important benefits in triage. Because direct-to-patient telehealth services are also suitable for self-quarantine, they can be used to assess patients with the novel coronavirus disease COVID-19 who show respiratory symptoms. Access to patients' travel and electronic health records obtained from servers, along with regional outbreak data, will also help in making appropriate decisions. In addition, community emergency medicine or mobile-supported health programs offer patients the opportunity to receive treatment in their own homes with high-level virtual medical assistance. For seriously ill patients at home, such programs facilitate assessment before hospitalization, potentially enabling them to bypass the emergency department and go directly to a hospital bed, thereby reducing exposure to the disease among healthcare workers and other patients.

At present, the greatest obstacle to large-scale telemedical screening for the novel coronavirus (SARS-CoV-2) that causes COVID-19 is coordinating testing. As testing centers increase, local systems that can test appropriate patients while minimizing exposure to the disease will need to be developed and integrated into telemedicine workflows.

Patients who present directly for treatment and test positive need to be quarantined without delay to prevent contact with other patients and healthcare workers.

Before the COVID-19 outbreak, many emergency departments developed a "provider-in-triage" model that allows intake by a remote provider (rapid initial assessment and testing). For example, Aurora Health worked with a commercial telemedicine provider, while others developed their own software for this purpose. In an emergency, web conferencing software on a secure connection between the triage room and physicians can be deployed relatively quickly. Covering multiple locations with a single remote physician may of course create some staffing difficulties, but a queuing function in your software can partially overcome this problem.

Tablet computers shared among patients and healthcare workers should be cleaned according to well-defined infection control procedures. At emergency department sites, patients who screen positive can be given a tablet and isolated in an examination room. Using commercial systems over a dedicated connection or smart tablets that allow communication with a physician, televisits can be conducted without exposing healthcare workers to the disease. We hope COVID-19 testing will become more accessible soon, but for now we quarantine patients who are well enough to go home, while also coordinating home-based testing. Although this system works for patients who are doing well, it does not completely eliminate healthcare workers' exposure to patients who need procedures. Similar televisit systems are also used for hospitalized patients to reduce the risk of disease among visitors and staff.

Services such as those provided by Mercy Virtual Care Center, Sutter Health and Sentara Healthcare allow nurses and physicians to remotely monitor the condition of 60-100 patients in intensive care units across multiple hospitals through electronic intensive care unit (e-ICU) monitoring programs, which are ideal for monitoring seriously ill patients. Although technological and staffing difficulties make it impossible to develop such a program in a short time, rapid adoption of the two-tablet approach may reduce healthcare workers' contact with infected patients in intensive care.

Clinical Decision Support

Medical decision-making is a cognitive process, and telemedicine can provide rapid access to subspecialists who are not nearby at the time. This approach has been studied most extensively in patients who have had a stroke and is offered at many centers as a virtual emergency neurological healthcare service. The main barriers to implementing such programs are payment, credentialing and employing specialists.

Reports showing that as many as 100 healthcare workers at a single healthcare institution were quarantined at home because of exposure to COVID-19 have raised concerns about workforce capacity. Office-based practices can also allow quarantined physicians to provide services to patients remotely. However, other healthcare workers (nurses, medical assistants, resident physicians) also contribute to direct care, and telemedicine cannot replace them all.

To prepare for scenarios such as a local outbreak that causes healthcare workers to be quarantined, become ill or be absent, Jefferson Health is deploying a telemedicine system so physicians can convert scheduled visits into telemedicine visits and continue serving patients who have not been exposed to the disease. These visits can take place while both the patient and physician are at home, substantially limiting travel and disease exposure and allowing uninterrupted treatment of patients who have not been exposed. Online training modules and remote training sessions are available for physicians and patients who need instruction or support for their first call.

What are the barriers to telemedicine?

The main barriers to providing routine treatment through telemedicine are establishing payment systems and preparing the necessary legal changes in health insurance and regulations.

Disasters and outbreaks create unprecedented difficulties in healthcare delivery. Telehealth will of course not solve them all, but it is ideally suited to scenarios in which infrastructure remains intact and physicians can see their patients. Payment and regulatory structures, licensing, interhospital credentialing and program implementation all take time, but health systems that have already invested in telemedicine will ensure that patients with COVID-19 receive the treatment they need. In this example, telemedicine may be a virtually perfect solution.