What factors help a medical professional decide whether a patient needs remote or in-person care?

Telehealth and Telemedicine during COVID-19 in Low Resource Non-U.S. Settings

Telehealth and Telemedicine during COVID-19 in Low Resource Non-U.S. Settings

Summary of Recent Changes

Updated and combined webpages:

• Telehealth during COVID-19 in Low Resource Non-us settings
• Telemedicine

Key Points

• In 2020, countries reported on average, about half of essential health services were disrupted -WHO “pulse survey“
• Pursue telehealth as an alternative to face-to-face healthcare services, commonly used pre-pandemic, to:
  • Reduce unnecessary exposure to COVID-19,
  • Help mitigate the spread of the virus, and
  • Reduce surges in hospitals and clinics.

This guidance document is developed to encourage healthcare providers to explore ways of meeting the essential healthcare needs of the community using innovative telehealth modalities and technologies; and expand the use of telehealth in the care of patients, and telemedicine in the care of COVID-19 and other non-COVID-19 patients.

Background

World Health Organization -WHO  “pulse survey“ implemented over one year into the COVID-19 pandemic, reports substantial disruptions persist in continued essential health services. In 2020, countries reported on average, about half of essential health services were disrupted. In the first 3 months of 2021, however, countries reported progress, with just over one third of services now being disrupted. WHO developed a guidance for maintaining essential health services during the COVID-19 outbreak and another guidance to assess each facility’s readiness to continue frontline service during the COVID-19 pandemic. For continued essential services assessment, facilities can use the WHO facility assessment tool.  This assessment includes Healthcare provider readiness training on -Personal Protective Equipment -PPE and Facility Infection Disease Prevention and Control -IPC.

To reduce staff and patient exposure to sick people, preserve personal protective equipment (PPE), and minimize the impact of patient surges on facilities, Telehealth services help provide necessary care to patients while minimizing the transmission risk of SARS-CoV-2, the virus that causes COVID-19, to healthcare workers and patients. The way health care is delivered during the COVID-19 pandemic has changed. Healthcare systems may need to adjust the way they triage, evaluate, and care for patients using methods that do not rely on in-person encounters:

• Pan American Health Organization -PAHO highlights teleconsultations as a safe and effective way to assess suspected COVID-19 cases and to guide the patient’s diagnosis and treatment, minimizing the risk of disease transmission. Telemedicine enables many of the key clinical services to continue to operate regularly and without interruption in the course of a public health emergency. PAHO also developed COVID-19 and Telemedicine Tool for assessing the maturity level or readiness of health institutions to implement telemedicine services.
• The American College of Obstetricians and Gynecologists for example developed and published telehealth recommendations including access to technology, equipment, patient privacy, payment modality, and licensing. WHO also published a guidance document on how to plan and conduct telehealth consultations with children, adolescents and their families, encouraging telehealth among children and their families. The guidance document encourages and informs facility managers developing telehealth systems.

Telehealth

Telehealth is remote patient care and monitoring. It allows direct transmission of a patient’s clinical measurements from a distance to their healthcare provider and may or may not be in real time. The telehealth session may also be facilitated by a Healthcare Professional (to other healthcare professionals), Village Health Volunteer -VHV, a Community Health Worker -CHW visiting the patient, or by the patient him/her-self, a parent or a legal guardian. Telehealth can be any combination of healthcare services including telemedicine. Some healthcare specialties default to “referring to all of such services” as telehealth. “TeleCOVID-19” care is Telemedicine.

Examples of Telehealth Care include:

• Screening for COVID-19, testing recommendations, and guidance on isolation or quarantine
• General health care (i.e. wellness visits, blood pressure control, advice about certain non-emergency illnesses, like common rashes)
• Non-emergency follow-up clinics
• Prescriptions for medication
• Nutrition counseling
• Mental health counseling
• Physical therapy exercise
• Teleradiology
• Tele-intensive care (in infectious disease hospitalizations)
• Telemedicine

Telehealth  decreases contact with healthcare facilities, other patients, and healthcare staff in order to reduce the risk of COVID-19 spread in the community.

Generally, Telehealth Modalities include:  

• Synchronous: Real-time telephone or live audio-video interaction, typically with a patient, using a smartphone, tablet, or computer.
  • For example: In some cases, peripheral medical equipment (e.g., digital stethoscopes, otoscopes, ultrasounds) can be used by another health care provider (e.g., nurse, medical assistant) physically with the patient, while the consulting medical provider conducts a remote evaluation.
• Asynchronous:The provider and patient communication does not happen in real time.

For example, “store and forward” technology allows messages, images, or data to be collected at one point in time and interpreted or responded to later. Patient portals can facilitate this type of communication between provider and patient through secure messaging. Other examples of telehealth modalities developed/used by American College of Obstetricians and Gynecologists include:

1. Live, two-way (or real-time) synchronous audio and video allows specialists, local physicians, and patients to see and hear each other in real-time to discuss conditions e.g. via phone or computer (also defined above).
2. Store-and-forward, also referred to as “asynchronous telemedicine,” sends medical imaging such as X-rays, photos, ultrasound recordings, or other static and video medical imaging to remote specialists for analysis and future consultation (also defined above).
3. Remote patient monitoring collects personal health and medical data from a patient in one location and electronically transmits the data to a physician in a different location for use in care and related support.
4. mHealth is a general term for self-managed patient care using mobile phones or other wireless technology and does not necessarily involve monitoring by a physician. It is most commonly used to deliver or reinforce patient education about preventive care and provide medication reminders, appointment reminders, and other essential self-care steps that patients should undertake to maintain their optimal obstetric health.

Telemedicine

Telemedicine is the use of electronic information and telecommunication technology to get needed health care while practicing physical distancing.  This encourages meaningful use of patient health measures to help guide the engagement of patient in care.

Telemedicine goals for Developing Countries should include, but not be limited to:

• Remote diagnosing and teleconsulting* system. Data (including signals and images) are locally (patient-side) acquired and stored, and then forwarded to the main hospital, where physicians can analyze those data. The remote (physician-side) hospital will then send back the diagnosis.
• Remote diagnosis performed with patient assisted by nurses. If no physician is in the neighborhood: such a situation typically occurs in rural locations of developing countries, and in some cases a preliminary diagnosis is locally performed by the aid of a decision support system (DSS).
• Remote monitoring system. The patient is monitored in the remote location, his/her signals are continuously acquired, forwarded to the main hospital, and possibly, locally analyzed by a DSS. Alarms are remotely detected and transmitted back to the patient-side. The monitoring system can be managed and locally controlled by a physician or by a nurse.
• Remote intervention system. The patient enters the operating room, the intervention is performed through a local (patient-side) robot that is remotely controlled by a physician in the main hospital. The remote intervention requires that some local assistance is performed by a physician or by a nurse.
• Remote education (e-learning) system. Students or caregivers (mostly physicians, nurses, and technicians) attend classes taught from remote academic institutions, and possibly by a bi-directional communication interact with the teacher by making up questions. Remote education can be locally assisted by a local tutor, during and/or after the classes.

*Note: Teleconsulting, i.e., expert second opinion, is performed among physicians, where a non-specialist physician requires a remote consultation with one or more specialist physicians: typically, such a situation occurs in emergency centers of rural locations or in minor hospitals of developed countries, or in any location of developing countries.

Potential uses of telemedicine during COVID-19 Pandemic

1. Triaging and screening for COVID-19 symptoms
   Telehealth can be used to screen for COVID-19 symptoms and assess patients for potential exposure. Phone screening, online screening tools, mobile applications, or virtual telemedicine visits can be used to evaluate patients for COVID-19 symptoms, assess the severity of their symptoms, and decide whether the patient needs to be seen for evaluation, admitted to the hospital, or can be managed at home. Screening algorithms can be used in telehealth communication.
2. For patients who may need to be hospitalized, mobile phones and tablets or other telehealth technology can be used for homebased evaluation for hospital care by mobile home health care units, community health volunteers/workers, or emergency services to communicate with healthcare providers at a health facility. Health care providers can use telehealth to conduct a remote evaluation of the patient’s medical condition and determine if the patient needs to be in a regular hospital bed or in an intensive care unit. Making this decision remotely can avoid rushing the patient through the emergency room upon arrival at the hospital, limiting the exposure of emergency department personnel and other healthcare workers and preserving PPE.
3. Telehealth can also be used to screen patients before they visit the healthcare facility for non-COVID-19 care. If COVID-19 symptoms are reported during the telehealth interview, patients could be advised to delay non-emergent care and first seek testing for COVID-19.

1. Contact tracing
   Telehealth, especially via phone, can be used to interview patients with COVID-19 to determine who they were in contact with during the time they were potentially infectious, and to follow-up with their contacts to inform them of the need to quarantine, assess whether they have any symptoms, and tell them what to do if symptoms develop.
2. Monitoring COVID-19 symptoms
   Patients with mild or moderate COVID-19 symptoms can isolate in a community isolation center or be monitored at home to avoid overcrowding in healthcare facilities and save hospital beds for more severe cases. Using telemedicine technology (e.g.  phones or apps), healthcare providers can check in with patients frequently to monitor their condition, provide advice, and determine if the patient’s condition is deteriorating and if they need to be evaluated for in-person care, such as hospitalization.

1. Providing specialized care for hospitalized patients with COVID-19
   Patients who are hospitalized with COVID-19 may require care from a diverse team (e.g., nurses, respiratory therapists, physicians). One member of the team can enter the patient’s room and consult with the rest of the team using telehealth technology (tablets, phones) to assess the condition of the patient, adjust therapies or treatment plans, and manage complications.
2. In addition, health facilities can use telehealth to consult with physicians who have specialized training or expertise in respiratory infections like COVID-19. Tele-intensive care unit platforms, which consist of real-time audio, visual, and electronic connections between remote critical care teams (intensivists and critical care nurses) and patients in distant Intensive Care Units -ICUs, can also be used to monitor critically ill patients and provide expert guidance for care.
3. Tele-radiology can also be used to consult with radiologists at remote locations. Telehealth can also be used to provide online training on COVID-19 for medical professionals and healthcare workers.

1. Providing access to essential healthcare for non-COVID-19 patients
   Telehealth can be used as a strategy to maintain continuity of care, to the extent possible, to avoid negative consequences from preventive, chronic, or routine care that might otherwise be delayed due to COVID-19 concerns. Telehealth visits can help determine when it is reasonable to defer an in-person visit or service.
2. Follow-up visits can be conducted by phone or internet to reduce the number of in-person visits and overcrowding in outpatient settings. Providers can use internet-based drug prescription and provide multi-month dispensing of medications to further reduce the need for in-person encounters.
3. Remote access to other Telehealth modalities can also help assure healthcare access when an in-person visit is not practical or feasible due to COVID-19 concerns. To mitigate stress during COVID-19, mental and behavioral health services can be provided to the population through hotlines or virtual provider-patient visits.

1. Monitoring recovering COVID-19 patients
   After COVID-19 patients are discharged from the hospital, healthcare providers can use telehealth technology to follow up with those who might need to continue isolation at home or be monitored for any sudden deterioration or long-term health effects due to COVID-19.

Steps to take when setting up telemedicine practice

The American Medical Association (AMA) Telehealth Implementation Playbook gives a step-by-step guide on the implementation of a digital health solution.  In order to set up a telehealth practice, the aim of continuity of care, license needed and the approved reimbursement process, for the local location of the practice has to be in place. The twelve steps to implementation include:

1. Identify the Need for Telemedicine
2. Create a Telemedicine Team
3. Develop Clear Definition of What a Successful Telemedicine Practice is
4. Evaluate Digital Technology Vendors to be Engaged throughout the Process
5. Make a Case for Telemedicine by getting Patient, Provider and Political/Financial Buy-in
6. Develop Appropriate Contracts for Vendors, Providers and Financial/Reimbursement Institutions
7. Design the Workflow, Integrating Digital Technology into the Clinical Workflow, taking into Consideration Patient Privacy Acts and Laws and Healthcare Data Security
8. Prepare the Telemedicine “Care Team” who will take care of “All Telemedicine Patient”
9. Develop Patient Partnership Documents based on information gathered during the Need Identification and Patient Buy-in Steps
10. Implement the process in Pilot Mode First before Full Telemedicine Project Implementation
11. Monitor and Evaluate to Improve the Process
12. Scaling your Success Measures to Position the Telemedicine Practice for Expansion

Lessons Learned

In the WHO Southeast Asia region, telemedicine supported strengthening of primary care.  Lessons from the COVID-19 pandemic experiences include implementing integrated information systems, stakeholder engagement, capacity building and carefully managing the transition which could further help in mainstreaming telemedicine as the new normal in comprehensive health services delivery.

Telemedicine has shown potentials in salvaging the dwindling healthcare system in low and middle-income countries but faced certain challenges that may create new health inequalities especially based on income.

In the study, “Pulse Oximetry for Monitoring Patients with Covid-19 at Home — A Pragmatic, Randomized Trial”, a  Philadelphia U.S randomized trial that assessed a text message–based remote-monitoring program (COVID Watch) supplemented with monitoring of oxygen saturation by means of a home pulse oximeter, remote monitoring was implemented using pulse oximetry. Telemedicine visits were documented visits between a licensed prescriber (advanced practice practitioner or physician) and patient, typically with the use of videoconference technology. Monitored for 30 days, among patients with Covid-19, the addition of home pulse oximetry to remote monitoring, did not show any significant difference in survival, that is, days alive and out of hospital, when compared to those with subjective assessments of dyspnea alone, with no continuous monitoring at home. Home monitoring (COVID Watch) showed the same outcomes as non-home monitoring (physician videoconference) modalities and did not have a worse outcome.

Potential limitations of telehealth

Adaptations to telehealth may need to be considered in certain situations where in-person visits are more appropriate such as:

• Due to urgency, a person’s underlying health conditions, or the fact that a physical exam or laboratory testing is needed for medical decision making.
• If sensitive topics need to be addressed, especially if there is patient discomfort or concern for privacy.
• Limited access to technological devices (e.g., phones, tablets, computers) or connectivity. This may be especially true for those living in rural settings.
• When healthcare workers or patients may be less comfortable with using the technology, and may prefer an in-person visit.
• When virtual visits are not readily accepted in lieu of in-person visits by healthcare workers or patients.

Disclaimer:

CDC operational considerations documents and/or resources are developed in partnership with global partners and specifically designed as reference guides in non-U.S. settings. CDC guidelines are intended for a U.S. audience and not meant to supersede guidance issued by the World Health Organization or any country.

References

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