Fundamentals of Telemedicine and Telehealth

Shashi Gogia, Shashi Gogia

• Publisher: Academic Press
• Year: 2019
• ISBN:
  9780128143100
• Topic: Medicine
• Subtopic: Biotechnology in Medicine

Fundamentals of Telemedicine and Telehealth provides an overview on the use of information and communication technologies (ICTs) to solve health problems, especially for people living in remote and underserviced areas. With the advent of new technologies and improvement of internet connectivity, telehealth has become a new subject requiring a new understanding of IT devices and how to utilize them to fulfill health needs. The book discusses topics such as digitizing patient information, technology requirements, existing resources, planning for telehealth projects, and primary care and specialized applications. Additionally, it discusses the use of telemedicine for patient empowerment and telecare in remote locations.

Authored by IMIA Telehealth working group, this book is a valuable source for graduate students, healthcare workers, researchers and clinicians interested in using telehealth as part of their practice or research.

• Presents components of healthcare that can be benefitted from remote access and when to rely on them
• Explains the current technologies and tools and how to put them to effective use in daily healthcare
• Provides legal provisions for telehealth implementation, discussing the risks of remote healthcare provision and cross border care

Section III

Telemedicine

Chapter 9

Telesupport for the primary care practitioner

Shashi Gogia Society for Administration of Telemedicine and Healthcare Informatics, New Delhi, India

Abstract

The current chapter discusses telecare from the perspective of the primary care practitioner or PCP. These include the community health worker (CHW), nurse, or GP. The main emphasis is from the GP’s perspective, what deters them from widespread adoption, and what can be done about it. The last section on wound care may seem to be anomaly but is very relevant as a use case, since the care is administered largely by PCPs with occasional inputs needed in the form of specific knowledge and equipment and the same, as of now, is believed to be the biggest beneficiary of telecare.

Keywords

Primary care practitioner; Family practitioner; Nurse practitioner; Woundcare; Lymphedema; Community health worker

Introduction

Healthcare delivery is broadly classified into three types: (A) primary when care is provided by local practitioners or PCPs, which could be a GP if private, or in a primary or community health center (PHC/CHC), if by government agencies; (B) secondary wherein care is provided in a place with in-house admission and basic diagnostic facilities; and (C) tertiary, which means super specialized care requiring an ICU and specialized diagnostic as well as therapeutic equipment like nuclear medicine or radiotherapy. Variations of B and C exist in the form of isolated single-specialty centers like for dialysis, cardiac or eye care, and some restricted to daycare surgery.

For almost all patients, it is recommended that except for emergencies, each health-related episode should first undergo a consultation with the local PCP. If not possible to manage the same, the patient can be referred up the chain to a secondary care provider and further to the specialist. Chronic care needs more frequent visits and hence best managed by the PCP who, when faced with challenges, can and should ask for help, preferably in the form of online support. Not only does this decrease the need for travel but also provides the PCP an opportunity to learn to manage future similar episodes better. Keeping specialists in a high population area makes sense, as they have to see a certain minimum number of patients to justify their high cost of training as well as income. The United Kingdom has one neurologist per 200,000 population, somewhat half of the felt need.^145,157

In villages or remote places, as the cost of retaining a doctor is difficult, the role of PCP is likely to be fulfilled by a nurse or CHW. They would be all the more likely to need help for anything outside routine dressings or medicine administration.

So far, this system of local care by whatever PCP is available with a need-based referral or transfer has worked well. However, rising incomes, a continuous global phenomena since the middle of the last century, have led to higher aspirations. There is also a longer life span and a higher incidence of chronic diseases, calling for a higher dependence on specialty support. This calls for a redistribution of health resources to match the demand. Costs increase as one goes up higher (see Fig. 2). Telemedicine can come in as a method to fulfill this shifting demand even while the local populace waits for actual physical redistribution of the human resources for healthcare (HRH).

Ensuring the physical presence of a doctor in each and every hamlet is challenging not simply because of monetary concerns. The reasons relate to a smaller number of patients requiring his specialized skills. Besides that, he/she shall be requiring a certain number of qualified and specially trained paramedical personnel with related equipment to ensure care quality; for example, a neurologist will need an EEG and EMG and its technician, besides the mandatory CT/MR. An important additional aspect, though less mentioned, is that qualified medical personnel do have a family of their own and keeping them in a remote place means ensuring good schools for the children, besides general social and entertainment facilities. This is problematic and adds to frustration.

From the independent practitioners’ perspective, using telehealth has some additional benefits. A PCP by definition is a general practitioner (GP). He/she is the first point of contact for any health problem, be it a child, an elderly, a pregnant woman, a remote person visiting relatives, or maybe even a tourist. The initial advice has to be appropriate, even if it is further referral to the most suited specialist. The range of problems he needs to be aware about is mind boggling. Also, after the initial training in medical school, there is little chance of skill upgradation. Data about recent advances, and there have been many, are only available through the medical representatives. Continuing medical education (CME) meetings, despite fulfilling the mandated insistence in many countries for retaining the license, can never be enough. They cannot fully prepare one for what the next patient will present with. News, other media, and lately the internet are there, but then the GP should know better than the patient!

Telesupport offers something better in the form of learning on the job from a more qualified and experienced specialist. Since there is direct one-to-one contact with the patient on his/her side, it beats getting details after reading the discharge summary or notes provided after a transfer.

Telesupport is important during emergencies as chances of finding physical help are well, remote! However, similar or more justification exists for those in constant need of care, for example, the infirm; elderly; those with chronic disease, who can always get an added less understood problem; and the disabled, who cannot be transported easily.

Telemedicine in primary healthcare

Carlos Aita

The core attributes of primary healthcare centre (PHC) are to provide first-contact accessibility, relational continuity, comprehensiveness, as well as coordination of care. Among these, first-contact accessibility, by definition—the making of PHCs as the preferred care gateway for all new health problems as well as fresh episodes of an existing one (except for actual urgencies and emergencies), is considered the most important. Without first level contact, health provision cannot proceed, hence any deficiencies here, get converted to system-wide deficiencies.¹⁵⁸

Healthcare delivery is evenly poised between access, quality, and cost of health provision. It is believed that any preferred choice of two, generally precludes the third. This is commonly known as Oregon’s dilemma or the iron triangle of healthcare.¹⁵⁹ However, expanding access and improving quality in health while reducing cost is within the possibilities of telemedicine. Recent studies have shown results in this regard, both in the context of PHC and in the management of chronic conditions. Besides that, although less commonly performed, cost analyses have shown reduction in overall cost of care delivery if telehealth has been utilized.^160,161 Another essential attribute of PHC, the coordination of care—which involves referral of patients to specialist care—can also be leveraged better through telemedicine interventions.¹¹³

Support to primary care providers

Even in countries such as the United States, where care models are more focused on medical specialties, up to 55% of consultations occur in the primary care setting.¹⁶² However, only 15% of family physicians surveyed by the American Academy of Family Physicians in 2014 reported current use of telemedicine, while in hospitals and specialist care, this percentage ranged from 40% to 60%.¹⁶³ Professionals working in rural areas, urgent care, emergency departments, and programs with integrated health services were more likely to use telecare; while those in practice for more than 10 years, worked in primary care, in private practice, or did not have access to an electronic medical record (EMR) were less likely to do so. Cost, training, and reimbursement issues also had a negative impact.¹⁶⁴

On a daily basis, a general practice generates between 15 and 20 clinical queries, or questions for which the PCP needs to further consult the books, the Internet, or the easiest, a senior colleague.¹⁶⁵ Despite that, studies have revealed underutilization of telemedicine tools.¹⁶⁶ Even though multifactorial clinical acceptance exists, telemedicine is still largely considered a disruptive innovation (i.e., one that redefines standards, as opposed to sustaining innovation, which follows current standards). This creates barriers and is posed as a threat to traditional forms of healthcare delivery.¹⁶⁷ Hybrid models, which combine old technologies with new ones (e.g., telephone plus Internet), can be used to overcome this resistance. Another factor to consider is that, unlike in most developed countries, r...