Propuesta técnica de equipamiento para un teleconsultorio / Technical equipment proposal for a teleconsultation

INTRODUCCIÓN: Las acciones de telemedicina demostraron ser de gran utilidad, principalmente, durante la pandemia por coronavirus en 2019. Diversas instituciones, con el fin de dar continuidad a la atención de la población, optaron por la utilización de plataformas y herramientas tecnológicas que permitían realizar actividades a distancia como seguimiento, asesoría y consulta y, con ello, se respetaban y fomentaban las medidas para disminuir la propagación del virus del COVID-19, como la implementación de la sana distancia. Si bien, los servicios presenciales han regresado prácticamente a la normalidad, muchas actividades de atención a distancia se siguen realizando a través de plataformas tecnológicas; sobre todo, aquellas que por su poca complejidad no generan barreras adicionales y otorgan resultados de gran beneficio en salud para la población y las instituciones. Con el objetivo de que los servicios de atención a distancia se lleven a cabo con calidad, han surgido modelos y lineamientos que favorecen una mejor comunicación e interacción a través de las tecnologías de la información y las comunicaciones, tanto para el cuidado de la salud como para temas generales. Además, se han propuesto una serie de recomendaciones operativas que mejoran la experiencia de las personas usuarias de los sistemas electrónicos. Estas recomendaciones son básicas y muchas veces obvias, pero si no son tomadas en cuenta pueden disminuir la calidad de la comunicación y, en el caso de la atención médica, la relación entre las personas beneficiarias y el personal de la salud que lo asiste a la distancia, puede verse disminuida. En este documento, se comentan aspectos para el manejo de la luz, posición de las cámaras y de los micrófonos, colores y texturas, todo con la finalidad de que el profesional de la salud obtenga una mejor información de la persona y la comunicación no se vea afectada por artefactos, sombras, ruidos y alguna situación imprevista mientras se lleva a cabo la atención a distancia. ALCANCE: Las recomendaciones descritas están encaminadas a ser utilizadas, primordialmente, durante cualquier videoconferencia o teleconsulta, además, pueden aplicar para diversas acciones de atención médica a distancia. Se requiere inversión para acondicionar los espacios donde se encontrará el equipo de trabajo que atiende de forma remota, y creatividad para utilizar la infraestructura existente en aquellos casos donde no es posible realizar un gasto adicional en el corto tiempo, en ocasiones es suficiente con incorporar adecuadamente elementos con los que ya cuenta la unidad y con una mejor redistribución de los espacios y ubicación de los equipos. RELACIÓN CON EL MODELO DE LA UNIDAD DE CONTACTO PARA LA ATENCIÓN A DISTANCIA EM SALUD (UCADS): Con el objetivo de fortalecer el primer nivel de atención, se establecen estrategias para una mejor comunicación y organización entre las redes de atención. Para ello, se desarrollan modelos a distancia basados en la calidad y el acercamiento con la población y no enfocados exclusivamente, en el diagnóstico o entrega de un tratamiento. Esto permite una relación más estrecha entre las personas beneficiarias y personal de salud, antes de sus consultas y posterior a ellas. El modelo de atención, basado exclusivamente en la teleconsulta, se modifica notoriamente. Se incorporan más actores como enfermeras, auxiliares, promotores de salud y su participación es mucho más amplia. Por lo tanto, cobra mayor importância conocer criterios para mejorar la calidad del servicio basados en tecnologías digitales, e independientemente del tipo de equipo con el que se logre establecer contacto, y de la modalidad de la atención (seguimiento, asesoría o consulta). En todos los casos, es fundamental cuidar aspectos como la privacidad de las personas beneficiarias, el manejo adecuado de la seguridad de la información, un canal de audio claro y sin ruido externo, una imagen lo más parecida y cercana a la realidad y una ubicación que permita total concentración para una mejor toma de decisiones. PROPUESTA TÉCNICA DE EQUIPAMIENTO PARA UN TELECONSULTORIO: Consultorio de telemedicina o teleconsultorio: "Espacio físico en el centro remisor con acceso a internet y flujo eléctrico donde se instalan los equipos para prestar el servicio de telemedicina." ESCENARIOS DE ACONDICIONAMIENTO DE ESPACIOS FÍSICO: Se considera que, en ambas propuestas, se cuente con un mínimo de mobiliario y materiales dentro del consultorio médico, con base en un análisis inicial.

Management of diabetes mellitus through teleconsultation during COVID-19 and similar scenarios - Guidelines from Indian Council of Medical Research (ICMR) expert group.

INTRODUCTION: Emergence of COVID-19 pandemic has led to increased use of telemedicine in health care delivery. Telemedicine facilitates long-term clinical care for monitoring and prevention of complications of diabetes mellitus. GUIDELINES: Precise indications for teleconsultation, clinical care services which can be provided, and good clinical practices to be followed during teleconsultation are explained. Guidance on risk assessment and health education for diabetes risk factors, counselling for blood glucose monitoring, treatment compliance, and prevention of complications are described. CONCLUSION: The guidelines will help physicians in adopting teleconsultation for management of diabetes mellitus, facilitate access to diabetes care and improve health outcomes.

Preliminary assessment of patient and physician satisfaction with the use of teleconsultation in urology during the COVID-19 pandemic.

PURPOSE: Lockdown during the COVID-19 pandemic compelled urologists to change access to healthcare, especially for oncology patients. Teleconsultation is a safe way to receive medical advice without a risk of infection, and was implemented urgently in our academic centres. Our purpose was to evaluate patient and physician satisfaction with teleconsultation set up during the COVID-19 pandemic. METHODS: From March 16th 2020, all face-to-face consultations were cancelled in France, except for emergencies. Teleconsultation was started immediately by five senior urologists in two academic hospitals. All patients received an email survey including the validated Teleconsultation Satisfaction Questionnaire (TSQ) and demographic questions. Data were collected prospectively. Physicians also responded to the TSQ. Patient satisfaction was measured objectively with the validated 14-item TSQ. Each item was scored on a 5-point Likert scale. Factors associated with positive satisfaction with teleconsultation were assessed by multivariable logistic regression. RESULTS: Overall, 105 patients replied to the survey (91.3%). Median age was 66 years (IQR: 55‒71) and 95 were men (90.5%). Median overall TSQ score was 67 (IQR: 60‒69); teleconsultation was judged to be a good experience by 88 patients (83.8%) and four physicians (80%). Patients who met their surgeon for the first time were more likely to have a good experience (OR = 1.2 [95% CI 1.1‒1.5], p = 0.03). CONCLUSION: Introduced rapidly during the COVID-19 lockdown, urology teleconsultation attained a high level of satisfaction among both patients and physicians. A major change in telemedicine use is foreseen in the post COVID-19 era.

Virtual Fracture Clinics in Orthopaedic Surgery - A Systematic Review of Current Evidence.

AIMS: Approximately 75% of fractures are simple, stable injuries which are often unnecessarily immobilised with subsequent repeated radiographs at numerous fracture clinic visits. In 2014, the Glasgow Fracture Pathway offered an alternative virtual fracture clinic (VFC) pathway with the potential to reduce traditional fracture clinic visits, waiting times and overall costs. Many units have implemented this style of pathway in the non-operative management of simple, undisplaced fractures. This study aims to systematically review the clinical outcomes, patient reported outcomes and cost analyses for VFCs. MATERIALS AND METHODS: Two independent reviewers performed the literature search based on PRISMA guidelines, utilizing the MEDLINE, EMBASE and COCHRANE Library databases. Studies reporting outcomes following the use of VFC were included. Outcomes analysed were: 1) clinical outcomes, 2) patient reported outcomes, and 3) cost analysis. RESULTS: Overall, 15 studies involving 11,921 patients with a mean age of 41.1 years and mean follow-up of 12.6 months were included. In total, 65.7% of patients were directly virtually discharged with protocol derived conservative management, with 9.1% using the Helpline and 15.6% contacting their general practitioner for advice or reassurance. A total of 1.2% of patients experienced fracture non-unions and 0.4% required surgical intervention. The overall patient satisfaction rate was 81.0%, with only 1.3% experiencing residual pain at the fracture site. Additionally, the mean cost per patient for VFC was £71, with a mean saving of £53 when compared to traditional clinic models. Subgroup analysis found that for undisplaced fifth metatarsal or radial head/neck fractures, the rates of discharge from VFC to physiotherapy or general practitioners were 81.2% and 93.7% respectively. DISCUSSION AND CONCLUSION: This study established that there is excellent evidence to support virtual fracture clinic for non-operative management of fifth metatarsal fractures, with moderate evidence for radial head and neck fractures. However, the routine use of virtual fracture clinics is presently not validated for all stable, undisplaced fracture patterns. LEVEL OF EVIDENCE: IV; Systematic Review of all Levels of Evidence.

Role of Telehealth in the Management of COVID-19: Lessons Learned from Previous SARS, MERS, and Ebola Outbreaks.

Concerns about the prevention and management of COVID-19 are on the rise, as it is crucial in contagious epidemics that travel and transfer of the patients be minimal for diagnosis, treatment, and follow-ups. Telemedicine or telehealth can play an important role, especially with previous successful experiences in the management of acute infectious respiratory epidemics such as SARS and MERS. In order to better control the rapid spread of coronavirus and manage the COVID-19 crisis, both developed and developing countries can improve the efficiency of their health system by replacing a proportion of face-to-face clinical encounters with telehealth. Recent technological advancement facilitates this reform, but there is a need for national or state-wide rules and regulations to be adapted accordingly.

Inpatient teledermatology: Current state and practice gaps.

BACKGROUND: Inpatient dermatology care can be challenging for dermatologists. Currently teledermatology is widely used in the outpatient setting but is not common in the inpatient setting, although it has the potential to reduce wait times and improve access to care. OBJECTIVE: To review the available literature on inpatient teledermatology, assess how teledermatology is currently being used in the inpatient setting, and recommend best practice use of inpatient teledermatology. METHODS: A literature review was performed and dermatology attending physicians were surveyed at the Society for Dermatology Hospitalists annual meeting about their current use of inpatient teledermatology. RESULTS: The majority of attending physicians (80.8%, n = 21/26) responded that their institution uses some form of teledermatology. Approximately half of those using teledermatology used it for both inpatient and outpatient consultations (55%, n = 11/20). For institutions with inpatient teledermatology, attending physicians used teledermatology to remotely staff inpatient consultations (81.8%, n = 9/11), triage consultations (63.6%, n = 7/11), and answer curbside questions from primary teams (18.2%, n = 2/11). LIMITATIONS: The limitations of this study include a limited sample size from a single meeting. CONCLUSION: Inpatient teledermatology is currently under-utilized has the potential to increase access to dermatology care and may be best used for triaging and remote staffing. Additionally, standardization of platforms and reimbursement would allow for increased use of inpatient teledermatology.

What makes a high-quality electronic consultation (eConsult)? A nominal group study.

INTRODUCTION: Poor communication between health professionals can compromise patient safety, yet specialists rarely receive feedback on their written communication. Although worldwide implementation of electronic consultation (eConsult) services is rising rapidly, little is known about the features of effective communication when specialists provide online advice to primary care providers (PCP). To inform efforts to ensure and maintain high-quality communication via eConsult, we aim to identify features of high-quality eConsult advice to incorporate into an assessment tool that can provide specialists with feedback on their correspondence. METHODS: Initial items for the tool were generated by PCPs and specialists using the nominal group technique (NGT). Invited PCPs were above-median eConsult users between July 2016 and June 2017. Specialists were purposively recruited to represent the range of available specialties. Participants individually wrote down items they felt should be included in the tool. A moderator with consensus group expertise then led a round-robin discussion for each item. Items were ranked anonymously and included if highly-ranked by over 70% of participants. RESULTS: Eight PCPs (six family physicians, two nurse practitioners) and three specialists (dermatology, hematology, pediatric orthopedics) produced 49 items that were refined to 14 after group discussion and two rounds of ranking. Highly-ranked items encompassed specific, up-to-date, patient-individualized, and practical advice that the PCP could implement. DISCUSSION: Features of high-quality eConsult correspondence derived from consensus methods highlight similarities and differences between face-to-face consultation letters and eConsult. Our findings could be used to inform feedback and education for eConsult specialists on their advice to PCPs.

A cost analysis comparing telepsychiatry to in-person psychiatric outreach and patient travel reimbursement in Northern Ontario communities.

INTRODUCTION: Residents of Northern Ontario have limited access to local psychiatric care. To address this, three program models exist: (1) telepsychiatry; (2) psychiatrists traveling to underserved areas; and (3) reimbursing patients for travel to a psychiatrist. Evidence shows that telepsychiatry has comparable outcomes to in-person consultations. The objective of this study was to determine the cost difference between programs. METHODS: A cost-minimization analysis estimating cost per visit from a public healthcare payer economic costing perspective was conducted. Data on fixed and variable costs were obtained. Evidence-based assumptions were made where relevant. Base-case scenarios and a break-even analysis were completed, as well as deterministic and probabilistic sensitivity analyses, to explore the effects of parameter variability on program costs. RESULTS: Costs per visit were lowest in telepsychiatry (CAD$360) followed by traveling physicians (CAD$558) and patient reimbursement (CAD$620). Among the 100,000 Monte Carlo simulations, results showed telepsychiatry was the least costly program in 71.2% of the simulations, while the reimbursement and outreach programs were least costly in 15.1% and 13.7% of simulations, respectively. The break-even analysis found telepsychiatry was the least costly program after an annual patient visit threshold of approximately 76 visits (compared to traveling psychiatrists) and 126 visits (compared to reimbursed patients). DISCUSSION: Our analyses support telepsychiatry as the least costly program. These results have important implications for program planning, including the prioritization of telepsychiatry, increased integration of telepsychiatry with other modalities of outreach psychiatry, and limiting use of the patient remuneration program to where medically necessary, to reduce overall cost.

Development and Implementation of a Methodology for Quality Assessment of Asynchronous Teleconsultations.

Background: There is a lack of evidence regarding audits or quality analysis of telehealth strategies in clinical practice. Our aim is to develop and implement a methodology for quality assessment of asynchronous teleconsultations. Materials and Methods: A random sample of asynchronous teleconsultations performed by the specialists from the Telehealth Network of Minas Gerais (TNMG), a public telehealth service in Brazil, was selected. The responses were evaluated regarding size, objectivity, quality, ethics, courtesy, and grammar, and received a score for each category: 1 = fair, 2 = moderate, and 3 = good. As each domain has a different importance in rating the overall quality of teleconsultation, each one was assigned a different weight, and a final score was calculated. Results: A total of 576 teleconsultations were assessed. Overall, the scores were good or moderate for all items. Only a few cases were classified as fair. Among medical specialties, pediatrics was the one that proportionally received the highest number of fair classifications, and the item "quality of the answers" was the one with highest number of worse classifications for this specialty. Corrective actions were implemented. With regard to the nonmedical specialties, the majority of the items were classified as good or moderate, and in rare cases some items received the fair rating. Conclusion: The methodology showed to be useful to evaluate the teleconsultation service. We established six domains that we considered important components to be assessed. This assessment was essential to identify the priority areas to receive correct actions. It may be easily replicated in other services worldwide.

Tele-psychiatric after care clinic for the continuity of care: A pilot study from an academic hospital.

BACKGROUND: There is a need of continuity of care research in psychiatric disorders to deal two important issues such as accessibility of psychiatrists, and travel. AIMS: This pilot was designed to evaluate the acceptability, feasibility, possible clinical effectiveness and cost benefit of video based tele-psychiatric aftercare (TAC) clinic from an academic hospital. METHODS: Fifty selected patients were recruited to provide direct video-consultations (DVC). RESULTS: This study shows higher score on acceptability, satisfaction and respect to privacy on these TAC. DISCUSSION AND CONCLUSIONS: This is first pilot study as one of the patient friendly and less expensive continuity of care.

Supporting the spread and scale-up of electronic consultation across Canada: cross-sectional analysis.

OBJECTIVE: To examine the process of implementing an electronic consultation (eConsult) service and evaluate its impact along key metrics outlined by the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. DESIGN: Cross-sectional study. SETTING: Clinics using eConsult in four provinces across Canada: Alberta, Manitoba, Quebec and Newfoundland and Labrador. PARTICIPANTS: All eConsult cases submitted in four participating provinces were included. INTERVENTION: The eConsult service is a secure online application that allows primary care providers and specialists to communicate regarding a patient's care. We measured the impact using system utilisation data and mandatory close-out surveys completed at the end of each eConsult. MAIN OUTCOME MEASURES: Implementation progress and impact were examined using the five categories outlined by the RE-AIM framework: reach, effectiveness, adoption, implementation and maintenance. RESULTS: Four provinces provided data from different periods, ranging from 4 years (Alberta) to 10 months (Manitoba). Total cases completed ranged from 96 (Manitoba) to 6885 (Alberta). Newfoundland had the largest menu of available specialties (n=35), while Alberta and Quebec had the smallest (n=22). The most frequently requested groups varied across provinces, with only endocrinology appearing in the top five for all provinces. The average specialist response time ranged from 3 days (Manitoba) to 16.7 days (Alberta). Between 54% (Newfoundland) and 66% (Manitoba) of cases resulted in new or additional information. Primary care providers avoided completing referrals they had originally considered in 36% (Newfoundland) to 53% of cases (Manitoba), while only between 27 % (Quebec) and 29% (Newfoundland) of cases resulted in a referral. In every province, services demonstrated higher rates of usage in their last quarter of data than their first. CONCLUSIONS: eConsult was successfully implemented in four new provinces across Canada. Implementation strategies and scope varied, but services demonstrated substantial consistency on several key metrics, most notably on whether new information was learnt and impact on decision to refer.

Action on neovascular age-related macular degeneration (nAMD): recommendations for management and service provision in the UK hospital eye service.

This report by a group of UK retina specialists and health professionals considers best practice recommendations for the management of sight-threatening neovascular age-related macular degeneration (nAMD), based on collective experience and expertise in routine clinical practice. The authors provide an update for ophthalmologists, allied healthcare professionals and commissioners on practice principles for optimal patient care and service provision standards. Refinement of care pathways for nAMD has improved access to intravitreal anti-vascular endothelial growth factor therapy but there are still variations in care and reported outcomes between clinic centres. Innovative organisational models of service provision allow providers to better match capacity with increasing demand. The authors review the recent NICE guideline for diagnosis and management of AMD, considerations for switching therapies and stopping treatment and need for regular monitoring of non-affected fellow eyes in patients with unilateral nAMD. Actions for delivery of high-quality care and to improve long-term patient outcomes are discussed. Local pathways need to detail nAMD target time to treat, maintenance of review intervals to ensure proactive treatment regimens are delivered on time and appropriate discharge for patients deemed low risk or no longer benefiting from treatment. Actual visual acuity outcomes achieved and maintenance of the level of vision when disease stability is achieved are considered good measures for judging the quality of care in the treatment of patients with nAMD. Robust community referral pathways must be in place for suspected reactivation of choroidal neovascularisation and rapid referral for second eye involvement. Practical considerations for intravitreal injection therapy are outlined.

Assessment of the Generalizability of an eConsult Service through Implementation in a New Health Region.

INTRODUCTION: Excessive wait times for specialist care are a significant issue in many countries. Electronic consultation (eConsult) services have demonstrated the ability to improve access to specialist care. In this article, we evaluated the implementation of a successful eConsult service in a new jurisdiction to test its generalizability. METHODS: We used a multimethod approach to evaluate the Champlain Building Access to Specialists through eConsultation eConsult service's implementation in the South East Local Health Integration Network of Ontario, Canada. Our quantitative analysis drew on use data collected automatically by the service and survey responses completed between February 1, and June 15, 2017. For our qualitative analysis, we conducted a thematic analysis of 3 focus groups with primary care providers and specialists participating in the pilot study. RESULTS: Forty-nine out of the potential 219 primary care providers in Kingston submitted 301 cases to 24 specialty groups during the study period. Monthly case volume grew from 15 in February to 90 in May. The most frequently requested specialties included dermatology (n = 59), cardiology (n = 27), and gastroenterology (n = 26). Specialists responded in a median of 2 days, and a referral was originally contemplated but ultimately avoided in 40% of cases. Providers spoke positively of the service, citing high levels of satisfaction, enhanced collegiality, increased trust, and improved patient flow. CONCLUSIONS: Adoption of the eConsult service in the South East Local Health Integration Network was successful. The service exceeded all adoption targets, and the number of completed cases demonstrated a consistently upward trend, suggesting continued growth beyond the study's duration. The service's rate of adoption, high levels of satisfaction, and use data similar to other regions all demonstrate eConsult's generalizability.

A cost savings analysis of asynchronous teledermatology compared to face-to-face dermatology in Catalonia.

BACKGROUND: A teledermatology pilot scheme was first conducted in the town of Manresa (Barcelona) in the summer of 2010. The clinical success of the scheme prompted its expansion to the whole county of Bages in 2011 and to the adjacent county of Berguedà in 2012. In the teledermatology service, primary care physicians take a photograph of the lesion and attach it to the electronic medical records of the patient together with a brief clinical account. In the referral hospital, the consultant dermatologists access the electronic medical records, review the images and suggest a treatment or action plan. Next, the primary care physicians review these recommendations and call the patient to report the results. This whole process is usually completed in less than 5 working days. METHODS: A cost saving analysis comparing teledermatology with dermatology face-to-face visits was performed in the county of Bages measuring the cost difference attributable to visits saved. RESULTS: The estimated added costs of the teledermatology service during 2016 amounted to 61,870 €. For the same period, the estimated costs of traditional outpatient dermatology services were of 113,034 €. This represents savings of 51,164 € per year. After subtraction of societal costs, the savings equal 10,350 € per year. CONCLUSIONS: Using a teledermatology service instead of face-to-face dermatology consultations could save 51,164 € per year (11.4 € per patient visited) in the county of Bages. Societal savings are the most significant.

Financial and Temporal Advantages of Virtual Consultation in Veterans Requiring Specialty Care.

Background: Access to specialty health care in the Veterans Affairs (VA) system continues to be problematic. Given the potential temporal and fiscal benefits of telehealth, the Madison VA developed a virtual consultation (VC) mechanism to expedite diagnostic and therapeutic interventions for Veterans with incidentally discovered pulmonary nodules. Materials and. Methods: VC, a remote encounter between referring provider and thoracic surgeon for incidentally discovered pulmonary nodules, was implemented at the Madison VA between 2009 and 2011. Time from request to completion of consultation, hospital cost, and travel costs were determined for 157 veterans. These endpoints were then compared with in-person consultations over a concurrent 6-mo period. Results: For the entire study cohort, the mean time to completion of VC was 3.2 d (SD ± 4.4 d). For the 6-mo period of first VC availability, the mean time to VC completion versus in-person consultation was 2.8 d (SD ± 2.8 d) and 20.5 d (SD ± 15.6 d), respectively (p < 0.05). Following initial VC, 84 (53%) veterans were scheduled for virtual follow-up alone; no veteran required an additional office visit before further diagnostic or therapeutic intervention. VA hospital cost was $228 per in-person consultation versus $120 per episode for VC - a 47.4% decrease. The average distance form veteran home to center was 86 miles, with an average travel reimbursement of $112 per in-person consultation, versus no travel cost associated with VC. Conclusions: VC for incidentally discovered pulmonary nodules significantly decreases time to consultation completion, hospital cost, and veteran travel cost. These data suggest that a significant opportunity exists for expansion of telehealth into additional practice settings within the VA system.