Challenges and opportunities for telehealth during the COVID-19 pandemic: ideas on spaces and initiatives in the Brazilian context. / Desafios e oportunidades para telessaúde em tempos da pandemia pela COVID-19: uma reflexão sobre os espaços e iniciativas no contexto brasileiro.

COVID-19 has created enormous challenges for health systems worldwide, with the rapidly growing number of deaths and critical patients with pneumonia requiring ventilatory support. Alternative methods to control the spread of the disease such as social isolation, extreme quarantine measures, and contact tracing have been used around the world. However, these measures may not be totally effective to fight COVID-19, in step with the necessary national preparations to meet the new patient care demands. A wide range of digital technologies can be used to enhance these public health strategies, and the pandemic has sparked increasing use of telehealth. This field has grown considerably in Brazil in recent years. Still, despite the intense proliferation of recommendations and rules, until the current pandemic the country still lacked a fully consolidated regulatory framework. The emergence of COVID-19 marks a key moment in the expansion of applications and use of telehealth for improving the health system's response to the current crisis. The article discusses telehealth's contribution to the fight against COVID-19 and the recent initiatives triggered in Brazil as opportunities for the consolidation of telemedicine and improvement of the Brazilian Unified National Health System. The authors conclude that telehealth offers capabilities for remote screening, care and treatment, and assists monitoring, surveillance, detection, prevention, and mitigation of the impacts on healthcare indirectly related to COVID-19. The initiatives triggered in this process can reshape the future space of telemedicine in health services in the territory.

Trends in Telestroke Care Delivery: A 15-Year Experience of an Academic Hub and Its Network of Spokes.

BACKGROUND: Telestroke provides access to vascular neurology expertise for hospitals lacking stroke coverage, and its use has risen rapidly in the past decade. We aim to characterize consultations, spoke behavior, and the relationship between spoke telestroke utilization (number of telestroke consults per year) and spoke alteplase treatment metrics in an academic telestroke network. METHODS AND RESULTS: We analyzed prospectively collected data on all telestroke consults from 2003 to 2018. Trends in network performance and spoke characteristics were analyzed using generalized estimating equations and Kendall τß nonparametric tests as appropriate. Unadjusted and adjusted linear regression models determined associations between telestroke utilization and treatment metrics. The network included 2 hubs and 43 spokes with 12 803 consults performed during the study period. Network growth overall was +1.8 spokes per year, and median duration of spoke participation was 7.9 years. The numbers of consults and alteplase-treated patients increased annually, even after adjusting for the number of spokes in the network (P<0.01 for both). Although times from last seen well to spoke emergency department arrival and to consult request increased, door-to-needle time, time from teleconsult request to callback, and time from teleconsult to alteplase administration all decreased (all P<0.01). With time, the network included more spokes without a Primary Stroke Center designation. In adjusted analyses, for every 10 telestroke consults requested by a spoke, the spoke door-to-needle decreased by 1.8 minutes (P=0.02), number of patients treated with alteplase was an additional 1.7 (P<0.01), and the percent of eligible patients treated with alteplase increased by 8% (P=0.03). CONCLUSIONS: Telestroke network size and utilization increased over time. Increased use of teleconsults was associated with increased and timely use of alteplase. Over time, the delivery of timely emergency care has improved significantly among emergency departments participating in this telestroke network. Replication of these findings in other networks is warranted.

Telestroke in Catalonia: Increasing Thrombolysis Rate and Avoiding Interhospital Transfers.

OBJECTIVES: The study aimed to evaluate the impact of a telestroke network on acute stroke care in Catalonia, by measuring thrombolysis rates, access to endovascular treatment, and clinical outcome of telestroke patients in a population-based study. METHODS: Telestroke network was implemented on March 2013 and consists of 12 community hospitals and 1 expert stroke neurologist 24 h/7 day, covering a population of 1.3 million inhabitants. Rest of the population (6.2 million) of Catalonia is covered by 8 primary stroke centers (PSC) and 6 comprehensive stroke centers (CSC). After a 2-way videoconference and visualization of neuroimaging on a web platform, the stroke neurologist decides the therapeutic approach and/or to transfer the patient to another facility, entering these data in a mandatory registry. Simultaneously, all patients treated with reperfusion therapies in all centers of Catalonia are prospectively recorded in a mandatory and audited registry. RESULTS: From March 2013 to December 2015, 1,206 patients were assessed by telestroke videoconference, of whom 322 received intravenous thrombolysis (IVT; 33.8% of ischemic strokes). Baseline and 24 h NIHSS, rate of symptomatic hemorrhage, mortality, and good outcome at 3 months were similar compared to those who received IVT in PSC or CSC (2,897 patients in the same period). The door-to-needle time was longer in patients treated through telestroke, but was progressively reduced from 2013 to 2015. Percentage of patients receiving thrombectomy after IVT was similar in patients treated through telestroke circuit, compared to those treated in PSC or CSC (conventional circuit). Population rates of IVT*100,000 inhabitants in Catalonia increased from 2011 to 2015, especially in areas affected by the implementation of telestroke network, achieving rates as high as 16 per 100,000 inhabitants. Transfers to another facility were avoided after telestroke consultation in 46.8% of ischemic, 76.5% of transient ischemic attacks, and 23.5% of hemorrhages. CONCLUSIONS: Telestroke favors safe and effective thrombolysis, helps to increase the population rate of IVT, and avoids a large number of interhospital transfers.

[Current status and future of telemonitoring : Scenarios for telemedical care in 2025]. / Aktueller Stand und Zukunft des Telemonitoring : Szenarien für die telemedizinische Versorgung im Jahr 2025.

Telemonitoring is an already realized implementation of digital transformation in the healthcare system. It has the potential to support and secure a sustainable and comprehensive provision of healthcare for a rising number of chronically ill patients, e. g. patients with chronic heart failure. Remote regions in particular can profit from the benefits of telemonitoring; however, so far telemonitoring services have not become truly established in the German healthcare market. Together with experts from politics, science and practice, a scenario analysis "Health Care System 2025 - A Place for Telemonitoring?" was carried out with the aim to examine the future development of the healthcare market and to draw conclusions for providers of telemonitoring services or devices. The scenario analysis contained two workshops and an expert survey and was supported by a scenario software. The current drivers and barriers of the diffusion of telemonitoring were identified and the most relevant factors that influence the future development of the healthcare market were discussed. Based on those influencing factors, three different scenarios were determined: (1) administrating rather than shaping, (2) safely into the future and (3) interconnected and digital world. In the subsequent consequence analysis activities were defined, which describe the necessary infrastructure, software instruments, organizational structures and provision of services and discuss possible activities, which prepare telemonitoring solutions for the future.

The Year in Cardiology 2013: arrhythmias.

The Year in Cardiology 'arrhythmias' presents an update on the latest studies and innovations published in the field within the last 12 months. Recent advances in the management of atrial fibrillation and novel treatment strategies and technologies are presented. New consensus documents to improve the diagnosis and treatment of patients with inherited cardiac arrhythmias and for paediatric patients with cardiac arrhythmias are summarized. Great progress has also been made in the field of cardiac implantable electronic devices: improvements in implantation techniques and novel technologies have been introduced and successfully applied. In addition, novel data on prevention of implantable cardioverter defibrillator-shocks and cardiac resynchronization therapy will certainly help to improve the quality of care for patients with cardiac arrhythmias and heart failure.

Tackling the global mental health challenge: a psychosomatic medicine/consultation-liaison psychiatry perspective.

BACKGROUND: Consultation-liaison (C-L) psychiatry, informed by principles of psychosomatic medicine, is well-positioned to address the global impact of mental disorders through primary care C-L models. OBJECTIVE/METHOD: The authors review the international burden of mental disorders, highlighting medical comorbidity, undertreatment, and the rationale for enhancing primary-care management. RESULTS: C-L psychiatry fosters the skills required for global mental health work. The authors describe successful C-L models developed in a low-income country (Ethiopia) and an under-resourced region of a high-income country (Australia). CONCLUSION: C-L psychiatrists have the potential to marshal their unique skill-set to reduce the global burden of mental disorders.

Models of care for co-occurring mental and medical disorders.

In this article we review practice models for treating common mental disorders in primary care. Novel treatment approaches by primary care providers and specialty providers, including collaborative care and telepsychiatric models, show considerable promise. An understanding of remaining barriers to improved care suggests several possible solutions and future directions for outpatient psychosomatic medicine.

[Telemonitoring of cardiovascular diseases in Germany. Standing position and perspectives]. / Telemonitoring bei Herz-Kreislauf-Erkrankungen in Deutschland: Stand und Perspektiven.

The changes in the demographic structure, the increasing multimorbidity in connection with a rise in the number of chronic illnesses and the absence of an effective coordination of the different levels of healthcare services with its discontinuous processes and redundancies will lead to intolerable economic burdens in the German health-care system, affecting medical, health-political and economic dimensions alike. This is the significance in terms of content and strategy of "health telematics" as an application of modern telecommunication and information technologies in the health-care system, and of "E-Health" as a specification of all services, quality improvements and rationalization effects, which are achievable by digitizing data collection as well as communication processes. Not only do digitizing and electronic transmission offer a better, faster and safer way of communication, but by possibilities of combining data they also allow the rationalization and quality-improving introduction of new methods of diagnosis, therapy and aftercare. The latest developments and appropriate logistic premises nowadays offer a realistic basis for implementing telemonitoring as a central service and information tool as well as an instrument controlling the information and data flow between patient, hospital and medical practitioner. Considering the enormous significance of cardiovascular diseases, focusing on corresponding cardiologic disease patterns seems almost self-evident. Notwithstanding remarkable medical progress during the past few years, cardiovascular diseases are still the number one cause of death in industrialized countries. In the cardiologic sector, telemedical systems are most commonly used with patients suffering from coronary heart diseases, e.g., for the detection of unclear dysrhythmia, as well as with patients suffering from chronic heart failure. Seen from a medical point of view, it is paramount to judge the clinical situation without delay as well as to take necessary therapeutic measures timely and to control their efficiency over a long period of time.Consequently, telemedical projects include the establishment of a nonstop monitoring of patients with increased or high risk of cardiovascular incidents, starting with the hospitalization, postoperative/post in-house health care and up to home care. This kind of monitoring needs to be adjustable to the respective situation modularly in order to guarantee a smooth possibility of surveillance both in the stationary and the ambulant sector, which, in addition, has to be individually adjustable to the demand of required monitoring functions (heart rate, blood pressure, S-T segments, oxygen satiation, weight, breathing rate, and temperature) and the intensity of the monitoring (event recording, "on-demand" vs. continuous monitoring). Certainly rich in meaning for the future is the integrated telemedicine care of a "primary" cardiac patient with his relevant comorbidities: diabetes and coagulation monitoring, respectively.

Integrating telehealth into Aboriginal healthcare: the Canadian experience.

Telehealth, the use of information communication technologies to deliver health care over distance, has been identified as a key mechanism for improving access to health services internationally. Canada is well suited to realize the benefits of telehealth particularly for individuals in remote, rural and isolated locations, many of whom are of Aboriginal descent. The health status of Canada's Aboriginal population is generally lower than that of the non-Aboriginal population emphasizing the need for new health care solutions. The challenges associated with implementing telehealth are not unique to Aboriginal settings but, in many instances, are more pronounced as a result of cultural, political and jurisdictional issues. These challenges are not insurmountable however, and there have been a number of successes in Canada to serve as a blueprint for a national strategy for sustainable Aboriginal telehealth. This review will highlight challenges and successes related to telehealth implementation in Canadian Aboriginal communities including: geography, technical infrastructure, human resources, cross-jurisdictional services, and community readiness. The need for champions within government, community and health care settings and the use of a needs-driven and integrated approach to implementation are highlighted. Several Canadian examples are provided including lessons learned within the MBTelehealth Network.

[University clinics as centers of radiologic performance alliances in the ambulatory and inpatient sector]. / Universitätskliniken als Zentren radiologischer Leistungsallianzen im ambulanten und stationären Sektor.

PROBLEM: Health care delivery in Germany has to face severe challenges that will lead to a closer integration of services for in- and out-patients. University hospitals play an important role due to their activities in research, education and health care delivery. They are requested to promote and evaluate new means and ways for health care delivery. METHODS: The Institute of Clinical Radiology at the University Hospital of the Ludwig-Maximilians-University started teleradiological services for hospitals and general practices in January 1999 in the framework of the "Imaging services--teleradiological center of excellence". Legal, technical and organizational prerequisites were analyzed. RESULTS: Networks between university hospitals and general practices are not likely to solve all future problems. They will, however, increase the availability of the knowledge of experts even in rural areas and contribute to a quality ensured health care at the patients home. Future developments may lead to international co-operations and such services may be available to patients abroad. CONCLUSION: Legal, technical and organizational obstacles have to be overcome to create a framework for high quality telemedical applications. University hospitals will play an important role in promoting and evaluating teleradiological services.