Telemedicine and Speciality Referrals

aspects of telemedicine

In this article:

  • Three modes of telemedicine i.e. televisit, telesupervision and telemonitoring
  • Telemedicine and referrals: Pros & Cons
  • Hub & spoke model for specialty referrals
  • Tips for successful referrals in telemedicine

 

The anxiety associated with a doctor’s visit is an all to familiar feeling for so many people. As a child, the large needles, the smell of antiseptic, and the feel of a cold stethoscope on the back are enough to stir up feelings of unease. Entering adulthood, the fears become more concrete as concerns shift to thoughts of morbid conditions, lifelong illness, and the financial burden of treatment. What is worse, seeing one doctor often isn’t enough to get to the end of the matter. The case must be passed from the primary physician to the relevant specialists who are better equipped. The patient is passed along, like a baton in a relay, from one doctor, to another, to another. Due to the hassle of this procedure, some patients decide it is not worth the trouble. Around 20% percent of patients don’t follow through with their referrals, and when investigated as to why, a whooping 37% of them said they didn’t have the time [1]. Nowadays, telemedicine is closing the gap and allowing for immediate consultations with specialists. This approach benefits the patient, is cost-effective, and prevents unnecessary delays in diagnosis.

Having the resources to visit a specialist, but also the ability to choose whom to visit is a luxury taken for granted by those living in cities. For much of India’s population, not much other than primary care is an option in their towns and villages. In fact, due to the lack of funds, even providing this basic care in rural areas becomes burdensome. In areas with dispersed populations, individuals often have to travel 10-20 kilometers to visit a primary healthcare centre . There are many difficulties posed when trying to ramp up infrastructure in such regions. They lack the required management to remain serviceable and efficient. Often only one primary care physician is posted, year round, and even s/he might not be available [2]. Moreover, these centers are not financially equipped to afford healthcare staff, specialty doctors and equipment are way beyond.

One model to better serve such areas is the hub-and-spoke model.

 

The DeSoto General hospital in Louisiana, USA is a success story in the implementation of this model, in which they were one of the many spokes and the Willis-Knighton Health System was the hub. Despite the willingness of the DeSoto General hospital staff to keep their hospital afloat, they faced many of the aforementioned issues. They reached out to the Willis-Knighton Health system to propose a mutually beneficial system. After rounds of discussions, it was realized that the hospital was no longer profitable despite the dedication of the staff and physicians. Moreover, a remodeling of the infrastructure was required to appeal to the community that they served. The Willis-Knighton health system was able to help provide the revamping as well as the managerial leadership to pull this off. This allowed the DeSoto General Hospital to provide better services, though not as extensively as the hub center. Those who required more substantial care were referred to the Willis-Knighton Health System. The Willis-Knighton health System benefitted as they were able to increase their patient volume [4]. Though this particular model did not implement telehealth as part of their system, the idea of one center providing support to the network of smaller areas provides the basis to move forward with telemedicine implementation. The Nebraska Statewide Telehealth network has managed to execute the same beautifully, and it is one of the most extensive of such projects undertaken in the United States [5].

The practice of implementing telemedicine is of great convenience to the patients as well. While improving access to specialty care, it saves them time to travel for specialist visits and decreases their apprehensions to find out what might be wrong [4]. For many patients, time is of the essence when it comes to diagnosis and receiving care. Many cancer patients fail to seek early treatment due to the distance of cancer treatment centers, and some even miss out on screening opportunities, which reduce their survival chances. With telemedicine, patients can swiftly follow-up with their care provider. With wearable devices, a continuous stream of information can be relayed to the treating doctor [6]. In a study conducted for telemedicine interventions in prostate cancer, not only did survival rate increase, but follow up was more comfortable for the patients availing telemedicine. This intervention also benefited both the patients and the healthcare system in terms of reduced costs [7].  Further uses include critical care and emergency medicine to lessen the time between contact with the hospital and the start of intervention. For instance, in case of stroke care, emergency room doctors as well as the emergency medical service providers in the ambulance itself can contact neurologists to diagnose a stroke early enough to implement life saving measures [4]. These are just a few of many ways that Telemedicine can improve access to specialty care.

 Presently, the three main forms of utilising telemedicine to provide specialty care are the following:

  1. Televisits

  2. Telesupervision

  3. Telemonitoring

 

Televisits

Televisits for specialty care are pretty much the same as a regular doctor’s visit. The only difference is, the entire visit is done either through video conference or over the phone. It has its limitations and in most fields detailed clinical examination is not possible remotely. However, preliminary examination can be carried out in most of the cases. In some specialties, almost in-person care can be delivered online. For example, in dermatology, with good video quality, lesions can be identified, diagnosed and treated on the basis of video conferencing. The patient or primary care center needs to buy a dermascope, which is attached to the mobile phone in order to provide good imaging of the lesion. In a study conducted by Krömer et al, it was shown that teledermatoscopy had both high sensitivity and specificity in diagnosing malignant melanoma as well as other malignant skin cancers [8]. If put into practice thoroughly, teledermatology could greatly improve treatment outcomes, especially in time sensitive cancers.

Telesupervision

Telesupervision refers to the practice of a midlevel health provider or general physician presenting to a specialist located in another area. This allows the physician posted in a remote area opportunity to grow in their desired field, while the supervisor is able to attend to a higher volume of patients. This holds more promise as there are trained professionals present on both ends of communication. The channels utilised to support the healthcare workers include but are not limited to videoconference, teleconference, and emailing. The method used depends on the task which is required of the supervisee. For example, when a supervisee is learning a clinical skill, the visual aid of videoconference would be more apt. However, in case of relaying data or information to the supervisor after having consulted with the patient, teleconferencing or emailing would suffice. Ideal use of the various mediums has shown to provide optimistic results [9].

 

Telemonitoring

Telemonitoring, also known as clinical supervision, uses various technologies to keep track of patients at a distance. It is invaluable in keeping the doctor up to date with the patient’s day to day condition. The tools used are microsampling blood test devices, continuous glucose monitoring devices, as well as wearable technology to monitor patient’s heart rate, oxygen levels and blood pressure. Remote monitoring is being implemented across the world to combat COVID19, including monitoring oxygen saturation, daily remote monitoring by nurse and tele-consultation with doctor after every few days.

In the long run, the usefulness of telemonitoring is mainly for chronic diseases in which diagnosis has already been done, and follow up and sometimes slight adjustments in treatment are all that is required. People often do not do what is in their best interest, and this can be a great source of frustration for physicians. However, remote monitoring allows physicians to have an oversight on their patients’ health while making them participate, thus leading to better compliance and in turn, better health outcomes with their treatments. In fact, the majority of patients want health care providers that allow them to be active participants in their own care [10]. 

 It cannot be predicted with certainty what the future holds in case of specialty care via telemedicine. Robotic surgery is one such area that has undergone rapid innovation. Though the steps taken may seem small and incremental, they are drastically improving the quality of lives of people around us.

References:

  1.  Reinberg, Steven. “Many Patients Don’t Pursue Referrals.” ABC News, ABC News Network, 23 Mar. 2008, https://abcnews.go.com/Health/Healthday/story?id=4508168&page=1#:~:text=3%20(HealthDay%20News)%20%2D%2D%20About,%2C%22%20noted%20lead%20researcher%20Dr.
  2. Mohan, Pavitra. “Why India’s Primary Healthcare Is Reeling and What It Can Learn from Others.” Business Standard, Business-Standard, 29 Oct. 2018, https://www.business-standard.com/article/current-affairs/why-india-s-primary-healthcare-is-reeling-and-what-it-can-learn-from-others-118102900069_1.html
  3. Elrod, James K, and John L Fortenberry Jr. “The hub-and-spoke organization design revisited: a lifeline for rural hospitals.” BMC health services research vol. 17,Suppl 4 795. 13 Dec. 2017, doi:10.1186/s12913-017-2755-5 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5751794/
  4. Wicklund, Erik. “Telemedicine Closes the Gap in Specialty Referrals.” MHealthIntelligence, 19 Oct. 2016, https://mhealthintelligence.com/news/telemedicine-closes-the-gap-in-specialty-referrals
  5. Meyers, Laura et al. “Building a telehealth network through collaboration: the story of the nebraska statewide telehealth network.” Critical care nursing quarterly vol. 35,4 (2012): 346-52. doi:10.1097/CNQ.0b013e318266bed1 https://pubmed.ncbi.nlm.nih.gov/22948368/
  6. “Telemedicine and the Future of Cancer Treatment in 2019.” InTouch Health, 17 Oct. 2019, https://intouchhealth.com/how-digital-health-technology-is-transforming-oncology-care/
  7. Agochukwu, Nnenaya Q et al. “Telemedicine and prostate cancer survivorship: a narrative review.” mHealth vol. 4 45. 8 Oct. 2018, doi:10.21037/mhealth.2018.09.08 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6232082/
  8. Brinker, Titus Josef et al. “Teledermatology: Comparison of Store-and-Forward Versus Live Interactive Video Conferencing.” Journal of medical Internet research vol. 20,10 e11871. 24 Oct. 2018, doi:10.2196/11871 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231765/
  9. Martin, Priya et al. “Effective use of technology in clinical supervision.” Internet interventions vol. 8 35-39. 22 Mar. 2017, doi:10.1016/j.invent.2017.03.001 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6096199/
  10. “Increasing Patient Compliance with Remote Patient Monitoring.” EP Lab Digest, 26 Sept. 2019, https://www.eplabdigest.com/increasing-patient-compliance-remote-patient-monitoring

 

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