Wave 1: There are many new factors to consider, from the disease in question itself, the extent of damage it can cause, how to triage cases, allocate care, and manage the piling number of cases. These should be done while ensuring the judicious usage of the available resources.

It would not be an exaggeration to say that frontline workers at ground zero were akin to the brave soldiers battling it out at any war zone in history.

As we approached the end of 2020, the number of daily new cases decreased; it all seemed fine and normal around us, and we thought the worst was over.

Little did we know that this was just a dress rehearsal for what was coming!

Enter wave 2: This time around, we know a tad bit more about the disease, the perpetrator in question, and its updated versions, and more importantly, the spectrum of its impact.

It is safe to say that although there were many aspects of this novel virus that were still unknown, we were equipped with the most important arsenal of all, ‘Experience’.

We are now aware that not all patients would necessarily become critical and need the highest level of care and that a good number of cases, especially those who were asymptomatic or mildly symptomatic could be safely managed at home. This is how the option of virtual consults and telemedicine turned out to be a big support, not only for patients in these frantic times but also for the stretched healthcare fraternity, for which it had significantly reduced the burden.

The World Health Organization has included telemedicine among its suggestions for vital services in enhancing the health system’s response to COVID-19 policy. It can be applied in forward triage, where patients can be screened before coming to the health care centre. Centre for Disease Control and Prevention (CDC), USA updated their interim guidance concerning infection prevention and stressed on the application of telemedicine facilities to reduce the probability of transmission. They hope this will assist in the early determination and transfer of suspected cases without physical contact, thereby mitigating the risk of infection among health care workers and the public.

The Ministry of health and family welfare (MOHFW), Government of India, has also undertaken various initiatives using information and communication technologies for improving the efficiency and effectiveness of the public healthcare system. One of the important aspects of it was the release of the “Telemedicine practice guidelines” in March 2020.

Experiences from breaking the ice in a virtual world.

Here at Kauvery Hospital, we have done more than350 teleconsults for mild and asymptomatic cases of COVID 19 alone.

In accordance with the MOHFW guidelines, there were few important steps to be followed while providing this service to Covid-positive patients.

First consult: In this consult, we obtain as much of the patient’s basic information as possible, including drug allergies, relevant medical history, family demographics, which is especially important when dealing with communicable diseases, to ensure strict isolation and home quarantine protocols are followed. And most important of all, it is here that we try to build a rapport with the patient and assure them that the quality of care will not be compromised in this mode of communication.

Patient or caregiver: The consultation is done with either the patient or his/her caregiver. Depending on the patient’s preference, clear instructions are given for caregiver protection and prevention of the further spread of the disease among other family members.

Consent: In booking an appointment for a teleconsultation, it is implied that the patient is consenting to virtual consultation, and the risks and benefits of the same are clearly discussed prior to the consultation.

Assessment: This is probably the most important aspect of a virtual consultation; it is extremely important at this stage to triage the patient based on the available information and decide if he/she is eligible for management via teleconsultation in the first place or whether he/she will necessarily require in-person care.

Treatment plan: The next step would be to draw up a treatment plan which includes advice on the necessary investigations to be done, vitals to be monitored, medications and supportive measures to be followed, and adhering to a follow-up schedule.

Followup: Based on the triaging results and categorising of the patient into asymptomatic, mild or moderate stage of disease and also based on the disease course, we would decide how to further manage how frequently to  do follow-up for the patient

Continuity of care: We also make it a point to ensure that patients feel confident that they can always come back to us for any COVID-related or unrelated health issue with the same ease and comfort.

Why telemedicine is here to stay?

History:

Since its introduction, the remarkable role taken by telemedicine was its implementation in offering healthcare services to space explorers in 1970s.

This was considered as the Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) which provided clinical care to Papago Indian Reservations in Arizona.

NASA also used satellite ingenuity in telemedicine and discovered its important role in disaster management at the time of earthquake at Mexico City and Soviet Armenia in 1985 and 1988, respectively.

Using Telemedicine, NASA cemented commercial space centre MITAC at Yale university.

In a likely fashion, the Indian Space Research Organization (ISRO), in collaboration with the Department of Information Technology, Ministry of External Affairs, Ministry of Health and Family Welfare, and the state governments, had a role in the progress of telemedicine services in India in 2001. From that time, we have had a steady development in the application of telemedicine by several renowned private health care organizations too.

Inequitable distribution of healthcare services:

For a country like India, where a sizeable amount of the population resides in remote and inaccessible locations, this virtual form of healthcare could be one of the practical solutions to ensure that these patients receive timely medical care and advice. Firstly, patients would be able to save a great deal of time and money spent on long distances to reach their healthcare provider, especially for routine consults. Also, days used for in-person consults would in turn mean loss of working/earning days; this could be saved with a virtual consultation. In addition, physicians will be able to have access to a geographically wider population. So, essentially, it’s a win-win situation.

Chronic medical disease management during unprecedented times:

Non-communicable diseases kill about 41 million people each year, which is equivalent to 71% of all deaths globally.

During a time when venturing outdoors for any reason other than a dire emergency was not advised, some of the chronic medical conditions like diabetes, hypertension, kidney, or liver disease were put on hold.

Patients could not have their medications titrated or continued to take the same dose of a drug that was prescribed during an acute episode even after the acute phase resolved.

Chronic medical diseases took a back seat during the pandemic, and the repercussions would have been tremendous had it not been for virtual consultations by way of which patients were able to ensure they were followed up to the maximum extent possible virtually and recommitted to following social distancing norms devoid of the fear of neglecting pre-existing issues.

Role in mental health:

The pandemic saw the rise in a new form of anxiety, and it became a greater matter of concern, when misinformation started circulating in all the channels of media. It was extremely important for patients to stay in touch with their health specialists to avoid untoward outcomes. Telemedicine helped to simultaneously ensure smooth riding over the infodemic wave alongside the pandemic. In addition, mental health experts were also able to provide uninterrupted care to their patients by way of virtual counselling, mental health awareness programs, online support groups, etc

The other side of the coin:

All said and done, as doctors, it is instilled in us from our formative years that practicing medicine without touching a patient is equivalent to driving with eyes closed. Therefore, we can never expect virtual medicine to be a substitute for the in-person management of diseases.

We agree that technology cannot replace the age-old art of forming a doctor-patient relationship, but we must also agree that there is no harm in using technology to support that relationship i.e., ‘Enhancing and not replacing in – person care’.

In Conclusion:

From the dawn of the digital era, we have seen many ways in which technology has aided the medical profession and reduced the overall burden of healthcare.

Telemedicine is one such valuable entity.

The onslaught of the pandemic has taught us a lot about the importance of utilising this resource.

From smart watches with a wearable ECG feature, mobile apps that monitor most of the vital parameters, to video consultations with specialists, we can ensure a complete clinic experience at the comfort of one’s home.

The only thing constant is change, so there is no doubt that ‘Smart healthcare’ is not only the new normal but also the way forward!

Dr. Shirley Andrews G
Family Physician
Kauvery Hospital Chennai