The coronavirus (COVID-19) pandemic had disastrous consequences worldwide and required rapid implementation of virtual care solutions to prevent transmission and spread. In order to minimize exposure to infection and maintain social distancing, digital health was used at a larger scale (Crawford & Serhal, 2020). Electronic visits (eg. video calls, secure messaging, and telemedicine) allowed for care without direct contact, which protected both the patient and the healthcare provider (Canada Health Infoway, 2021). The way in which we deliver health services is evolving, and this change was accelerated by COVID-19. For example, virtual triaging, patient access to COVID-19 results, health tools, and mental health services were available online (Canada Health Infoway, 2021). Even after the pandemic subsides, digital health will be integrated as a leading approach to providing efficient healthcare. New trends are influencing how provinces respond to problems and how Canadians will improve their health. The future of healthcare will see a greater shift towards virtual care.
Amidst this public health crisis there were positive transformations in virtual care solutions to mitigate the transmission of COVID-19. These innovations have brought to light some of the social determinants of health that create barriers to health equity (Crawford & Serhal, 2020). A digital health equity framework, shown in Figure 1, was created to identify contributing factors to poor health status in the context of virtual health services (Crawford & Serhal, 2020). The main barriers included lack of access to digital health, poor engagement, low levels of digital literacy, and poverty (Crawford & Serhal, 2020). Racial or ethnic minority groups have been found to have less participation in telemedicine visits (Rametta et al., 2020). Future directions in virtual care will require measurement-based approaches to digital health equity to better serve vulnerable populations (Crawford & Serhal, 2020).
Figure 1. Digital health equity framework (Crawford & Serhal, 2020).
Figure 2. Frequency of use of the institutional (left side) and personal (right side) use of telemedicine before (A) and after (B) the COVID-19 pandemic (Kuchenbuch et al., 2020).
Figure 2 shows the increasing popularity of remote work systems via telemedicine to serve epilepsy patients which was triggered by the COVID-19. Virtual care services beyond this pandemic will continue to be useful in chronic disease prevention and management. In my field of practice, Neurophysiology, digital health will positively impact my patient population.
Main Benefits of Telemedicine in Neurology/Epilepsy:
1) Improved follow-up for epilepsy patients.
Epileptologists can discuss a patient's seizure log, electroencephalogram (EEG) results, blood-work, and medication changes over virtual meetings. 93% of clinicians treating pediatric patients in outpatient neurology clinics, predominantly epilepsy patients, were satisfied with telemedicine encounters (Rametta et al., 2020). These doctors proposed follow-up care via this method for 89% of their patients (Rametta et al., 2020). Similarly, patients and their caregivers were pleased with telemedicine, with 86% stating they were interested in this approach for future meetings (Rametta et al., 2020). Overall, it has been concluded that telehealth visits are as effective as in-person visits for documenting breakthrough seizures and anti-epileptic drug compliance (Sattar & Kuperman, 2020).
2) Better access to services for those in remote regions such as Indigenous communities.
Most neurologists are in large urban centres. By eliminating the need to schedule in-person meetings, patients from rural or remote areas will have access to specialists outside their region without organizing an expensive and long trip. For example, instead of flying a patient to Vancouver General Hospital to get an EEG and then visit the epileptologist in person, a patient can have the electrodes placed on their head at a site in their community and the specialist can remotely view the data and provide an interpretation (Rametta et al., 2020). The World Health Organization created an app that helps diagnose and manage epilepsy (Patterson, 2019). Some villagers in Myagdi, Nepal were trained on how to use the app and were provided with basic education on how to identify someone with possible epilepsy (Patterson, 2019). These locals are referred to as epilepsy field workers (Patterson, 2019). The app would generate a probability score of epilepsy being the diagnosis, then they would telephone an epilepsy specialist in Kathmandu (Patterson, 2019). Based off the telehealth visit, the epilepsy field workers would then arrange for prescribed treatments (Patterson, 2019).
3) Remote intra-operative monitoring (IOM).
Throughout Canada, there are very few technologists that are trained to monitor the central nervous systems during surgeries. Since these IOM techs are hard to come by, one suggestion is for technologists from different sites to remotely view data and inform the team of any significant changes. In other words, having access to a server with real-time data will allow trained professionals to view the study and give their opinion despite not being physically in the operating room (OR). There are some challenges with this, particularly surrounding troubleshooting and having adequate information regarding surgical maneuvers and anesthesia. Therefore, the technologists in the OR will still require knowledge on how to set-up the study (ie. electrode placement, needle insertions, cable/amplifier plug ins etc.) and annotate what is happening (eg. clamping of major arteries, cautery and other surgical maneuvers); however, the interpretation of the results can be left up to the technologists that are at a different site. This is something that hospitals such as Victoria General Hospital are starting to explore.
4) Decreased wait-times to interact with a specialist.
Rural veterans using chronic neurology services via telehealth found it to be very efficient, with 96% reporting that they had saved time through this approach (Sattar & Kuperman, 2020). Pre-visit questionnaires can make visits less time consuming (Rametta et al., 2020). Visits having a shorter duration means a doctor is able to work through their waitlist faster.
5) Less expenses related to attending appointments and traveling.
Patients can save on various transportation related costs such as ferries, planes, gas, buses, and parking. Also, for patients out of town it eliminates costs such as a hotel accommodations.
Limitations of Telehealth for Epilepsy Patients
Technical challenges may occur during telehealth visits. Tech issues were frequently reported amongst clinicians and patients/caregivers, with 40% having problems such as poor audio, poor video, or interrupted communication (Rametta et al,. 2020). Bandwidth issues may result in poor quality feeds or lost connections (Sattar & Kuperman, 2020). Backup phone numbers are recommended as well as starting the visit with the video-intensive physical exam (Sattar & Kuperman, 2020). Doctors gain valuable info from in-person physical examinations; however, there are many instances in which this is not crucial to diagnosis or management. An in-person assessment was felt to be warranted in only 5% of cases (Rametta et al., 2020).
Another limitation is decreased ability to have a private and confidential discussion regarding lifestyle habits or moods, particularly amongst adolescent populations (Sattar & Kuperman, 2020). Discreet conversations via telemedicine are more challenging than asking a parent to briefly leave an office during in-person encounters (Sattar & Kuperman, 2020). Using headphones may help in some situations (Sattar & Kuperman, 2020).
Video 1. Three trends of defining the future of healthcare (Baer, 2020).
Video 1 identifies three areas of improvement for healthcare in the near future (Baer, 2020):
1) Digital health
Telemedicine, mobile health, and med tech
Example: Wearable device post-surgery can measure information including blood pressure and heart rate and these findings can be viewed by medical professionals through an app.
2) Genomics
Gene-based therapies Example: Tailor-made treatments based on unique DNA composition can be created to treat infectious disease.
3) Extended longevity
Improving lifespan
Example: Healthcare professions can remotely monitor the blood glucose levels of seniors in nursing homes via wearable devices to help with diabetes management.
Although pursuing newer technologies and artificial intelligence is exciting, the importance of the human element to patient care is emphasized in Video 1 (Baer, 2020).
Video 2. The future of healthcare (Cisco, 2019).
Advancements in information technology (IT) infrastructure is necessary to improve virtual care. Video 2 explains how collecting data and tracking wellness will change how chronic disease is managed, how patient's experience care, and how clinicians deliver health services (Cisco, 2019). Meeting with a doctor from home using telemedicine will become increasingly more common (Cisco, 2019). IT operations plays a role in creating accessible high quality healthcare as well as reducing healthcare costs in the longterm (Cisco, 2019). Video 2 also touches on some of the applications of augmented reality and virtual reality. For example, these technologies can be helpful in treating phobias, post-traumatic stress disorder, and addiction (Cisco, 2019). Moreover, doctors can practice surgical techniques and understand anatomy better using augmented or virtual reality (Cisco, 2019). Surgeons will be able to perform complicated procedures with guidance and enhancement from robotics and artificial intelligence (Cisco, 2019). In general, artificial intelligence will be used as a supportive tool for clinical decisions such as automated symptom triage (Cisco, 2019).
Technology is changing at a rapid rate and harnessing its power will have great impacts on public health. Each of the levels of influence in the social-ecological model can be targeted using technological advancements and virtual care. Although COVID-19 accelerated the digitization of healthcare, beyond this pandemic we will continue to see rapid growth in virtual care solutions.
Baer, J. [Julius Baer]. (2020, August, 10). Three trends defining the future of healthcare
[Video]. YouTube. https://www.youtube.com/watch?v=QjCSKKDcb40
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