The impact of the COVID-19 pandemic has led to the enforced growth in the use of telemedicine. Dr Brian Charles, emergency physician based in Barbados, looks at some of the benefits and risks
The COVID-19 pandemic has brought about many changes in our lives and livelihoods. There has been great economic fallout and significant financial and emotional stress among doctors and patients alike. Most of all, the way we live and practise is likely to change for a long time to come. The need for social and physical distancing has created a difference in how medical professionals interact with their patients:
- Vulnerable populations must be protected
- There must be an increased emphasis on respiratory hygiene
- Cleaning, disinfecting and sanitisation procedures at establishments of medical care have had to be revised, all of which has brought increased costs and different protocols to be adopted in our practices
- Non-Covid illnesses have not gone away and still merit the same standard of care as before.
To satisfy these conditions, telemedicine has been advised and adapted for the provision of care in a safe and economic environment.
What is required for effective telemedicine?
Culturally, our population is very sociable, and person to person contact is revered. This includes the doctor’s visit which, in some areas, is looked upon with great anticipation, especially among the elderly. Adapting to a culture of medical encounters without direct personal interaction will take some adjustment.
Most have access to devices enabling easy access to videoconferencing. However, a telemedicine consult must satisfy the same safeguards as a regular medical consult:
- There must be ‘trust’ in the doctor/patient relationship (even with new patients this trust must be developed)
- Participants (doctor and patient) must be identifiable by device and their identify must be verifiable, which is best done by video
- Consent must be attained for a telemedicine consult and documented. If video or photo evidence is used for diagnosis or decision, the video or photos must be also be recorded and saved
- The encounter must be confidential. Confidentiality is paramount whatever medium is used, and doctors must ensure information is processed and stored securely
- Adequate documentation and records must be kept. Access to past records for review is advisable
- Avenues for treatment and further care must be available and easily accessible, eg prescriptions, referrals etc.
In addition, even as telemedicine has been used in the ‘first’ world for decades for care home consults, psychiatry and some other disciplines, it has been used infrequently in the Caribbean region, and usually limited to telephone triage, to be followed by a regular consultation. There will be a period of understanding and trialing of telemedicine, both by the medical fraternity and our patients.
Weighing the benefits against the risks
Telemedicine ensures our patients are less exposed to likely infectious situations, reduces the need for the ‘doctor’s commute’ and providing a level of convenience for the patient, allows follow up and review of established illnesses – especially NCDs – with home monitoring, needs minimal infrastructure (apart from the security aspect), and requires little if any training to appropriately conduct a telemedicine consult. A by-product is also the reduced need for PPE and frequent deep sanitisation of offices.
Conversely, doctors engaging in telemedicine should use an appropriate medium. Social media platforms such as WhatsApp and Facebook are not recommended, even though widely available. Specific telemedicine software is available that allows recording and documentation within the software. These are suggested but not absolute, as security and confidentiality risk are prime concerns. Professionalism, documentation and record keeping should follow the same principles as a regular consult. Video engagements are preferred in trying to maintain the doctor-patient relationship, as eye contact will assist in creating and maintaining trust.
There are some limitations to the telemedicine consult. It is more straightforward to use it with known patients, where a relationship has already been established. Some cases may not be suitable, such as gynaecological, acute ophthalmology and surgical cases where examination is vital. Triage is required prior to undertaking a telemedicine consult to establish the appropriateness of this method of consultation. Other limitations include technical and confidentiality issues.
Some consideration must be given to the acceptance of medical claims for telemedicine consults by health insurance companies. This may influence how readily this service is adopted in the Caribbean.
Feedback from one clinic that has used a telemedicine service for the past month states the uptake has been very satisfying, though slow, with 90% of respondents to a satisfaction survey indicating that they will use the service again.
The future for telemedicine in the Caribbean
Because of the ‘new normal’ and potential acceptance of this form of consultation, Caribbean doctors should be adaptable to telemedicine and safeguard themselves against potential pitfalls of this new patient encounter. One has to be mindful that:
- For new cases, diagnoses without physical examination may be difficult though not impossible
- Telemedicine is possible for some disciplines and may not be suitable for certain cases within accepted disciplines. Some form of ‘triage’ should be done and patients made to understand the limitations of the telemedicine consult
- Confidentiality, consent, documentation, security can still be challenged if no safeguards are ensured
- Never conduct a telemedicine consult outside your scope of training/practice
- Have a backup/fall back plan in event of technical failure, need for physical examination, deterioration of condition, consideration of alternative diagnosis, and security or confidentiality breaches.