Is telemedicine the future?

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Medical care without leaving your home – has an attractive ring to it; but, one that has been a reality for many parts of the world where ease of access to healthcare has been an issue. For example, in Scotland, ‘Telestroke‘ was developed to allow acute stroke patients to be evaluated by a stroke specialist within the 4.5h thrombolysis window, remotely. Increasingly telemedicine is filtering into daily clinical practice, and is proving to be an attractive option not only for the patient, but the healthcare provider.

There are several ways by which telemedicine can applied, but commonly the one everyone favors is the ‘virtual house call’, where the clinic visit happens remotely via an audio-visual interface directly into your home. Not only is this an attractive option for those who are less mobile, it saves on time and money, and in the future may also be able to offer care from the world over.

In a study evaluating the feasibility, participant satisfaction and cost associated with web-based videoconferencing in multiple sclerosis, Robb et al. (see below for the abstract) report that the program is feasible, with 97% participating likely to recommend it. In addition, they report significant cost savings from parking, fuel costs, tolls etc., than face-to-face visits. The quality of the audio-visual connection in a majority was also not bad, with 94% reporting that connecting via telemedicine was easy. Although, not statistically different, 91% said that they were very likely or likely to return for a telemedicine visit compared with 100% for a face-to-face visit.

Some of the participant comments are listed below:

a) Best Parts of Telemedicine Visit
Convenience
“No drive time, parking fees or lost wages from my husband bringing me to the appointment”
“Not having to drive 6 h round trip to see a specialist”
“Time saving”
“The convenience of meeting with my doctor from my home”
Equivalence to in-clinic visits
“How similar it actually is to an office visit”
Importance
“I believe it is a great alternative to an office visit.”
“I was happy with the virtual house call and hope it is something that will be used more in the future.”
“I can see this being a revolutionary step in medicine!”
b) Areas for Improvement of Virtual House Calls
Technology Issues
“I need a better web cam.”
“The patient, if necessary, needs to have plenty of space to move with a camera that is adjustable.”
“I need to prop up my Notebook [and] made sure it’s 100% charged prior to the call.”
Connection Difficulties
“We had a slight problem connecting, but I just called [the neurologist] directly and we connected within minutes.”
Non-Replacement of In-Clinic Visits
“While useful for “off-schedule” visits, I don’t think this type of interaction can replace the live, one on one visit with the doctor on an annual basis for a proper and thorough MS evaluation.”

Although, this study was performed in the US, I doubt the findings would be very different from other parts of the developed world. I am, however, slightly concerned about the legislative issues with regard to the technology, but don’t foresee this as huge hurdle.

Abstract

Mult Scler Relat Disord. 2019 May 6;36:101258. doi: 10.1016/j.msard.2019.05.001. [Epub ahead of print]

Comparison of telemedicine versus in-person visits for persons with multiple sclerosis: A randomized crossover study of feasibility, cost, and satisfaction.

Robb JF, Hyland MH, Goodman AD.

BACKGROUND:

Telemedicine, the remote delivery of health care services, increases access to care for patients with mobility or geographic limitations. Virtual house calls (VHCs) are one type of telemedicine in which clinical visits are conducted remotely using an audio-visual connection with the patient at home. Use of VHCs is more established in other neurologic disorders but is only recently being formally evaluated in multiple sclerosis (MS). This randomized crossover study systematically assessed VHCs compared with in-clinic visits in persons with MS.

METHODS:

Recruitment occurred in a university based MS clinic. Each subject completed one VHC and one in-clinic follow-up visit. A 1:1 randomization determined whether the VHC or in-clinic follow-up visit occurred first. Baseline surveys included demographics and MS history; post-visit surveys elicited subject responses regarding each visit type to assess feasibility, satisfaction, and cost differences. Outcomes were compared using t-tests for continuous variables and Fisher’s exact test for proportions.

RESULTS:

Thirty-six participants completed both study visits and both post-visit surveys. VHC feasibility was demonstrated by a lack of statistically significant difference in the number of completed VHCs as compared with in-clinic visits. VHCs provided both cost and time savings to participants. The majority of participants reported that they would recommend telemedicine visits to others (97.1%) and rated it easy to connect via telemedicine (94.3%). In qualitative comments, participants expressed appreciation for VHCs due to convenience and similarity to in-clinic visits.

CONCLUSIONS:

VHCs were found to be feasible, cost-effective, and appealing to persons with MS and physicians, supporting their utility as a care delivery method for MS.

About the author

Neuro Doc Gnanapavan

6 comments

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  • I think this would have a lot of merit for the nurse service when you ring in to report relapses. Might help you feel less fobbed off, when they say “I cant explain your symptoms, I dont think this is a relapse”, whilst you are really struggling on the end of the phone and just want to be taken seriously. I think telemedicine is an improvement on the phone interaction and is a good option

    Replacing the consultant interaction with telemedicine wouldnt be for me. Its the only face-to-face you get, and they are difficult anyway due to poor communication barriers. Making it teleconference would only make it worse, and would just feel like budget cuts. Particularly as this is an american paper and the system they used was probably very expensive, the NHS equivalent would inevitably be terrible. As with all these things it should be about choice. For me I dont want to lose out; but if I was housebound, unable to get ambulance transport and unable to attend face-to-face, I would be very relieved at the opportunity to have any formal discussion even if it was virtual.

  • I think it will always remain a priority for a clinician to actually see their Ms patient in order to properly evaluate their functioning otherwise how will they accurately decide what treatment and rehabilitation their patient needs. Mri’s can’t be relied on for a true reflection of the physical problems.
    A patient could even withhold some new information regarding their physical problems in order to present a more favourable Impression in order to acquire medication.

    It would also be be an easy way for some some neurologists to to lighten their workload as telephone or video consultations never last as long as face-to-face

    That said as a top-up appointment to further discuss any issues this is a good idea.

  • Speaking solely for myself, I think that there should be more flexibility in the means of patient and clinician interaction. The vast majority of us are all so comfortable now with texts, voice message, FaceTime, etc that it can feel as if the NHS is still badly stuck in the past. The idea of not travelling to a hospital and having to, what can feel like, endure a rushed consultation with an overstretched clinician is appealing. I was pleased when the MS nurse at the London centre began to alternate our face-to-face appointments with phone calls.

    The fact that I’m stable since receiving alemtuzumab in 2017 and that I fund seeing a neuro physio once every six months, who undertakes thorough assessments, is clearly going to influence my take on this. But it is also true that I feel sometimes that I am inadvertently wasting precious clinician time that can better be spent with others. The system is at breaking point and if the neurologist making use of the physio assessments, alongside my self reporting and VHCs is able to see me less, then great. I’d like to think that way, when I really need to be seen I could access a quality consultation period with less evidence of a stressed medical practitioner!

    • The current guidelines by NICE is at least an annual review. I suppose an opt out system for visits is a fair use of everyone’s time if it’s of the person’s choosing.

      Digital NHS never got fully funded and therefore we’re behind when it comes to these innovations.

  • Great if it suits you to communicate in this way (and it would meas i am comfortable with skype etc through work).
    But some people are not tech savvy enough to be comfortable, even if they have the equipment.
    Also some people need the face to face human contact. The quote from the lady who like me has a husband to drive her to appointments would like me benefit from having one less journey to fit into the family schedule. But for people who do NOT have a family that social contact of going to the appointment (which apart from meeting their medical team also means interacting with transport operaters, other patients and even the person serving in the cafe etc!) builds their social capital … which you recently highlighted the importance of.
    So it would not be appropriate for everyone but some of us would be very happy with this at least occasionally – preferably once we have got to know the person.

  • I think it is a good idea for those of us who have to rely on others to get us to appointments. I don’t like to bother people for lifts so would consider an online consultation.

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