Dr. Alberto J. Muniagurria and Gustavo Del Fabbro

Telehealth and everything it encompasses has been progressively integrated into health delivery systems and medical practices. This new technology offers a working method for both medicine and healthcare providers. Argentine medical schools do not include the study of telehealth in their curricula, except in isolated experiences such as the Scenario Office at the Faculty of Medical Sciences of Rosario.
In order to evaluate the bibliography and unify concepts, this article is described.
A classification of the systems can be developed by grouping them into the term TeleHealth. This includes Telemedicine, Remote Monitoring and Mobile Health Systems.

Telehealth

• Telemedicine
• Remote monitoring
• Mobile health system

Telemedicine

René Laënnec, the inventor of the first stethoscope, can be considered as the pioneer of telemedicine by putting a distance between the doctor and the patient to be able to hear what was going on inside their body. Almost unintentionally, he became the forerunner of “Medicine at a distance”, although in reality he moved only a few centimeters away, perhaps motivated by the modesty that comes from resting the ear on the chest and back of a young patient.

Different health service scenarios throughout the history of man required remote care and confinement, and most of them were driven without microbiological knowledge for protection against potential contagions.

The COVID-19 pandemic brought isolation and distancing again as the main problem factor at the time of medical consultation. This new paradigm coincides with a technological development in which it is possible, until now, to see and hear the other person through video calls. This not-so-recent mode of communication, which has been going on for some decades, allows for an acceptable, virtual and non-face-to-face medical consultation.

In the course of time and with the advance of the sciences, outstanding experiences occurred with patients residing in inhospitable and remote places such as deserts and bases in Antarctica. In the 1960s, the most remote consultations were carried out so far, where doctors on Earth treated patients on the Moon during space missions, an activity that continues today on the International Space Station. Likewise, surgical procedures have been performed at kilometers away by means of surgical robots, where the specialist remotely operates on a patient even on another continent.

Although this evolving technology was very useful for the development of new means of communication, it must be understood that face-to-face medical consultation is not only an exchange of visual and verbal information, it is sharing a lot of other information that telemedicine media are not yet. fully capable of transmitting and that are of utmost importance for the holistic evaluation of the patient, such as paraverbal language, aromas and perfumes, the expressive message and most importantly, the space specially set for the consultation to develop normally , an environment of doctor-patient trust that has an essential component for the interview and the relationship between interviewer and interviewee.

A telemedicine consultation made from two different spaces is not the same as one made in an office. The patient may be comfortably in her room but not be with the confidence of the place of the medical consultation, since she could feel invaded, or that other people in the house intervene in the consultation, the professional may not be adequately prepared for it. , etc. (Importance of place: Transfer and countertransference)

It is important to highlight that this new technology is within the reach of all professionals and is extremely useful to avoid unnecessary consultations that could put the patient and professional in a situation of potential contagion and, in turn, saves time and money. means. General and Family Medicine and Internal Medicine are the gateway to this healthcare model. Of the specialties, Dermatology is the one that has the greatest potential for action in these consultations, along with Psychology and Psychiatry where practically little or no physical contact.

First, within telemedicine , it can be considered that the care to be developed can include the following approaches:

• Health promotion
• Prevention of disease
• Attention to acute problems
• Chronic care
• Follow-up of patients or evolution
• Interconsultations with patients and with other doctors
• Health benefits not limited by distance (rural areas for example)
• Maintain healthcare provision within a medical environment
• High performance quality
• Articulated care in Public Health problems

Technology

To develop this healthcare experience, it is necessary to have appropriate technology. Internet services with good speed, WiFi systems, computer, tablet or iPad with good resolution screen, external speakers if possible and external microphone for better sound quality.

Video conferencing platform such as: Zoom, Skype, WhatsApp or Facetime.

Cellular. With video conferencing capacity (iPhone or Android).

There are also stethoscopes, ophthalmoscopes and electronic otoscopes that could be used for this purpose.

Clinic history

During the videoconference, an interrogation is conducted aimed at the reason for the consultation. It is useful to have the patient database and complete medical history that facilitate the experience. In this sense, you can count on the data file provided by the patient via a USB flash drive if they have one. The alternative is contact with the centralized system of the Office Center or Hospital Center where the person is regularly attended and that the Center has a systematized and centralized medical history.

For the physical examination, there is a video image to develop following the professional indications with the availability of good lighting and familiar elements such as thermometers, tongue depressor spoons and a companion to follow the indications.

Very good part of the semiological maneuvers require the presence of an examiner, but another part does not, for which, in this circumstance, the patient himself or someone accompanying him could perform the maneuver and be evaluated remotely by the health professional.

The maneuvers where the presence of a professional is totally necessary are those that require skill and development of a sense in question, such is the case of auscultation where it would be difficult for an untrained person to distinguish any relevant sound, as well as palpation of liver, abdomen, ligaments, joints, etc.

If the use of a complementary diagnostic method is necessary, the patient is referred to a preferably ambulatory healthcare center to carry it out and then the results of the study will be referred to the requesting professional for evaluation. We can mention within this group, laboratory analysis, diagnostic imaging, functional tests, etc.

Messenger service

It is useful to have an available message and report transfer system added to the virtual system, which can be the staff of medical centers.

Study centers to refer

It is useful to have an Outpatient Center to refer patients in which it is necessary to complete their study. Laboratory, X-rays, Ultrasounds, Dopplers, Computed Axial Tomographs, Magnetic Resonances, as well as other more complex procedures can be developed with a virtual order that is issued in the consultation.

Workspace, confidentiality

The workspace for the virtual consultation or videoconference can be developed both in a home area and in an Office Center. You must have the necessary systems to be able to work with the appropriate technology and the necessary silence. The confidentiality of the encounter with the patient must be protected

Elements of a virtual consultation

To develop a virtual consultation with suitability, good sensitivity and predictability, you should consider:

Professional training: This is essential to carry out a virtual consultation. The doctor's experience in this technology plays an important role.

Patient knowledge: Without a doubt, the patient's prior knowledge is highly relevant in the virtual consultation. Reduces consultation times and the need for a complete anamnesis. It also improves the sensitivity and predictive value of the data, both symptoms and signs. Strengthens the doctor-patient relationship and the tranquility of the consultant

Technology: Video image and sound tools must be available

Professional specialty: Influences the approach. The specialties of General and Family Medicine, Internal Medicine, Psychiatry, Psychology and perhaps Dermatology are the ones that best suit the virtual system.

Hours: As it is a task that can be carried out at home, it is necessary to order the consultation hours throughout the day. The collaboration of a member of the professional's family can be useful to avoid saturation of queries. Once the need has been established, an application could be implemented to organize shifts and their duration.

Fees: It is necessary to agree on a way to pay for the consultation. Either by an accepted social security system or by electronic means of payment such as credit / debit card, transfers, deposits, etc.

Insurance: Protection with practice insurance should be considered for the professional with this consultation model. Your civil and criminal liability must be covered for which advice is appropriate.

Legal framework: Faced with this new paradigm, new regulations on legal care and support should be evaluated. As it is a virtual meeting, there is no record other than the meeting, there are no signatures or stamps that can be exchanged and testify to the interview, so the recording of the meeting could be evaluated, with the prior consent of the patient and the doctor to that both parties have a non-disclosure copy, this, in addition to witnessing the virtual meeting, could be useful in evaluating the dynamics and improving this type of care that will surely increase, would also be useful in the event of an unwanted incident and would be of proof before a possible dispute in a malpractice conflict. This also opens a new question about current regulations: What if there is an incident in two different jurisdictions, the patient from Argentina and the doctor from Uruguay? Each new paradigm opens up new questions that must be evaluated in the future. As is often the case, technology is imposing changes on society to adapt to it.

Doctor-patient relationship: If the link with the patient exists previously, this is strengthened, otherwise it is a complex space that allows open debate. Much depends on the personality of the doctor and the patient who consults. It also varies with the size of the reason for the query. This should be studied in the future, and advances in technology will bring their own.

Case examples

Headache: In this reason for consultation, the questioning of the patient and the observation of his face become very important. The anatomical place of the pain, its intensity, the persistence over time and its irradiation, the change with different force maneuvers, coughing, breathing, etc., etc., is important to evaluate. Age, previous and family history, habits and other manifestations will have to be added to size the picture (arteritis temporalis, anisocoria, neck stiffness)

Sore throat: In this reason for consultation, age, evolution time, fever, and personal history with allergies, habits, and previous treatments become important. The physical examination can be conducted by observing the throat in good light and following indications for palpation of the neck (general lymph node groups)

Dysuria, polakiuria (Hematuria, three-vessel test, uroscopy, body temperature, urinary urgency, history, risk behaviors, personal hygiene)

Low back pain (intensity, irradiation, associated symptoms, chronology, duration, etc., pain positions, fist-percussion, Lasegue, osteotendinous reflexes, posture, gait)

Abdominal pain (palpation and topographic location, Blumberg's sign, Murphy, McBurney, Geneau de Mussy, fist-percussion, points of henia, etc.)

Red eye (Pain, discharge, sclera and conjunctivae)

Ankle pain (Edema, mobility, pain, lump)

Edema (sign of the fovea or Godet, sign of the means, signs of heart or liver failure, facet of kidney failure, anasarca, weight of the patient).

Chronic patients (according to base pathology, diet, controls, hygiene, diabetes, hypertension, dyslipidemia, etc.)

Anxiety (listening and eventually pharmacological treatment)

Remote Monitoring

The data is collected on portable devices that send the information online in real time. This methodology is very useful in monitoring cardiovascular diseases with the use of pacemakers and implantable cardioverter-defibrillators, or in metabolic diseases such as insulin infusion pumps, etc.

Mobile health system

Through the use of the Internet and wireless devices for the use of medical professionals where they obtain specialized health information, as well as discussion groups among colleagues where they can discuss topics of their practice. (UpToDate, DynaMed, etc.)

It is worth mentioning the use assisted by robots in remote surgery to perform procedures remotely and the automated apparatus to carry out laboratory tests, where personnel could be instructed in their operation and the taking of samples for it, such is the case of hard-to-reach places such as bases in Antarctica and other remote settlements

"The doctor must possess, on the one hand, solid and extensive knowledge that constitutes the foundation of his medical capacity, and on the other, have judgment, tact, prudence, compassion and interest in the care of his patients. New technologies allow him to extend or extrapolate these qualities " 

Bibliografía

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