Phase two of Covid-19 will see a resumption of non-urgent medical activities that have been postponed due to the emergency and in order not to increase the spread of the infection within health care facilities – (Article published in AboutPharma May 2020).
The social distancing measures that are planned will however make access to medical clinics difficult and will not eliminate the risk of contagion between healthcare staff and patients.
Quarantine and home isolation have led to a sudden interest in telemedicine which, after so many years of neglect, has become a medical practice used by family doctors, paediatricians and hospital doctors. From a solution reserved for a few patients, generally through dedicated portals, for consultations and visits with private specialists, telemedicine has been discovered.
Telemedicine has therefore become one of the tools with which to tackle phase two, reducing patient visits and contacts with medical clinics to an absolute minimum.
There are many doctors who, armed with good will, have started to use audio-videoconferencing systems to make televisits to their patients; Skype, Jitsi and Zoom are the applications that have been most used. E-mail and WhatsApp are the channels through which doctors and patients exchange information and documents. These forms of do-it-yourself telemedicine, useful to manage an unforeseen situation for which ad hoc solutions were not available, have however generated in many doctors the belief that the above mentioned tools are sufficient and safe to remotely visit their patients.
In addition, there is also a do-it-yourself tele-health service, i.e. the detection by patients of vital parameters and the transmission of values by phone or email to their attending physician. The pulse oximeters, for example, have been the object of strong purchases by people, becoming in a few days almost unobtainable in pharmacies and e-commerce sites.
If we want to address the issue of telemedicine and understand the role it can play in the management of the covid-19 phase, it is necessary to broaden our horizons and consider all the aspects that contribute to characterize a medical service that we want to carry out at a distance, whether it is home care for chronic, fragile or covid-19 patients, or remote consultations and visits.
The transformation of the medical clinic into a virtual digital environment must take into account the access that can be free, through a waiting room or by booking. In this case it is necessary to provide functions to request an appointment, cancel it or remember it.
The virtual clinic must then allow both teleconsultations, carried out not in the presence of the doctor but asynchronously, and televisits.
In both cases it may be necessary to share reports or radiological images between patient and doctor. A secure system is therefore necessary for the physician to access the documents provided by the patient and the tools for their consultation, for example a DICOM viewer for images.
The television can then request the prescription of drugs or examinations, either from the NHS or from the patient. In the first case it is necessary to send the prescriptions to the regional or national systems for the management of dematerialized prescriptions. It is then necessary to safely deliver the reminders and/or electronic prescription numbers (NRE).
The televisit then normally requires a report to be signed digitally and delivered securely to the patient.
In some cases, certification to INPS or the production of certificates for other uses may be required.
For private televisits and teleconsultations, the payment by the patient and the related collection by the professional must be securely managed and the invoice issued to the patient must be electronic.
If the services are carried out under the regime of free profession the contribution must be calculated to the health facility where the doctor works, as well as the tax and accounting obligations.
Finally, before and after televisit and teleconsultation, a secure mode of communication (not email or WhatsApp) between doctor and patient must be available.
All these functions can be carried out by an integrated platform or by several systems; in the latter case, however, all communication and document exchange between patient and doctor must take place with encrypted, secure systems, according to the law.
In home healthcare, tele-health must be carried out through specialized platforms able to allow telemonitoring of vital parameters through certified medical devices, detection of symptoms and collection of patient information through questionnaires. The platform must also allow the forwarding of information to the patient and the possibility to carry out educational activities.
However, it should be stressed that tele-health not only requires a technological infrastructure but also an organisational model and dedicated resources for patient management.
The adoption of telemedicine cannot be undertaken with shortcuts or homemade solutions. Investment is needed in professional technology platforms, organisational and economic models to regulate this type of activity. Telemedicine must be organic and systemic to the healthcare system, public and private.
This consideration is particularly important for a sector that is very lively: health apps. Many of them are designed and implemented as independent systems, often implementing few and well specific functions, without any integration with corporate information systems.
One area that has seen a great development following the covid-19 is that of symptom checkers. These are chatbots or apps addressed to patients that allow, through a series of questions or guided choices, to formulate a diagnostic hypothesis and to direct the person to their doctor or, in the most serious cases, to the emergency services.
Very widespread abroad for some years and, in some cases, integrated and functional to public or hospital care services, in Italy they made their first appearance in conjunction with the spread of coronavirus. These solutions have been adopted to allow a self-assessment of the patient and guide him/her on the steps to take.
Other apps, including for example that of the Lazio Region, were developed in record time to allow people at home to record their symptoms and vital parameters and communicate with their family doctor. The aim in this case is to activate a sort of voluntary home surveillance to intercept patients in need of hospital care at an early stage.
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