|Year : 2022 | Volume
| Issue : 5 | Page : 238-243
Teleconsultation for anaesthesiologists - Update and limitations
Anju Romina Bhalotra
Department of Anaesthesiology, Maulana Azad Medical College, New Delhi, India
|Date of Submission||18-Jul-2022|
|Date of Decision||23-Aug-2022|
|Date of Acceptance||02-Sep-2022|
|Date of Web Publication||31-Oct-2022|
Anju Romina Bhalotra
A-1/59 Safdarjung Enclave, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhalotra AR. Teleconsultation for anaesthesiologists - Update and limitations. Curr Med Res Pract 2022;12:238-43
The WHO defines telemedicine as the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment and prevention of disease and injuries, research and evaluation and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities. India, with a population >135 crores, has a large share (68.84%) of the population residing in the rural areas with minimal healthcare services, while 75% of doctors are based in cities. This inequitable distribution of healthcare suggests that telemedicine has great potential applications to reshape the contours of India's healthcare. The penetration rate of smartphones has increased (54% in 2020), patients are used to interfacing with healthcare systems using E-mail or mobile phones, mobile computing, cellular phone technology, high-fidelity cameras and telecommunication hardware have advanced to allow smooth video teleconferencing and remote patient monitoring is becoming feasible and accurate. All these advances suggest that the time is ripe for the advent of telemedicine. According to the American Telemedicine Association, 'Telemedicine is the natural evolution of healthcare in the digital world'.
| History Of Telemedicine|| |
One of the first reported uses of telemetry for long-distance medicine was in space travel by the National Aeronautics and Space Administration which proved that the health of astronauts in space could be monitored by physicians on the earth. In 1964, the first interactive video link between two places 112 miles apart was used to allow interaction between Norfolk State Hospital and inmates at the Nebraska Psychiatric Institute in Omaha. Further advances first extended telemedicine in psychiatry, radiology and emergency medicine and presently to critical care medicine, ophthalmology and cardiology. The use of telemedicine in anaesthesiology was first reported in 2004.
| Telemedicine In India|| |
The Indian Space Research Organisation (ISRO) deployed the first satellite communication-based Telemedicine Pilot Project in 2001 linking Chennai's Apollo Hospital with the Apollo Rural Hospital at Aragonda village in the Chittoor district of Andhra Pradesh. Subsequently, combined initiatives taken by ISRO, Ministry of Health and Family Welfare (MoHFW), Ministry of External Affairs, DIT and State Governments are advancing the role of telemedicine in India. The Ministry of Health has initiated various projects such as the National Rural Telemedicine Network, National Cancer Network, Integrated Disease Surveillance Project, National Medical College Network and the Digital Medical Library. The External Affairs Ministry has taken up worldwide activities like the SAARC Telemedicine Network Project and the Pan-African e-Network Projects, and in 2005, the Government of India (GoI) constituted the National Telemedicine Task Force.
It is hoped that combined efforts of government and private healthcare institutions will go a long way in bridging the gap between rural and urban India. At present, Apollo Telehealth has about 700 healthcare centres in public − private partnership mode over the various states in India. Various health tech start-ups are striving to build up a useful telemedicine framework in rural India such as Practo, rxtelemed, mfine, DocsApp and Lybrate interfaces and start-ups like Meddo and NaviaLifecare, Biocalculus, I Online Doctor, MedCords and iStart to name a few. The Ayushman Bharat Scheme by GoI empowers telemedicine for the health sector's progress. With the advent of the COVID pandemic, on 25th March 2020, NITI Aayog released new Telemedicine Practice Guidelines empowering Registered Medical Practitioners to provide remote healthcare. On 9th August 2020, the GoI introduced eSanjeevani, as part of its 'Digital India' initiative allowing Doctor to Doctor (eSanjeevani) and Patient-to-Doctor (eSanjeevani outpatient department) teleconsultations. The aim is to connect larger hospitals to smaller remote health centres with medical college hospitals and large government hospitals acting as 'hubs' to provide teleconsultation to 'spokes', or primary health care centres (a 'Hub and Spoke' model). The MoHFW has set up a National Telemedicine Portal for promoting e-health, a National Medical College Network for e-Education, and a National Rural Telemedicine Network for e-Healthcare delivery. The National Digital Health Authority of India/National e-health authority (NeHA) to help achieve high-quality health services and a set of Electronic Health Records (EHRs) has been developed to ensure safe data transmission during telemedicine. Telemedicine is being extended to traditional medicine with the development of the National Rural AYUSH Telemedicine Network. Arogyasree, is an initiative of the Indian Council of Medical Research and integrates many hospitals, mobile medical specialists and rural mobile clinics. The ISRO has devised the concept of Village Resource Centres to provide teleeducation, telemedicine, online-decision support, interactive farmers' advisory services, tele-fishery, e-governance services, weather services and water management. These are learning centres and provide connectivity to speciality hospitals. The GoI has taken major initiatives to provide bandwidth connectivity over the country. The National Knowledge Network is entrusted to provide high-speed network for all knowledge-related institutions, State Wide Area Network to provide bandwidth connectivity up to the Block Level, the National Optical Fibre Network for providing high-speed bandwidth connectivity to Gram Panchayats (GPs) and the latest 'National Broadband Mission' or 'Rashtriya Broadband Abhiyan' to operationalise 'Broadband for All'.
| Telemedicine For Anaesthesiologist|| |
Telemedicine can potentially expand the anaesthesiologist's role throughout the peri-operative period but is, unfortunately, one of the specialities least utilising it. Apart from leading to growth and expansion of anaesthesiology, telemedicine can take the anaesthesiologist into the home of the patient, bringing increasing recognition to a speciality usually confined within the walls of an operating suite.
| Pre-Operative Care|| |
The first reported use of telemedicine for pre-operative evaluation was in a 2004 case series by Wong et al. In 10 patients' pre-operative evaluation was done using a viewing screen and mounted camera operated by a nurse at a remote facility. Both patients and anaesthesiologists reported high satisfaction with the experience. Similar patient and staff satisfaction have been noted in subsequent studies.,, Rollert et al. found that incarcerated patients with complicated travel need requiring oral and maxillofacial surgery could undergo successful online pre-operative evaluation.A telemedicine consultation before visiting a clinic for further testing was found to reduce subsequent in-person visit times. The average in-person pre-operative clinic appointment took 24 min less for those who had received an advance telemedicine consultation. Anaesthesiologists can also use telemedicine to prehabilitate surgical patients and measure and achieve healthcare milestones before surgery such as control of blood pressure and blood glucose, coagulation, nutritional and fluid status, weight management, stopping smoking and optimisation of functional capacity. Waterland et al. implemented a telehealth prehabilitation education session received well by patients preparing for major cancer surgery.
| Intraoperative Care|| |
The first intraoperative use of tele-anaesthesia was by Cone and colleagues in 2004 who reported telemonitoring by an anaesthesiologist in Virginia, United States, for assisting anaesthesia for cholecystectomy in Ecuador using real-time patient monitoring and transmission of heart and lung sounds by an electronic stethoscope and images of the airway by fiberoptic cameras. The patient had an unanticipated difficult airway and cardiac arrhythmias during direct laryngoscopy. Both concerned teams took a combined decision to awaken the patient and perform awake nasal intubation after which surgery was done uneventfully. These investigators subsequently used intraoperative telemedicine for seven other procedures.
In 2009, Fiadjoe and colleagues described the use of remote monitoring by a team at Children's Hospital Philadelphia to assist with two elective live-related paediatric liver transplants being done in Bangalore, India. In Bangalore, they used a video camera, video conference device and Integrated Services Digital Network (ISDN) line. GoToMeeting served as a backup communication system during the anaesthetic.
Ihmsen and colleagues conducted a pilot study to assess the feasibility of EEG-controlled closed-loop administration of propofol for total intravenous anaesthesia over a distance of 200 km in 11 patients undergoing general surgery. Computers at the patient site in Munich and the control site in Erlangen were connected via the Internet using a virtual private network (VPN).
Miyashita and colleagues reported reliable communication between mainland Japan and a private island 300 km away by the use of a VPN and FaceTime application. Teleanaesthesia was required due to a shortage of qualified anaesthetists on the island when 2 patients required surgery simultaneously. One patient was looked after by the local anaesthetist but for the second patient, an anaesthetist on mainland Japan gave online instructions to a nurse who provided the anaesthesia care. This pilot study reported the use of parallel anaesthesia for 25 patients with a total anaesthesia time of 37 h, during which 888 anaesthetic commands were completed. There were seven reported FaceTime disconnections lasting for total ten minutes. All these interruptions were at times when no anaesthetic commands were required and caused no patient harm (luckily!).
Telemedicine can be used for tele-education, tele-conferencing and tele-proctoring/tele-mentoring to guide and train anaesthesiologists for performing newer techniques such as ultrasonography-guided nerve blocks. The use of intraoperative tele-anaesthesia may be especially applicable in disaster situations or infectious outbreaks where emergency care is simultaneously required for lots of people and there is a staff shortage.
| Post-Operative Care|| |
Telemedicine can be used to monitor patients in the immediate post-procedure period in the hospital and after discharge. Collins and colleagues described a virtual intensive care unit (VICU) for patients in the hospital who required intensive care unit (ICU)-level care, but no ICU beds were available. At the Medical University of South Carolina, adult intensivists provide ICU care to 10 different hospitals within the state of South Carolina using telemedicine.
As more high-risk and older patients come for increasingly complex surgical procedures, patients need restarting of anti-hypertensives, heart failure medications and anticoagulants, coordination of dialysis schedules and management of post-operative pain. Anaesthesiologists can help in post-operative rehabilitation, recording of post-operative milestones, etc., using teleconsultation.
As ICU mortality rates decline, more and more ICU survivors are being discharged home and the prolonged effects of critical illness are being recognised as a post-intensive care syndrome, in which ICU survivors are left with physical, cognitive and psychological impairments that compromise their quality of life. Virtual follow-ups may be particularly beneficial in these patients who are weak, debilitated and often unable to attend a clinic physically. Teleconsultations can extend the reach of critical care physicians into the homes of ICU survivors and accelerate their recovery from critical illness.
Chronic pain clinics are the largest outpatient venues for anaesthesiologists. Patients with any form of severe pain will have limited mobility. Telemedicine allows the adjustment of multimodal pain management regimens for acute post-operative pain and chronic pain.
| Types Of Telemedicine|| |
Telemedicine is of predominantly two types; real time (synchronous) or store and forward (asynchronous). In synchronous telemedicine, both parties are present at the same time and a real-time interaction takes place. In asynchronous telemedicine, medical data is acquired and transmitted to a doctor or another medical specialist at a later and more convenient time for assessment. Both parties are not present at the same time. The third type of telemedicine is self-testing or remote monitoring in which technological gadgets are utilised for remote patient screening.
Telemedicine may also be categorised into two types depending upon the people who interact. It may be between the health expert and patient or health expert and another health expert (for consultation, referral and speciality care).
| Equipment|| |
The telemedicine infrastructure requires hardware and software. Hardware includes the telemedicine platform, clinical devices, video-conferencing unit and communication hardware. The software includes the operating system, licensed telemedicine software with an appropriate user interface and a back-end database. The connectivity options include a very small aperture telephone network, public services telephone network, ISDN, leased line or a wireless local area network/wide area network.
The equipment required varies depending on the type of teleconsultation. Formal video towers are available at remote brick and mortar teleconsultation sites that have audiovisual communication technology, like a video screen, high-quality microphones and speakers and integrated examination tools like digital stethoscopes, otoscopes, adjustable cameras, fiberscopes, spirometers, 12-lead electrocardiogram and ultrasonography. Staff must use these equipment and transmit the data to doctors at another site. These are called facilitated visits. On a smaller scale, videoconferencing between doctors and patients can be done using a personal tablet, smartphone, or home computer and software programmes such as Skype, GoToMeeting, Zoom, Doxy. me, Vidyo and several others. These are called DTC or direct to consumer visits.
For a facilitated visit, the institution where the physician is sitting requires a video-capable device (laptop/computer), speakers/audio headset, access to the internet and electronic medical record (EMR) keeping. A video tower, monitoring equipment and internet access are required at the remote site. There is face-to-face interaction and the ability to discuss medical history and anaesthesia plan, conduct an airway and cardiorespiratory examination and do basic testing (electrocardiogram, spirometry, etc.) and the patient does not need any equipment. However, patient participation from home is not possible, and the patient has to visit the remote centre. Also, medical staff and administrative support are required. In a DTC visit, the institution where the physician is sitting requires a video-capable device, speakers/audio headset, internet access and EMR keeping. Face-to-face interaction can be done from the patients' home and medical history, anaesthesia plan and some degree of airway examination can be shared. No cardiopulmonary examination or any testing is, however, possible. No medical or administrative support is required, but the patient needs to have a personal device with necessary software and internet access.
The staff operating video-conferencing equipment must understand telemedicine technology for which certification courses are available from Centre for Development of Advanced Computing and the Information and Communication Technologies University.
| Remote Surveillance Technologies|| |
Remote surveillance is a rapidly developing medical technology area that allows physicians to remotely monitor, diagnose and ultimately intervene to provide timely care and improve patient safety. It involves the collection and digital transmission of monitoring and clinical data of a patient in a location remote from where the monitoring physician is located. Data can be collected from invasive and non-invasive monitors and by using newer devices, like patches, biosensors, watches and convenient wearables, allow continuous non-invasive monitoring even during activity and ambulation, and track newer data, like cardiac output, tidal volume, stroke volume variation, blood glucose, etc. The data collected are then transmitted through biomedical device interfaces to the EHR database, for which the data must be structured in a standard language and then stored. Storing data on traditional servers require hardware installations and licensing fees. Cloud-based data storage is more affordable, easier to install and maintain and enables data storage in a centralised repository or 'data lake. For the clinical use, the data must be analysed, and sophisticated prediction algorithms devised to predict constellations associated with adverse clinical events. A manageable number of highly sensitivity and specific alarms should be activated to alert appropriate responders within a time frame which will allow clinician intervention to improve patient outcome. Combined, these advances in data, prediction and alert/response form the elements of effective remote surveillance systems.
| Impact Of Covid|| |
The COVID-19 pandemic created massive global economic and healthcare disruptions, with widespread lockdowns and travel bans. With mounting economic pressures and health needs of the people, governments were forced to reopen societies gradually. This had to be balanced with measures to protect public health safety, creating an urgent need for digitalisation and reinforcing the need for telehealth program expansion to allow delivery of care in the face of mandatory distancing and shortage of staff.
| Benefits|| |
Remote pre-operative evaluation leads to cost savings, convenience and reduced day-of-surgery cancellation rate for patients. Money is saved on travel, transportation and lodging. While this is of undoubted benefit to patient's travelling long distances or coming from rural areas, it is also beneficial to patients living in metropolitan cities with traffic and parking concerns, elderly patients, patients in wheelchairs, bedbound and incarcerated patients. A virtual consultation also obviates the need for patients to take time off work and/or arrange alternative childcare. Due to the above problems, patients may fail to reach a hospital in time for a preoperative visit, so it is envisaged that compliance with preoperative evaluation may be better if there is a virtual option. Patients needing early surgery may find teleconsultation beneficial due to the paucity of time to arrange travel. Teleconsultations from urban to rural locations provide speciality care where none is available. They reduce hospital visits, thus lowering the chances of hospital-acquired infections. Telemedicine facilitates prehabilitation and rehabilitation and helps reduce the hospital stay of chronically ill patients. It helps reduce the isolation of severely ill, handicapped, or infectious persons and can help educate patients about their disease and reduce barriers to illiteracy.
For service providers/physicians, teleconsultations permit better decision making as analysis of stored data increases practice efficiency, allows second opinions to be quickly taken and allows better patient follow-up. As physicians can reach out to many patients, this saves their time and may translate into higher revenue for the doctor. In addition, it allows patient distancing in case of infectious illnesses.
During teleconsultation, there are privacy concerns for the patients who must provide their personal details and may need to expose parts of their body. There is no direct contact between the physician and the patient in asynchronous teleconsultation; even in synchronous teleconsultation, the patient and physician cannot speak simultaneously. Some important findings on general examination and airway assessment may be missed, and while the elderly and those with significant comorbidities may benefit from the reduced travel need, they are medically complex. They may require an in-patient visit for a complete evaluation. Furthermore, all patients are not willing or satisfied with teleconsultation which may be due to discomfort with technology or the desire for human interaction. The cost versus benefit of setting up teleconsultations needs to be determined. For successful intraoperative telemedicine, reliable data transmission and communication are necessary with little/no interruption in transmission feed. Patient conditions change rapidly intraoperatively, and losing data transmission and communication could result in catastrophic patient outcomes. Video recording of the operating room is desirable so the remote guiding physicians can see the surgical field, monitors, etc. Intraoperative telemedicine may not be suitable for prolonged procedures or those involving extensive blood loss and haemodynamic instability. The guiding physician may be unfamiliar with the skills/language/training, etc., of the staff providing the patient care. Therefore, a baseline level of staff competency with common intraoperative procedures should be ensured before instituting an intraoperative tele-anaesthesia programme. It is necessary to maintain the patient's record at both locations simultaneously, as in the event of a mishap; there arises the question of liability. Systems must be established to overcome these hurdles before more frequent intraoperative tele-anaesthesia can be encouraged.
For the post-operative period, VICU's are described, but further research is required to determine which surgical populations will see the maximum benefit and the cost-benefit ratio of using VICUs compared to traditional ICUs. Furthermore, there is very little literature describing the involvement of anaesthesiologists in these scenarios. Remote monitoring potential in the peri-operative period exists, but there is a need for standardising data collection methods and data storage and devising advanced algorithms for the early detection of patient deterioration. There is still a lack of appropriate telecommunication technologies, and remote surveillance's impact on patient outcomes remains uncertain, as do its reliability and cost-effectiveness.
Considerable funding is required to develop the infrastructure for telemedicine. While some private corporations and telecommunication companies are willing to provide services, government and legislative agencies must make more funds available. There are risks of security breaches with third-party applications on computers, tablets and telephones to transmit personal information. India needs a data protection law like the USA's Health Insurance Portability and Accountability Act (HIPAA) to develop regulations to protect the privacy and security of health information. There are two draft legislations in this regard, the Personal Data Protection (PDP) and Digital Information Security in Healthcare Act (DISHA) by the Health Ministry. The Parliament passed a PDP Bill in December 2019, which defines both Personal and Non-personal Data and is a substantive framework that introduces a specialised regulatory approach for the Protection and Privacy of Data in any form (digital or non-digital) in India. DISHA is the Indian counterpart to HIPAA and lays down provisions that regulate the generation, collection, access, storage, transmission and use of Digital Health Data and associated personally identifiable information. The Health Data Privacy and Security Act in India will likely take a lot from HIPAA.
Other legal concerns are related to state medical licensing laws, tele-prescription and billing for virtual services. Tele-prescribing is less of a concern in most anaesthesia-run pre-operative clinics as anaesthesiologists rarely prescribe home medications before surgery. Informed consent is necessary, and patients should be informed of teleconsultation's risks, benefits and limitations.
| Conclusion|| |
The use of telemedicine within anaesthesia is a relatively new concept compared with some other specialities; however, its use within the pre-operative, intraoperative and post-operative phases of care is now gaining momentum in practice as well as in the literature. Further growth is likely with technological advancements. The surgical episode is a very appropriate time for inculcating lifestyle changes in patients, and telemedicine can provide a portal for anaesthesiologists to play an active role in improving population health both pre and postoperatively. Secure internet connections, medical data storage, compliance with medical licensure and the overall cost-benefit analysis are some of the issues requiring further exploration and research. In 2016, the American Medical Association suggested that undergraduate and post-graduate accrediting bodies include core competencies for telemedicine in their curriculum. It is the time that medical education regulators in India consider the same so that teleconsultation may achieve its full potential.
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Conflicts of interest
There are no conflicts of interest.
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