Telemedicine in healthcare
Author: Andres Castilo
Information and communication technologies have become a useful tool in people’s daily lives. This situation has not remained unnoticed to the medical field, where technologies improve nowadays the quality and safety of the services which are provided to the patients. Telemedicine for example, can be defined as the use of telecommunication for diagnosis, monitoring or treatment, when the distance separates the participants, whether they were doctor-patient, doctor-caregiver or doctor. It exists since 1950 and experienced high development in the fields of Radiology and Pathological Anatomy. At present, two types of technologies are mostly used: one designed to transfer digital images, especially radiological or cardiological studies; another that is used when the transmission of information in real time is necessary. The use of videoconferencing equipment between two places, allows real-time communication between professionals, as well as the possibility of viewing and monitoring the patient at home or wherever his location is. There are also peripheral accessories connected to the computers that enable the realization of an interactive scan, and even the performance of certain surgical techniques.
In 1995 revisions of telemedicine affirmed its effectiveness. A study which was published in 2000 demonstrated how to accurately collect and send vital signs (heart rate, respiratory rate, blood pressure and temperature) by a radio telemetry system from the home of the patient to the hospital. The data was stored, sent and valued later.
In 2001 a statement issued by the US Agency for Healthcare Research and Quality (AHQR) to assess the effectiveness of telemedical interventions divided the technology in two kinds of applications: hospital-home and interhospital communication. In the first case, the communication occurred between the doctor and the patient or his caregiver, while he was at home. In the second, the patient and the doctor were in different institutions at the same time. Based on that experience AHQR concluded that telemedicine is an effective support for emergency specialists, with regard to neurosurgical patients and in the field of critical care. After an exhaustive review, it was concluded that only in a few medical specialties the diagnostic capacity and decision making empowered by the telemedicine are comparable to those of the face-to-face visit. The highest diagnostic capacity in telemedicine was in psychiatry and dermatology.
Although telemedicine is still underdeveloped, it offers important advantages such as:
- specialized care, lowering the costs of health care in under-urban or urban areas
- interaction with other sections and services of the same or other centres
- home surveillance of high-risk or technology dependent patients
- improvement of the quality of care in any medium, freeing professionals from bureaucratic and administrative tasks
- access to countless data from multiple patients from different centres for quality control, statistical and experimental studies
- videoconferencing which opens up new possibilities for continuing education for health personnel from different locations with difficulty or inability to travel
A recent example illustrates how electronic ICU monitoring system for ICU boarders is implemented in an emergency department with the goal to investigate its effect on morbidity, mortality and ICU usage. The motivation behind the study was to find a solution to the overcrowding and limited critical care resources. Critically ill patients in the emergency department may spend hours to days awaiting transfer to the ICU. The target group of the study were the emergency department patients with admission orders for medical ICU, who spent more than 2 hours boarding in the emergency department after being accepted for admission to the medical ICU. A total of 314 patients were admitted to the medical ICU from the emergency department, 214 of whom were considered ICU boarders with a delay in medical ICU transfer over 2 hours. From the ICU boarders, 115 (53.7%) were enrolled in electronic ICU telemonitoring (electronic ICU care), and the rest received usual emergency department care (emergency department care). Age, illness severity (Acute Physiology and Chronic Health Evaluation IVa scores), and admitting diagnoses did not differ significantly between ICU boarders receiving electronic ICU care and emergency department care. Forty-one electronic ICU care patients (36%) were ultimately transitioned to a less intensive level of care in lieu of ICU admission while still in the emergency department, compared with zero patients in the emergency department care group. Among all ICU boarders transferred to the ICU, in-hospital mortality was lower in the electronic ICU care cohort when compared with the emergency department care cohort (5.4% vs 20.0%; adjusted odds ratio, 0.08).
Another study of the department of Pediatrics of the University of California, Davis, in Sacramento (CA) tried to compare the severity of illness and outcomes among children admitted to a children’s hospital PICU from referring emergency departments with and without access to a pediatric critical care telemedicine program. 582 patients from 15 emergency departments with telemedicine and 524 patients from 60 emergency departments without telemedicine were transferred and admitted to the PICU. Children admitted from emergency departments using telemedicine were younger (5.6 vs 6.9 yr; p< 0.001) and less sick (Pediatric Risk of Mortality III score, 3.2 vs 4.0; p < 0.05) at admission to the PICU compared with children admitted from emergency departments without telemedicine. Among transfers from emergency departments that established telemedicine programs during the study period, children arrived significantly less sick (mean Pediatric Risk of Mortality III scores, 1.2 units lower; p = 0.03) after the implementation of telemedicine (n = 43) than before the implementation of telemedicine (n = 95). The observed-to-expected mortality ratios of post-telemedicine, pre-telemedicine, and no-telemedicine cohorts were 0.81 (95% CI, 0.53-1.09), 1.07 (95% CI, 0.53-1.60), and 1.02 (95% CI, 0.71-1.33).
The conclusions of this study states that the implementation of a telemedicine program designed to assist in the care of seriously ill children receiving care in referring emergency departments was associated with lower illness severity at admission to the PICU. This study contributes to the body of evidence that pediatric critical care telemedicine programs assist referring emergency departments in the care of critically ill children and could result in improved clinical outcomes.
The implementation of telemonitoring in ambulances seems to have become possible from the point of view of connectivity and availability of software. Nevertheless, there are still some issues regarding privacy and security of data transmission which points out the need of appropriate data governance regulations that have to be put in place together with the technological basis.
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