Abstract
Recent studies published in the Telemedicine and e-Health journal stated the reality in Italy of the importance of telemedicine promotion during the coronavirus 2019 (COVID-19) pandemic. In Italy, we gradually approached the second phase of the COVID-19 pandemic. During this phase, the activities restarted according to a temporal plan. During the second phase, “social distancing” will continue and telemedicine will continue to play a pivotal role. Now, during the second phase of the fight against the pandemic, we need: (1) to maintain social distancing; (2) to face new imminent criticalities highlighted in recent studies published in Telemedicine and e-Health; (3) to protect fragile subjects and to support disabled subjects; and (4) to still care/rehabilitate critical patients (still present even if in a decreased number). Telemedicine is still important and must also be rethought. The study, starting from the needs of chronic patients, highlighted in the recent studies published in this journal, expanded the possibilities of multiple opportunities for telemedicine integration during the second phase. An emerged categorization takes into consideration (1) the subjects with fragility, including those with rare diseases; (2) the experience gained during the emergency; (3) the new opportunities emerged for telemedicine boundaries; and (4) the new needs for telemedicine-based pulmonary rehabilitation at home.
The Omboni 1 and the Viganò et al. 2 articles addressed the importance of telemedicine utilization during the coronavirus 2019 (COVID-19) pandemic. The articles approached this from two different angles—the technology point of view and the clinical point of view.
Omboni's article focused on the world of technology.
1
It is related and particularly centered on the first phase of the COVID-19 pandemic (the most critical phase of this pandemic), characterized by the famous Italian lockdown. The author expressed dissatisfaction with the lost opportunity to spread widely the telemedicine during the lockdown. In particular, he believes that, it is quoted verbatim “Italy was found unprepared to manage lockdown patients with chronic diseases, due to limited availability and diffusion of large-scale telemedicine solutions.” Among the specific causes hindering the implementation of effective telemedicine solutions, the author indicates specifically for long-term patients' management: The scattered distribution and heterogeneity of available tools. The lack of integration with the electronic health record of the national health system. The poor interconnection between telemedicine services operating at different levels. The lack of a real multidisciplinary approach to the patient's management. The heavy privacy regulations, and lack of clear guidelines, together with the lack of reimbursement.
The second article by Viganò et al. 2 comes from the world of the clinic and offers some considerations that emerged during the first phase of the pandemic. These considerations are related to their direct experience. They noticed that from March 1 to April 15, 2020:
The mean number of patients for month admitted to the emergency recovery dramatically dropped during the pandemic and were largely caused by a drop in neurological, gastrointestinal/liver, and heart diseases.
The mean number of visits of the outpatient clinical activity dropped in all the medical specialties.
Viganò et al. 2 are worried because this is likely to have two major outcomes in the near future: (1) an increase in morbidity and mortality rates for nonrespiratory diseases (as also supported by Cosentino et al. 3 ) and (2) the need to increase the capacity of the hospitals. Therefore, the strong need to reason also in terms of telemedicine to aid the health care for the next months.
In Italy, we gradually approached the second phase of the pandemic. During this phase, the activities restarted according to a temporal plan.
During the second phase, the keyword will continue to be “social distancing.” Telemedicine will, therefore, still have a pivotal role. The Omboni 1 and Viganò et al. 2 articles must both inspire and force a reflection of the scientific community. This is particularly important in the regions where the diffusion of telemedicine has margins of improvements. 1 As it has been written by Bashshur et al., 4 we must treasure the experience evolved during the emergency. Now, during the second phase of the fight against the pandemic, we need the following:
To maintain social distancing.
To face imminent criticalities highlighted by Viganò et al. 2
To protect fragile subjects and to support disabled subjects.
To still care/rehabilitate critical patients (still present even if in a decreased number).
Telemedicine is still important and must also be rethought. It also must be considered that recent studies do not exclude a resurgence of the pandemic in the autumn (and, therefore, to return again to the typical activities of the first phase 5 ). In a sense, the studies of Omboni and of Viganò et al. have, from one side, the role to stimulate both scholars and stakeholders to reinforce and stabilize the role of telemedicine and from, the other side, to introduce the debate on the role of telemedicine in the second phase, starting from the needs of chronic patients, which they have highlighted, 1,2 and further expanding the possibility of multiple opportunities.
The Renewed Opportunity of Telemedicine in the Second Phase
During the first phase of the pandemic, we scholars had the opportunity to observe the impact of telemedicine during the emergency. Now it is time to think about its intensive use when the emergency has diminished, but the risk of contagion is still present. Figure 1 illustrates some shareable directions of the development described in the following sections.
The renewed opportunity of telemedicine in the second phase of the COVID-19 pandemic.
Telemedicine and Fragility for Multiple Chronic Diseases
Certainly, a very important sector, where telemedicine must intrude is that of the frail. All of us have observed how the impact of the COVID-19 pandemic has been particularly strong on frail: those subjects suffering from single or multiple chronic pathologies (often elderly but not always), frequently disabled, and those with an unstable health status. Furthermore, during the pandemic, the concept of fragility has been expanded. Subjects previously not considered fragile, but with the need of attention for their chronicity in relation to the COVID-19, are now considered COVID-19 fragile. In this sense, we can certainly also include the subjects at risk indicated by Omboni 1 and Viganò et al. 2 Personally, I agree with Viganò et al. on the increased health risks for some patients who had avoided the emergency room during the crisis and, therefore, increased their fragility. However, I think that some restrictions (e.g., the limitation of motor activity and social interaction) probably will have an additive impact on these risks 6 and, therefore, on the increase of the fragility (due to correlation, e.g., of the poor physical activity with the increase of some pathologies such as, e.g., the diabetes and the heart disease).
Telemedicine and Fragility for Rare Diseases
Figure 1 separates the fragility caused by a “Rare Disease.” As it is well known, a Rare Disease can generate multiple chronicity and disabilities, all together. During the emergency, a special work group at ISS (the Italian NIH) was dedicated to support the Rare Diseases. The group has continually highlighted the importance of the role of telemedicine for those subjects. 7,8 Typically, a fragile subject with a rare disease has a very rare pathology that may require not only a pharmacological intervention but also a personalized motion rehabilitation support, a behavioral therapy, and a communication support. A telemedicine application must be in this case tailored to the patient.
Television, Telecooperation, and Teleconsultation
Figure 1 also reports all those telemedicine solutions stabilized during the first phase: television, teleconsultation, and telecooperation. These solutions have yet shown to be useful to maintain social distance and to minimize the risk of contagion; certainly, they must continue in the second phase and, in the future. 4
Expansion of Telemedicine Boundaries
The first phase was also an opportunity to explore the new boundaries of telemedicine (Fig. 1) ranging from psychological screening using self-awareness tools 6 up to the remote investigations of new factors affecting the psychological sphere (as, e.g., the importance of the pet animals in the reduction of anxiety). This will be valid also in the second phase.
New Models for Pulmonary Rehabilitation Using Telemedicine
During the pandemic, there was a lot of discussion on the treatment of those subjects with lung problems caused by the virus. A lot of space was dedicated both to the technologies used in intensive care rooms and to the home-monitoring devices (such as, e.g., the pulse oximeters). In general, a patient returning home after weeks of intubation needs a properly designed home rehabilitation program, based also on pulmonary stimulation tools suitably integrated into e-health and m-health. Looking at the science during the COVID-19 emergency, it can be observed that the viewpoint 9 published in the Telemedicine and e-Health journal is still strongly valid.
In this viewpoint, new technological needs for pulmonary telerehabilitation were described. 9 In particular, the need to integrate dedicated devices into telemedicine processes to exercise the respiratory acts was highlighted (Fig. 1). These devices eventually could be connected with tools for the 6-min tests for monitoring 10 and with other devices for physiological monitoring (Fig. 2).
New model for lung rehabilitation for COVID-19 patients.
We must also consider that currently in the second phase, patients are still leaving hospitals after long periods of acute respiratory events. Therefore, new models, such as the already described models, could be highly useful.
Conclusions
The studies of Omboni 1 and of Vigano et al. 2 inspired reflections on the needs and potentialities of telemedicine during the pandemic, especially now while we are approaching the second phase. Italy was one of the countries hardest hit by the pandemic. The Italian lockdown model used in the first phase has been exported to many other states. Probably Italy lost the chance to be a model also for telemedicine. 1 However, there is still a chance to reflect around this and inspire models useful for the second phase. This commentary would like to be a small contribution in this direction.
Footnotes
Acknowledgment
The author gratefully thanks Monica Brocco for her support in editorial and linguistic revision.
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.