Abstract
Background:
There is increasing interest in the use of telemedicine as a means of health care delivery especially in circumstances of pandemics. This is partly because technological advances have made the equipment less expensive and simpler to use and partly because increasing health care costs and patient expectations have increased the need to find alternative modes of health care delivery.
Introduction:
Telemedicine and telepsychiatry, in particular, are rapidly becoming important delivery approaches to providing clinical care and information to patients in cases wherein the medical resources and the patients are very hard to be brought together with respect to rules of behavior in case of epidemics.
The reliance on technology to bridge the obstacles between the patients (consumers) and medical resources (providers) can create problems that impact service delivery and outcomes, but in cases such as this (COVID-19 pandemics), this is virtually the only tool for providing clinical care and information to patients.
Materials and Methods:
A client satisfaction survey was undertaken in a daily hospital (a part of University Clinic of Psychiatry in Skopje). The anonymous modified self-report questionnaire (short form patient satisfaction questionnaire [PSQ-18]) covering demographic, gender, and age variables was endorsed by 28 participants. The mean age of the subjects was 40.25 ± 22 years, with a small majority of men (18 participants) versus women (11 participants).
Results:
Overall satisfaction with psychiatric care was high (80.22%). None of the demographic or other variables correlated significantly with satisfaction.
Discussion:
We had to reduce rate and time length of our face-to-face contacts with patients as a result of pandemics but they were able to reach their doctors virtually at all times.
Conclusions:
Many mental health professionals are using widely available, commercial software downloaded from the internet to provide care directly to a patient's home.
In Greek (1923 Loeb edition)
ὄμνυμι Ἀπόλλωνα ἰητρὸν καὶ Ἀσκληπιὸν καὶ Ὑγɛίαν καὶ Πανάκɛιαν καὶ θɛοὺς πάντας τɛ καὶ πάσας, ἵστορας ποιɛύμɛνος, ἐπιτɛλέα ποιήσɛιν κατὰ δύναμιν καὶ κρίσιν ἐμὴν ὅρκον τόνδɛ καὶ συγγραϕὴν τήνδɛ:
ἡγήσɛσθαι μὲν τὸν διδάξαντά μɛ τὴν τέχνην ταύτην ἴσα γɛνέτῃσιν ἐμοῖς, καὶ βίου κοινώσɛσθαι, καὶ χρɛῶν χρηΐζοντι μɛτάδοσιν ποιήσɛσθαι, καὶ γένος τὸ ἐξ αὐτοῦ ἀδɛλϕοῖς ἴσον ἐπικρινɛῖν ἄρρɛσι, καὶ διδάξɛιν τὴν τέχνην ταύτην, ἢν χρηΐζωσι μανθάνɛιν, ἄνɛυ μισθοῦ καὶ συγγραϕῆς, παραγγɛλίης τɛ καὶ ἀκροήσιος καὶ τῆς λοίπης ἁπάσης μαθήσιος μɛτάδοσιν ποιήσɛσθαι υἱοῖς τɛ ἐμοῖς καὶ τοῖς τοῦ ἐμὲ διδάξαντος, καὶ μαθητῇσι συγγɛγραμμένοις τɛ καὶ ὡρκισμένοις νόμῳ ἰητρικῷ, ἄλλῳ δὲ οὐδɛνί.
ὅρκον μὲν οὖν μοι τόνδɛ ἐπιτɛλέα ποιέοντι, καὶ μὴ συγχέοντι, ɛἴη ἐπαύρασθαι καὶ βίου καὶ τέχνης δοξαζομένῳ παρὰ πᾶσιν ἀνθρώποις ἐς τὸν αἰɛὶ χρόνον: παραβαίνοντι δὲ καὶ ἐπιορκέοντι, τἀναντία τούτων.
In English
I swear by Apollo Physician, by Asclepius, by Hygeia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.
To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician's oath, but to nobody else.
Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I break it and forswear myself, may the opposite befall me.
Translation by W.H.S. Jones.
Introduction
The idea of telemedicine started with a group of doctors from North Macedonia that attended a seminar of telemedicine in Alaska and Arizona in 2007. Several seminars were organized in the years after this initial training in states of Balkans region (North Macedonia, Kosova, Montenegro and Albania) to provide basic knowledge of telemedicine for medical professionals and to identify stakeholders, possible weaknesses and obstacles in respective states for establishing sustainable telemedicine system. Due to different challenges, some states were successful in building a telemedicine system while others were not. Among the latest was North Macedonia. 1
The COVID-19 pandemic has changed health care delivery throughout the world. People must keep their distance from one another, yet they must also receive health treatment. In these circumstances, there was fairly only one method that could fulfil both requests—abridge physical distance between patient and doctor while delivering health care and thus keeping medical security high.
Due to its specifics, telepsychiatry was even more suitable. Thanks to the latest development in telecommunication technology, both psychiatrists and their patients were able to connect, run through psycho diagnostics and even recommend (pharmacology and psychotherapy) treatment, all that by keeping necessary physical distance in the process. 2
Methods
A client satisfaction survey was undertaken in daily hospital, a part of the University Clinic in Skopje, North Macedonia. The anonymous self-report questionnaire (short form patient satisfaction questionnaire [PSQ-18]) covering demographic, gender, and age (as well as satisfaction with service) variables was endorsed by 28 participants. 3
The mean age of the subjects was 40.25 ± 19 years, with a small majority of men (18 participants) versus women (11 participants). Vast majority of participants were from the capital, Skopje (26), and only 2 of them were from settlements nearby. All of them were patients in our ward during past few (4–6) months, both during the period of COVID-19 pandemics and before it. This was opportunity for patients to notice the difference between “face-to-face” treatments versus telepsychiatry.
There are seven subclasses in PSQ-18: (1) general satisfaction, (2) technical quality, (3) interpersonal manner, (4) communication, (5) financial aspects, (6) time spent with doctor, and (7) accessibility and convenience. The scores of each subclass are obtained by adding the scores of the items that make it up and dividing by the number of items to get a score that will be compared between the subclasses. For the overall scale, all scores are added. Higher score = greater satisfaction with treatment, for each subclass, as well as for the whole scale.
The short-form instrument, the PSQ-18, contains 18 items tapping each of the seven dimensions of satisfaction with medical care measured by the PSQ-III: general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with doctor, and accessibility and convenience. PSQ-18 subscale scores are substantially correlated with their full-scale counterparts and possess generally adequate internal consistency reliability. Moreover, both the magnitude of the correlation coefficients and the overall pattern of correlations among PSQ-18 subscales are highly similar to those observed for the PSQ-III. These preliminary analyses support the use of the PSQ-18 in situations where the need for brevity precludes administration of the full-length PSQ-III.
Results were presented by descriptive quantitative analysis, in percentage.
Results
All of the patients fulfilled their questionnaires. Overall patient satisfaction was high—80.22%.
Answers to PSQ-18 in complete are given in Table 1. As for other subscales, results are given in Table 2.
Overall Results
Variables Results
In our health system, it is quite hard for patients to make an appointment with a specialist especially if one lives out of Skopje; it is a demanding task, especially in financial aspects. Therefore, it is not a surprise that subscales “financial aspects (questions 5, 7)” and “accessibility and convenience (questions 8, 9, 16, 18)” have the highest averages.
Analyzing added variables (gender, age, and place of living), no significant differences occurred.
Discussion
Patients usually come in our daily hospital every working day around 8:30 am and leave around 2:30 pm. During this period of time, they commit themselves to various activities in our ward (group work, creative therapy, psychotherapy, etc.). But, for the rest of the day and on weekends, they are on their own. Frequently, patients expressed their wish at least to be in contact with us (doctors) even when they are out of our ward. To fulfill our commitment as doctors, we agreed to be on disposition to our patients by means of telepsychiatry in the afternoon from 6:00 pm to 8:00 pm. This was greeted by patients because this would lessen their fear that “they would not know what to do if their situation worseness in the evening.” Unfortunately, our efforts were met with distrust.
The health system in North Macedonia was distrustful of telemedicine for quite long but COVID-19 pandemics changed it all, since it was obvious that only telemedicine could fulfill requirements of the World Health Organization concerning pandemics.
The current dilemma facing health care systems worldwide is how to sustain the capacity to provide service not only for those afflicted with COVID-19 but also for patients suffering from other acute and chronic diseases while protecting the physicians, nurses, and other allied health personnel. It is no surprise that health systems globally are now resorting to telemedicine to provide care while keeping patients in their homes. The massive conversion to telemedicine demonstrates its utility as an effective tool for the so-called social distancing in clinical or other settings. 4
We had to reduce rate and time length of our contacts with patients: twice a week for ∼2 h respecting all precautions (wearing face masks, keeping distance, etc.). Thanks to the telepsychiatry system, patients were able to reach their doctors virtually at all times. From patients' standpoint, they (maybe) lost some time of “direct” (face-to-face) contact but they gained a lot of telepsychiatry time to be with their doctors.
Maybe the best examples of how patients feel about this kind of treatment are answers to question numbers 8 (“I have easy access to the medical specialists I need”) and 18 (“I am able to get medical care whenever I need it”): >71% of participants “strongly agreed” or “agreed” with this statement given in the questionnaire.
Conclusions
Mental health professionals today are using inexpensive technologies available through the proliferation of personal computers, the internet, mobile devices, and videoconferencing software to provide mental health services. For example, many mental health professionals are using widely available commercial software downloaded from the internet to provide care directly to a patient's home or other noninstitutional setting. 2
This is a rapidly growing and evolving field, and the risks and benefits of telemental health services delivered using videoconferencing technologies are not widely discussed or addressed in formal training of mental health practitioners. Therefore, thoughtful elucidation of the key issues and the potential solutions are needed to better inform those who want to practice responsibly.
Lessons Learned
The proliferation of relatively cheap devices and software allows even states in transition, such as North Macedonia, with limited resources and capacities to develop simple yet effective telepsychiatry activity. Even having in mind that this telepsychiatry system was brought to life under pressure of pandemics with COVID-19, it still shows the vitality of the public health sector at least to react to threats for public health when necessary.
In the long run, the future health system must triage patients to encourage appropriate and discourage inappropriate use of services. Ideally, the triaging system would be implemented state wide or region wide for maximal efficiency. Telemedicine offers tools for implementing triage at the point of need. 5
For the moment, cooperation between clinic, health insurance fund, and ministry of health is on a very high level, allowing the clinic telepsychiatry consultation “from home,” for both patients and medical staff.
We can only hope that this system will continue functioning (and, of course upgrade) after the pandemic is over because one old Macedonian saying says: “Ceкоe лошо, зa добpо” (“Every bad (thing), for (brings something) good”).
Footnotes
Acknowledgments
Dr. K.H. acknowledges and dedicates this work to his teachers of telemedicine—Dr. Rifat Latifi, Professor Charles Doarn, and their associates.
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received.