Telehealth Opportunities in the COVID-19 Pandemic Early Days: What Happened,Did Not Happen,Should Have Happened,and Must Happen in the Near Future?

Telehealth and Primary Care in the Iberian Peninsula

From the beginning of the pandemic, in Portugal, >85% of patients infected with COVID-19 were treated at home, mostly controlled at distance by primary care physicians using mass telephone consultations for mild or asymptomatic cases, ¹ as were their contacts and suspected cases, which contributed to keeping hospital (intensive) care more operative.

There was a >75% reduction of face-to-face consultations, and telehealth procedures combined with full paperless prescription allowed most patients to be followed up. The total decrease in consultations was of 6.6% compared with the previous year. ² Teleconsultation method (mainly phone) was decisive in avoiding the collapse of the care system and allowed a minimum control and support to the general population. Chronic patients, such as respiratory patients, for example, felt, however, that the lack of rehabilitation and other more specialized care had an impact on their health.

In Spain, health centers had maintenance contracts with hardware suppliers for those centers that already had audiovisual equipment. Primary care centers in the region of Extremadura have implemented contingency plans that include the transformation of nonessential consultations into telephone and videoconsultations. Nonface-to-face consultations have grown by 5,000% between January and July 2020 compared with the same period in 2019. Also, e-consultation and nonpresential prescription have been implemented.

In the Catalan region, public and private health centers asked service providers for fast, robust, and affordable videoconsultation solutions to be integrated into clinical workstations. The main challenge was the lack of infrastructure in primary care. These solutions were implemented in mid-April 2020 in almost all centers, with users requesting that support materials be available for their use.

The tools that were already implemented in some centers, such as teledermatology and teleophthalmology, telestroke, ³ or even e-consultation, facilitated the implementation to other centers. The use of personal computers with video by health personnel from their homes was allowed at large scale and was made possible by VMWare's desktop virtualization environments. This meant that from mid-April to mid-July, clinicians in Catalonia performed 11,000 videoconsultations, a number considered very low compared with the potential and necessity.

The massive implementation of nonface-to-face health care solutions did not start with the onset of the quarantine, but rather it took several weeks for professionals to have the appropriate tools. Technological solutions that could ease the strain of this pandemic already existed, but there was no real interest, or organizational inertia, in applying them widely. The telephone was the main form of contact between health professionals and patients, although professionals would have preferred a robust videoconsultation system to the telephone. Although it worked surprisingly well, we could and should have gone much further due to stagnant organizational models and government regulations still often inhibiting health care innovation promoting.

Telehealth in the Hospital and Home Care

In the Extremadura region of Spain, essential teleconsultations were maintained with external centers (asylums, prisons, and centers for the protection of minor children), as well as to support telestroke and teletraining to professionals. Scheduled nonessential consultations were transformed into telephone consultations due to a convenience factor and lack of materials. In most centers, the audiovisual equipment needed to perform the consultations did not exist previously. Another example was Maternal and Child Hospital of Sant Joan de Déu, where existing telecare services, online consultation, teleconsultation, telemonitoring, telerehabilitation, and telecare for diabetes were expanded. Telemedicine videoconferences are conducted for improving patient outcomes, maximize the resources, and encourage internal communications (Figs. 1 and 2).

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Fig. 1.

Telemedicine evolution in Hospital Sant Joan de Déu.

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Fig. 2.

Alternative site visits from September 2019 to August 2020.

Telemonitoring of Chronic Obstructive Pulmonary Disease Patients

In the Unidade Local de Saúde do Alto Minho, remote monitoring of parameters and real-time clinical intervention (doctor/nurse) controlled most of these patients in their home, allowed remote awareness campaigns focusing on containment measures, and successfully avoided any COVID-19 infection in this group.

This home tele-assistance model, which proved to be very effective in the initial phase of the COVID-19 pandemic, may be crucial in the run-up to the autumn/winter months, if it could be enlarged to more chronic obstructive pulmonary disease (COPD) and other respiratory patients.

Cardiology Perspective

The telemonitoring of symptoms, electrocardiograms, blood pressure, heart rate, and blood glucose has led to improved delivery of care in cardiac high-risk patients. Telemedicine can also play a role in cardiac rehabilitation programs. ⁴ Patients with chronic heart failure (CHF) are particularly vulnerable to respiratory infection and subsequent decompensation of the syndrome, therefore, avoiding any COVID-19 exposition by staying home is paramount.

During the first phase of the pandemic, the number of events (heart failure decompensations) was very low and similar to that of the previous year. However, patients were confined at home during the pandemic and none had COVID-19 infection (at least based on clinical symptoms). So, similar results observed during 2020 and 2019 make sense, as pandemic patients were relatively “protected” in relation to environment exposure.

Compensation was defined as the absence of symptoms (and/or clinical signs), assessed by health care professionals in response to specific questions asked to patients and caregivers during periodic remote consultations by phone. To patients with CHF included in the noninvasive remote telemonitoring program, specific questionnaires are also applied periodically by phone and evaluated in association with the transmitted patient's biodata, allowing the diagnosis of clinical and hemodynamic stability or the risk of heart failure decompensation. In this program, biodata are transmitted daily (or three times a week in stable patients) and the electrocardiogram is also performed at least once a week, by the patient or caregiver and transmitted remotely. Patients included in the CHF telemonitoring program have the necessary instruments at home, provided by the institution, and specific instruction is given so that they learn how to use them and how to transmit the biodata and the ECG remotely.

From February to July 2020 at Centro Hospitalar Universitário Lisboa Norte (CHULN), for example, there was no increase in decompensations or hospital admissions and no cases of COVID-19 infection in the patients under telephone care. During this period, several potentially severe situations were recorded, which were solved remotely, avoiding unnecessary trips to hospital and minimizing the risk of exposure. ⁵

Perspective of Dermatology

During the restriction of face-to-face visits in dermatology, strict teletriage measures were implemented to adequately prioritize the clinical activity ^6,7 in several hospitals in Portugal.

In Cardiovascular Centre of the University of Lisbon (CCUL), for outpatients, dermatology consultation system was introduced based on clinical and photographic data collected at the original point of care by local physicians, like in other Portuguese hospitals. This information was analyzed, and selected patients were teletreated and followed up; teleprescription renewal for chronic conditions and the telecommunication of diagnostic test results were also implemented. These measures had already been promoted by the national MoH degree but local adoption lagged due to resistance. Although adopted in an extremely specific context, these show that telemedicine can be practiced without compromising the quality of care.

Perspective on Rehabilitation

It has been recently estimated that ∼2.2 million Europeans were deprived of outpatient rehabilitation care daily during COVID-19–associated lockdown. ⁸ Equally there was a decrease in nonurgent hospital admissions for rehabilitation, and a delay in necessary urgent rehabilitation. ⁹ This reality has consequences in the present and future: functional deterioration in people who were already disabled, and an increase in the number of people with disabilities, such as survivors of COVID-19 in its most severe forms. In the short and medium term, more people will need rehabilitative care. In recent months, recommendations on the inclusion of telehealth in the future of rehabilitation have become commonplace. ¹⁰

The pandemic has exposed people to the danger of physical inactivity and sedentary behavior due to confinement standards. ¹¹ For patients with chronic lung disease, pulmonary rehabilitation is an integral part of clinical management and health maintenance, with both psychological and physical benefits, as it reduces anxiety symptoms and improves dyspnea, health status, and exercise tolerance. ¹² Home programs are a safe option, but patients have had to cope with conditions for which they were not prepared, including environmental factors, distress, frustration, and stress. ¹³

Patients' Perspectives

Telemedicine promotes expert and empowered patients with continuous care and health care professionals who can make more informed, timely, and accurate decisions. ¹⁴ An expert patient is a chronic patient who can take responsibility for his or her health status and self-care. He or she can identify symptoms and cope with them, as well as acquire tools to manage their physical, emotional, and social impact, so he or she will live with improved health-related quality of life.

During the early COVID-19 pandemic period, patient associations such as chronic respiratory patients, or diabetic patients, were not targeted as communication channels by authorities. A more active role could have reduced anxiety in many patients, and better inform them about what was happening, but especially what it really means for them. Particularly respiratory patients were disturbed as many of the exacerbation symptoms of COPD are close and resemble COVID-19 presenting symptomatology. Informed patient associations could have provided informative telehealth services to patients and families who already know and trust them.

Although the training of patients and caregivers has to improve with specific programs, it is even more significant in this era of the pandemic. Instruction has become urgent if we want to reduce the number of patients seen in primary care centers.

What Should Have Happened and Must Happen in the Near Future?

It would be highly advantageous to use the current situation to implement without delay field teams, applications, action, and articulation programs that, unlike what has been in place until now, benefit significantly from the existing technological and organizational potential.

In Portugal, there should have been a better coordinated approach between hospitals and health or government clinics. The health system includes a public and a private health care, but government dictates general rules that shall be applied for both. However, as the two systems are not directly interrelated, a better local coordination (either intra- or interinstitutions) should have been desirable.

It requires a more organized national/regional approach to telehealth tools, involving not only professionals and technology but also patient groups and companies that offer e-health services. Responding rapidly with phone-based services should and could have been followed by more complete telehealth technologies after the immediate response, including the promotion of telerehabilitation and the expansion of remote clinical assistance pilot or small programs to larger populations of well-known chronic patients.

In Portugal, the practice of telehealth is not widespread and has been applied only in specific contexts. In most hospitals and primary care health units, there is no organized telehealth plan and the computers of public health institutions do not have web camera. Telephone consultation was actually more economical, simple, and convenient, even for patients, as most elderly people are not familiar with remote audiovisual communication.

Since the start of the pandemic, the advantages of telehealth are being strongly discussed; however, no practical differences have been observed in the public health system till now.

Teleeducation and distance learning were highly promoted in medical schools, but similar efforts could have been continued to educate patients and caregivers.

It is fundamental to promote good clinical practices for the management and treatment of chronic diseases and home rehabilitation. Other equally important interventions can be carried out remotely by health professionals, such as training patients (e.g., COPD patient's education about cold environments and exposure to biomass) and other professionals.

Telemedicine and telehealth strategies are urgently needed to establish organizational models and valid tools for their implementation in various scenarios. Models that allow non-face-to-face or semi-face-to-face health care for the entire population—so called mixed health care. Nonface-to-face care must take its rightful place in a digitalized society, and guarantee standards of security, quality, and equity. These strategies should revisit referencing networks, as well as contemplate the improvement of health in centers with institutionalized populations (care of the elderly, the disabled, prisons, children underage, nursing homes, etc.) using telehealth systems. These contribute to the continuity of care, the dissemination and uptake of health care protocols, and to better coordinate between health and social care.