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Turning a New Chapter in Neurosurgery Outpatient Services: Telemedicine A “Savior” in this Pandemic
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.314523
Keywords: COVID-19 pandemic, neurosurgery, patients' perception, survey, telemedicine
Amol Raheja and Niveditha Manjunath contributed equally. Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) or coronavirus disease (COVID-19) pandemic has transformed clinical practice globally, with channelization of a significant volume of hospital resources and workforce to patients afflicted with COVID-19.[1] Such a reassignment of resources has created a considerable void in providing optimal healthcare in many specialties for non-COVID-19 patients. Furthermore, the lockdown in many parts of the world has left patients stranded at their homes with limited access to healthcare facilities, especially for those patients needing outpatient evaluation for non-emergent conditions. Since the onset of the COVID-19 pandemic, there has been a massive paradigm shift worldwide towards the use of telemedicine modality for remote diagnosis and management of patients using telecommunication technologies, especially after the impetus from the World Health Organization (WHO).[2],[3],[4] The Ministry of Health and Family Welfare (MOHFW), Department of Information Technology, and Indian Space Research Organization have played pivotal roles in propagating telemedicine with the establishment of the Telemedicine Task Force in India in 2005.[5],[6] However, its use in mainstream clinical practice in India was negligible until the recent pandemic when telemedicine was the only option left for most of the patients.[7],[8],[9],[10] Till date, there are a few seminal reports of telemedicine use in neuroscience from India.[11],[12],[13],[14],[15] However, none of them directly deals with the patients' perspective on the impact of telemedicine in neurosurgery. Thus, we conducted an anonymized patient survey to ascertain the lacunae in the current telemedicine practice employed in our neurosurgery department and address them for future teleconsults.
Study design This study was designed as a cross-sectional telephone-based survey of consecutive neurosurgical patients, who used telemedicine facility (audio or video-based telecommunications, which were rendered for the first time in our institute) from May 5th to July 7th, 2020 during the cessation of routine outpatient services at our department due to the COVID-19 pandemic and nationwide lockdown. Process of telemedicine A system was initiated wherein patients requiring neurosurgical advice could take an appointment for a teleconsultation, either through a web portal or the call center. Before confirmation, patients provided explicit consent for teleconsultation either verbally, or by clicking a “Yes” button on the website. Surgeons, i.e., residents or operating faculty if available, from the department initiated the teleconsult at the designated date and time. Each consultation was held for 3–15 min depending on the patient's queries and to address their concerns. If a patient had a smartphone, the teleconsultation could be converted into a video consultation, using any video-calling application available on patients' phones. No audio or video recording was stored by the surgeon. The patients with investigations, i.e., radiological or hematological were asked to send the same after obtaining their verbal consent via online messaging platforms. The same were then reviewed by the surgeons and patients were advised accordingly. The physician provided oral advice and documented the advice given on the patient's file at the hospital. If the patient had a smartphone, the surgeon sent an image of the documentation to the patient. Collection of feedback A structured questionnaire was created using the Google Forms platform [English version, [Supplementary File 1]], and translated into the Hindi language [Supplementary File 2] to ensure better patient communication in their vernacular language. To eliminate reporting bias, three individuals, who were not involved in the study design or analyses, performed telephone-based interviews for the survey. The time interval between survey and teleconsult was recorded. All patients provided verbal consent to participate in the survey, and only patients or their care providers willing to participate in the survey were included for analyses. Each patient was given 15 min to understand and respond to the questions of the survey. The institutional ethics committee approved the study. Survey questionnaire graded patients' perception of usefulness and performance of teleconsultation on a 5-point Likert scale. Subjective challenges and suggestions for optimal utilization of teleconsultation services were recorded. To reduce recall bias, apart from limiting the time interval between teleconsult and survey to less than 10 weeks, special attention was given to the interviewing techniques and quality of questionnaire by running test runs before actual interviews and simplifying the validated questionnaire in patients' vernacular language, respectively. [Supplementary File 1]:[Additional file 1] [Supplementary File 2]:[Additional file 2] Questionnaire content and validation The structured questionnaire contained 16 questions including patient informed consent, clinical diagnosis, patients' perception of the usefulness and performance of teleconsultation practice in neurosurgery, subjective challenges faced by the patients, and their suggestions to improve the current telemedicine service. Four independent neurosurgeons working at other centers, not involved in the study design, did face validation and content validation of the survey questionnaire. The validating neurosurgeons rated the relevance of each question individually on a scale of 1 to 4. Using the validation feedback, we calculated the item-content validity index (I-CVI) and scale-level content validity index (S-CVI/Avg), both of which met a satisfactory value of 1.[16] Furthermore, any other feedback related to the questionnaire was taken, and the necessary changes were made. Statistical analysis Statistical analysis was done by converting the Google Forms database into Microsoft Excel (Version 2010) and using Statistical Package for the Social Sciences (SPSS) statistical software version 23.0 (IBM corporation). Nonparametric data were expressed as numbers (percentage) and analyzed using the Chi-square test, wherever relevant. A P value <0.05 was considered statistically significant.
Patient profile A total of 330 patients utilized telemedicine facilities at our department from May 5th to July 7th, 2020. Out of the 330 patients, 231 patients (70%) provided verbal consent for their participation in the survey. The remaining patients were either not able to be contacted via telephone or refused to participate in the survey. The patients hailed from 116 districts across 16 states of India [Figure 1]. The majority of these patients were followed for cranial pathology (n = 139, 60%) followed by spinal pathology (n = 81, 35%), and peripheral nerve ailments (n = 8, 4%); [Figure 2]a. The median time to survey from their teleconsult was 19 days (interquartile range [IQR], 8–31 days).
Information technology and communication modality Of the 231 surveyed patients, 149 (64.5%) patients got the information regarding the starting of telemedicine services at our hospital via internet-based communications [Figure 2]b. At the same time, the remainder became aware via self-inquiry, mutual verbal communication, newspaper, or television news channels. The majority of the respondents (n = 211, 91%) patients had smartphones with video calling capability and available internet connectivity, while the rest of the respondents did not have access to such features [Figure 2]c. Despite the high prevalence of smartphones in the study population, only a fraction (n = 21/211, 10%) of the respondents were consulted using video-based teleconsults; [Figure 2]c. Patient satisfaction with telemedicine services Overall, 82% (n = 189) of patients felt that the teleconsultation call was made on time as per the allotted appointment schedule [Figure 3]a. The clinical diagnosis did not significantly influence the patients' perception of the relevance of telemedicine (P = 0.21); [Figure 4]a. On a Likert scale ranging from 1–5 (1 – being strongly in disagreement and 5 – being strongly in agreement), the majority of patients (61.5%; n = 142, Likert scale 4 and 5) either agreed/strongly agreed that the time allotted for their queries during teleconsults was sufficient [Figure 3]b. Overall 15% (n = 35) patients faced difficulties during teleconsults, some in the form of poor network connectivity (n = 16, 7%), while others in the form of suboptimal verbal communication and discussion (n = 13, 5.6%), lack of physical examination (n = 14, 6%), and misinterpretation of prescription by pharmacist or patient (n = 14, 6%) [Figure 3]c and [Figure 3]d. The majority (n = 133, 58%) of the respondents either agreed/strongly agreed that teleconsultation helped them tide over the medical exigency during the lockdown and nearly similar (n = 139, 60% agreed/strongly agreed) wanted us to continue with the service for their benefit [Figure 4]d. Interestingly, we also observed that 33.3% of patients (n = 77) will prefer teleconsultation services over physical outpatient services even after its resumption, and an additional 26% of patients (n = 59) said they would like to have the option of teleservices in future as well [Figure 4]c.
The vast majority of the patients (n = 225, 97%) felt that teleconsultation is beneficial [Figure 4]b. The primary reasons for perceived advantage were minimizing the exposure to potentially COVID-19 positive patients/staff in hospital (n = 206, 89%), reduction of travel expenditure (n = 155, 67%), efficient utilization of time and resources for patients and their caregivers (n = 113, 49%), and allaying the hassles associated with traveling with a dependent patient (n = 56, 24%) [Figure 4]d. Moreover, 55% of the respondents (n = 127) felt that the overall performance of present telemedicine services in neurosurgery was either above/far above standard [Figure 5]a. Upon inquiring about any constructive criticism or suggestions to improve our telemedicine services (n = 74, suggestions received), the most frequent suggestion was to include video-based teleconsults as the primary mode of communication (n = 39, 53%), preferably using a dedicated professional app for the same. In addition, patients requested for direct communication with senior attending (n = 22, 30%), additional calling lines for emergency services (n = 10, 13%), and requests for interdepartmental transfers (n = 3, 4%); [Figure 5]b.
The study has demonstrated that despite challenges of poor network, lack of physical interaction, and so on, a large proportion of patients in neurosurgery practice agreed that teleconsultation helped them tide over the medical exigency during the lockdown and want the hospital to continue with the service in the future. They found teleconsultation to be beneficial, and preferred the video mode of telecommunication. Telemedicine in neurosurgery – Future or fallacy Despite the conceptualization and formulation of the Telemedicine Task Force in India in 2005, there has been only limited use of telemedicine in routine clinical practice.[5] The limited use of telemedicine was primarily due to lack of appropriate telecommunication infrastructure, high-speed internet connectivity, patient and healthcare provider unawareness, associated medico-legal issues of prescribing/treating without physical evaluation, and reimbursement issues [Figure 5].[17] COVID-19 pandemic has forced both the patients and healthcare workers to adapt to the changing health scenario amid the limited available options for rendering continued patient care. The evolution of better telecommunication infrastructure, high-speed internet connectivity, and pressing needs in the COVID-19 era have led to the rapid adoption of telemedicine in routine practice.[17] Despite its inherent limitations, telemedicine in neurosurgery is there to stay, even in the post-COVID-19 era. We observed that 58% of patients either agreed or strongly agreed that teleconsultation helped patients significantly during the nationwide lockdown period. Moreover, the majority of patients (60%) agreed/strongly agreed that, for patient safety, it is an acceptable option to continue teleconsultation practice for follow-up neurosurgery patients until the COVID-19 pandemic is over. Interestingly, we also observed that one-third of patients will prefer teleconsultation services over physical outpatient services even after its resumption, and an additional 26% of patients said they would like to have the option of teleservices in the future as well. In general, the vast majority of patients (97%) felt that teleconsultation has at least one advantage. This benefit is likely to be more apparent for patients coming from remote areas in our country to get an outpatient consult. Telemedicine offers massive advantages in the form of rapid triage, reduction of travel expenditure, efficient utilization of time and resources, and minimizing the risk of acquiring COVID-19 infection through hospital exposure.[17] However, to ensure a smooth transition to telemedicine practice, continuous patient feedback mechanisms and training of healthcare providers are paramount. A keen observation was also made that the clinical diagnosis of a patient did not influence the patients' perception of the relevance of telemedicine (P = 0.21). Similar findings were observed in a study from the Department of Urology, Johannes Gutenberg University, where they demonstrated no significant difference between patients of benign or oncological diagnosis opting for telemedicine.[18] Integration of information and technology in telemedicine – Roadmap ahead The integration of electronic medical records of patients into app-based telemedicine consults holds the key to effective communication, decision making, and treatment prescription for patients using this technology.[19] Real-time assessment of patients' physical data using principles of telemetry and rapid sharing of patients' neuroimaging could enable a more comprehensive tele-evaluation and management strategy. The widespread availability of 4G internet services and low-cost data packs holds the key to successful telemedicine practice, even in remote areas of our country. The much-anticipated launch of high-speed 5G internet connectivity could further bolster the telecommunication framework for efficient telehealth services.[20] The impact of the existing internet services can be validated by the fact that the majority of patients (64.5%) got the information regarding the starting of telemedicine services at our hospital while surfing the internet. Moreover, during teleconsultations, almost 93% of patients had no network or internet related connectivity issues, again emphasizing the existing robust telecommunication framework in India. We also noticed that 91.3% of patients had smartphones with video-calling enabled features and a significant proportion of the respondents who gave their constructive criticism or suggestions (53%), felt that video-based teleconsults should be the primary mode of interaction. Similarly, a study from a neurosurgical facility in the United States (US), noted that video calls are useful to examine patients.[21] The authors further opined that except for a few cranial nerve examinations, the majority of the clinical examination could be done successfully over a video call. The authors further recommended appropriate positioning and lighting for the performance of successful neurological examination over video calls.[21] Furthermore, the inclusion of artificial intelligence (AI)-based tools to enable machine learning can help refine patient diagnosis and optimize treatments via telemedicine interface.[19] Moreover, AI-based applications can map out the best physicians for a particular disease and geographic area, and assist in timely referral.[19] Medicolegal liability, prescription, and reimbursement issues – Pearls and pitfalls In the past, rampant use of telemedicine practice was kept on a tight leash due to a lack of defined legal framework in India, which left interpretation of laws to individuals, and neurosurgeons were at high risk of being sued for frivolous malpractice suits. With the gazette notification and release of updated telemedicine practice guidelines on March 25, 2020 by the MOHFW, Government of India (GOI), and its addition to the Appendix 5 of the Indian Medical Council (IMC; Professional Conduct, Etiquette and Ethics) Regulations, 2002, various gray zones in the earlier recommendations were clarified, and it has empowered medical practitioners to practice telemedicine within the prescribed legal framework.[22] However, the emergency cases requiring in-person visits, telesurgery, and prescription of certain restricted drugs are still not permissible as per the guidelines. Moreover, telemedicine may have a limited role in medicolegal cases requiring more detailed documentation, which ironically comprise a significant proportion of neurosurgery practice. The mode of teleconsult has been specified as a video for new patients. Prescription of medical treatment is another loophole in the current telemedicine practice guidelines. As per the notification, registered medical practitioners (RMP) should only prescribe if all the relevant information is gathered and is deemed adequate, and the prescribed medicines are in the best interest of the patient.[22] There are specified restricted lists of medicines that can be prescribed in case a new patient consults and for follow-up consulttions. Prescribing medicines without an appropriate diagnosis/provisional diagnosis will amount to professional misconduct.[22] Limitations in prescribing medication may further limit the practical applicability of a large-scale successful telemedicine model in India, especially if safe prescription practices are going to be the Achilles heel of telemedicine. Lastly, the nitty-gritty of a direct patient to RMP financial transaction, payment of teleconsult charges via teleconsult apps, and reimbursement via insurance companies may need some sorting out to streamline the current telemedicine practice. In the US, the relative value units (RVU)-based system is utilized to calculate the medicare reimbursement formula for physician services to standardize the value for service provided.[23] Similar standardization mechanisms need to be put in place for uniform coding of telemedicine services rendered in our country. Patient confidentiality and data privacy – Pandora's box The laws concerning medical ethics, including professional norms for patient confidentiality and data privacy, have been laid out as per the IMC act.[24] However, there is a potential for misuse of patients' personal and sensitive information using the telemedicine facility. It can be due to malicious software or teleconsult apps being utilized, or due to the utilization of non-Health Insurance Portability and Accountability Act (non-HIPAA), US compliant teleconsult platforms.[25] Hence, it has been clarified in the GOIs latest guidelines, appended to IMC regulations 2002, that an RMP will not be held liable for any breach of privacy if there is reasonable evidence to believe that the fault lies with the software/app being utilized for teleconsult or a person other than the RMP.[24] Overall, the sanctity of patient confidentiality needs to be upheld with the utmost care, and all necessary precautions should be taken to ensure it. There is a dire emergency to develop a secure, rules compliant video-conferencing facility in India to guard data privacy. Future of telemedicine in India Telemedicine use in India has rapidly expanded in the last 3–4 months despite many infrastructural, social, medicolegal, and economic challenges precluding its use. India had 1026.37 million active mobile users in 2019,[26] and a recent report pegs the usage of smartphones by 36.2% of users in 2021.[27] The number of users of smartphones is showing a year-wise increment trend from 2014 onwards. Our survey shows the use of smartphones by 91% of respondents, which may be an overestimation of actual numbers. This selection bias maybe since those with access to technology, could only book the telemedicine appointment in the beginning. Compared to 2015, mobile phone internet use has nearly doubled in 2021 (18% vs 34%), thus telemedicine facilities can now be extended to many users and our services should quickly adapt to changing times and needs.[26] Lack of regulatory framework has also been considered as a roadblock to telemedicine's widespread use in India. This issue has been tackled partially by the recent release of Telemedicine Practice Guidelines, by the GOI, and ambiguity about what is permissible via telemedicine and what is not has been lifted.[22] On the social front, patients in India are not accustomed to a digital interface while interacting with healthcare providers. Another important aspect for countries with universal healthcare and low-cost outpatient services, such as ours, is the fact that many patients would still prefer coming to the hospital for in-person consultation as it's always perceived as more gratifying than a teleconsult.[28] This barrier can be removed by educating and increasing awareness among patients that not all ailments require physical visits to the hospitals, especially relevant during the current pandemic. Successful integration of telemedicine into routine clinical practice will also require tectonic cultural and behavioral modification of healthcare providers in our country, as pro bono advice by doctors over the telephone is a routine practice in this part of the world.[29] Moreover, remuneration issues are still likely to plague rapid transfer to telehealth platforms. However, many of these issues can be settled by targeted media outreach, which can improve the overall perspective of patients and caregivers for accepting the dawn of a new era in global healthcare [Figure 6].
Telemedicine in neurosurgery offers a valuable alternative to physical clinic services, especially during the COVID-19 pandemic. Video-based teleconsults should be the preferred modality of communication for neurosurgery patients, irrespective of the clinical diagnosis. The integration of electronic medical records to the teleconsult platform, use of telemetry for remote physical assessment, rapid transfer of neuroimaging using high-speed internet connectivity, and incorporation of AI-based tools into telemedicine practice will hold the key to effective telecommunications, rapid diagnosis, correct decision making, and optimal management strategy in neurosurgical practice. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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