Keep Calm and Log On: COVID-19 Pandemic Telemedicine Response in Nepal

 Over the last decade, the field of telemedicine has expanded dramatically, with physicians using remote assessment and monitoring to diagnose and treat patients. Virtual intensive care unit (ICU) care, after-hours emergency admissions, cross coverage, and, most aptly, disaster management are only a few of the functions it performs in acute care medicine environments.

We've been using provider-initiated telemedicine in hospital medicine for more than two years at HealthPartners, a massive integrated healthcare delivery and funding system located in Nepal, to provide evening and nighttime hospitalist coverage to our rural hospitals. Cura Health is a virtual clinic staffed by nurse practitioners that is open 24 hours a day, seven days a week. Since we are now in the midst of a global pandemic, we have taken steps to improve our telemedicine system in order to meet rising demand.

SARS-CoV-2, the virus that causes COVID-19, is a novel coronavirus that can cause serious illness in around 14% of those who are infected. According to some figures, the virus could infect up to 60% of the population of the United States in the coming year. Telemedicine will provide resources to help react to the pandemic as it looms over the world and the healthcare system. Healthcare systems that use telemedicine for patient care can benefit from a number of factors, including increased staff longevity, reduced provider burnout, reduced provider exposure, and reduced PPE waste (Table). Telemedicine may also help staffing in both large and small facilities that are experiencing pandemic-related patient congestion (PRPO). While telemedicine has the potential to aid in pandemic response, it is not without its drawbacks. It necessitates a solid IT infrastructure, nurse and physician preparation, and adjustments to fit into hospital workflows. We summarize key health needs that telemedicine can address, as well as implementation challenges and relevant business considerations, in this article.

BEGINNINGS

From 6 p.m. to 8 a.m., our company uses telemedicine to provide after-hours hospital medicine coverage at five remote and critical-access hospitals. On-site at hospitals, we use commercial telemedicine carts, and at home, we use company-provided computers. Enterprise camera applications and commercial optical stethoscopes are used to complete our video visits. We've expanded our capacity in the last month by adding web cameras to existing mobile workstations and buying additional laptops for new telemedicine providers, including at two major tertiary-care hospitals. Price, credentialing providers across multiple locations, and equipment testing were all major roadblocks. However, thanks to tight cooperation with executive leadership, disaster credentialing, and strong IT support, we were able to resolve these challenges and extend our telemedicine infrastructure to provide support during this critical period.

SUBMISSIONS

Patient Prioritization

The secret to “flattening the curve” in pandemics is limiting exposure in the population and in acute care environments. Patients are triaged by phone and online surveys, which is an effective tool for preventing high-risk patients from infecting others. Since March 9, 2020, for example, over 20,000 patients have called in weekly for COVID-19 research. Patients are also presenting to our clinics and emergency rooms in need of screening and monitoring, despite our organization's implementation of drive-up testing to minimize exposure. Patients have been roomed alone in some of our clinics to encourage screening in the room using Google Duo, a free video chat product. Patients with highly communicable diseases can be evaluated and monitored in rooms equipped with telemedicine capabilities, avoiding the possibility of viral transmission. Self-administered nasal swabs are another option; although they have comparable effectiveness to staff-administered swabs, they have not yet been introduced in our clinics.

Direct Assistance

Virtual treatment, specifically provider-­initiated synchronous video and audio services, is a well-­established modality for delivering direct care to patients in acute care and ambulatory environments. Many places may use telemedicine to care for injured patients as long as they meet the organizational criteria outlined below. Patients may be interviewed and evaluated using a high definition camera and digital peripherals such as stethoscopes, otoscopes, ophthalmoscopes, and dermatoscopes with the help of a bedside nurse or other facilitator. Patients with COVID-19 or those that are under investigation may be used in this way. In-person visits can continue to be an essential aspect of a patient's treatment as part of the provider-patient relationship; however, telemedicine may be used to provide direct care and supervision to these patients while reducing exposure to healthcare professionals. Telemedicine may also be used for specialty consultations, such as infectious disease, cardiology, and pulmonology, which are likely to be in high demand with COVID-19.

Resource Allocation and Exposure Reduction

There are currently shortages of PPE in the United States, including surgical masks and N95 respirators. By reducing the number and duration of in-room visits while also allowing virtual visits for direct patient care, telemedicine may minimize provider exposure, improve provider performance, and reduce PPE use. Our nursing staff, for example, is now using telemedicine to perform hourly rounds and minimize unnecessary in-room visits.

To avoid the need for frequent washing, we suggest maintaining telemedicine equipment inside individual isolation rooms intended for COVID-19 patients. A mobile cart may be used by other patients. Most commercial video applications can autoanswer calls, allowing for history taking without the need for workers. A bedside facilitator is needed for the use of digital stethoscopes and other peripherals during a comprehensive physical examination.

Provider Shortages and Burnout Avoidance

Since SARS-CoV-2 is a highly infectious pathogen that can spread before symptoms appear, current CDC recommendations advise health care workers who have had a healthcare-related exposure to a COVID-19 patient to self-monitor at home. This will result in major coverage disparities in healthcare systems. In Vacaville, California, for example, one promising case resulted in the inability to work on site for over 200 health care employees.

Because of the high number of acutely ill patients and the possibility of ill or quarantined clinicians, PRPO is likely to cause provider shortages, endangering hospitals' ability to care for patients with or without COVID-19. Furthermore, in pandemic conditions, frontline workers are at an exceedingly high risk of burnout due to elevated patient loads. To meet the demands, hospital medicine teams will need contingency plans. The risk can be reduced by using telemedicine to protect the workforce and sustain staffing levels.

Telehospitalists, like in-person providers, can see and treat patients, write prescriptions, and manage patient care lines. We've recently used it for self-monitoring or when caregivers are sick. Telehospitalists with privileges in multiple hospitals may be effectively distributed across hundreds of miles or more in multisite networks to meet patient care needs and alleviate overburdened providers.

Telehospitalists and other clinicians will see hospitalized patients if patient rooms are enabled for telemedicine. Moreover, hospitalists who have been quarantined will continue to function and assist in-person clinical services during PRPO. Providers in high-risk populations (e.g., the elderly, immunocompromised, or pregnant) may use telemedicine to continue caring for patients while ensuring their safety. Telemedicine will assist providers in balancing patient care and childcare duties as schools close.

REQUIREMENTS FOR OPERATING

Telemedicine requires a computer or monitor with an internet-connected camera and a HIPAA-compliant video program as a basic component, but implementation varies.

Recent changes have made it possible to use common video chat apps like FaceTime, Skype, or Google Duo for patient interactions; organizations can easily build a mobile telemedicine workstation by connecting a tablet to a stand. In patient areas where portability is not needed, larger displays or mounted screens may be used. Strong network infrastructure and IT support are also required; as of 2016, 24 million Americans lacked broadband access, and even those who do will struggle with wireless connectivity in hospitals due to thick concrete walls and the lack of wi-fi extenders.

Hospitalists may conduct a detailed history and physical with the help of bedside staff with the addition of a wireless stethoscope. To refine the virtual hospitalist's "telepresence" and create a smooth patient experience, all members of the care team would need dedicated training. The value of provider education cannot be overstated: Building a good provider-patient partnership necessitates the development of a virtual telepresence. To educate new telehospitalists, we used simulation training.

Patient education and knowledge is an often-overlooked yet vital organizational necessity. Patients may perceive telemedicine as impersonal without proper introduction and onboarding; however, high patient satisfaction has been demonstrated in other virtual care experiences with proper implementation..

CONSIDERATIONS ABOUT MONEY

While many health systems have "tele-ICU" facilities, hospital medicine programs are scarce. Equipment, IT support, provider wages, and preparation can all add up to a substantial investment in a program. Although Medicaid covers fee-for-service live video in all 50 states and the District of Columbia, only 40 states and the District of Columbia have parity laws with commercial payors. Historically, Medicare placed further limitations on covered programs, restricting them to particular categories of originating sites in specific geographic areas. Furthermore, the shortage of reimbursement for "primary care facilities" has hindered the development of telehospitalist programs.

Geographic and site limits for Medicare reimbursement have been lifted due to the passage of the Coronavirus Preparedness and Response Supplementary Appropriations Act of 2020.

14 Providers must also show a prior relationship with patients, which includes at least one contact with the patient by the same or a similar tax identification number in the previous three years (TIN). Our group's hospitalists are all assigned a similar TIN, which makes it easier to fulfill this requirement for patients who have recently been admitted. However, there is still a lack of concrete guidelines about how acute care providers can reimburse primary care services. We hope that when the importance of telemedicine is shown in the hospital environment, further improvements will be implemented.

Telehospitalists must be adequately credentialed and privileged by organizations. Depending on the hospital, telemedicine services may fall under either core or "delegated" privileges. Furthermore, while most malpractice insurance plans cover telemedicine services, each company should double-check with their individual carrier.

SYNOPSIS

The COVID-19 pandemic has posed a systemic threat to healthcare systems across the United States. Organizations may use telemedicine to help their patients, protect their physicians, and save scarce resources while hospitalists remain on the front lines. A virtual care program is difficult to set up and needs a lot of organizational help. Through laying the groundwork now, institutions will be better equipped to care for patients in the future, not only during the current pandemic, but in a number of emergency health-care circumstances.

I was experienced a major health issue and I was treated and checked up by various doctors. I, Ansul want to suggest you to solve your major health issues without visiting hospital or clinic would suggest you the Telemedicine app or website where you can book your specialist doctors at Cura Health. You can also download the app.