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Is Patient Care Losing its Personal Touch? Exploring the Paradigm Shift in Health-care Systems

2023; Medknow; Volume: 10; Issue: 3 Linguagem: Inglês

10.4103/ijves.ijves_67_23

2394-0999

Edwin Stephen, Darpanarayan Hazra,

Patient Satisfaction in Healthcare

INTRODUCTION The COVID-19 pandemic brought about seismic changes in the health-care landscape worldwide. To meet the urgent need for social distancing and reduction in physical contact, telemedicine (teleconsultation, WhatsApp, Google Meet/Team, and Webex) emerged as an indispensable tool for providing medical care to patients.[1] This entailed the remote delivery of health-care services, including consultations, prescription reviews, and appointment scheduling. The pandemic has underscored the immense value of advanced digital technology in delivering patient care from a distance, leading to a rapid adoption of teleconsultations and remote consultations. In this article, we explore the suitability of telemedicine as a health-care delivery model and delve into its advantages and challenges.[1,2] TELEMEDICINE'S ROLE IN GENERAL PRACTICE Remote consultations have become a cornerstone of telemedicine, and vascular surgeons have had to adapt. It enables the exchange of medical information and enhances patients' clinical well-being, especially when physical proximity between the patient and their surgeon is not feasible.[2–4] However, this transformation prompts critical questions about patient confidentiality. Should consent be obtained for every telemedicine consultation? Should sessions be recorded? What are the potential consequences of the unauthorized use of patient images for educational or publication purposes? How can we address the ethical and practical implications of prescribing medications or suggesting treatment plans without a physical examination? These questions form the core of our review as we navigate the intricate landscape of telemedicine in vascular surgery. EXPANDING HORIZONS OF TELEHEALTH Telehealth, a subset of e-health, encompasses a wide range of digital tools and platforms designed to enhance human health.[5] It includes the delivery of health-related information to health-care professionals, health-care worker education, health-care management, and direct medical services for patients through virtual channels. Telehealth transcends mere remote interactions and offers a diverse array of applications, such as patients monitoring their blood pressure, heart rate, and oxygen saturation levels through mobile applications, accessing laboratory reports, booking appointments, ordering medications online, and receiving reminders for medication refills, vaccinations, or medical checkups.[6–8] The advantages of telehealth are substantial. Remote health monitoring allows for preventive checkups, bridging the gap between physical health-care settings and patients' locations. Physicians can remotely track patients' health progress, identify abnormalities, and address minor issues before they escalate; thanks to devices that record data such as weight, blood pressure, and pulse rate. Video consultations foster seamless connections between patients and health-care providers, enabling discussions about treatment plans and sharing medical reports. Telehealth also promises significant cost savings by reducing infrastructure and maintenance expenses. Importantly, it enhances health-care accessibility, particularly in rural areas with Internet access, enabling patients to consult specialists even in cases of limited mobility or caregiver absence while addressing challenges related to time and transportation.[5,7,8] TELEMEDICINE'S IMPACT AND LIMITATIONS Telemedicine is a transformative force in health care, enabling physicians to deliver care remotely through communication tools for diagnoses, consultations, and treatment. During recent epidemics/pandemics, telemedicine applications have played a critical role in ensuring the delivery of quality remote health care. According to the World Health Organization, telemedicine is synonymous with "healing from a distance." It allows for real-time information sharing and remote prescription authorization. Examples range from sending X-ray reports online to consulting with physicians through video chat for chronic conditions, unusual skin conditions, or nonhealing ulcers. Telemedicine reduces pathogen exposure, provides around-the-clock care, enhances doctor safety, supports chronic disease patients, and offers valuable psychiatric support.[1,4,8] Despite the transformative potential of telemedicine, it is not without limitations. Urgent medical interventions, such as those needed for cardiac arrest, trauma, or strokes, remain outside its scope. Telemedicine excels in addressing symptoms, conducting follow-ups, and performing health checkups, but falls short in handling emergencies requiring immediate physical intervention. A vascular surgeon needs to examine patients to give appropriate advice and help make an informed decision. The "personal touch" is lost and so is the rapport that one builds with a patient and their carers with the use of telemedicine. THE PARADIGM SHIFT IN HEALTH CARE The COVID-19 pandemic accelerated the shift toward virtual health-care models, a trend expected to persist and rise. As early as 2020, outpatient appointments in India (and the world over) predominantly transitioned to telephone or video formats, a trajectory likely to continue and get refined.[1] While the advantages of time and cost savings are evident for both health-care systems and patients, the suitability of telemedicine for specialized fields like vascular surgery remains uncertain.[9–11] Alarming evidence suggests that this new normal could exacerbate existing health disparities, particularly in underserved populations, further magnified by the pandemic's impact. Telemedicine holds the potential to mitigate patient access constraints and enhance the education of general practitioners (GPs). Existing literature reveals that many GPs favor a care model that provides virtual access to specialists, offering expert guidance for complex cases rarely encountered in routine practice. Telephone/virtual consultations emerge as a promising alternative to face-to-face primary care, especially in sparsely populated rural areas where providing primary care necessitates extensive travel and is gaining traction globally. However, the substantial adoption of telemedicine in India occurred postpandemic, with numerous doctors relying on it as their primary source of income.[4,6,7] In India, telemedicine offers a comprehensive range of services, including specialist consultations, disease management, and videoconferencing with experts across various medical and surgical fields. Clinician perceptions of telemedicine vary, encompassing concerns about heightened administrative burdens and the loss of visual inspection as a diagnostic tool. The deployment of telemedicine during the pandemic may have contributed to these frustrations. Nevertheless, refining the system's design through interventions like appointment reminders and a gradual shift from in-person to telemedicine appointments could enhance the clinician experience. BALANCING CONVENIENCE AND COMPREHENSIVE CARE The efficiency of telemedicine in terms of time and cost savings remains uncertain. While patients appreciate the convenience of avoiding travel and work disruptions, concerns persist regarding missed calls, appointment delays, and the absence of physical examinations, considered pivotal for comprehensive care. Clinicians share similar concerns about the inability to physically examine patients, with the significance of examinations varying based on patient health and diagnosis.[2,3,5,6] Both patients and clinicians emphasize the paramount role of personal relationships and rapport in health care, with patients valuing clinician demeanor and personality alignment over the consultation mode. Furthermore, the absence of holistic care and multidisciplinary team support in remote consultations poses a challenge, hindering the delivery of patient-centered care. Achieving widespread successful integration of telemedicine may require addressing these concerns and establishing an equilibrium between convenience and comprehensive care. OBTAINING INFORMED CONSENT AND ENSURING PATIENT CONFIDENTIALITY In most countries, obtaining official informed consent from patients is a prerequisite for delivering telehealth treatment. It is advisable to consistently secure consent for telehealth appointments due to varying country-specific requirements. Patients can provide consent through signed paperwork completed before each session or verbally at the session's outset. If additional participants, such as caregivers or other providers, are involved, they must also grant consent. Recording informed consent involves reassuring patients about the privacy of their shared information, addressing confidentiality with children and adolescents, specifying when information may be shared, clarifying the extent of information access (especially regarding electronic medical records), ensuring discretion during appointments, and confirming that household members respect the patient's need for privacy.[12,13] Given the likelihood of discussing sensitive and confidential matters during telemedicine consultations, it is crucial to obtain both verbal and written consent. In rare instances where patient images might be used for educational or publication purposes, introducing oneself by stating name and credentials is essential. Ensuring both you and the patient are in a private setting conducive to open discussion, utilizing the device's camera to survey the room at the beginning of a video session, and using headphones to prevent eavesdropping are important steps.[12,13] Public Wi-Fi should be avoided, and password-protected devices should be used when logging into the telehealth visit. Using a patient's medical history for publication without their consent can result in legal repercussions, including privacy law violations, breaches of doctor–patient confidentiality, civil lawsuits, professional penalties like disciplinary actions, and, in extreme cases, criminal charges such as identity theft or fraud. MALPRACTICE AS A DOWNSIDE OF TELEMEDICINE The Mint online portal recently exposed disconcerting malpractices associated with Pristyn Care, a telemedicine start-up specializing in elective surgeries. As founded in 2018, their approach involves partnering with hospitals, leasing operation theaters, and utilizing digital marketing and a robust sales team to convert online inquiries into surgeries across various medical specialties. In addition, the company brings its own doctors, medical equipment, and supplies, potentially isolating patients from the broader hospital ecosystem. This hybrid health-care model combines digital marketing, assertive sales strategies, and competitive surgical pricing, reflecting the influence of venture capital in the health-care sector.[14] Alarming reports from patients have emerged, highlighting disconcerting malpractices, substandard care, unnecessary surgeries, and instances necessitating corrective procedures. Some patients seeking second opinion have discovered inadequately performed initial surgeries, aggravating their medical conditions. Furthermore, patients encountered difficulties when attempting to voice their grievances through the call center. In some cases, sales executives and doctors initially pushed patients toward surgery, only later offering nonsurgical options. Insiders have disclosed that Pristyn Care maintains a registry to monitor individual doctors' conversion rates from the outpatient department to the inpatient department. Many doctors reportedly achieve notably high conversion rates, with some even reaching 98%–99%. Sales executives frequently guide patients to doctors with higher conversion rates, creating incentives for doctors to advocate for surgical solutions. These reported practices and the associated pressure on employees raise concerns about the potential prioritization of revenue and targets over patient welfare, potentially impacting the quality of health care.[14] CONCLUSION Leveraging the potential of telemedicine Telemedicine has emerged as a transformative force in health care, offering notable advantages such as enhanced access to medical services, cost-effectiveness, and the ability to bridge gaps in specialist care. It proved invaluable during the COVID-19 pandemic, providing safe and timely health care. However, challenges include the loss of personal interaction and the importance of rapport in health care, as well as uncertainty regarding time and cost savings. Telemedicine holds significant potential, but striking the right balance between its benefits and challenges remains an ongoing endeavor. Addressing concerns and adapting its implementation to specific patient and clinical needs will be essential to maximize its advantages for both patients and health-care providers. As health-care systems continue to evolve, telemedicine promises to play a pivotal role in shaping the future of health-care delivery.