Hello, this is Derek, Student physiotherapist. I’m speaking to you at the end of my placement here at JB Occupational Therapy. I thank everyone here for a great, rewarding experience, especially those patients who let me take part in their consultations. I’ve gained invaluable knowledge from you about your complex conditions with multiple symptoms. And how we, as healthcare professionals, can work with you to improve your quality of life.
So, I leave you with this article about the nature of consultations from ‘telehealth’ platforms. Including my previous experience attempting to make telephone diagnoses due to Covid restrictions. Finally, how the future use of remote technology can create holistic, virtual communities of professionals and patients in one easily accessible space. Perhaps an end to postcode lotteries in medical care?
Definition: ‘Telehealth is the use of digital information and communication technologies, such as computers and mobile devices, to access health care services remotely and manage your health care’.Mayo Clinic
I was first introduced to telehealth on a previous student physiotherapist placement in an outpatient Orthopaedics setting. In fact, it was my first attempt at applying any sort of healthcare to real patients. It involved telephone consultations to try to diagnose patients presenting with musculoskeletal maladies. Though in these cases, ‘presenting’ was limited to oral description over the telephone. Treatment was offered by verbal response with follow-up written including links to video advice. This was a forced measure due to Covid 19. Rather than a researched, new approach to healthcare to maintain or improve patient outcomes. I was therefore fascinated by the chance to work in a setting dedicated to video telehealth consultations. Especially with a specific chronic illness community.
There seemed to be good reason to offer this form of remote healthcare. But what motivated the patients since this was a choice rather than a Covid mediated imposition? I had received mixed reactions in attitude to virtual consultations from patients in Orthopaedic outpatients. I became aware of the limitations of providing an informed diagnosis and treatment over the telephone.
My new adventure was met with scepticism from certain healthcare professional colleagues. The ‘old school’ hands on approach to physiotherapy is still alive and kicking. A general antipathy to the efficacy of remote diagnosis and treatment pervades this healthcare community.
As I began to research the topic of telehealth, I was drawn to an article entitled, ‘Telehealth: a quarter-trillion-dollar post Covid reality?’ (Healthcare Systems and Services 2021). I discovered that pre-Covid US investment in virtual healthcare was $3billion a year. It had increased seven-fold for 2021 and was projected to potentially rocket into the trillions post covid. Physicians and patients both had vastly increased favourability to this form of healthcare than pre-covid. Both had a desire to continue using telehealth post-Covid.
The article offered future improvements to telehealth which would facilitate such a paradigm shift and massive reinvestment.
- Increasing convenience to receive routine care.
- Improving access especially for rare diseases requiring specialist healthcare professionals.
- Improving care outcomes, especially for chronic conditions.
I can relate these proposed service improvements too my current placement providing a telehealth platform for those with Ehlers-Danlos Syndrome and Joint Hypermobility Syndrome. These communities, with such a combination of rare disease and chronic symptoms, may be ahead of the telehealth adoption curve. Perhaps because of their previous difficulties experienced in using NHS services. They have, by virtue of necessity, already sought alternative access to effective treatments. Rather than having telehealth forced upon them by Covid restrictions curtailing real-life consultations.
The first concept of convenience, telehealth offers, could apply to many patients with a variety of ailments. Being able to have a consultation from the comfort of your own home removes the hassles, time spent and costs of commuting to the medical venue. A limitation to telehealth can be the nature of the consultation. Can it be provided safely and effectively on a video call? Or does it require some form of manual therapy or specific tests to be conducted?
Those of you who have recently tried travelling abroad, may have self-completed a Covid Lateral Flow test and either returned it by post or courier or used a video hook-up with the test provider to scan and verify your results. Technological advances have enabled an expansion of this virtual reality two-way interaction with healthcare providers and patients. Many necessary tests such as blood pressure, heart rates, blood sugar levels, etc can not only be taken by the patients at home, with easy-to-use equipment, the results can be monitored in real time by remote health care professionals through link-up with sophisticated sensors.
In the case of chronic and rare conditions the commute to a real-life consultation can be a triggering activity for their symptoms, making their condition worse. A whole raft of ‘pacing’ management strategies is required to ameliorate such a triggering event. In this way the benefit of remote consultation goes way beyond general convenience and becomes a treatment by removing the real-life form of consultation which triggers symptoms.
Another issue addressed by telehealth is the problematic geographical location of specialists in relation to patients. Specialists are not uniformly distributed through the NHS and therefore difficult to physically access through travel. You will also likely be referred to a healthcare professional in your designated NHS region who does not specialise in your condition and may only recognise and treat those specific symptoms they are familiar with. The overall big picture of your chronic condition can be missed or misunderstood. Telehealth offers an opportunity for bespoke patient access to appropriate professional healthcare wherever it may reside in geographical space. Is this happening though?
This question of access is the second improvement identified in future telehealth provision. The problem with increased telehealth access due to Covid is that there has largely been a straight swap between face-to-face consultations to video or telephone calls. The motivation and reasoning at the time was limited to removing the risk of spreading Covid by human-to-human contact. There was no overarching plan recognising the problems of real-life access and its triggering potential and the disparate distribution of specialists which can make consultations in real life further away to commute with longer waiting lists.
This straight swap has spurred innovation such as the remote Covid tests. But the actual structural provision of healthcare has retained its pre-covid format. Along with all the inherent problems for many, especially those with rare and chronic diseases. They not only require specialists but ongoing healthcare plans which need to be progressed, regressed or modified to deal with changes in symptoms over time. This may require a team of healthcare professionals. GPs, OTs, Physios and Psychologists etc who may well be acting independently of each other. To optimise an effective treatment strategy would require these professional healthcare resources to be working in tandem, singing from the same hymn sheet.
This idea of creating a community of healthcare professionals and patients has been enacted by the Ehlers-Danlos Society. Using telehealth as a forum to be bring all interested parties under one proverbial roof called ‘Project Echo.’ The fundamental concept is to provide a digital hub for professionals and patients to share knowledge, in other words, ‘all teach, and all learn’. This is a break from the idea that one professional is assigned one patient, instead a multidisciplinary team of professionals, work with a multitude of patients with the medical goal of increasing their independence and self-efficacy to manage their own condition. This greater pool of professional knowledge and greater reserve of patient experience and know how, interact in one accessible space, with potentially better healthcare outcomes than the traditional one to one professional, patient interaction.
The third contention of the new proposed paradigm for healthcare relates to this improved medical and quality of life outcomes for patients. Does telehealth deliver this? For the foreseeable future some healthcare will still require a hands-on element, so maybe a hybrid approach could be devised. A combination of real and virtual interface intertwined for maximum healthcare effect. An example is the latest suggestion to reduce numbers of people using A&E who don’t need to be there. The proposal is to have Doctors and nurses as a pre-emergency triage system at the entrance of A&E so those not needing emergency room care can be directed to appropriate non-emergency facilities in an appropriate time-frame.
Interestingly a hybrid system already exists with the 111, emergency telephone number, for those who self-diagnose, or who are not sure if they need full-on emergency treatment. This could be refined to a potential mobile phone/computer triage system with interactive apps to measure vital signs. This could rule in those needing emergency treatment as well as, rule out those who do not. This potentially results in a far more efficient real life emergency service whose very expensive treatment is far better targeted, more rapidly, with subsequent better healthcare outcomes.
Placement experiences with JBOT
This leads me to my current experience working from a telehealth platform. The patients I have seen have tales of long waiting lists, stress and triggering of symptoms to get to real life consultations. Then being faced with healthcare professionals not familiar with such rare and chronic symptoms. There can also be a lack of understanding or indeed believing what the patients are saying when recounting their ailments and symptoms.
The patient often has the best understanding of their symptoms, what triggers them and what can alleviate them. They are a potential goldmine of useful information. This can be used in formulating an effective treatment plan that patients are on board with, and more likely to adhere to. This in turn has better health outcomes.
I have found myself in joint consultations, working in a team with professionals from other disciplines such as OT and Psychotherapy. Patients were encouraged to speak as a fellow team member. Describing the entirety of their condition, the symptoms and the unique environment and situation in which they live. Rather than professionals acting independently in a fragmented way. Virtual reality coming-together enables a holistic exploration to better identify what exacerbates symptoms or what can potentially provide relief. With this information, self-management strategies and physical tweaks around the home with the addition of equipment can make activities of daily living less fatiguing and less stressful.
Chronic patients are in this for the long-haul and need to be able to manage their own symptoms. In this way the patients’ lived experience becomes part of the knowledge bank on this telehealth platform. These advantages of telehealth can provide a wide reach to those in need, with minimal triggering of symptoms. This creates a community from a global population on a platform that provides a practical means for holistic healthcare. A true partnership of healthcare professionals and patients optimising healthcare outcomes.
Telehealth can in fact be a template for the holy grail of the proposed medical ‘one-stop-shop’ Doctors’ surgeries. A feature of the near future NHS proposed local healthcare systems. Telehealth can create communities of conditions and related professionals. A more effective ‘one-step-healthcare-shop’ for medical need rather than imposing it on communities defined by geography and postcodes.