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How to Implement Telemedicine in Daily Practice

 

TELEMEDICON 2022 is an annual meeting organized globally. It’s the 18th International Telemedicine Conference in Kerala organized by the Telemedicine Society of India (TSI). “Strengthening Health Systems through Sustainable Telemedicine and Digital Health” is the theme for this year with the objectives of gathering the healthcare regulator platforms, health funding authorities, service providers and international experts exploring emerging telehealth models and breakthrough technologies. Examining new telehealth models, entrepreneurship, cutting-edge technology and the socioeconomic impact of telehealth implementation on healthcare access and equity will also be highlighted. The event was held on 10th November 2022. The offline event is scheduled from 10th-12th November 2022 at Amrita Hospitals, Kochi.

Dr Rajesh Pai, COO, of BMH Hospital, Kannur spoke about Remote Healthcare Technology and How to implement Telemedicine in Daily Practice. 

Remote Healthcare Technology: A New Paradigm 

  • There is an increased life expectancy because of adapting remote healthcare technology. 
  • Cardiac disease, the most common cause of death can even be cured sometimes.
  • Remote healthcare technologies are being offered for patients with Dementia, Alzheimer’s disease, cerebrovascular accident, and stroke, which are common neurodegenerative diseases affecting the elderly population at large. 

Remote Healthcare Components 

Technological advancements have aided the treatment of the above-mentioned diseases and helped to deliver quality patient care within a home environment. There are several components of a remote health monitoring system, some of the fundamental ones being- 

  • Sensing mechanism proximal to the patient acquiring information on the vital/ monitored parameters,
  • A remote sensor or doctors’ interface ( eg: personal data assistant, i.e., PDA, personal computer etc. and 
  • Secure communication gateway linking the above two infrastructures.
  • A doctor sitting at the hospital or even at home visualizes the parameters and advice the patients daily if required regarding the more acute illness. The advice can be provided even on an hourly basis too.

    Benefits to the patients

The benefits are mainly the logistical benefits which can be delivered at convenience, and it helps in reducing the benefits. The factors significantly contributing towards home-based/ remote rehabilitation can be summarized as follows:

  • Logistical convenience, since it helps to reduce unnecessary patient transfer to the clinic or a hospital, 
  • Cost-effectiveness, since it helps to reduce the expenses incurred towards hospitalization and human intervention, 
  • Maximizing the number of patients being treated at home across a wide spectrum of populations. 

A Holistic Overview of a Typical Wireless Body Area Network (BAN) System.

State-of-the-art IoHT systems exist for ECG electroencephalogram (EEG), diabetes and vital signs including PPG, blood oxygenation (SPO2), respiration rate, body temperature, glucometer, galvanic skin response, blood pressure, position (accelerometer, gyroscope etc.) and electromyography (EMG).

Various companies do help and guide in the remote monitoring systems and assisted living technologies like Beclose, Fade, Medisafe, On Track, Early sense etc. 

Wireless Telecardiology

Wireless Telecardiology is one of the most highly developed technologies. Within cardiology, a wide variety of both non-invasive and invasive medical signals are available for telehealth care. 

Most are recorded manually by the patients via a device (e.g., systolic and diastolic blood pressure, pulse, 3 lead electrocardiogram (ECG), heart rate variability, body weight, oxygen saturation, blood glucose, natriuretic peptides). 

Telecardiology…

Others obtained from invasive devices are recorded automatically (e.g., impedance, the incidence of arrhythmia, pulmonary and left atrial pressure).
In addition to the provision of care to patients with heart disease, it has a vital role in educating these patients on the 

Acute Cardiology Syndrome (ACS) / Stem 1

A particularly attractive application for telecardiology in the pre-hospitalization phase is in diagnosing and treating patients with acute cardiology syndrome.  

Patients with ST-elevation myocardial infarction (STEM1) should receive reperfusion therapy as soon as possible to reduce mortality and morbidity. Guidelines recommend primary percutaneous coronary intervention (PCI) as the preferred strategy if this can be performed promptly. Thus, to treat STEM 1 patients within the recommended time limits, early diagnosis is essential to allow timely transportation to a PCI centre in a due time. 

Importance of ECG

The diagnostic modality of choice has been the ECG. The ECG is recorded in the ambulance and transmitted to a PCI centre. The ECG recording is interpreted by the on-call oncologist and after consulting the patient and/ or paramedic a decision is made to either direct the patient for primary PCI or carry him/ her to the nearest local hospital for further diagnosis and initial pharmacological therapy. 

Telecardiology in the Management of Acute Coronary Syndromes 

When the patient is having chest pain, ambulance services are alerted. In an ambulance, the analysis of ECG is performed by a doctor. The doctors approach the PCI centre or the nearest hospital for pharmacological intervention. 

Teleconsultation

  • All studies prove that ECG teleconsultation is technically feasible either from a moving ambulance or from remote places. 
  • ECG teleconsultation allows faster triage, shortens door-to-needle time and reduces in-hospital delays. 
  • ECG teleconsultation screening may lower the rates of false negative diagnoses in the case of Stem 1. 
  • The pre-hospital diagnosis of stem 1 has been associated with other favourable outcomes such as a reduction of the infarct size, a lesser impairment of the ejection fraction, a shorter length of stay, and a reduction in early and late mortality. 

Conclusion

In conclusion, telecardiology in ACS enables more widespread access to rapid reperfusion therapy (by either pharmacological or mechanical intervention), thereby reducing treatment delay, morbidity and mortality.  

Telecardiology in the Management of Chronic Heart Failure 

  • Hospitalization for heart failure is a growing and major public health issue. Presently heart failure is the leading cause of hospitalization among patients above 65 years of age and heart failure patients who have frequent hospitalizations are at risk for poor outcomes. 
  • Effective use of telemedicine in managing heart failure patients has been expanding considerably worldwide. A substantial reduction in hospital admission, in the length of hospitalization, and an increase in survival among heart failure patients who are managed by telemedicine. 
  • Patients get a better understanding of their disease by being responsible for monitoring and being involved in some self-managing, which enhances patients’ education and empowerment. 
  • Psychological interventions such as cognitive behavioural therapy and mindfulness exercises have already been shown to be successful in changing lifestyle behaviour and significantly reduce anxiety, depression and clinical symptoms which are common in heart failure patients. 
  • Telemonitoring in heart failure not only reduces the costs and increases the revenue but also saves lives and prevents complications by also improving patient safety and quality of care. 

Telecardiology for Arrthymia and Cardiovascular Implantable Electronic Devices 

  • The number of patients with CIED such as pacemakers, ICDs and CRT, has increased tremendously in the modern era. 
  • CIEDs are managed through various mechanisms.
  • Conventional follow-up for these patients has been in-person during office or hospital-based visits, which requires patients to commute to offices for assessments and optimization of device function. These time-consuming visits are a burden to the patient and their relatives, as they often require long transportation, waiting time and time off work. 

Wireless Technology for Arrhythmia

  • Remote monitoring has also been shown to have a beneficial impact on survival. 
  • Remote monitoring is associated with a reduction in inappropriate ICD shocks.
  • Remote monitoring may finally be a valuable tool to assist in the diagnosis of arrhythmias or ECG abnormalities. 
  • Again here, Telemedicine usage is very vast. 
  • Symptoms secondary to arrhythmias such as palpitations and syncope can be documented on ECG tracings, but many ECG changes are transient or paroxysmal, and the search for corroboratory evidence of these arrhythmias can be lengthy and problematic and missed even by long-term Holter ECG recordings. 
  • The usage of the remote device enables real-time cardiac arrhythmic monitoring and can provide a specific diagnosis and recommendations of action have been demonstrated to raise the rate of diagnosis and the efficiency of treatment. In addition, it enabled patients to undergo dose titration or change of their medication in the outpatient setting, thus reducing the rate of hospitalization. 
  • Remote monitoring is advantageous in patients with paroxysmal AF because alerts could identify the start point of the arrhythmia, resulting in an unscheduled follow-up either in the office or by phone and appropriate interventions. 

How Elderly people can be benefited from Remote Monitoring 

Monitoring of Elderly care: The role of wearable sensors in Fall detection and Fall Reduction Research 

  • Falls are a prominent cause of injuries and injury-related deaths for today’s growing population of older adults, posing a major health risk in even the most ordinary settings of daily life. 
  • A fall is defined by the World Health Organization as “inadvertently coming to rest on the ground, floor or lower level excluding intentional change in position to rest in furniture, wall or other objects.”
  • Approximately, one-third of community-dwelling residents aged over 65 experience at least one fall a year, with the chance of falling increasing the age. 
  • This has led to a recent focus on developing quantitative protocols for accessing fall risk, by the use of body-worn inertial sensors, pressure mats and motion capture systems. 
  • Fall detection methods designed by mechanical engineering researchers are generally based on triggering a sensor-based system, whether of the wearable sort or within a system installed in a home or residential dwelling. Clinicians, on the other hand, have devised decades of many different fall risk assessments and surveys. 

Personal Alarms

The most basic approach to reducing the impact of a fall is with the use of personal emergency alarms, which the wearer can use to call for help. Such systems offer peace of mind and can assist in reducing the occurrence of long lies after a fall, where the fall is unable to get up and several hours or more can pass before help is received. Wearable button-activated alarms that can communicate with emergency services are already commercially available. 

Other than these methods, there are various technologies which are in wide usage. 

  • Wearable sensors
  • Accelerometry 
  • Gyroscopy ETC are available 

Activities of Daily Living Monitoring

  • Human activity recognition (HAR) is a well-researched topic across AAL.
  • The varying approaches to HAR are representative of the underlying sensing techniques, the signal processing methodologies and the environment from where the activity data is acquired.

The Key Research Steps involved in a Successful HAR system

  • Activities to be monitored
  • Types of sensors utilized
  • Methodology to determine and classify the activities performed
  • Embedded implementation of low-complexity algorithms for real-time information extraction and lastly,
  • Reconfigurability of the system for new users 

Sensor Technology

  • Inertial measurement units (IMUs) compromising accelerometers and gyroscopes are the most commonly used sensors for HAR. 
  • IMUs help measure acceleration, distance, rate of rotation, time etc. which act as health indicators for gait posture, tremor and spasticity, aiding clinical assessment.
  • In addition to IMUs, smartphones provide access to a wide range of built-in sensors such as Bluetooth, Wi-Fi, microphones, pedometers and proximity and light sensors. 
  • Smartphones are attached to the elbow joint for detecting activities of his arm.
  • In the long run, the quality of care offered for both patients and doctors would be better. 

 

 

 

 

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