Future of Virtual Clinics



This publication was made by the collaboration of Dr. Srikanth K N who has graciously shared his unique insights and experiences in the world of telehealth.


The contents of this white paper are a summary of a live webinar hosted by Dr. Ismail Sayeed - CEO of ViOS,Inc on June 30 2020.


The opinions and content of this event and its written publication are the personal insights of the above mentioned individuals.


To view the recorded event, click on the following link:

www.viosapp.com/webinar





What is Telemedicine?



It is a software enabled information technology platform whereby healthcare professionals can directly interact by instant messaging, audio and ofcourse video portals.


Telemedicine is a rapidly emerging method of providing cost-efficient and safely distanced communication for patients in need of healthcare or health-related information. This may take the form of a sort of frontline triage, second medical opinion, counselling, pre-intervention consultation or sometimes just to confirm a prescription.


Before the COVID-19 pandemic, there was significant hesitancy by the health sector to adopt telehealth (which is a wider definition related to telemedicine). Most common reasons were issues with new technology, regulations, insurance reimbursements and others. But in light of social distancing, there was an almost overnight appreciation and acceptance of telemedicine from all levels of the health system.


There are dozens of telemedicine models, programs and even healthtech startups that are rapidly onboarding various healthcare providers to their platforms.


Before joining such organisations, it is essential for healthcare professionals and the wider community to understand the issues and abilities of telehealth in the new digital era.




How has the covid lockdown affected your practice?



Since the worldwide covid lockdown in March 2020, the total number of walk-in patient appointments have reduced a lot. If I had to place a figure, I would say more than 40% of average foot traffic had decreased, even more so in June.


However, scheduled appointments have increased because people want to avoid unnecessary waiting in the waiting lounge.


Naturally to safeguard ourselves and our patient community, we have placed greater emphasis in hygiene standards and protocols.


There has been more importance on wearing masks, face shields and gloving even just for outpatient interactions. My team has increased their sanitation practices tenfold as well.


Greater reliance on telemedicine in all forms has been a welcome transformation for my practice. Patients and doctors have become more confident in using telecommunication portals as the primary mode of communication and initial clinical management.


To highlight, I would say that this pandemic has brought some form of order and conformity in practice - which I had never thought possible in such a short time.




What are the obstacles to specialised healthcare for your patients, not related to covid?





  • Difficulty in standardisation of quality


  • Hard to find doctors willing to see them


  • Higher expectations given to setting up a proper holistic referral and appointment method


  • Travelling distance to meet qualified specialists


  • Triage training is essential - starting from the secretary onwards


  • Not able to do regularly scheduled elective procedures


  • Haphazard referral process


  • Medical tourism is exceptionally difficult for international and domestic travelling patients


  • Some patients need more time to understand that doctors need to spend more time in history taking and following policies and best practices




How are your regular patients contacting you?



As telemedicine became widely accepted and became a legal entity with the Medical Council of India - many eminent specialists became aware of its benefits.


Even many tech-savvy patients are recommending their known doctors to join a telemedicine platform or to set up some form of remote video conference system with mobile apps.


Many clinics and hospitals have shared various materials in social media channels. Also many institutions contacted their regular patients by sms, calls and email to use telemedicine when possible.




What steps have you taken to ensure safety in your practice?



  • We insist on scheduled appointments


  • Staff and Patients must wear masks at all times


  • Hand sanitation stations at key locations


  • App tracker with contract tracing checks have been developed and distributed for public access in India - know where your patient came from (eg. red zone)


  • Staff training on practical hygiene protocols


  • Complete patient registration policies


  • District and Central government bodies are notified of all suspected covid cases


  • Clear plexiglass partitions


  • Double gloving in surgical or any interventional procedures


  • Comprehensive sanitation process between patients - appointments schedules are spaced this way to allow for cleaning procedures



Do you have any recommendations for private care specialists in Bangladesh?



Do not underestimate Covid-19


It is not like the flu

Take it serious



  1. Remember universal precautions

  2. Follow the protocols mentioned in the previous segment

  3. Follow national guidelines - completely



Protect yourself and staff first, then patients - prevent yourself from becoming a ‘superspreader’ to your colleagues, other patients and most importantly your own family at the end of your shift.


Remember, the highest risk of coronavirus infection is towards the doctor, nurse and support staff in the outpatient and emergency departments.



The entire hospital has to become an ICU unit - from parking lot, canteen, washrooms….everywhere.


Have a ‘buddy-system’ - someone to see and make sure you are donning and removing ppe properly - and maintaining precautions



List 5 benefits of telemedicine for patients



  1. Safety for all parties

  2. Easy consults from the comfort of your home

  3. No unnecessary travel required

  4. Saves time in scheduling an appointment

  5. No need to buy PPE and extra mask - saves money in the long run




List 5 benefits of telemedicine for doctors


  1. Organises your practice

  2. Ensures staff safety

  3. Reduces mortality of healthcare professionals

  4. Payment guaranteed before specialised consults

  5. Reduce costs and need for PPE and travel




What are the 5 challenges in Telemedicine?



  1. Not able to physically examine the patient & do on spot investigations

  2. Hard to identify the right patient - proxy interviews may take place

  3. Consent issues

  4. Data privacy

  5. Ethics & medico-legal regulations




How do you prescribe e-prescriptions?



  • Ensure identity

  • Consent

  • Right diagnosis

  • Past medical history must be ascertained

  • Proper documentation

  • Use lay terminology in describing management

  • Use certified portals for prescribing & delivery when possible





What is the importance of history taking in video consulting?



As per peer-reviewed publications and research by Royal College of Surgeons - more than 80% of correct diagnosis can be made by comprehensive history taking


A skilled clinician can arrive at an accurate differential diagnosis - just be taking the time to ask the right questions




What do you understand by the term ‘bedside manners’?



Cornerstone of the professionalism of a medical personnel - mannerism you display to convey your utmost dedication to the patient


  • Your posture

  • How you approach a patient

  • Attire

  • Communication

  • Tone of voice

  • Maintaining eye contact

  • Respect patient dignity

  • Treat them how you want to be treated



All about putting the patient at ease - to establish their perception of a doctor

Not always about the number of degrees



This improves the social impact and social capital of a good clinician.




Should a doctor earn the same consult fees for online care as the office visit? And why?



Yes.



A well trained competent doctor should be able to give the same calibre of consult online as well as offline (in his clinic).


The reality is that Covid-19 is not going away soon - people need to respect and adapt to the new normal - especially telemedicine.


People have to realise that online consults are the new normal of initial healthcare management.


Therefore, doctors have the right to insist on a value-based reimbursement - according to their specialised capacity as a professional.


After all, people need to change their mindset, and how they put a price on their own health, especially in private care.


What you are paying for is not the opportunity to sit in a room of degrees and air conditioning - you are paying for access to a professional with atleast 20 yrs experience who is certified and qualified to take care of you, at your convenience.



If quality of care will not be affected - why should the pricing be affected?




How long should an ideal doctor-patient session be?



Based on NHS (National Health Service UK) guidelines:


First consult

20 min for a comprehensive history taking


Follow up

7-10 min


Varies from different specialities and patients



In telemedicine, the initial visit might take longer to establish that initial rapport between the parties




If a patient’s condition is suggestive of a serious and acute condition - what would be your next step in management?




The clinician must immediately assess the situation


Depending on the geographic location - if there is a large geographic distance involved - they should be instructed to visit the nearest facility in their locality.


Patient safety is very important


Doctor has to take an executive decision - situational awareness


It is the Doctors duty to explain the seriousness of the situation


If they are in the same vicinity of the telemedicine specialist - you can ask them to arrange an ambulance and take them to the nearest ER to stabilise





How will you manage an uncooperative or hostile patient during a video call?



First of all, identify that the patient is not an imposter, due to some underlying psychological disturbance, some may take the telemedicine opportunity to enact certain ‘sick-role’ playing activities.


To the best of your abilities, you can have to identify an organic reason for the hostile behaviour eg. inebriation, subacute hypoxia, medication side effects and maybe psychiatric issues to best understand the referral process.


If not, you can apologise to the patient and say that this consult will not be of benefit to either party - and cordially end the session. Perhaps even refund the person according to the policies of the telehealth provider.


Medical law states that a doctor has the right to accept and refuse a case accordingly ie patient cannot impose themselves on a doctor if a meaningful outcome cannot be gained


That is the reason why healthcare soft skills are essential for doctors to develop - to manage and communicate in adverse situations. To control the tone of a discussion and defuse the situation, and prevent unnecessary escalation.





What is your clinical management for a patient who may have another illness that is not associated with your credentials and training?




This depends on how you cross refer as per the policies of the telemedicine provider or your own practice guidelines.


It all depends on how big your own professional circle is - this is the value of a specialist who is well versed in other disciplines and knows colleagues who are competent enough to meet those standards - so you can trust the life of your patient to this person.


A good professional network has a lot of value in these situations. It helps if your colleagues are also practicing via telemedicine as well.





How would patients who approach you in telemedicine, reach your practice for any interventional management?



A structured appointment system is needed to facilitate a future physical clinical visit,

to safely assess and manage a potential interventional operation.


Appropriate hygiene standards should be prepared well in advance.


Telemedicine serves not only as a method of triage, it is a tool to establish rapport and trust in the surgeon. This allows the patient to mentally prepare themselves to believe in the competency of the surgeon and surgery team for the next step in their care.


Even a post-op video follow-up with the same specialist can aid in proper clinical outcome, wound healing and rehabilitation.



How can you order e-investigations & e-pharmacy service for your patients?



In the context of continuity of care - what happens after the screen turns off is essential.


An established value chain where necessary prescriptions can be logged, ordered and delivered in a safe seamless manner - is another step in comprehensive telehealth management.


Along with telemedicine startups - a collaboration should be made with lateral thinking pharmaceutical and diagnostic companies, preferably in the same originating source of the patient, to be part of this continuity process.





CONCLUSIONS



Although the event had proceeded for atleast 90 minutes, there was a great deal of interest and demand for a series of such online discussions, surrounding the salient concepts in telemedicine.


Naturally not every aspect could be extracted and transcribed for this publication. Nonetheless we invite the reader to view the recorded session to fully grasp the feedback from Dr. Srikanth.



The link below will take the reader to the official ViOS website to see the webinar at their leisure.

viosapp.com/webinar



We conclude the webinar event by agreeing that telemedicine enhances patient safety - by enhancing trust and belief in having a registered network of competent healthcare professionals in a transparent platform.




Those who adopt well, & adopt early - survive




About the Speaker



Dr. Srikanth K N

MBBS, MSc Trauma & Ortho (Wrightington hospital, UK)

AFRCS, FRCS - Trauma & Orthopaedic Surgery


Fellow in Computer Navigation and Robotic Joint Replacement Surgery - Plymouth Teaching Hospitals, UK, 2011

British Association for Surgery of the Knee

British Orthopaedic Association

Member of Indian orthopaedic association

British Orthopaedic Research Society

Karnataka Orthopaedic Association

Bangalore Orthopaedic society and arthroscopy chapter



Dr. Srikanth is a Super specialist, Consultant Joint Replacement Surgeon and specializes in Computer Assisted/Robotic Knee & Hip Surgery, Patient-Specific joint Replacements, with a special interest in Minimally Invasive Surgery, Revision(Re-do surgery), Infected Revision, Sports Injury & Arthroscopic Surgery and General Trauma.


He is passionate to offer a 3D solution to the knee and hip Arthritis which is a 3D problem but presently offering a 2D solution in the developing world.







About ViOS

Vooruitgang is ons Streven

Dutch: ‘Progress is our Aim’



ViOS is a groundbreaking software development and digital product distribution company, incorporated in Delaware, USA since June 2020.


The ViOS team is made up of ambitious physician entrepreneurs and technology experts, with 20yrs combined experience in the medical field, healthtech and in software-as-a-service (saas) industries.


The ViOS mission is deeply ingrained in the guidelines of SDG 3.c of the United Nations General Assembly - with a strong focus on sustainable universal healthcare coverage and impact.


Our signature patent-pending products - ViOS Doctor and ViOS Patient apps, are free to download for immediate use by the global population, in need of affordable on demand health-related video telecommunications access to certified and qualified healthcare specialists, anywhere and anytime.


We believe in creating the right technologically-driven solution for the new normal in value-centered access to universal healthcare.






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