<i>Letter to the Editor:</i> Is the COVID-19 Pandemic an Opportunity to Enlarge the Telemedicine Boundaries?
Daniele Giansanti, Irene Aprile
Abstract
Telemedicine and e-HealthVol. 26, No. 9 Letter to the EditorFree AccessLetter to the Editor: Is the COVID-19 Pandemic an Opportunity to Enlarge the Telemedicine Boundaries?Daniele Giansanti and Irene AprileDaniele GiansantiAddress correspondence to: Daniele Giansanti, PhD, Istituto Superiore di Sanità—TISP, Via Regina Elena 299, Roma 00161, Italy E-mail Address: [email protected]E-mail Address: [email protected]Istituto Superiore di Sanità—TISP, Rome, Italy.Search for more papers by this author and Irene AprileIRCCS Fondazione Don Carlo Gnocchi, Milan, Italy.Search for more papers by this authorPublished Online:10 Sep 2020https://doi.org/10.1089/tmj.2020.0159AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail Dear Editor:We write in regard to the recent editorial entitled, “Telemedicine and the COVID-19 Pandemic, Lessons for the Future” by Bashshur et al.1 recently published in Telemedicine and e-Health,1 with the aim both of sharing our thoughts with you and to ask for the authors' feedback on our position regarding a possible evolution of the boundaries of telemedicine caused by the COVID-19 pandemic.There is no doubt that telemedicine as a diagnostic, monitoring, and treatment tool is showing, as highlighted in the editorial, potentialities to fight the epidemic, to avoid the risk of contagion and to ensure continuity of treatment.As researchers in this discipline who have been working for about 20 years in this area, we have greatly appreciated the editorial that summarizes what we scholars are feeling right now. We are convinced that all of us, working in this field are asking the questions on Table 1.Table 1. Questions Emerging on the Future of Telemedicine After the COVID-19 Pandemic DESCRIPTIONQ1Was there really the need of COVID-19 epidemic to finally launch telemedicine?Q2Will this fabulous boom in telemedicine systems last even after the pandemic?Q3If it lasts, how will we avoid abuse of these systems?Q4Is this boom valid for the entire evolved world?Q5What further possibilities, previously unthinkable, are showing telemedicine?We would like to list and share our personal reply to each one of these questions.We have reflected on the first question and we believe that, compared with before, unprecedented conditions of technological availability and exceptional circumstances have been created. One aspect that drove this boom was certainly the vastness of the pandemic, the most terrible of the past century; but the real engine of the boom in telemedicine, during the epidemic for the SARS-CoV-2 virus of 2019, compared with the SARS-CoV epidemic of 2003, is certainly the mobile technology and in particular the smartphone with its enormous potential; such as the possibility of installing apps for communication, digital tracking, availability and integrability with sensors, and ease of interaction with multimedia content. During the epidemic of 2003, the smartphone was not yet widespread and to make a message with the mobile phone using the SMS one had to write “s” by typing the “7” key of the composer four times!To the second question, we answer that we noticed that many factors contributed to this boom and a great role in this moment was played by social networks and video communication apps, in all of the telemedicine sectors, from the mental health to the ophthalmology.2–5 The use of these systems is very often disseminated in smartphones and was allowed in telemedicine in derogation of regulations (that prohibited their use before the pandemic in telemedical applications due to limits in confidentiality and privacy). We will have to see if after the pandemic it will still be possible to use them in telemedicine applications.To the third question, we believe that the editorial has responded widely. During the pandemic, exceptional changes have happened in the health care. As an example, we laud the regulatory derogation in the United States in telepsychiatry with regard to the possibility of selling online drugs through telemedicine architectures. Psychiatrists hope that this will be possible even when the pandemic is over; however, as highlighted in the editorial, in general it is important that quality in care must be the guiding principle and that abuse must be avoided.As for the fourth question, we answer both as researchers and as European and Italian citizens. We do not think this boom has been identical across the world. Different regulations and a less enlightened and more conservative political approach in some cases have in many cases hampered the spread of telemedicine. Just to cite a first example, whereas in the United States the system based on medical insurance has clearly defined the reimbursement procedures, in Italy and in Europe this has not happened so explicitly. For example, think of the derogations to law for the use of messaging and video communication systems that have occurred in the United States: even on this issue, Europe has not clearly made explicit derogations to current regulations.To the fifth and final question, we want to answer in an articulated way and also report our personal experience during the pandemic. One of us works at the Istituto Superiore di Sanità (ISS), the Italian National Institutes for Health. At the outbreak of the pandemic, 21 working groups were created at the ISS on various topics, from epidemiology to telemedicine and scientific updating. While reviewing the publications of telemedicine for one of these groups, we realized that new potentialities are weakly emerging in telemedicine. The pandemic has generated conditions of enormous stress, for example, due to the severe restrictions on social life, home isolation, and the fear of being contaminated. Stress and reduced motor activity are certainly leading to an increase in various pathologies (not only in borderline subjects), from cardiovascular to metabolic ones (such as diabetes), to anxiety and depression also in subjects who did not have any never suffered. Telemedicine, currently during the COVID-19 pandemic, is used for remote care, monitoring, diagnosis and rehabilitation.In our opinion, the aforementioned considerations show that telemedicine should also be used as a tool for mass preventive investigation, widening its limits, becoming also a preventive type tool for the pathologies listed earlier and beyond. However, in the scarcity of resources, as a first step it would be at least necessary to hypothesize simple solutions, based on mobile-technology capable of, at least acting in the health sector as self-awareness tools. In the field of psychology they could be useful for (a) verifying the extent and presence of problems of anxiety and/or depression; (b) identify the factors that influence (also positively) the psychological sphere; (c) offer tools for self-awareness of one's state of health and, for example, be a trigger to suggest a subsequent visit; (d) also offer suitable exercises for the self-therapy. Certainly, the mobile-survey (m-survey) tool6 administered through mobile technology, sent, for example, with social networks, could contain psychological tests on self-awareness anxiety/depression, a self-reported quality of life questionnaire, and investigate other factors that influence these problems for subjects, and respond to monitoring aspects (a–c). Tools such as those proposed by Bäuerle et al.3 could play a self-therapy role. At the ISS, we have proposed a tool to investigate (a–c), with also the curiosity to explore the role of the pet during the lockdown (a newer tried experience before).The tool, based on an m-survey, has been designed using Microsoft forms. The tool is arranged into three sections (Fig. 1: Contents on the m-health tool): (1) this section was dedicated to the characterization of the subjects involved in the study (all subjects with history of psychological problems were excluded); (2) the second section was dedicated to the relationship with the pet; and (3) the third section included an anxiety self-assessment scale.7,8 The m-survey was submitted through the social networks and the messaging tools (English version of the link: https://forms.office.com/Pages/ResponsePage.aspx?id=DQSIkWdsW0yxEjajBLZtrQAAAAAAAAAAAAZAAOUXdFhUQUNQWTFTTlBYRk1aOVhBNVRWVEEzTVlJNi4u; QR code in Fig. 1).Fig. 1. The proposed tool of an enlarged in boundaries telemedicine.A total number of 3,905 subjects with and without a pet (dog and/or cat) participated to the complete survey with an age comprised between 14 and 77 years; 781 of them were elderly subjects (≥65 years). The data mining (Fig. 1: The postprocessing) is still ongoing, however preliminary results are encouraging; the 546 elderly subjects with pet (dog and/or cat living at home) showed a lower degree of anxiety when compared with the other ones without a pet: Δ score = 8.3 in mean value; standard deviation = 4.2 (p < 0.01, T-Student). The study taken as an example as further chance of the telemedicine is showing a useful approach answering to points (a–c).Conclusions of the Letter and Question to the Authors of the ArticleAt this point, in the light of the considerations set out earlier, we wonder a basic question concerning telemedicine as a medical and technological tool, and we leave the question to Bashshur et al.1 Surely telemedicine comes out of this period definitely enhanced (although not evenly); however, we wonder if the pandemic was also an opportunity to explore the new boundaries of the telemedicine. We have always been accustomed to a telemedicine focused on monitoring, diagnosis, and treatment. But we rarely thought of a preventive telemedicine and/or a telemedicine capable of evaluating the effectiveness of unconventional therapeutic pathways such as a therapy/remote support based on the pets9 that the COVID-19 pandemic, a never tried experience before, allowed to explore, as in the reported example.References1. Bashshur R, Doarn CR, Frenk JM, Kvedar JC, Woolliscroft JO. Telemedicine and the COVID 19 pandemic, lessons for the future. Telemed J E Health 2020;26:571–573. Link, Google Scholar2. Khanna R, Forbes M. Telepsychiatry as a public health imperative: Slowing COVID-19. Aust N Z J Psychiatry 2020 [Epub ahead of print]; DOI: 10.1177/0004867420924480. Crossref, Medline, Google Scholar3. Bäuerle A, Graf J, Jansen C, Dörrie N, Junne F, Teufel M, Skoda EM. An E-mental health intervention to support burdened people in times of the COVID-19 pandemic: CoPE it. J Public Health (Oxf) 2020 [Epub ahead of print]; DOI: 10.1093/pubmed/fdaa058. Crossref, Google Scholar4. Saleem SM, Pasquale LR, Sidoti PA, Tsai JC. Virtual ophthalmology: Telemedicine in a Covid-19 era. Am J Ophthalmol 2020 [Epub ahead of print]; DOI: 10.1016/j.ajo.2020.04.029. Crossref, Medline, Google Scholar5. Zhou X, Snoswell CL, Harding LE, Bambling M, Edirippulige S, Bai X, Smith AC. The role of telehealth in reducing the mental health burden from COVID-19. Telemed J E Health 2020;26:377–379. Link, Google Scholar6. Giansanti D. Towards the evolution of the mHealth in mental health with youth: The cyber-space used in psychological rehabilitation is becoming wearable into a pocket. Mhealth 2020;6:18. Crossref, Medline, Google Scholar7. Dunstan DA, Scott N. Norms for Zung's self-rating anxiety scale. BMC Psychiatry 2020;20:90. Crossref, Medline, Google Scholar8. Balsamo M, Cataldi F, Carlucci L, Fairfield B. Assessment of anxiety in older adults: A review of self-report measures. Clin Interv Aging 2018;13:573–593. Crossref, Medline, Google Scholar9. Giansanti D, Maccioni G. 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