Teleconsultations in Pediatric Surgical Patients: Where We Stand and What is the Future?

Sir,

Teleconsultations are patient-doctor communications established at a site remote from the patient or primary physician for the purpose of diagnosis, treatment, or follow-up. Teleconsultation is not which is something new but dates back to the time of the plague when heliograph was used to establish communication between a doctor and patient.[1] Over the years, this communication has become immensely sophisticated as a result of the ongoing technological advances. The modern video-conferencing or video-consultation is an example of this that avoids direct face-to-face contact between the clinician and the patient.

ROLE IN PEDIATRIC SURGERY

The utility of telemedicine in pediatric surgical patients has been highlighted by Beals and Fletcher in their limited experience.[1] By that time, only four programs were available across the United States of America and Europe. Only one of them highlighted the application of telemedicine for patient consultation, evaluation, and follow-up. These programs have evolved considerably in the past decade and have taken a completely new shape in countries like Canada, where funding for telehealth is provided by the government.[2] Teleconsultations between the patient and pediatric surgeon or a primary care provider and a pediatric surgeon have multiple benefits. Firstly, it decreases the patient load arriving at the healthcare facility. Akkoyun[3] had shown that unnecessary consultations or referrals to the pediatric surgeon constitute a sizeable proportion. Teleconsultations can be beneficial in reducing the physical appointments to pediatric surgeons. Secondly, this reduces the waiting time for the specialist consultation. Finally, teleconsultations can lower healthcare costs incurred by patients in rural or remote areas by avoiding physical visits.[2] This can be really helpful in developing countries like ours, where patients tend to travel hundreds of kilometers due to the scarcity of Pediatric Surgeons.

A major misunderstanding among the parents or the caretaker of the child is whether an accurate diagnosis and a correct treatment plan can be established with teleconsultations. Various studies have highlighted this aspect again and again. Robie et al. have demonstrated that an accurate diagnosis of neonatal surgical conditions can be established utilizing video-conferencing.[4] Similar results have been depicted by other studies,[3] where sharing of clinical photographs and images during teleconsultations has been shown to greatly augment the decision-making power of pediatric surgeons.

CHANGING TRENDS DURING THE COVID-19 PANDEMIC AND OUR EXPERIENCE

The present COVID-19 pandemic has disrupted routine healthcare services to a great extent. The importance of teleconsultations has immensely increased in these testing times due to the diversion of the healthcare professionals to COVID-19 duties. Furthermore, it has emerged out to be the only way by virtue of which the continuity of care can be maintained without establishing direct physical contact. In our experience of teleconsultations during the pandemic, it was found that only 10% of the consultations booked by the parents or caretakers via the electronic medical record system required urgent attention.[5] Almost half of the patients did not require any further investigation or treatment. Therefore, teleconsultations can serve as a boon to triage the patients and reduce the final proportion that visits the healthcare facility.

DRAWBACKS

Although teleconsultations have several benefits, some major drawbacks associated with telemedicine need to be mentioned. First, the physical examination is limited. The clinician cannot do a complete physical examination. This is a major drawback in surgical specialties where “palpation” forms a major component of the physical examination. Second, the continuity of care can suffer if teleconsultations are not managed properly. This can occur if the tele-operators do not record the teleconsultations appropriately, make errors in recording, or shuffle (change) the consultants/specialists on follow-up visits of the patients. Third, the security of personal health information being transferred to the e-facility is a major concern. Fourth, prescribing medicines to patients over teleconsultations is a major limitation, and doctors have to follow certain guidelines issued by the Government.[6] Finally, infrastructure difficulties like the availability of telehealth facilities is a major drawback in resource-limited settings.

AREAS OF CONCERN

First, periodic training of the healthcare professionals for triaging the telephone calls needs to be done. The professionals must know which calls need a step-up approach (video-conferencing) and a step-down approach (directed to the hospital website for general information). Second, there has to be a facility for consultation with an expert or consultant. Third, the issues of consent and confidentiality need major attention. This can be done by providing a unique number (confidential ID) to each consultation, recording an audio consent statement repeated by the patient, and keeping the consultations (audio and video) in a repository as medical records. Finally, all the prescriptions (provided during teleconsultations) must be according to the telemedicine practice guidelines by the Ministry of Health and Family Welfare, Government of India.[6]

FUTURE

After the pandemic, telemedicine will continue to expand. Teleconsultations between the patients and the healthcare providers, including those across the globe (International experts), will help in better management of the cases. This will be extremely helpful in countries like India with a huge patient load and scarcity of pediatric surgeons. Another important area that needs special attention for better delivery of telemedicine is the development of a central web-based referral system connecting the primary-care providers and pediatric surgeons. The government-funded teleconferencing units linking the primary care provider clinics and pediatric surgeons are expected to prevent unnecessary delays in the optimal treatment of the most challenging conditions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.