Electronic Medical Record System-Based Teleconsultations in Pediatric Surgery: An Initiative from a Tertiary Care Public-Funded Hospital in North India to Alleviate the COVID-19 Imposed Hospital Visit Restrictions.

Background: There has been a dramatic effect of the coronavirus disease 2019 pandemic on the daily health-care services. The era of physical consultations is slowly being replaced with teleconsultation, and this current pandemic has tipped the scales further. This study highlights the preliminary experience in providing teleconsultation to pediatric surgical patients at a tertiary care hospital in north India. Materials and
Methods: A retrospective analysis of the electronic medical record system records of the patients undergoing teleconsultation at the authors' department between the June 26, 2020 and the September 26, 2020 was performed. The data were categorized on the basis of the type of consultation (urgent, semi-urgent, or routine) and the type of intervention. A comparison with the data from the corresponding months of 2019 was also performed.
Results: A total of 261 teleconsultations were conducted during the study period, with a success rate of 69% (181/261). Of these, 96% (171/178) were follow-up patients and 56% (99/178) presented with genitourinary complaints. After triaging, only 10% (18/178) of the patients required urgent medical/surgical attention.
Conclusion: In the current as well as postpandemic phase, teleconsultation can act as a potent triaging tool and can help in better utilization of resources alongside helping in the maintenance of social distancing by decreasing the number of physical visits to the hospital. Copyright:

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has affected the health-care delivery adversely on an unprecedented magnitude. Although the national lockdown was configured to prevent the sick from being affected adversely, the restrictions of long-distance travel and the re-organization of the hospital services to accommodate the volcanic rise in pandemic cases, didactic consultations, and face-to-face counseling were limited. In the wake of various stages of lockdown to curb the pandemic and improve social distancing, various health-care and academic institutions have incorporated telemedicine as an integral part of health-care delivery. Although teleconsultation is at a nascent stage in developing countries, it holds promise as a good alternative to the traditional way of evaluating and treating patients. Here, we present the experiences of our department in providing teleconsultation facilities utilizing the electronic medical record system (EMRS) to the pediatric surgical patients with the aim to highlight the importance of teleconsultation facility as a potent screening tool to identify patients who require active intervention by descriptive analysis and characterization of the teleconsultations provided and the advices given thereof to the consultation seekers. An attempt has also been made to gauge the effect of prevailing restrictions on the quantum of outpatient consultation services provided during the study period in comparison to the previous year.

MATERIALS AND METHODS

A retrospective analysis of the teleconsultation services provided by the pediatric surgery department of a tertiary care public-funded hospital in the National Capital Region was performed. All the teleconsultations scheduled between the June 26, 2020 and the September 26, 2020 were included. To book the teleconsultation appointment, one of the two following options were adopted by the parents/guardians. Either they called the designated landline numbers of the hospital or used the online registration website by the Government of India (ors.gov.in). All the consultations for a particular day were retrieved using a browser-based EMRS [Figure 1]. These were addressed by the on-duty senior resident and the consultant on-call on the same day. Using the duty smartphone, a voice call was made to the phone number provided at the time of scheduling the appointment. If required, after informed consent, the informer was asked to send the images of the previous records, case files, discharge summaries, or clinical photograph through WhatsApp messaging platform to gain further clinical information.

Figure 1

Browser-based electronic medical record system portal

Electronic medical record system-based teleconsultation protocol

Basic details including name, age, gender, and telephone number of all the patients who booked an appointment were available on the hospital EMRS [Figure 1]. Besides this, there were three sections including investigations, clinical notes, and advice (including prescription) in each patient's tele-consultation database. Previous investigations were linked to the investigation section. Clinical notes, including concise history and a provisional diagnosis of the patient, were entered by the attending doctors. They were also made available for interdepartmental consultations and for further appointments. Final advice, including prescriptions, was entered in the EMRS and was communicated to the patient over short messaging service. All the prescriptions were according to the telemedicine practice guidelines by the Ministry of Health and Family Welfare, Government of India.[1]

Characterization of the consultations provided, the advice given, and comparison of total consultations provided with previous year

For the study, all the phone calls were triaged into three levels depending on the priority of attention needed. Level 1, 2, and 3 were urgent, semi-urgent, and routine consultations, respectively [Table 1]. The consultations were also categorized based on the involved organ system. The categories included genitourinary, gastrointestinal, hepatobiliary, oncology, central nervous system, vascular, thoracic, and miscellaneous [Table 2]. Patients who were regular follow-up and new registrations were labeled as follow-up and new registrations. The final advice was also categorized into four levels depending on the urgency of the hospital-care needed. These were Level 1, requiring an urgent visit to the Pediatric emergency room; Level 2, requiring nonurgent hospital visit/admission or repeat teleconsultation within 1–2 weeks; Level 3, where teleconsultation was required after 2 weeks or the patient was advised to visit the hospital outpatient department (OPD) after the resumption of routine services; and Level 4, were advised to visit the hospital after the pandemic ends. The protocol to address the teleconsultations is summarized in Figure 2.

Table 1

Triaging protocol of the teleconsultations

Category of tele-consultation
Urgent	Acute abdomen
	Accidental gastrostomy dislodgement/removal of stents
	Children receiving chemotherapy or having persistent fever on chemotherapy
	Oesophageal stricture on dilatation
	Irreducible/strangulated hernia
Semi-urgent	Chronic constipation (new patient)
	Awaiting surgery for urgent surgical conditions (PUJO, PUV)
	Requiring early medical attention: UTI in predisposing conditions, renal calculus with haematuria, increase in the size of the haemangioma
	Oncological follow-up (within five years after treatment completion)
Routine	Awaiting routine surgeries
	Routine post-surgery follow-up
	Constipation under follow-up
	Oncological follow-up (> 5 years after treatment completion)

Table 2

Categorization of teleconsultations on the basis of involved organ systems

Organ system involved
Genitourinary	Hydronephrosis, Urinary tract infection (UTI), pelvi-ureteric junction obstruction (PUJO), posterior urethral valve (PUV), Vesicoureteric reflux (VUR), hypospadias, labial adhesions, exstrophy, epispadias, micropenis, neurogenic bladder, renal calculus, horseshoe kidney, urethral diverticulum
Gastrointestinal	Hirschsprung’s disease, chronic constipation, anorectal malformations (ARM), abdominal tuberculosis, duodenal atresia
Hepatobiliary	Cholelithiasis, biliary atresia, Choledochal cyst, extrahepatic portal vein obstruction (EHPVO)
Oncology	Wilms tumour, neuroblastoma, Ewing’s sarcoma, soft-tissue sarcoma, germ cell tumour
Central nervous system	Meningomyelocele, craniosynostosis
Vascular	Vascular malformations
Thoracic	Oesophageal atresia, congenital pulmonary airway malformation (CPAM)
Miscellaneous	Inguinal hernia, undescended testis (UDT), abscess, cellulitis, cervical rib

Figure 2

Detailed protocol to address the teleconsultations

A comparison of the total number of consultations done (teleconsultations as well as physical consultations) in July–September 2020 was made with those of the respective months of 2019 by reviewing our archives.

Statistical analysis

Descriptive statistics were used. Categorical variables were presented as frequency and percentages. Continuous data were presented as mean ± standard deviation if normally distributed, and median (range), if data were nonnormal.

RESULTS

A total of 1654 consultations were attended during the study period [Figure 3]. Of these, 1393 were physical appointments and were excluded from the final analysis. Remaining 261 were scheduled teleconsultations. Eighty teleconsultations (80/261; 31%) were unsuccessful due to incorrect registered telephone number (23/80; 29%), phone not reachable (20/80; 25%), and phone not picked-up (37/80; 46%). Of the successful 181 consultations, three were not pertinent to pediatric surgical ailments and were excluded from the final analysis. Two were advised to take teleappointment for pediatrics while one had a skin eruption and was advised to take an appointment for dermatology.

Figure 3

Summary of the consultations during the study period

A total of 178 teleconsultations (for 172 patients) were included in the final analysis. The median (range) age of the patients was 47 (3–240) months. There was a male predilection (135/178; 76%) in these consultations. Majority of the patients were previous follow-ups with only seven (4%) consultations as new registrations. Three patients had scheduled a teleappointment more than once. One had a total of four teleconsultations due to recurrent dislodgment of the gastrostomy tube. He was advised to strap the gastrostomy site and review in the emergency room urgently. The second patient had recurrent urinary tract infection (UTI) after successful surgery for the posterior urethral valve. He had consulted the telefacility thrice. The third patient had undergone colostomy for Hirschsprung's disease and had severe peristomal excoriation, due to which he had booked a teleappointment twice.

The majority (99/178; 56%) of the teleconsultations were for the children having a genitourinary ailment [Figure 4]. Upon triaging, only 10% (18/178) required urgent medical attention. The proportion of consultations triaged as routine and semi-urgent were 64% (114/178) and 26% (47/178), respectively. The majority (50.6%; 90/178) of the appointments were regular follow-ups and required a Level 4 advice. Only 5.6% required (10/178) were given Level 1 advice. Level 2 and 3 advice were given to 25.8% (46/178) and 18% (32/178) of the teleconsultation.

Figure 4

Categorization of the teleconsultations based on the involved organ systems

The total consultations done in July–September 2019 were 6809 that included both new and follow-up patients. In contrast, for the respective months of 2020, the total consultations were only 1654, i.e., only one-fourth of the previous year's numbers [Figure 5].

Figure 5

Comparison of the monthly trends of the consultations during the pandemic era with the previous year

DISCUSSION

The rapid outbreak of novel COVID-19, which was first reported in Wuhan, China, has morphed into a global pandemic which has affected the health-care infrastructure and practices at an unprecedented level.[2] With the discovery of new cases in the various states of India, the government had imposed a nationwide lockdown on March 24, 2020.[3] This led to an abrupt disruption of routine health-care services, while the emergency services were more or less unabated. With the diversion of health-care personnel to COVID-19-related duties and closure of routine OPD services, teleconsultation was adopted to review the patients and provide continuous health-care services.

After the lockdown announcement, our department started to proactively follow-up the operated cases telephonically wherever the phone number was available in the medical records to continue patient care. However, from 26th June 2020, the institute started online EMRS for teleconsultation of follow-up as well as new patients. The patients were evaluated telephonically, and after obtaining telephonic informed consent, the investigations and clinical records were retrieved. Subsequently, they were either advised treatment or were asked to review urgently in the emergency if the need arises.

Eventually, from the July 22, 2020 onward, our department resumed the OPD services; however, the patient load was limited because of existing social distancing protocols.[4] Our analysis of the limited period of 3 months revealed that the vast majority (96%) of our consultations were follow-up patients with only 10% of them being urgent, besides this, the majority (64%) were routine consultations. It is also interesting to note that almost half of our patients did not require any active intervention or investigations. This high proportion of old patients probably reflects the human tendency to avoid building a doctor–patient relationship without being face to face with the doctor first. Those patients who were seen by us before already had the “trust” that forms the foundation of the doctor–patient relationship and were the most to explore telemedicine as an alternative channel to seek advice. It is also possible that the patients who were sick acutely were taken to the nearest emergency health-care facility rather than waiting their turn for an appointment for teleconsultation. Therefore, our findings of rather higher proportions of cases having routine consultation and those not requiring active investigations are understandable.

Genitourinary complaints formed the predominant subgroup of patients that we had reviewed with one-third of these presenting with complaints of UTI. These patients were all triaged to Level 2 of intervention. These results are in tune to the published literature, where urological services constitute more than 40% of the bulk of pediatric surgery practice.[5]

The above data show that teleconsultation can act as an adjunct in triaging the patients before routine OPD visit and hence decreasing the patient load in the OPD which is the need of the hour as it saves both the patients and the health-care workers from unnecessary potential exposure to COVID-19. There was a drastic difference in the number of consultations provided for the corresponding months of 2019 and 2020 with an astounding 92% decrease in the total cases suggests a shift in the healthcare-seeking behavior of the patients as well as a it may be a reflection of a direct fallout of the prevailing traveling restrictions and social distancing norms. It is also noteworthy that 31% of our scheduled teleconsultation appointments were unsuccessful due to either an incorrect contact detail or connectivity issues exposing a major but surmountable lacuna in the current practice of teleconsultation which can be easily rectified by increasing the awareness level of the patients. Another way by which this deficit can be addressed is by incorporating one-time password facility to verify the contact number the patients provide during registration.

Conclusion

The above results demonstrate that, with sufficient awareness in the patients pertaining to tele-consultation facilities, this approach can act as a powerful tool to help the government and health-care sector in implementing judicious use of resources in the postpandemic period when the primary focus will be rebuilding the economy of the country. In such a scenario, telemedicine can act as a suitable triage method for health-care professionals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.