Introduction
Since the detection of the first case of the novel coronavirus diseases (COVID-19) in 2019 in Wuhan, China; the infection has spread at an alarming pace throughout the world.1, 2, 3, 4 The rising cases have created unprecedented challenges for the healthcare systems. With the disease reaching the pandemic stage, countries all over the world are facing acute shortage of healthcare staff, health resources such as ventilators, personal protective equipment, facemasks etc.5, 6, 7, 8, 9 Since the infection is spread by person-to-person transmission, control measures including social distancing, stay-at-home guidelines, contact tracing, early self-isolation and quarantine, travel restrictions, prohibition of mass gatherings etc. are being adopted.10, 11, 12, 13, 14, 15 Additionally, it is also imperative that diligent efforts be made to ensure that people suffering from other medical or surgical ailments are not deprived of their healthcare needs.
In such a scenario, utilization of existing technologies such as telemedicine is playing a very important role. Virtual healthcare delivery is being scaled up and integrated into the current healthcare system. Virtual care can reduce the burden on the hospitals and healthcare system while simultaneously protecting healthcare workers as well as patients from exposure to the novel coronavirus.16, 17, 18 This review aims at understanding telemedicine and its various benefits and disadvantages with special emphasis on the emerging scope of telemedicine in perioperative anaesthesia and chronic pain.
This review is being written with an objective to summarize the existing literature related to the applications of telemedicine in perioperative anaesthesia, chronic pain and academic training. The literature search was done from various search engines including PubMed, Cochrane Library, and Google Scholar. The search words included “telemedicine”, “telehealth” “telemedicine advantages”, “barriers telemedicine”, “telemedicine history”, “telemedicine Covid-19”, “telemedicine coronavirus” “telemedicine India”, “telemedicine MCI guidelines”, “teleanaesthesia”, “tele-pain”, “telemedicine anaesthesia”, “telemedicine preoperative”, “telemedicine intraoperative”, “telemedicine postoperative”, “telemedicine chronic pain”, “teleanaesthesia training”, and “teleanaesthesia education”.
The published literature related to application of telemedicine in anaesthesia has been included and all study designs including systematic reviews and editorials were studied. During the search, any published literature not related to telemedicine were excluded. The literature published till December 2020 were included in this review.
What is Telemedicine?
Literally meaning ‘medicine at a distance’, the term telemedicine was first used in the 1970s and since then has seen multiple definitions by various authors.19, 20 This itself underscores the fact the technology of telemedicine is in a constant state of flux with continual advancements.
World Health Organization (WHO) has defined telemedicine as “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”21 Recently, the Medical Council of India (MCI) adopted the same definition in its Telemedicine Practice Guidelines published in March 2020.22 The role includes online consultations with specialists via telephone or videoconference, telemonitoring patients’ health parameters and transmitting them to their healthcare departments, and tele-learning and training of healthcare workers and /or patients, etc.
Types of telemedicine
Telemedicine can be classified into two main types depending on the timing of transmitting information-synchronous and asynchronous. Synchronous telemedicine employs real-time communication between patient and healthcare provider via video, audio or text. Asynchronous (store-and-forward) telemedicine involves relaying of health-related data via images, videos, texts, e-mails etc. which can then be evaluated at a later time.22, 23
Advantages of telemedicine
Digital healthcare has offered numerous benefits to patients as well as healthcare professionals even in the pre-COVID times:24, 25, 26, 27
Improves access of healthcare, especially specialist services, in rural or otherwise remote areas.
Provides better availability of medical care to disabled, elderly, or those with dearth of adequate transportation facilities
Decreases travel time and costs, and thereby healthcare costs for patients
More environmental-friendly due to reduced travel-related emission of pollutants.
Increases patient convenience; decreases time spent waiting for appointment.
Helps in tele-monitoring of patients’ health at home.
Facilitates consultations between healthcare workers present at different locations.
Tool for e-learning and education for medical professionals; especially those located in remote areas.
Studies have shown improved or similar outcomes when patient suffering from chronic ailments such as diabetes mellitus or hypertension received medical care via telemedicine.26, 28 The unique constraints during the COVID-19 pandemic have provided a new impetus to telemedicine. Healthcare providers worldwide are scrambling to adopt virtual healthcare and incorporate it into their patient care routines.18, 29 In addition to lessening the risk of exposure for healthcare workers and patients, it can also enable more efficient screening and triage of patients before admission to hospitals.23, 30, 31, 32, 33 Telemedicine can also help provide medical care to patients suffering from other chronic diseasesin the convenience of their homes without having to potentially get exposed to the infectious virus.17
Barriers to telemedicine
Despite all its benefits, the technology of telemedicine is not without limitations:
Absence of physical examination leading to missing out on important clinical information.31
Certain diagnoses and treatments may not be possible without face-to-face examination.31
Perception of virtual care as being impersonal and remote by patients.24, 34, 35
Lack of knowledge about telemedicine and dearth of access to good internet connectivity; especially for the elderly, illiterate or those living in the rural areas.24, 34, 35
Resistance from physicians and/or patients for adoption of new or unfamiliar technology.24, 27, 36
High initial cost of investment and lack of reimbursement for virtual care.27, 36
Maintenance of confidentiality and security of personal medical data and the susceptibility of digital health for cybercrime.36, 37, 38
Lack of clear and specific guidelines in majority of the countries regarding the use of telemedicine and its legal and ethical concerns, especially before the advent of COVID19.24, 27
Telemedicine in India
Though the technology of telemedicine is not new to India, it has not been utilized to its maximum potential in India. However, because of its many benefits, telemedicine can prove to be an invaluable tool for healthcare in a populous country like India with a diverse topography. Moreover, it can also help in making both specialised and routine healthcare more accessible to the vast population residing in rural areas.22, 39
Initial initiative for telemedicine in India was taken by the Indian Space Research Organization (ISRO) in 2001 via a Telemedicine Pilot Project connecting Apollo Hospital at Chennai to the Apollo Rural Hospital at a village in Andhra Pradesh. Since then, ISRO has been expanding its telemedicine network each year.40 Other government organizations such as Ministry of Health and Family Welfare and Department of Information Technology as well as leading technical and medical establishments have also been contributing to virtual healthcare delivery in India.17, 24, 39, 41 Nonetheless, the use of telemedicine wasstill being approached warily by the healthcare workers. In addition to the other barriers, the absence of well-defined guidelines has actedas a significant deterrent for physicians to adopt telemedicine into their routine practice. However, taking into consideration the present COVID-19 pandemic and its distinctive precautions; the Medical Council of India (MCI) brought forward its Telemedicine Practice Guidelines in corroboration with NITI Aayog. These are meant to allow Registered Medical Practitioners (RMPs) to deliver healthcare via telemedicine. It is hoped that with the support of these guidelines, digital health will be adopted by more and more medical professionals in the future.22
Scope of Telemedicine in Anaesthesia
The field of medicine must continuously embrace the novel technological advancements and innovations in order to keep up with the ever-changing world. Applications of telemedicine have been explored by various medical specialities such as dermatology,42 neurosurgery,43 neurology,44, 45 radiology46, 47 etc. Though various authors have reported the use of telemedicine in anaesthesia, however, it is still not widespread (Table 1).
The galloping advances in information and communications technology and access of internet services, even in remote areas, are increasing the possibilities and applications of telemedicine in anaesthesia. The COVID-19 pandemic has further given its use and acceptance a forcible push in the various phases of anaesthesia care (Figure 1).
Preoperative Applications
Various authors have discussed and described the use of telemedicine for remotely conducting a pre-anaesthetic check-up. Ansary et al have described possible methods of a virtual physical examination. Apart from routine equipment such as blood pressure monitors and glucometers, newer technologies such as electronic stethoscopes, smartphone applications, wearable sensors etc. can aid the remote physical examination.48 This can very well be incorporated into the physical examination needed for PAC.
A tele-PAC is economical with respect to both time and money with high patient and provider satisfaction (Figure 2). It has not been seen to cause any unnecessary cancellation or delays in surgery. Tele-PAC can be especially viable for geriatric patients by decreasing the inconvenience of travel. However, the associated comorbidities, airway challenges etc. in the elderly population may, in fact, necessitate an in-person PAC. A virtual PAC can also be utilized to educate the patient regarding the procedure and risks of anaesthesia using videos.49
Another possible application of telemedicine, which has not been explored widely, is virtual prehabilitation before surgery. Telemedicine can be used to educate patients about their individualized needs to increase their functional capacity and optimize their preoperative status. Smoking cessation, breathing exercises etc. can be explained and demonstrated. Remote spirometry can also be explored. A telespirometric system has been described by Nowinski et al in 2015.50 Patients’ preoperative medications, diet and fluid status, weight, glucose levels etc. can be monitored and optimized. These can help to prepare the patient for surgery in a better way and possibly improve the postoperative outcome.
Intraoperative Application
A handful case reports have described the use of telemedicine for remote anaesthetic monitoring and even remote drug delivery. It can help expand the reach of anaesthesiologists to remote areasfor more complex procedures. However, intraoperative use of tele-anaesthesia facessignificant challenges. A high-speed internet connection with a good bandwidth without any disruption in transmission is a minimum requirement. The transmission should involve not just the vital monitors but also the live video telecast of the surgical field so asto better guide the anaesthetic management. Though the availability of these services is increasing even in remote areas, but maximum caution needs to be taken as any interruption in transmission can prove to be disastrous for the patient.
Table 1
Shows the various studies related to the application of telemedicine in anaesthesia and pain medicine
|
Reference |
Study Type |
Objective |
Sample Population |
Results |
|
Preoperative |
||||
|
Applegate et al (2013)51 (48) |
Prospective randomized trial |
To compare telemedicine pre-anaesthetic check-up (PAC) with face-to-face PAC on perioperative processes |
160 adult patients slated for head and neck surgery |
Telemedicine and in-person PAC found to be comparable with high patient and doctor satisfaction with both methods |
|
Boedeker et al (2007)52 |
Prospective questionnaire based survey |
To assess patient perception for virtual PAC clinic |
13 patients scheduled for elective surgery |
Demonstrated patient preference for tele-PAC |
|
Brull et al(2006)53 |
Randomized controlled trial |
To evaluate patient satisfaction with a preadmission tele-consent on day of minimal-risk surgery |
124 patients scheduled for arthroscopic shoulder surgery |
Tele-consent did not improve patient satisfaction |
|
Dilisio et al (2014)54 |
Case report |
To present a case of virtual preoperative airway examination to gauge viability of office-based anaesthesia |
An adult patient scheduled for dental extraction |
Airway examination using telemedicine can offer important information about achievability of office-based anaesthesia |
|
Kamdar et al (2020)55 |
Retrospective non-randomized descriptive study |
To study implementation of PAC via telemedicine |
2204 patients scheduled for elective surgery |
High patient satisfaction, more cost-friendliness, and no increase in case cancellation rate with virtual PAC |
|
Karim(2020)56 |
Correspondence |
To describe cloud-computing based virtual PAC |
- |
Possible benefit to patients but has various limitations |
|
Lozada et al(2016)57 |
Prospective survey |
To evaluate patient satisfaction with PAC via telephone |
75 postoperative patients |
Patient preference for Tele-PAC with no rise in case cancellations |
|
Mullen-Fortino et al (2017)58 |
Retrospective data review |
To determine effect of telemedicine on presurgical assessment |
7803 patients scheduled for elective surgery |
Better patient satisfaction, decreased time for PAC, no increase in surgical cancellation rate |
|
Rogers(2020)59 |
Non-randomized pilot study and evidence based project |
To employ telemedicine for paediatric PAC and assess patient and provider satisfaction |
14 patients and 6 nurse practitioners |
High patient and provider satisfaction with Tele-PAC |
|
Srivastava et al (2020)60 |
Correspondence to editor |
To highlight the importance and practical application of Tele-PAC during Covid-19 pandemic |
- |
Encouraging alternative to in-person PAC |
|
Wong et al (2004)61 |
Pilot study |
To study feasibility of PAC via telemedicine |
10 patients scheduled for elective surgery |
Successful use of telemedicine for PAC with high patient and anaesthesiologist satisfaction |
|
Intraoperative |
||||
|
Cho (2011)62 |
Pilot study |
To evaluate utility of Tele-Airway Management System (TAMS) for intubation of patients in emergency |
25 patients with inability to maintain airway |
Comparable result of TAMS with in-person intubation in terms of time for intubation and success rate |
|
Chung et al (2007)63 |
Randomized controlled trial |
To compare efficacy of TAMS vs video-laryngoscope alone for emergency intubation |
33 trainee intubators (medical students and interns) |
Better success rate with TAMS with lesser time for intubation |
|
Cone et al (2004)64 |
Case report |
Description of use of telemedicine for remote monitoring of anaesthesia |
Adult female scheduled for cholecystectomy |
Demonstrated successful use of remote intraoperative monitoring |
|
Cone et al (2006)65 |
Description of use of telemedicine for PAC and intraoperative anaesthetic monitoring using satellite communication |
5 patients posted for elective surgery under general anaesthesia (GA) and 2 under spinal anaesthesia (SAB) |
Successful description of teleanaesthesia for preoperative discussion and intraoperative monitoring |
|
|
Fiadjoe et al (2009)66 |
Case reports |
Description of telemedicine use to assist living related paediatric liver transplants |
Two paediatric patients planned for elective liver related liver transplant |
First report of successful use of remote anaesthesia for preoperative and intraoperative consultation for organ transplantation |
|
Hemmerling et al (2013)67 |
Prospective pilot study |
To assess feasibility of transcontinental remote anaesthesia |
20 patients undergoing elective thyroid surgery |
Demonstrated good hypnosis and analgesia with remotely controlled total intravenous anaesthesia |
|
Ihmsen et al (2007)68 |
Prospective pilot study |
To evaluate viability of a remote EEG-controlled closed-loop propofol administration intraoperatively |
11 patients undergoing surgery under GA |
Successful demonstration of teletherapeutic administration of propofol for GA |
|
Miyashita et al (2015)69 |
Prospective pilot study |
To determine correlation between transmission bandwidth and delay time in tele-anaesthesia system |
25 patients undergoing minor surgery under GA |
Decrease in delay time and increase in frame rate achieved with a higher bandwidth in tele-anaesthesia system |
|
Postanaesthesia care unit (PACU) |
||||
|
Blankush et al (2016)70 |
Prospective observational study |
To determine if postoperative monitoring with automated notification techniques can identify patients at risk for deterioration |
133 postoperative patients |
Automated notification systems can be used in postoperative patients but need further studies |
|
Boer et al (2018)71 |
Narrative review |
To summarize concept of remote vitals monitoring in PACU and review its existing evidence |
- |
Remote vitals monitoring in PACU may prevent severe postoperative complications |
|
Breteler et al (2018)72 |
Observational study |
To determine reliability of wireless wearable sensor for remote monitoring in high-risk postoperative patients |
25 postoperative patients |
Accurate measurement of heart rate (HR) but not of respiratory rate (RR) by the wireless sensor |
|
Downey et al (2019)73 |
Randomized controlled parallel group trial |
To validate accuracy of wearable remote sensor for monitoring vitals in high risk postoperative patients |
51 postoperative patients after major elective surgery |
Discrepancies in HR measurements and low correlation in RR measurements |
|
Posthuma et al (2019)74 |
Prospective observational study |
To evaluate feasibility of continuous wireless RR monitoring in postoperative patients |
126 patients undergoing moderate and major general surgery |
Reliable measurement of RR upto 4 days postoperatively |
|
Perioperative |
||||
|
Bridges et al (2020)75 |
Narrative review |
To review literature pertaining telemedicine in preoperative, intraoperative and postoperative phases of anaesthesia |
- |
Telemedicine in anaesthesia is novel but rapidly evolving. However, it has limitations and needs further research |
|
Galvez et al (2011)76 |
Narrative review |
To review applications of telemedicine in anaesthesia |
- |
Telemedicine in anaesthesia shows promise |
|
Chronic Pain |
||||
|
Burton et al (2000)77 |
Descriptive study |
To describe the operation of a telepain clinic |
280 patients suffering from chronic pain |
More time-efficient for physicians |
|
Byrne et al (2020)78 |
Survey |
To study experience of patients using telepain service |
66 patients |
Positive patient perception (decreased travel time, better access to care) |
|
Dario et al (2017)79 |
Systematic review with meta-analysis |
To assess if telehealth services decrease pain and disability in non-specific low back pain |
11 studies |
Limited benefit demonstrated |
|
Emerick et al (2020)80 |
Commentary |
To discuss expert opinion regarding use of telemedicine in chronic pain |
- |
Considerable benefits of telepain services which warrant use beyond Covid-19 pandemic |
|
Ghai et al (2020)81 |
Special article |
To describe use of telemedicine for chronic pain management during Covid-19 pandemic |
- |
Telemedicine can be used for pain management even beyond the period of Covid-19 |
|
Li et al (2020)82 |
Editorial |
To discuss the use of telehealth for chronic pain management during Covid-19 pandemic |
- |
Digital health can be applied to chronic pain management but limitations need to be considered |
|
Mariano et al (2019)83 |
Systematic review |
To assess advantages of telemedicine in chronic pain management |
12 studies |
Teletherapy can be effective for chronic pain management but further controlled trials are needed |
|
Peng et al (2006)84 |
Prospective pilot study |
To evaluate feasibility, cost-benefit and patient/provider satisfaction for chronic pain consultation |
11 telemedicine follow-up consultations involving 8 patients |
Follow-up consultations found to be feasible and economical with high patient and provider satisfaction |
|
Provonost et al (2009)85 |
Randomized crossover trial |
To determine cost-effectiveness of telemedicine for chronic pain management |
26 patients |
Cost-effectiveness of telemedicine is more than in-person consultations |
|
Training and education |
||||
|
Eaton et al (2018)86 |
Cluster randomized controlled trial |
To assess effect of telementoring on knowledge and competence in chronic pain management |
41 primary care providers |
No increase in knowledge and perceived competence; further research needed |
|
Furlan et al (2019)87 |
Pre-post online survey |
To study impact of tele-education on knowledge, self-efficacy and satisfaction of physicians |
296 primary healthcare providers |
Better knowledge and self-efficacy with tele-education programme |
|
Laurent et al (2016)88 |
To discuss feasibility of telesimulation for teaching ultrasound guided regional anaesthesia (UGRA) |
19 anaesthetists |
Successful demonstration of remote telesimulation-based training for UGRA |
|
Postoperative Application
In the immediate postoperative period, telemedicine can be used for remote monitoring of vital parameters. Intermittent monitoring can cause oversight of early signs of deterioration; whereas continuous monitoring of vital signs can help detect these changes in the physiological parameters of patients in the PACU. The use of remote monitoring devices and automated notification systems which continually give information to the attending anaesthetist can facilitate early identification and timely treatment of any derangement in these parameters. However, further research and studies are needed to develop reliable and cost-effective systems for such virtual surveillance.
Application in Chronic Pain
Telemedicine can be a valuable alternative for management of chronic pain. Patients with chronic pain are often of old age, have other comorbidities and may have mobility issues. Therefore, virtual therapy can be more convenient for them. Physicians also can get a better understanding of the patients’ mental status and social factors in their home which can help in better adjustment of their management. Prescribing medicines, especially in a follow-up consultation which usually only requires titration, can be done conveniently via telemedicine. In addition, non-pharmacological modalities such as posture adjustment, exercise, lifestyle modification etc. constitute an important part of the treatment of chronic pain. These can be easily communicated and evaluated via virtual therapy.
Training and Academics
Training and education using telemedicine; also known as telementoring; can help bridge the divide between premiere medical institutions and remote places with inadequate access to specialists. Training and consultations can be provided to students and primary care providers living in geographically distant places. In the field of anaesthesia, telementoring has been described for chronic pain management and UGRA. However, further studies are needed for better implementation of such programmes on a wider scale to cover other aspects of anaesthesiology as well.
Conclusion
Any large-scale crisis, such as a war or pandemic, leads to unprecedented efforts from government organizations for medical research; often leading to a spurt in medical and surgical innovations.89 The Covid-19 pandemic has also created a huge upheaval in the healthcare system with more focus being placed on Covid-19 and its related research and a wider acceptance of telemedicine. The benefits of telemedicine are well-documented. The ongoing pandemic has offered a special opportunity to expand the utilization of virtual health systems in anaesthesia. The learnings during this experience can very well be extended into use during the post-pandemic period also. After this health crisis abates, it will be interesting to see how the healthcare system overall and the field of anaesthesia in particular resurfaces and reforms itself. But going by the present acceptance of telemedicine by both patients and providers in various fields, virtual health seems to be here to stay.
However, before its use becomes more universally accepted in the realms of anaesthesiology even beyond the period of the pandemic, more controlled studies and research needs to be done so as to better refine its applications in anaesthesia.
Declaration of Conflicting interests
The authors declare that there is no conflict of interest Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Authorship
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Dr Kritika Agrawal and Dr Satyajit Majhi. The first draft of the manuscript was written by Dr Kritika Agrawal and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.