Santa Comba was the guinea pig. The city council of a coruña, an area of passage between the municipalities of Costa da Morte and Compostela, is the paradigm of the rural galician. A large territory, divided into 17 parishes with more than a hundred villages, and covers a population of a little over 9,400 people, with 33% older than 65 years. The plan: to deploy a system of remote monitoring of chronic patients to save them time-consuming visits to the health center. “The technological level of the patient of Santa Comba is different from the one of Santiago. But we think that if we could get to Santa Comba, which is very rural, we could get to the rest of Galicia”, now explains dr. Felipe Street, one of the ideologists of the project and head of primary care area of Santiago and Barbanza. And they came. The plan, of name Telea, began with 49 patients of Santa Comba with diabetes, hypertension, or heart failure. Today it works in the whole of Galicia and there are already 2,600 people, included in the platform.
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A working group was commissioned, back in 2017, to adapt the clinical guidelines for some ailments to be able to make a follow-up home and selected a few profiles of patients: those with heart failure, diabetes, hypertension, chronic obstructive pulmonary disease (COPD) and atrial fibrillation. The plan was that they could measure, from their home, some parameters such as blood pressure, blood glucose level in blood, weight, and body mass index, oxygen saturation, heart rate, and the range of clotting (INR). “The goal is not to alleviate the demands on the query, but to be more proactive and to anticipate potential complications of their disease,” notes Street. The patients themselves were the one who, once a week, incorporating electronically the data to its clinical history, which were then reviewed by their primary care teams.
Ramon Canay was the first patient in Telea. Lives in Allon Top, a village four kilometres away from Santa Comba. Is hypertensive since 20 years ago. “I already used to measure the voltage from the house and he had it written on a piece of paper to the doctor. It is now more comfortable,” explains the man, now 75 years old. Take the stress two times a day, every two weeks, and his daughter, Maria Dolores, is in charge of incorporating them into the platform. “He always had a strain of white coat: when I saw the doctor, he got nervous. The taking of a house is more real,” says the daughter. According to Street, 100% of the patients in the pilot preferred to do the checks on your address and health outcomes, also improved. 90% of the hypertensive patients had better blood pressure levels, and reduced hospital admissions among those with heart failure. “Patients with diabetes have hemoglobin glycosylated [the average of glucose in the last three months] better than when they come to the consultation. The data indicate to us that they are best followed,” concluded Street. The analysis of the deployment in the rest of Galicia is still cooking, but the first data suggest that has been reduced by 27% on the income of patients with heart failure.
Telea has become an initiative of success that has already been installed widely in the System Galego de Saúde (Sergas). But it is not the tonic that is the case with other health-care projects at a distance. In fact, according to the experts consulted, the universe of telemedicine is very variable in all the Spanish territory, it lacks a roadmap of common and progresses —or regresses— to will of professionals and administrations at the helm. “The feeling is that telemedicine seems that everyone does , but the reality is that we are losing the great opportunity to improve the accessibility issues. There are very few formal programs”, values David Moreno, president of the International Society of Teledermatología.
dermatology is one of the disciplines where the most advanced telemedicine
Precisely, their specialty, dermatology is one of the disciplines where more advanced is the concept of telemedicine. Communities such as Galicia, Andalusia, Madrid, Catalonia, and Extremadura, among others, already have, of regular form, of a system of remote health care for ailments skin. Through a camera conventional, for example, the family doctor can take an image of a lesion in the skin of a patient and transfer the photo and the clinical information of the patient to a platform where the dermatologist evaluates it and gives a response.
At the Hospital Virgen Macarena of Sevilla, the team, Moreno has had 15 years to perfect this system. “In the last six years we have seen 100,000 patients. It is a routine way of working,” says the specialist. Although he admits that not even this system is implemented in a generalized way in the rest of Spain. “The reason for the variability is not a question of technology. The most important barrier are the professionals and organizations. The first, because there is a lack of a culture of change and some see it as a threat or a form of work for which we’re not trained. And the second, by the difficulty of organizations to change the way you work”, value Moreno.
Against the waiting lists
70% of the Catalan health centres use the telediagnóstico and the long-distance consultation
With the extensive waiting lists that asuelan the health care system —more than 671.000 to June 2019, the telemedicine aims also to improve the accessibility. “There is a strong culture in specific things and certain specialties are more advanced by the pressure of care and waiting lists. A primary care physician take a photo of the patient and the move to the dermatologist is a privilege,” says Rodrigo Gómez, an expert in telemedicine and the management of innovation. Although there is not a clear consensus on the improvements in accessibility. “The project of telemonitoring basque Osarean, for example, increased the number of queries, instead of downloading them”, values Fernando Alonso, coordinator of the working group on new technologies of the Spanish Society of Family and Community Medicine. “It will improve the quality and efficiency, but the waiting lists I don’t know. Lists can end up being mobile, and prioritize by the urgency according to the patient’s evolution. Although as citizens we have to know that one, as it comes up in the list, you can go down,” continues Joshua Sallent, director of the Foundation TicSalut Social of Catalonia.
Catalonia is preparing a strategic plan to order the provision of services that are not face-to-face. In the community, in addition tos of the teledermatología, is implanted the eConsulta in primary care —a virtual consultation between doctor-patient through a secure e-mail—. In 2018, 4.505 professional and 60,763 grant patients the used. The health system Catalan has also with Telestroke, a platform for video conferencing and transmission of medical images to assist strokes strokes that occur in isolated areas of the reference hospital, and have to be cared for, in the first instance, in the emergency department of county hospitals. According to the latest report of Trends of Ticsalut, the 70% of the Catalan health centres use the telediagnóstico and the long-distance consultation. Telemonitoring, however, barely reaches 20%.
“We have been many years of delay. We spend a lot in partial plans. The teledermatología is more visual and easier to apply, but it all depends on the receptivity of the specialist”, points out Alonso. At this point, agrees Sallent: “radiologists are clear that theirs has changed clarísimamente. The primary care physicians, which are quite trench and their position is much less technological, it costs them more.”
The experts consulted agree on the lack of guidelines to boost telemedicine. In fact, the Ministry of Health lacks a strategic plan or any initiative to boost this area, as pointing to a spokesman. There is also no data available to measure the implementation of this new model of care in the territory.
The outstanding accounts of the virtual consultations
doctors have discarded, at least in the short term, an eventual consultation by Skype between doctor and patient, but it does warn of the risk of the dehumanization of the health care with these new strategies. “You have to drive the remote control, but you should go slowly to not interpret it wrong: it is not our intention to diagnose via video conferencing,” warns the doctor Street.
Are, in any case, many pending tasks. For example, the safety of technological devices: “There are limiting factors of confidentiality and privacy, as the risk of hacking,” says Alonso.
The debate is on the table but, according to experts, the training of professionals will be capital. “The way of interacting with the patient is different and to succeed in the field of technology you need the professionals to have new skills. Most of the professionals are convinced but not just to see how would be the model,” says Sallent.
The profile of patients can also condition the advancement of telemedicine. “Most of the patients with chronic complex, it is older people, and that means you have a digital divide and things that are not ready for them,” says Sallent. In fact, in Telea, for example, not everyone in the world gave the profile. “They had to be diagnosed and to have technological skills he or someone close to you. Not everyone is a candidate because there are people who need to go through the consultation,” explains the doctor gallego.
all in all, Moreno has it clear: “telemedicine has come to stay. This is not a change that has happened to four locos. It is the evolution of the society”. But Street adds: “medicine is a career that is humanistic and will remain so. No tool is going to replace the consultation of a physical presence”.
