The Covid-19 pandemic has recorded a growing demand for technological tools, including those used for medicine the use of televisions and telemonitoring, alongside other tools (such as contact tracing tools), has grown in a disordered at the beginning of the pandemic, it has over time been supported by scientific societies and health institutions. But is the spread of these technologies the result only of the emergency? And what are their limits and prospects?
The demand for new technologies has been growing in this period of the Covid-19 pandemic, especially during the lockdown. It is estimated, for example, that the number of active daily users on Zoom has risen in a short time from 20 to 300 million, as well as that its stock market value has grown by 300%. At the same time, the applications of telemedicine have grown, that is, all those tools that have allowed (and today allow) the delivery of health care services at a distance. In the United States, virtual visits increased tenfold in the course of a few weeks. This phenomenon has also been witnessed in Italy. As of March 1st, 175 initiatives have been implemented for the use of digital tools undertaken by the Italian Health Authorities to support remote patient visits, 29% of which for the management of Covid-19 patients and 71% for the management of chronic diseases such as diabetes and cardiovascular and oncological diseases.
In the space of a few weeks, what has happened internationally has failed in ten years, not even in the most technologically advanced countries. The doubts that for years have held back the change (the rigid regulation for their use, the ambiguous reimbursement policies, the lack of evidence on their reliability and cost-effectiveness, the privacy problems, the difficulty in integrating the new tools into daily clinical practice, distrust on the part of doctors and patients) dissolved in the face of the health emergency.
Let’s take the television services based on the main video conferencing and video chat tools (such as Skype, Zoom, Google Hangouts, and Apple FaceTime). These systems have been widely used to visit Covid-19 patients and patients with chronic diseases from home. Their use, which grew in a disorderly manner at the beginning of the pandemic, has over time been supported by scientific societies and health institutions, which have provided indications on how to use these tools appropriately and integrate them into clinical practice. For example, the American Medical Association has published guidelines that suggest to American doctors how to integrate these tools with the medical records or other systems (digital or paper-based) already in use, so that the data collected during the visit and the communication with patients are correctly stored and accessible at all times.
However, the choice to adopt television and telemedicine systems is not valid for all patients. The Istituto Superiore di Sanità has published guidelines which, in addition to focusing on the technical aspects and those relating to the personal responsibility of the physician, data security, and privacy, provide suggestions on how to choose candidates for telemedicine services. Which are not limited to people “not affected by previous illnesses at the time when quarantine or isolation was required (symptomatic or asymptomatic) and who fall within the definition of close contact or confirmed case”, but who include “people suffering from chronic pathologies, rare diseases and people in fragile conditions, or who require long-term treatment or special assistance and/or support not in the hospital “and those people” in need of psychological tele-support who are in isolation or quarantine, or de facto isolated following the rules of social distancing, in the course of Covid-19 “. On the other hand, mental health is one of the fields where the adoption of television systems has been most favored, as shown by the decision of the Food and Drug Administration to expand the availability of digital health tools and digital therapies for psychiatric disorders throughout the period of the pandemic.
Unfortunately, the television systems based on videoconferencing and video chat systems are not sufficiently secure, although some of them (for example Skype), adopt encrypted protocols that guarantee the protection and confidentiality of communications. This is the reason why more advanced systems have been developed by companies specialized in digital health and by some Regions to favor, in protected and integrated environments, teleconsultation and telemedicine services that also guarantee the archiving of consultations and documents shared with the patient. This is the case of the Tuscany Region, where the Single Regional Information System for the Covid-19 Emergency Management was created, an integrated system for the management of triage and telemedicine services, and the analysis, through big data methods, of the large amount of data collected, useful for providing important information on the spread of the infection and suggestions for its possible containment.
Telemonitoring tools that collect and monitor the physiological parameters of patients directly at home (often via devices equipped with Bluetooth) have also made their rapid appearance and that allows doctors to view the trends of the parameters detected and receive alerts and automatic messages in the presence of altered or critical values. The usefulness of these tools in remotely monitoring the most fragile patients and those suffering from chronic diseases has not escaped some scientific societies (such as the Italian Society of Diabetology, the Medical Diabetes Association, and the Italian Society of Endocrinology) which jointly have drawn up guidelines aimed at adopting them for the outpatient management of diabetic patients even when the emergency is over.
Other Tools For Digital Health
Alongside the television and telemonitoring systems, digital health tools have been used to activate triage systems (through chatbots and virtual assistants that evaluate the symptoms manifested by an individual to identify subjects at risk Covid-19), contact tracing systems for identifying, based on proximity (measured via Bluetooth or GPS) between two subjects equipped with smartphones and the same app, any contacts of individuals who have tested positive for Covid-19, and epidemiological surveillance systems capable of monitoring epidemic, identify new outbreaks on which to intervene and provide useful information to the health policymakers of individual countries for its better management.
Artificial intelligence and machine learning have also made an important contribution to the management of some aspects of the pandemic by providing predictive models on how and where the disease would spread in the world and within individual countries, proposing diagnostic systems to detect pneumonia caused from Covid-19 starting from chest X-rays and identifying existing drugs but registered with other indications that could also be useful against Covid-19.
Is The Spread Of Digital Health Tools Only The Result Of An Emergency?
However, the emergency alone cannot explain such massive use of technologies to manage the emergency generated by Covid-19. In the United States, for example, the process was favored by the decision by the Trump administration to act on two points: the deregulation of telemedicine services provided through non-certified instruments and the reimbursement of services provided remotely.
As regards the first point, the Department of Health and Human Services has allowed doctors to use, for the entire period of the health emergency, generalist video conferencing and video chat tools to provide television services in derogation from the observance of the rules identified by the Health Insurance Portability and Accountability Act (which manage aspects related to the confidentiality of health information), which these instruments, not being medical devices, are not obliged to respect.
The second concerns the equalization, in terms of reimbursements, between telemedicine interventions (on average lower and therefore not very incentivizing on the part of those who offer them) and traditional ones. The decision, operational for the entire period of the health emergency, determined, among other things, the possibility for patients of the Medicare program to benefit from free television services provided through apps that allow them to interact in audio and video with the doctor.
If in the United States the equalization of reimbursement is temporary, in Italy, where national guidelines on the use of Telemedicine have existed since 2014, it is permanent (at least in the Regions where telemedicine is reimbursed), a choice that has not contributed little to its diffusion. To date, telemedicine services (which are seen as a different method of providing health and social-health services) are reimbursed by the Tuscany Region, the Province of Trento, and the Veneto Region (where payment of the ticket has also been suspended), but it is p
If in the United States the equalization of reimbursement is temporary, in Italy, where national guidelines on the use of Telemedicine have existed since 2014, it is permanent (at least in the Regions where telemedicine is reimbursed), a choice that has not contributed little to its diffusion. To date, telemedicine services (which are seen as a different method of providing health and social-health services) are reimbursed by the Tuscany Region, the Province of Trento, and the Veneto Region (where payment of the ticket has also been suspended), but other Regions may follow shortly.
WHO Towards Digital Health Tools
On 25 June, the WHO held a press conference during which Dr. Hans Henri P. Kluge, regional director for Europe, highlighted the potential of digital health tools, artificial intelligence, and digital technologies in general in performing contact tracing, inactivating surveillance of the epidemic, in identifying new cases and in the remote management of patients with Covid-19 or with concomitant or chronic diseases. However, according to the WHO, great attention must be paid to the use of these solutions because of the issues they raise, starting with data protection and privacy. Aware of the fact that digital technology can help health systems to cope with essential health care, particularly during emergencies, there are three crucial points on which WHO insists.
The first concerns the integration of digital health with the tools currently in use, which must be done with care and, above all, in collaboration with those who represent citizens and patients. The second has to do with the concept of trust. The use of digital tools is based on public trust in them and therefore the proposed solutions must take into account the privacy and security of individuals and their data. Hence the invitation to governments to identify solutions that allow to the management of the ownership, use, consent, and protection of data. In this regard, it should be pointed out that the deregulation implemented in the USA on the use of videoconferencing systems, which also several American scientists are starting to question, is not going in this direction, because it could potentially jeopardize patient privacy where such systems they do not guarantee coding and encryption of the communication/conversation.
The third point concerns the digital divide. Not all social groups are equally capable of harnessing the potential of digital technologies to fight the virus. In Europe, for example, households’ access to the Internet varies from 74% to 87%, with significant inhomogeneities within individual countries and between population groups. The invitation is therefore to work at a national level so that the technological gap does not add to the social and economic gap in the population.
To these points, others could be added. For example, the fear, expressed by doctors and scientists, that new technology (regardless of type), when applied to the care and assistance of patients, could lower the level of quality of services provided and compromise the doctor-patient relationship. It is, therefore, no coincidence that the scientific world is starting to raise the request to take advantage of this period of widespread use of telemedicine systems to activate clinical studies to study their impact on the doctor-patient relationship, on clinical practice, and on the quality of care and obtain important and useful information to decide whether (and under what circumstances) to continue using these systems even after the pandemic has ended.