Online medicine will change home healthcare
Author: Makoto Kosaka
The University of Tokyo Faculty of Medicine
Editor： Chiharu Kawasaki
Teikyo University School of Medicine
This article was translated from an article posted at MRIC on September 28, 2021.
Vol.186 オンライン診療で変わる在宅医療の現場 | MRIC by 医療ガバナンス学会 (medg.jp)
I am going to tell a story about a woman in her 90s with early-stage cancer and chronic heart failure. She was in a facility and had been receiving home visits twice a month because it was difficult for her to get to the hospital independently.
One night, after more than a week of phlegm and breathlessness, the facility nurse contacted the clinic. Her voice was hoarse at her last visit 12 days earlier, but she had no noticeable symptoms, and a doctor told her to make a phone call if anything happened immediately.
The clinic doctor could not head there immediately, so the visiting nurse went to the site and made a video call with the doctor. Considering that she could stand and sit smoothly, there was no apparent lung murmur, and the patient's color was not pale, the possibility of pneumonia was considered low. The physician ordered a blood draw to examine the patient for infection or worsening heart failure closely. The visiting nurse drew blood and brought the specimen back to the clinic. At the same time, once herbal medicine was prescribed to alleviate her symptoms, the visiting pharmacist brought the medication to the facility. Subsequently, the blood draw results revealed worsening heart failure, diuretics were started, and the patient's symptoms improved.
This is one example of video calls in a home health care setting.
Even though the physician was unable to visit the site, the support of the home care nurse enabled him to obtain the necessary information for close examination of the cause, such as blood sampling, and to provide prompt medical care via video. Furthermore, in collaboration with the visiting pharmacist, the doctor could administer medications without leaving the facility. The patient was taken care of successfully and ready for his next regular visit.
Online medical care has been gradually spreading in recent years, allowing patients to receive consultations from the workplace or home with no waiting time. However, it is preferable to do so with a firm understanding of the patient through face-to-face consultations. Under the pandemic, online consultations were finally permitted for the first visit on April 10, 2020, on a notable exception basis. In this regard, emergency care in a home-based practice with regular visits is a compatible environment for online medical care. However, its effectiveness and safety have not been much discussed.
Our research team analyzed a videoconference clinic conducted as an alternative to house calls for emergency in-home care and published the results in the Journal of Medical Internet Research, an English-language journal. The contents are introduced below.
The Orange Home Care Clinic is a clinic specializing in home health care in Fukui City, Fukui Prefecture. They handled 17 cases via video call over the two years of 2018-19. In 15 of the total cases, a home care nurse or facility nurse was available onsite to provide the necessary response at the patient's side during the video call. It is called Doctor to Patient with Nurse (D to P with N), which is introduced in the Ministry of Health, Labor and Welfare's notice on online medical care and is a form of medical care in which the nurse goes to the patient and connects online with the doctor. Home nursing stations are distributed in a more detailed, community-based manner than home health care clinics, so they are more likely to be able to go to the site. The ability to perform procedures such as blood draws is a significant advantage, but another important role is to support the video call itself when the patient's family does not usually have access to a smartphone or other means to make video calls.
In the 17 cases analyzed, two were transported to the hospital after the physician determined that emergency transport was necessary, and the patients were admitted directly to the hospital. In the other 15 cases, the physician prescribed new medications, gave injections, administered existing medications, and provided follow-up care. Only one of the 15 cases resulted in subsequent emergency transport, and the remaining 14 cases went on to the next visit as scheduled. Compared to an actual visit by a physician, this system is beneficial to the patient in that the situation can be assessed more quickly, and the physician's workload can be greatly reduced.
Here is another case.
A man in his 30s is bedridden due to cerebral palsy. One day, a family member called the clinic to report redness on his left hand, which appeared to be a cold burn. To see if a doctor needed to visit him urgently, we connected the family member's cell phone to the clinic and made a video call. After visually examining the reddened area through the video, he talked to the family member. He confirmed that the left hand became red after prolonged contact with a hot water bottle and that there was only redness and no pain. Therefore, we responded with steroids, prescribed initially to address the inflammation around the gastroduodenal tube, and told them to contact us again if the symptoms worsened.
In this case, because the family had a video call environment, they could receive remote medical care directly from the doctor without having to wait for the nurse to visit. Because the symptoms could be handled with home medications, the symptoms were quickly addressed without anyone traveling.
While there are many advantages to online home medical care, there are some disadvantages compared to in-person care. Dr. Miyatake, who has provided online medical care, said, "Physical examination, which requires the physician's five senses, is inevitably limited, and I feel that it is important to have a 'sense of presence' including the family members, who tend to be out of sight in online medical care. It is difficult to tell from words alone whether the patient is satisfied with what they were told," he says. Even if the patient has already received care online, it is vital to decide to visit the patient for a face-to-face consultation as soon as possible if necessary.
For those who already receive home medical care or may do so in the future, the quality of home medical care they receive may be improved by making sure that communication devices are available. On the other hand, for those in their 70s or older who receive their primary medical care, the Internet usage rate is still below 50% as of 2017. D to P with N supported by nurses is likely to be the norm for some time to come. All of the examples in this study used the iPhone app FaceTime to make calls, but it may be essential to be able to use one in the future.