Digital Health

Telemedicine: Is video consultation already everything?

When Corona came along, the numbers skyrocketed. With the outbreak of the pandemic, thousands of medical practices installed software for data-secure video consultations. In Bavaria alone, the Association of Statutory Health Insurance Physicians approved 6,000 video practices, compared to less than 100 a year earlier, an increase of 6,000 per cent. Since then, we have been celebrating the breakthrough of telemedicine, with e-prescriptions and sick notes via videovisite. But hand on heart - is that all we can achieve in terms of telemedicine?  

Strictly speaking, Loopers are criminals. They let technology and telemedicine make decisions that, according to German legislation, can only be made by humans. Loopers, diabetics, mostly type 1, have to feed themselves insulin for life because the pancreas no longer works. Many have to do this from childhood: measure, inject, measure, inject - every day, many times.

To make the procedure easier, they use chips transplanted into their skin, which allow them to measure their blood sugar level continuously without having to prick themselves again and again. They also carry insulin pumps, small vessels with motors that are connected directly to the bloodstream. After measuring, they only have to set the insulin dose, the pump does the rest.

They only become loopers when they technically close the loop. They connect the blood glucose measurement, which is controlled by a sensor, with the insulin pump - they "close" the loop and set an automatic mechanism in motion. If the sensor reports a drop in the level, the pump reacts and injects the exact dose required. Humans no longer have to intervene.

From the experience reports of some loopers, we know that the HbA1c - the long-term blood sugar - has settled at a pleasingly low level since the loop was closed. The diabetes doctor could now add telemedicine, monitor the data, advise, get alerts and automatically send help if something is wrong. Technically, we could already install telemedicine today, which is on its way to becoming a new standard of care.

Linking video consultation with measuring wearables

The fact is, telemedicine coupled with gadgets and wearables that patients carry with them could trigger a second tele-thrust. The point of care, i.e. the point at which diagnosis and therapy take place, could shift towards the patient - or where the patient is at the moment.

"A digital ECG on the wrist is theoretically no problem at all - basically, an Apple Watch already offers many real application possibilities," says Manuel Puntschuh, Director of Medgate Mini Clinics in Switzerland. Such an ECG wearable could send data live to the doctor - a decisive advantage in the case of serious illnesses. "At the moment, however, these devices are still far too little included," he continues.

The "Mini Clinics" for which Puntschuh is responsible are digital medical practices in which, however, no doctor is physically present. Patients are cared for on site by specialised medical assistants. GPs and specialists are added via telemedicine. The telemedics receive information via diagnostic instruments that can digitally transmit collected data. This enables them to better diagnose and prescribe the right treatment from a distance.

Digital polyclinics with specialists who connect in

Dr Oliver Tiedke, a neurologist from Erfurt, is a specialist who connects to the family doctor's practice via telemedicine. He is testing a German counterpart to the Mini Clinics, the so-called without-specialist practice. In this experimental set-up, the switching of specialist disciplines into the family doctor's practice is being tested. The practices are equipped with digital stethoscopes and cameras that can be used, for example, to look digitally into the ear canal. But ultrasound visits can also be transmitted without any problems.

Tiedke is already convinced of the concept after the first test sessions. "Recently I had an 80-year-old patient with severe back pain in my telesurgery session. He could have gone to an orthopaedist first, but the family doctor had an initial suspicion. However, the fact that it was Parkinson's disease, which I was able to diagnose immediately, and which had been triggering the back pain for two years, was not on anyone's mind. I am optimistic that we can now manage him with medication." Parkinson's can be treated well from a distance, he says.

Tiedge promotes such assisted telepractices because a large proportion of patients today and in the years to come would still not be digital enough and would fall through the cracks. "None of the patients I have examined via telemedicine have ever experienced a Zoom meeting, let alone a video consultation. It's their first time sitting in front of a screen at the doctor's office. For us it's completely normal, but for the much larger group of patients it's an incredible hurdle."

Older people need to be picked up, says Tiedge. People are needed who are interposed and moderate the technology. "Especially the clientele I look after, the over-65s, have to be picked up in a different way, they need help. 

Telemonitoring for heart failure

In a study at the Charité hospital in Berlin, patients were implanted with a sensor in the pulmonary artery, and an intelligent cushion served as a measuring station and forwarded the values live to a database. The patients all suffered from severe heart failure. With the live tele-monitoring, the care team was able to monitor the therapy in real time. This telemedical care concept, which the Federal Joint Committee has allowed for "telemonitoring in heart failure" in its method guidelines, can thus potentially become a lifesaver.

Without the need for an appointment and without any time delay, a pressure increase in the pulmonary artery can be detected, and the innovation can thus prevent hospitalisation or worse. During the study period, the number of unplanned hospital stays in the telemedicine group was reduced by 30 percent. Mortality also decreased.

Half of all medical interactions will be online

David Meinertz, head of the online practice Zava, told WirtschaftsWoche (link in German): "Covid-19 has brought telemedicine five years forward." In another five years, Meinertz predicts, half of all interactions between doctor and patient will already take place online.

Manuel Puntschuh from MiniClinics agrees. He is convinced that telemedicine working with data from wearables will set a whole new standard. "Can I do it via telemedicine or do I still have to go to the doctor, that's how we'll be thinking in a few years," says the expert from Europe's largest telemedicine centre based in Switzerland.

The dynamics are astonishing. Only two and a half years ago, the so-called ban on remote treatment was relaxed. Until then, telemedicine was simply forbidden in Germany, except for a few experimental projects. What has happened since then, with providers like TeleClinic, Kry, Zava or Medgate, shows what is possible. According to Manuel Puntschuh, what is perfectly obvious in medicine is being caught up with at a rapid pace. 

Is it a shortage of doctors or just a question of better allocation?

Puntschuh still addresses one topic in the interview, it is important to him: the shortage of doctors. In rural areas in particular, more and more surgeries are closing and the distances to the nearest doctor are becoming longer and longer.  

Puntschuh is convinced that in reality there is no absolute shortage of doctors. The problem, he says, is that "patients are just not being directed to the right doctor efficiently enough. He wants to prove this with the Mini Clinics.

"Why should I have to wait until the next dermatologist has an appointment for a skin change? Maybe the colleague on the other side of the country is free at the moment. Then I can have him look at my birthmark on the screen," says Puntschuh. Especially for people who live in rural areas, telemedicine is an enormous improvement.

Text: Ron Voigt

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