Santa Comba was the guinea pig. The municipality of Coruña, a passageway between the municipalities of the Costa da Morte and Compostela, is the paradigm of the Galician rural. A large territory, atomized in 17 parishes with more than a hundred villages, shelters a population of just over 9,400 people, 33% over 65. The plan: deploy a telemonitoring system for chronic patients to save you cumbersome visits to the health center. “The technological level of the Santa Comba patient is different from that of one in Santiago. But we thought that if we could reach Santa Comba, which is very rural, we could reach the rest of Galicia, ”explains Dr. Felipe Calle, one of the project’s ideologues and head of primary care in the Santiago and Barbanza area. And they arrived. The plan, called Telea, began with 49 Santa Comba patients with diabetes, hypertension or heart failure. Today it works throughout Galicia and there are already 2,600 people included in the platform.
A working group was in charge, back in 2017, of adapting the clinical guidelines of some medical conditions to be able to do a home follow-up and selected some patient profiles: those with heart failure, diabetes, hypertension, chronic obstructive pulmonary disease (COPD) and atrial fibrillation. The plan was that they could measure, from home, some parameters such as blood pressure, blood glucose level, weight and body mass index, oxygen saturation, heart rate and coagulation range (INR) . “The objective is not to relieve the demand in the consultation, but to be more proactive and anticipate possible exacerbations of its pathology,” says Calle. The patients themselves were who, once a week, telematically incorporated the data into their medical records, which were then reviewed by their primary care teams.
Ramon Canay was the first patient in Telea. He lives in Alón de Arriba, a village four kilometers from Santa Comba. He has been hypertensive for 20 years. “I used to measure tension from home and had it written on a paper to the doctor. Now it is more comfortable,” explains the man, 75. Tension is taken twice a day every two weeks and his daughter, Maria Dolores, is responsible for incorporating them into the computer platform. “He always had white coat tension: when he saw the doctor, he was nervous. The one taken at home is more real,” says the daughter. According to Calle, 100% of the patients in the pilot test preferred to do the controls at home and the health results also improved. 90% of hypertensive patients had better blood pressure levels and hospital admissions were reduced among those with heart failure. “Diabetes patients have glycosylated hemoglobin levels [el promedio de glucosa en los últimos tres meses] better than when they come to the office. The data indicates that they are better followed, ”concludes Calle. The analysis of the deployment in the rest of Galicia is still being cooked, but the first data suggest that the income of patients with heart failure has been reduced by 27%.
Telea has become a successful initiative that has already been widely installed in the Galego de Saúde System (Sergas). But it is not the real tonic of what happens with other distance health care projects. In fact, according to the experts consulted, the universe of telemedicine is very variable throughout the Spanish territory, it lacks a common road map and advances – or goes back – at the will of the professionals and administrations in command. “The feeling is that telemedicine seems like everyone does, but the reality is that we are missing out on the great opportunity to improve accessibility problems. There are very few formal programs, ”said David Moreno, president of the International Teledermatology Society.
The dermatology is one of the disciplines where telemedicine has advanced the most
Precisely, his specialty, dermatology, is one of the disciplines where the most advanced is the Telemedicine concept. Communities such as Galicia, Andalusia, Madrid, Catalonia or Extremadura, among others, already have, on a regular basis, a remote health care system for dermatological ailments. Through a conventional camera, for example, the family doctor can take a picture of an injury on the skin of a patient and transfer the patient’s photo and clinical information to a platform where the dermatologist evaluates it and gives an answer.
At the Virgen Macarena Hospital in Seville, Moreno’s team has been perfecting this system for 15 years. “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 this system is not widely implemented in the rest of Spain. “The reason for the variability is not a technological issue. The most important barrier are professionals and organizations. The first, because there is a lack of culture of change and some see it as a threat or a way of working for which we are not trained. And the latter, due to the difficulty of organizations to change the way they work, ”says Moreno.
Against waiting lists
70% of Catalan health centers use telediagnosis and teleconsultation
With the long waiting lists that roam the health system – more than 671,000 as of June 2019 -, Telemedicine also aims to improve accessibility. “There is a strong culture in concrete things and certain specialties are further advanced by the care pressure and waiting lists. That a primary care physician take a picture of the patient and transfer it to the dermatologist is a privilege, ”says Rodrigo Gómez, an expert in telemedicine and innovation management. Although there is no clear consensus on the bonanzas in accessibility. “The Osarean Basque telemonitoring project, for example, increased the number of consultations, instead of lowering them,” said Fernando Alonso, coordinator of the new technologies working group of the Spanish Society of Family and Community Medicine. “It will improve quality and efficiency, but waiting lists do not know. The lists can end up being mobile and prioritize the urgency according to the evolution of the patient. Although as citizens we have to know that one, as it goes up in the list, can go down, ”continues Josué Sallent, director of the TicSalut Social Foundation of Catalonia.
Catalonia is preparing a strategic plan to order the provision of non-face-to-face services. In the community, in addition to teledermatology, the eConsultation in primary care is implemented – virtual consultations between doctor-patient through a secure email. In 2018, 4,505 professionals and 60,763 patients used it. The Catalan health system also has Teleictus, a platform for videoconferencing and transmission of medical images to assist cerebrovascular infarctions that occur in isolated areas of the reference hospital and must be treated, in the first instance, in the emergencies of regional hospitals. According to the latest Ticsalut Trends report, 70% of Catalan health centers use telediagnosis and teleconsultation. Telemonitoring, however, barely reaches 20%.
“We have been many years late. We spend a lot on partial plans. Teledermatology is more visual and easier to apply, but everything depends on the receptivity of the specialist”Says Alonso. At this point, Sallent agrees: “Radiologists are clear that theirs have changed very clearly. Primary care doctors, who are very 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, according to a spokeswoman. There is also no data available to measure the implementation of this new healthcare model in the territory.
Doctors rule out, at least in the short term, an eventual Skype consultation between doctor and patient, but they do warn of the risk of dehumanizing health care with these new strategies. “You have to boost telecare, but you have to go slowly so that it is not misinterpreted: our intention is not to diagnose by videoconference,” warns Dr. Calle.
There are, in any case, many pending tasks. For example, the security of technological devices: “There are limiting factors of confidentiality and privacy, such as the risk of piracy,” says Alonso.
The debate is on the table but, according to experts, the training of professionals will be capital. “The way to interact with the patient is different and to succeed in the technological field you need professionals to have new skills. Most of the professionals are convinced but they have not just seen how the model will be, ”says Sallent.
The profile of patients can also condition the progress of telemedicine. “Most of the complex chronic patients are older people and that implies that you have a digital divide and things that are not prepared for them,” says Sallent. In fact, on Telea, for example, not everyone gave the profile. “They had to be diagnosed and have technological skills him or someone close. Not everyone is a candidate because there are people who need to go through the consultation, ”explains the Galician doctor.
However, Moreno is clear: “Telemedicine has come to stay. This is not a change that has occurred to four crazy people. It is the evolution of society. ” But Calle nuances: “Medicine is a humanistic career and will continue to be. No tool will replace the physical presence query“