June 2020Spotlight feature

Family medicine teams defy COVID-19 by linking to patients via telehealth

All it took was a few moments for Dr. Mark Karanofsky to look at his patient and realize something was seriously wrong: Antonio José Santiago was clearly walking with a limp, and the right side of his face was drooping noticeably.

A stroke—no doubt about it!

Quickly, Dr. Karanofsky explained the nature of the emergency to Mr. Santiago and his wife, Eunice Gomes Santiago, who were able to get prompt medical help before his condition grew much worse.

It was an urgent situation, of course, but one that happens almost daily in Montreal. So why single it out? Because Dr. Karanofsky made his diagnosis by looking at a computer screen during a video conference with the Santiagos.

In a sense, Mr. Santiago was lucky. When his stroke hit on April 17, he was already scheduled to connect by Zoom from home for a routine checkup with Dr. Karanofsky, who is Interim Director of the Goldman Herzl Family Practice Centre at the JGH.

That meant the doctor was on hand when Mrs. Santiago explained that her 78-year-old husband had not been feeling well since finishing some repairs around their Candiac house earlier in the day.

Even so, the video link proved to be essential: By making it possible to have visual confirmation of Mr. Santiago’s symptoms, the way was opened for him to receive treatment within a reasonable amount of time.

For Dr. Karanofsky, this is proof of telehealth’s value—especially if video is involved—in circumstances like the COVID-19 lockdown, where the patient is in one location (usually at home), while the physician is in another.

“When I described the problem, I wasn’t panicking,” recalls Mrs. Santiago, “because it really felt like Dr. Karanofsky was there with us. His advice was so precious, because we knew he could really see and understand what was happening.”

Although the JGH is Mr. Santiago’s hospital, time was of the essence, so he was taken to the Charles Le Moyne Hospital, which is closer to his home. After four days of treatment, he was released and is making a steady recovery.

“Obviously, not everything can be done remotely,” says Dr. Karanofsky, “but before COVID-19, it wasn’t always clear, especially to patients, what telehealth was capable of. I think the situation is much different now.”

An alternative to most in-person visits

During the pandemic, Herzl appointments using telehealth (also known as telemedicine) became the norm, as the proportion of in‑person visits quickly plummeted to an average of about 12 per cent of all consultations.

During the first week of May, for example, only 243 in‑person appointments were logged, versus 1,964 via telemedicine (video or phone). That week’s total of 2,207 is roughly the same as all of the in‑person, pre‑COVID-19 visits that Herzl used to handle in a typical week.

Before COVID-19, telemedicine was relatively scarce, not just in the facilities of CIUSSS West-Central Montreal, but throughout Quebec. According to Dr. Justin Cross, the CIUSSS’s Chief Digital Health Officer, this was because the Ministry of Health and Social Services did not provide widespread reimbursement to physicians for most telehealth activities.

Herzl was ahead of the game, because it had installed an electronic medical record before the pandemic.

The watershed moment came this past February, just before COVID-19 struck the province. The Ministry realized that to prevent the spread of the virus, most patients (and many members of staff, including some clinicians) had to stay away from hospitals and certain other healthcare facilities.

So, moving quickly, the government “approved reimbursement for most physician services that were delivered by video and telephone,” says Dr. Cross.

Another major step by the Ministry was to negotiate directly with Zoom for “accounts that met higher standards of security and encryption,” says Dr. Marc Miresco, Director of Adult Psychiatric External Services in the Institute of Community and Family Psychiatry at the JGH.

Herzl was also ahead of the game, because the CIUSSS’s Directorate of Information Technology had finished installing the Centre’s electronic medical record before the pandemic struck. Regardless of where members of Herzl staff happened to be, they now had easy access to their patients’ charts and other vital information.

Making the switch almost overnight

Nevertheless, Dr. Karanofsky still shakes his head in amazement at the thought of what it took to push Herzl into telehealth. “On Friday, March 13, we got a directive that, as of Monday, 70 per cent of our activities had to be virtual.

“That was a mind-boggling moment because, on average, we had about 360 in-person visits a day before COVID-19, and to cut that to a little over 100 within 72 hours seemed impossible.

“But somehow we did it! In-person visits were down about 70 per cent by Monday. A week to 10 days later, we were at the point where roughly 90 per cent of our visits were by telemedicine.

Dr. Mylène Arsenault

Dr. Mylène Arsenault

“Every single team in Herzl pitched in to figure out what it could do to make telemedicine work. Looking back, we figure we accomplished something like five years of change in four weeks.”

“It was awesome reopening on that Monday morning in mid-March and seeing our waiting room essentially empty,” remembers Dr. Mylène Arsenault, a family physician at Herzl.

Dr. Arsenault also realized that since this was going be a new experience for many members of staff (and not just for patients), she decided to help develop a telemedicine teaching module for Herzl.

“We weren’t trained in telemedicine in medical school,” she says, “so we need the module to train our physicians and residents to do it safely. They soon discovered that the video screen was able to convey a great deal of information to them.

“What we can’t do by telemedicine is anything that involves palpation or the physical contact that’s needed for things like a vaccination or listening to a fetal heartbeat or conducting a gynecological exam. That’s why certain types of patients still have to be seen in person.

“But certainly, there’s a lot that can be done safely and properly by telemedicine, such as mental health-related counselling and follow-ups of chronic health conditions.”

A peek at the living environment

In some respects, says Dr. Karanofsky, telemedicine can be superior to an office visit, since it allows a physician to take a look at a patient’s living environment—something that used to be possible only during a home visit.

“For example, if the patient is elderly and has what seems like too much furniture, you can get a sense of whether they’re at risk for falling. We’ve easily diagnosed things like rashes and even musculo-skeletal injuries by video conference.

“The key is that you still have to have the leeway—which we do—of bringing patients in for a face-to-face visit, if circumstances demand it. Measures are also in place to ensure that an in-person visit can happen quickly, safely and in a way that prevents the spread of COVID-19.”

Sabina Figueira

Sabina Figueira

Since all of this is happening while patients are at home, they also tend to be more relaxed and comfortable, says Sabina Figueira, a clinical nurse at Herzl who specializes in diabetes and cardio-metabolic care.

“During the pandemic, they felt especially safe, since they weren’t in danger of being exposed to the coronavirus in the hospital. Follow-ups are also offered regularly, so that if, for instance, new medication is started, we can make the calls and keep monitoring their health.”

Even Herzl’s online portal has been busier, Ms. Figueira adds. “We’ve been able to send documents and requisitions digitally to our patients. Normally, they would have gone to the trouble of coming to the Centre, parking, picking everything up and driving home. Now all of that is unnecessary. This has been a huge change for them.”

But what of the future? Might the pre-COVID-19 status quo creep back into Herzl, once the threat has passed? Dr. Karanofsky strongly doubts it.

As a member of Herzl’s post-pandemic planning committee, he acknowledges that the level of telehealth visits is unlikely to remain in the range of 87 to 88 per cent. However, “in the medium term, we think that at least 60 per cent of all visits could be handled completely or in part by telemedicine.”

New patients will probably still have to be seen in person, Dr. Karanofsky explains, “because there are things we need to see and touch and feel. But we’ve done some research to find out what’s happening elsewhere in the world and, ideally, we think that 60 to 70 per cent of family medicine could be done with some element of telemedicine.”

“It’s the way of the future,” agrees Dr. Arsenault, “and COVID-19 has just accelerated us into the telemedicine era. It’s definitely here to stay.”

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