Álvarez-López, Humberto¹

Language: English
References: 8
Page: s254-258
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ABSTRACT

In a contemporary world accelerated by the COVID-19 pandemic, telemedicine has become an excellent option to offer remote consultations to control chronic degenerative diseases of high prevalence, such as hypertension, diabetes, and dyslipidemias. This review discusses precedents, ethical and legal aspects, and their current implementations towards managing high blood pressure (HBP). Although there are several reasons and clear benefits for implementing telemedicine, there are legal, ethical, and practical limitations and poor knowledge of its application within healthcare professionals. Appropriate ethical practice and an adequate legal framework within telemedicine will bypass all considerable risks related to quality, safety, and continuity of care associated with this practice. Regarding practical aspects, physician's clinical judgment is fundamental to know if it is possible to give medical consultation through telemedicine according to every patient's health requirement. Through diverse electronic and technological tools, the physicians could guarantee an appropriate medical consultation and handle follow-up visits. In general medicine, it could be possible that telemedicine would help to reduce the burden of care for patients with chronic diseases, decrease bureaucratic procedures, and support physicians practicing in isolated areas.

INTRODUCTION

The World Health Organization (WHO) defines telemedicine as "the delivery of health care services, where distance is a critical factor, by all health-care professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health-care providers, all in the interests of advancing the health of individuals and their communities".¹ In a contemporary world accelerated by the COVID-19 pandemic, telemedicine has become an excellent option to offer remote consultations to control chronic degenerative diseases of high prevalence, such high blood pressure (HBP), diabetes, and dyslipidemias. Furthermore, telemedicine has been postured as a novel strategy to increase the percentages of adequate treatment and pharmacological management to reduce cardiovascular morbidity and mortality. This review discusses precedents, ethical and legal aspects, and their current implementations towards managing HBP.

TELEMEDICINE BACKGROUND

According to the definition of telemedicine, remote medical care has been implemented for centuries for giving medical consultations using diverse technological tools. In 1879, the first recorded history of a remote consultation was given between a physician and a patient by telephone. In 1915, besides telephone, it was also possible to give medical consultation and clinical advice on ships across seas by radio frequencies. In recent decades, with the widespread use of the internet, there has been an increasing trend of access for telemedicine worldwide. Nevertheless, its massive implementation was accelerated in 2020 during the COVID-19 pandemic. This worldwide crisis accentuated the need for accessible healthcare access for everyone regardless of social distance restrictions or socioeconomic circumstances.² Although there are several reasons and clear benefits for implementing telemedicine, there are legal, ethical, and practical limitations and poor knowledge of its application within healthcare professionals. These conditions have been described as restrictions to systematically apply telemedicine as a strategy for all care levels summarizes the current advantages and disadvantages of using telemedicine (Table 1).

TELEMEDICINE: ETHICAL AND LEGAL ASPECTS

Telemedicine has considerable possibilities that could benefit uncountable adults living with chronic degenerative diseases, such as patients living with HBP. Nevertheless, its implementation also poses diverse ethical and legal challenges related to a medical-patient relationship. Appropriate ethical practice and an adequate legal framework within telemedicine will bypass all considerable risks related to quality, safety, and continuity of care associated with this practice.

It has been mentioned that the ethical aspects related to telemedicine should be identical to conventional medicine. The main objective of both practices is to prevent potential injuries that could happen to both patients and physicians. The medical-patient relationship is based on trust and mutual respect for both cases. Furthermore, it is necessary to guarantee privacy and confidentiality of all the clinical information using adequate data protection systems. This practice seeks to comply with the current regulatory and legal aspects from international, national, and regional institutions. We can rely on the guidelines set out in the Declaration of the World Medical Association (WMA) on the Ethics of Telemedicine. This declaration was adopted in the 58th General Assembly of the WMA in Copenhagen, Denmark, in October 2007 and subsequently amended in the 69th General Assembly of the WMA in Reykjavik, Iceland, in October 2018. Nevertheless, there are currently no international laws regulating telemedicine for most countries, including Mexico. During the COVID-19 pandemic, telemedicine's legal implications accelerated without a current positioning by any authority. However, it has been recognized that privacy and security standards practices are needed to guarantee appropriate security protocols. Like the American HIPAA protocol (Health Insurance Portability and Accountability Act).^2,3

TELEMEDICINE IN HIGH BLOOD PRESSURE

In this review, we will not analyze all the studies that have been published related to telemedicine implemented in the management of HBP.^4-7 Sufficiently is to mention that there have been multiple publications that show the potential benefits of telemedicine over the usual clinical consultations for several years. The use of telemedicine for the management of HBP provides more significant reductions in systolic and diastolic blood pressure and twice the number of patients that will reach blood pressure goals compared with traditional clinical visits. Recently the American Heart Association (AHA) has published a positioning related to telemedicine for controlling HBP.⁸

TELEMEDICINE: PRACTICAL ASPECTS

The physician's clinical judgment is fundamental to know if it is possible to give medical consultation through telemedicine according to every patient's health requirement. The administrative staff who assist each physician must ensure that all patients and relatives have: a stable internet connection, electronic devices with connectivity (cell phones, computers, electronic tablets) and that they can handle them properly.

Physicians will need to use different platforms to conduct the video consultation that complies with HIPAA regulations to guarantee privacy. Some platforms could be the following: a) Zoom (healthcare version), b) Google G Suite, c) Microsoft Teams, d) Skype, e) WhatsApp. The last one itself does not amend to HIPAA compliant; however, it is very accessible and has call and text functions. Its enterprise version is relatively more secure, but it still does not comply with all HIPAA regulations and, therefore, can only be used for healthcare practices that do not use sensitive patient data.

Although telemedicine can be applied for all patients living with HBP for the first consultation, it will depend on each patient for the subsequent or "already known" in person by the doctor. For these cases, the physical examination has already been performed and is only intended for follow-up care to evaluate adequate management of HBP and other cardiovascular risk factors.

The physician must provide each consultation within a suitable, private, and quiet place, with the appropriate lighting to show his face and generate trust in every patient. The camera should be pointed at eye level and a one-arm distance from the camera. It is also encouraged that a pre-established executive or assistant order a follow-up visit to achieve quality in medical care, which is very similar to when a face-to-face visit is granted. As shown in (Figures 1 and 2), the consultation must be scheduled appropriately to connect the patient and a family member. At the time of the scheduled appointment, the patients and their relatives must sign an electronic informed consent understanding the advantages and limitations of telemedicine are specified. Likewise, the patient or close relative must send electronically to the physician the vital signs measurements that were taken at home (blood pressure, heart rate, temperature, oxygen saturation, weight, glucometer, etc.). The physician may access the clinical record platform with integrated remote monitoring, laboratory tests, X-rays, or cabinet studies that the patient has, whether appropriate. The physician must also send the electronic link with the date and time for the connection.

For preventing the patient does not comply with the scheduled appointment, "no-show" policies must be established. This means that the consultation must be paid for at least one hour before the scheduled appointment (electronic transferring or payment within convenience stores such as OXXO, PayPal, Mercado Pago, Stripe, and other platforms that have already been integrated within several electronic clinical records). It is advisable to send a personal reminder of the appointment with a text message 5 minutes before the consultation to avoid making the video call when family members or patients are not yet ready to receive it. At the time of the telemedicine consultation, the doctor must document all the information in the electronic clinical record, including symptoms and signs, visual, physical examination perceived through the devices, paraclinical tests, and provide a digital prescription and lifestyle recommendations. At the end of the consultation, the doctor will make closing and will schedule a follow-up appointment either in person or by telemedicine, also will send the electronic prescription and laboratory tests to be carried out. He may also send written educational material, infographics, videos, or any information that can be considered helpful in educating the patient's disease. Finally, let the patient know that doctor-patient communication will always be open through different electronic channels to solve doubts, treatment adjustments, medical emergencies, or any communication. It is important to mention that this can be concluded by a telephone call in case of technical problems with the video call.

CONCLUSION

In the field of hypertension, telemedicine is an opportunity to achieve higher blood pressure control rates. Through remote monitoring, any physician could access home blood-pressure parameters and will be able to assemble various therapeutic changes that each patient requires. In general medicine, it will be possible to reduce the burden of care for patients with chronic diseases, reduce bureaucratic procedures, and support physicians practicing in an isolated area. Telemedicine is an excellent alternative to traditional medical practice but in no way replaces it. This practice is expected to grow significantly in the future.

REFERENCES

1. Ryu S. Telemedicine: Opportunities and Developments in Member States: Report on the Second Global Survey on eHealth 2009 (Global Observatory for eHealth Series, Volume 2). Healthc Inform Res. 2012; 18: 153-5. Available in: https://doi.org/10.4258/hir.2012.18.2.153.

2. Pfizer. Guía de telemedicina 2021.

3. World Medical Association. WMA - The World Medical Association-Declaración de la AMM sobre las Responsabilidades y Normas Eticas en la Utilizacion de la Telemedicina 2017. [Accessed March 26, 2022] Available in: https://www.wma.net/es/policies-post/declaracion-de-la-amm-sobre-las-responsabilidades-y-normas-eticas-en-la-utilizacion-de-la-telemedicina/

4. Pellegrini D, Torlasco C, Ochoa JE, Parati G. Contribution of telemedicine and information technology to hypertension control. Hypertens Res Off J Jpn Soc Hypertens. 2020; 43: 621-628. Available in: https://doi.org/10.1038/s41440-020-0422-4

5. Wang J-G, Li Y, Chia Y-C, Cheng H-M, Minh HV, Siddique S, et al. Telemedicine in the management of hypertension: Evolving technological platforms for blood pressure telemonitoring. J Clin Hypertens Greenwich Conn. 2021; 23: 435-439. Available in: https://doi.org/10.1111/jch.14194

6. Li R, Liang N, Bu F, Hesketh T. The effectiveness of self-management of hypertension in adults using mobile health: systematic review and meta-analysis. JMIR MHealth UHealth. 2020; 8: e17776. Available in: https://doi.org/10.2196/17776

7. McManus RJ, Mant J, Franssen M, Nickless A, Schwartz C, Hodgkinson J, et al. Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial. Lancet Lond Engl. 2018; 391: 949-959. Available in: https://doi.org/10.1016/S0140-6736(18)30309-X

8. Omboni S, McManus RJ, Bosworth HB, Chappell LC, Green BB, Kario K, et al. Evidence and recommendations on the use of telemedicine for the management of arterial hypertension: an international expert position paper. Hypertens Dallas Tex 1979. 2020; 76: 1368-1383. Available in: https://doi.org/10.1161/HYPERTENSIONAHA.120.15873

AFFILIATIONS

¹ Member of the Group of Experts in Arterial Hypertension (GREHTA) Mexico, Member of the National Association of Cardiologists of Mexico (ANCAM), Member of the Mexican Society of Cardiology, Delegate in Jalisco of the Medical Association of the Hospital de Cardiología A.C., Former President of the College of Cardiologists of Jalisco, Hospital de Especialidades Puerta de Hierro Andares, Zapopan, Jalisco, Mexico.

Author contributions: Each author contributed important intellectual content during manuscript drafting or revision and accepted accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved.

Funding: The authors received no specific funding for this work.

Conflict of interest/financial disclosure: The authors declare that they have no conflict of interests.

CORRESPONDENCE

Humberto Álvarez-López, MD. E-mail: beto66_mx@yahoo.com