Usefulness of a Telemedicine Tool TELEA in the Management of the COVID-19 Pandemic

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has strongly impacted Europe, with particular virulence in Spain and Italy. On April 4, 2020, the confirmed cases in the world exceed 2 million, of which ∼170,000 belonged to Spain, which was the second country in the world in number of infections.¹ Deaths in Spain are close to 17,500 and the capital, Madrid, was the center of the outbreak.² In several countries, a declaration of the state of alarm has been made, encouraging the population to avoid contact by social distancing. In this context, teleworking is recommended whenever possible. In the health field, this results in the cessation of nonessential activity, telephone consultations, and the use of tools that allow the medicine to be practiced in a virtual way.

Although with limited evidence, telemedicine has demonstrated results comparable with the standard of care in infectious diseases, increasing access to the health system, particularly in rural settings, at reduced costs.^3,4 The role of telemedicine in medical disaster response has been discussed previously.⁵

In the context of the COVID-19 pandemic, telemedicine acquires special relevance, especially to assess patients with suspected infection, avoiding their displacement to health centers. Health care providers have already begun to revise care recommendations by including telemedicine in their assistance process.⁶ However, the use of telemedicine has not been studied in the current pandemic scenario.⁷ A Pub Med search (April 23, 2020) using the terms “COVID-19” [Supplementary Concept] and “Telemedicine” [Mesh] revealed position or opinion articles, but it did not find any publication on clinical experience with telemedicine in the management of COVID-19.

On March 3, 2020, the first case of COVID-19 was detected in our area. Since then, >700 cases have been diagnosed. In view of previous experience in other health care areas, which collapsed because of a massive affluence of patients, a household follow-up proposal was developed for COVID-19 patients by adapting TELEA, a web-based electronic tool used in our area, originally designed as a home monitoring system for chronic patients.^* TELEA is a digital platform that, in a user friendly environment, allows any patient at home (with a tablet, a personal computer, or a smart phone) to record the clinical variables defined by their physicians. The patient can fill in questionnaires on the platform (symptoms, life quality, etc.) and register different clinical variables (temperature, heart rate, etc.). These data are directly uploaded to the patient’s electronic medical record, so the health care team can track the patient in real time. The platform generates various alarms according to the collected parameters, which are used as a guide for monitoring and clinical decision making. It also allows to call the patient by phone, make a videoconference, or send an e-mail.

In this report we communicate our early experience with this approach. We feel that our findings do provide substantial novelty and are of interest to clinicians.

Methods

The Department of Lugo, in the northwest of Spain, has 329,000 inhabitants distributed >9,856 km². It is characterized by an elderly population with high dispersion in small villages. Virtually, the whole population is insured by the public health system. It has one reference hospital with 800 beds and two smaller hospitals with 150 beds each. Both hospitals and primary care share the same electronic medical record.

A team was formed by internal medicine physicians and nurses who were trained in the use of the TELEA tool. To select the patients who could benefit from their inclusion in the program, the following risk factors for a complicated clinical course were considered: pregnancy, age >60 years, presence of comorbidities (hypertension, diabetes, heart disease, chronic kidney disease, chronic lung disease, and immunosuppression), or other conditions reflected in the medical record that, in the physician’s opinion, justified their inclusion in the program. A list of COVID-19–positive patients was received each day. After excluding the cases already admitted to the hospital, the electronic medical records of the remaining patients were reviewed.

If the patient met criteria for admission to the program, a telephone interview was conducted with the physician with special attention to the date of symptoms onset, type of symptoms, and the presence of “red flag” symptoms (confusion, breathlessness, chest pain, or pressure, etc.). If warning symptoms were reported, an immediate hospital assessment was scheduled. Otherwise, a TELEA platform-based follow-up was offered to the patient. A pulse oximeter, the access keys to the website, and a contact telephone number were sent to the patient. If the patient suffered from disabilities that precluded the use of the web-based tool, it was requested that the data be uploaded by a partner and, if this was not feasible, the nurse made a daily telephone contact. If the patient did not meet the criteria for enrollment or if he or she rejected his or her participation in the program, he or she was referred to his or her general practitioner.

The patient answered a symptoms survey daily, and three times a day he or she uploaded his or her temperature and oxygen saturation values to the web. The nurse reviewed the data and informed the physician if any of the data were not within previously established safety thresholds or if the patient had made a nonscheduled phone contact. Patients were followed for a period of at least 14 days, which could be extended at the physician’s discretion. When hospital admission was required, it was scheduled in coordination with the ambulance service and the hospital ward, avoiding the need to go to the emergency room.

The clinical data were recorded in a registry authorized by the Hospital’s Research Ethics Committee (Registry Code: 2019/245), and subsequently exploited for analysis.

Results

From March 3 to April 15, 727 COVID-19–positive patients were detected, with a mean age of 56 ± 18.2 years (range 1–101). A total of 59.6% were women. Their characteristics are presented in Table 1. Of these, 546 were evaluated for follow-up, of which 275 were enrolled in the program and 247 were referred to primary care. Of the patients followed in primary care, two required hospital admission, both to decompensation of a psychiatric disorder. Of the patients followed through the TELEA tool, 22 (8.03%) required admission. In 14 cases, admission was prescheduled by the responsible physician, whereas in 8 cases, the patient alerted the emergency services directly (Fig. 1).