¿Qué sabíamos de telemedicina y qué nos han propuesto durante la pandemia de COVID-19?

¿Qué sabíamos de telemedicina y qué nos han
propuesto durante la pandemia COVID-19?
Rafael Vidal Pérez
Rafael Vidal Pérez
Rafael Vidal Pérez
Servicio de Cardiología
Complejo Hospitalario Universitario de A Coruña
Comité TIC Sociedad Española de Cardiologia
e-communication committee member of European Society of Cardiology
@rafavidalperez
¿Qué sabíamos de telemedicina y
qué nos han propuesto durante la pandemia de COVID-19?

Rafael Vidal Pérez
Conflictos de interés
• Ninguno que declarar en relación con esta presentación

Rafael Vidal Pérez
Rafael Vidal Pérez
https://secardiologia.es/multimedia
/directos-online/11547-la-consulta-
virtual-para-el-cardiologo-clinico-
en-tiempos-de-covid-19

Rafael Vidal Pérez
Rafael Vidal Pérez

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.bmj.com/content/369/bmj.m1557

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.visualcapitalist.com/shoppers-
buying-online-ecommerce-covid-19/
¿Ha cambiado algo
en medicina?

Rafael Vidal Pérez
Rafael Vidal Pérez
Einthoven W. Le telecardiogramme. Arch Int de Physiol 1906;4:132–164. Translated into English in Am Heart J
https://www.ntvg.nl/system/files/publications/1906215170002a.pdf

Rafael Vidal Pérez
Rafael Vidal Pérez
European Heart Journal (2016) 37, 63–66

Rafael Vidal Pérez
Rafael Vidal Pérez
JACC 2017; 70 (21) : 2696–2718

Rafael Vidal Pérez

Rafael Vidal Pérez
http://boletines.prisadigital.com/Informe-TAD-50-Mejores-Apps-de-Salud.pdf
2014
2017
El problema de la
evaluación de las Apps

Rafael Vidal Pérez
Rafael Vidal Pérez
https://twitter.com/Berci/status/
1204043342587277319

Rafael Vidal Pérez
Rafael Vidal Pérez
N Engl J Med 2019;381:89-90
Follow-up ultrasound examination performed by the astronaut,
guided in real-time and interpreted by two radiologists on
Earth, confirmed the presence of venous thrombosis with
subacute characteristics
Vivid q

Rafael Vidal Pérez
Rafael Vidal Pérez
• Medir actividad física
• Detección de arritmias
• Consulta virtual y mensajería electrónica
• Telerrehabilitación
N Engl J Med 2019;381:956-68

Rafael Vidal Pérez
Rafael Vidal Pérez
N Engl J Med 2019;381:956-68

Rafael Vidal Pérez
Rafael Vidal Pérez
Lancet Diabetes Endocrinol. 2016 Dec;4(12):983-995

Rafael Vidal Pérez
Rafael Vidal Pérez
https://jamanetwork.com/journals/jama/article-abstract/2728473

Rafael Vidal Pérez
Rafael Vidal Pérez
N Engl J Med 2019;381:1909-17

Rafael Vidal Pérez
Rafael Vidal Pérez
Consulta virtual y mensajería electrónica

Rafael Vidal Pérez
Rafael Vidal Pérez
JAMA. 2015;314(12):1255-1263. doi:10.1001/jama.2015.10945

Rafael Vidal Pérez
Rafael Vidal Pérez
Longer clinical trials
For more diversity, need to break language barrier
Don’t rely on self-reported data: use wearables
Need to factor in “dose effects”
Evaluation as a standalone strategy isn’t good enough

Rafael Vidal Pérez
Rafael Vidal Pérez
2011 https://twitter.com/juliomayol/status/1229875335476531200
18/2/2020

Rafael Vidal Pérez
Rafael Vidal Pérez
https://twitter.com/EricTopol/status/1230174403146633219
19/2/2020

Rafael Vidal Pérez
Rafael Vidal Pérez
https://retina.elpais.com/retina/2020/02/21/tendencias/1582271422_514221.html
21/2/2020

Rafael Vidal Pérez
Rafael Vidal Pérez
https://topol.hee.nhs.uk/

Rafael Vidal Pérez
Rafael Vidal Pérez
No telemedicine program can be created overnight, but U.S. health systems that have already implemented telemedical
innovations can leverage them for the response to Covid-19.
A central strategy for health care surge control is “forward triage” — the sorting of patients before they arrive in the
emergency department (ED). Direct-to consumer (or on-demand) telemedicine, a 21st-century approach to forward
triage that allows patients to be efficiently screened, is both patient-centered and conducive to self-quarantine, and it
protects patients, clinicians, and the community from exposure. It can allow physicians and patients to communicate
24/7, using smartphones or webcam-enabled computers. Respiratory symptoms — which may be early signs of Covid-
19 — are among the conditions most commonly evaluated with this approach. Health care providers can easily obtain
detailed travel and exposure histories. Automated screening algorithms can be built into the intake process, and local
epidemiologic information can be used to standardize screening and practice patterns across providers.

Rafael Vidal Pérez
Rafael Vidal Pérez
Perhaps these Viewpoints could also serve to
provide suggestions to galvanize efforts about
what will need to be done beyond tomorrow.
Hippocrates saw patients face-to-face, and medical care still mostly relies on
personal encounters.COVID-19 has unmasked many clinical visits as unnecessary
and likely unwise. Telemedicine has surged; social proximity seems possible
without physical proximity. Progress over the past 2 decades has been painfully
slow toward regularizing virtual care, self-care at home, and other web-based assets
in payment, regulation, and training. The virus has changed that in weeks. Will the
lesson persist in the new normal that the office visit, for many traditional purposes,
has become a dinosaur, and that routes to high-quality help, advice, and care, at
lower cost and greater speed, are potentially many? Virtual care at scale would
release face-to-face time in clinical practice to be used for the patients who truly
benefit from it.

Rafael Vidal Pérez
Rafael Vidal Pérez
Outside of health care, discussions about reopening the economy
focus on how to return to work. However, the real engines of the
economy are not the producers of goods and services but the
consumers of them. Stories from hospitals trying to restart clinical
services suggest that many patients do not yet feel that it is safe to
come back. And so the need to make clinical services safe is matched
by the equally critical need to make them feel safe. That kind of
emotional connection with customers has never been medicine’s
strong suit

Rafael Vidal Pérez
Rafael Vidal Pérez
Improving access to care is another way in which patient-generated data and
mHealth could have a positive effect. With the aging US population and the
accompanying rise of chronic medical conditions, demand for health care
visits is outpacing supply. Wait times for new appointments increased by 30%
between 2014 and 2017. An alternative model that leverages a combination of
data from the patient’s electronic health record and routinely transmitted
patient-generated data could obviate the need for many routinely scheduled
visits. Electronic communication would provide reassurance to patients that
their health is being monitored via their patient-generated data
JAMA Network Open.
2020;3(4):e202971
Treskes RW, van Winden LAM, van Keulen N, et al. Effect of smartphone-enabled
health monitoring devices vs regular follow-up on blood pressure control among
patients aftermyocardial infarction: a randomized clinical trial. JAMA Netw Open.
2020;3(4):e202165

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.bmj.com/content/368/bmj.m1182
Although such consultations
can be done by telephone in
many cases, video provides
additional visual cues and
therapeutic presence
Note that many countries,
including the US, are formally
relaxing privacy and data
protection regulations for video
and other communications
technologies during the crisis;
the General Data Protection
Regulations which apply in the
UK and European Union
already include a clause
excepting work in the
overwhelming public interest.

Rafael Vidal Pérez
Rafael Vidal Pérez
BMJ 2020;368:m1279
BMJ 2020;368:m998

Rafael Vidal Pérez
Rafael Vidal Pérez
The covid-19 pandemic has necessitated many changes in US healthcare.
It has made me wonder which—if any—in three healthcare sectors will become permanent.
1) Public health-new investments
2) The payment systems for care – The change from fee-for-service to prospective payment system
3) Dramatic changes in how office based care is delivered.
The most obvious difference is the almost total abandonment of face-to-face visits in favor of telemedicine, by video and by telephone. Family
doctors tell me that they are shocked how quickly this change has occurred and amazed how comfortable doctors and patients are with it.
The dominance of telemedicine has led to many other changes: new requirements for what necessitates an in-person visit; less dependence on
and a higher threshold for laboratory testing; a corresponding increase in the importance of history taking; increased reliance on patient
reported clinical data from home monitors and wearable instruments; and others. Doctors have also reported increases in collegiality and
cooperation within and between specialties as everyone works together on behalf of covid-19 patients.
BMJ 2020;369:m1784 doi: 10.1136/bmj.m1784 (Published 30 April 2020)

Rafael Vidal Pérez
Rafael Vidal Pérez
https://doi.org/10.1016/S0140-6736(20)30818-7
Eric Topol, director of the Scripps Research Translational Institute in
La Jolla (CA, USA), praises these efforts, but laments that they have
been so long coming. “This is a very big moment for virtual health
care. But, of course, there isn’t a lot of readiness. There are so many
ways to monitor people’s health that we aren’t doing at any scale, in
large part due to interstate regulatory barriers that have meant we are in
no way ready for this moment

Rafael Vidal Pérez
Rafael Vidal Pérez
https://doi.org/10.1016/S2589-7500(20)30101-1
Remote shared care delivery is one such model, which enables multiple
patients to be seen at once, via virtual platforms. Outside of clinical
medicine, use of remote shared service delivery has rapidly increased—
eg, in education, where instructors with no prior online teaching
experience have been quick to transition
People who provide SMAs often report improved outcomes and
productivity gains through eliminating repetition of common advice;
however, acceptance of SMAs has been limited by inertia among patients
and clinicians.
In the current COVID-19 pandemic, embracing virtual SMAs has
potential to enhance provider capacity while mitigating transmission risks
and enabling privacy: identity can be withheld, voices disguised, and
patient video made visible only to the clinician

Rafael Vidal Pérez
Rafael Vidal Pérez
Ann Intern Med. doi:10.7326/M20-1982
This article was published at Annals.org on 14 May 2020.

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/specialty-guide-cardiolgy-coronavirus-v1-20-march.pdf

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.escardio.org/Education/COVID-19-and-Cardiology/ESC-COVID-19-Guidance

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.escardio.org/Education/COVID-19-and-Cardiology/ESC-COVID-19-Guidance
In this context, in order to minimize risk for COVID-19 transmission, the
use of telemedicine is highly desirable especially for vulnerable groups,
such as older patients. Additionally, telemedicine provides an opportunity
for tele-consultations with different specialists and professionals, thus
allowing patients to receive a comprehensive therapeutic approach without
moving from home to the outpatient clinic or to the hospital. Also
telerehabilitation (or home based rehabilitation with telephone contact
with the rehab team) is an option for patients discharged from the hospital
after an acute event. Finally telemedical follow up of HF and device
patients is becoming more and more standard and may be considered.
Telemedicine has been considered relevant in contributing to viral
outbreak containment while preventing patient health from deteriorating
because of misdiagnosed or mistreated CVDs

Rafael Vidal Pérez
Rafael Vidal Pérez
J Am Coll Cardiol 2020;75:2352–7

Rafael Vidal Pérez
Rafael Vidal Pérez
J Am Coll Cardiol 2020;75:2352–7
One important mechanism to help prevent transmission is
the use of telemedicine. This technology, already used by
numerous large health care systems around the world, is
ideal in public health crises as it allows for patients to be
triaged while minimizing exposure of patients and health
care workers to potential infection. Additionally,
telemedicine provides an opportunity for specialists that
might not otherwise be available to evaluate patients.
Although there are currently barriers to the widespread
implementation of telemedicine, such as coordination of
testing in patients triaged as high risk, this is a technology
that will likely prove important to promote viral
containment

Rafael Vidal Pérez
Rafael Vidal Pérez
Journal of the American College of Cardiology (2020), doi: https://doi.org/10.1016/j.jacc.2020.04.063
Protection of patients and HCWs
The protection of patients and HCWs must be
addressed before any reintroduction of cardiovascular
procedures and tests. Regions must have the
necessary critical care capacity, PPE, and trained staff
available before the recommendations summarized in
Table 1 can be implemented. Importantly, a
transparent plan for testing and re-testing potential
patients and HCWs for COVID-19 must be
operationalized before elective procedures and tests
are resumed.
Additional considerations include:
1) Physical distancing: Consider strategies to
minimize patient contact with HCWs performing
invasive cardiovascular procedures and diagnostic
tests. These may include virtual pre-procedural
clinics, virtual consenting for procedures and
diagnostic tests, and minimizing the number of
HCWs in physical contact with any given patient.
Restrictions should be implemented on the number of
people that can accompany a patient or visit a patient
after a procedure or test. Whenever possible, multiple
tests or procedures should be consolidated into a
single comprehensive visit.

Rafael Vidal Pérez
Rafael Vidal Pérez
https://doi.org/10.1016/j.jacc.2020.05.002

Rafael Vidal Pérez
Rafael Vidal Pérez
Caitlin Holt Siropaides, Melanie S. Sulistio, Sharon Coplen Reimold
10.1161/CIRCULATIONAHA.120.047374

Rafael Vidal Pérez
Rafael Vidal Pérez
Elizabeth H. Dineen, Jeffrey J. Hsu, Anum Saeed
Assess virtual clinical decision-
making: As programs are adopting
telehealth platforms, trainees can
continue to be supervised and
evaluated in this new era of clinical
decision-making
10.1161/CIRCULATIONAHA.120.047593

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.ccs.ca/images/Images_2020/NEW_CCS_RRT_Inhoptial_infection_reduction_30Mar.pdf

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.ccs.ca/images/Images_2020/Cardiac_Rehab_In_Covid_v2.4_Final_17_May_313.pdf

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.ccs.ca/images/Images_2020/CCS%20Guidance%20for%20Community%20Care%2025Mar2020.pdf

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.ccs.ca/images/Images_2020/COVID_or_HF_RRT_doc_01Apr.pdf

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.onlinejcf.com/article/S1071-9164(20)30367-5/
In this context, synchronous audio/video interactions, also known as
virtual visits (VVs), have been suggested as innovative and necessary
alternatives to in-person care. VVs provide a platform for real-time
interactive telehealth interactions between patients and clinicians using
commonly available home-consumer devices

Rafael Vidal Pérez
Rafael Vidal Pérez

Rafael Vidal Pérez
Rafael Vidal Pérez
Screen shots from video
virtual visits between an
HF cardiologist and a
patient. (A) Medication
review by video. (B)
Examination of ankles
showing sock markings
without edema. (C) Neck
With these expectations in mind we believe that VV models of care will
become the norm in the US health care system as we move forward,
especially for patients with HF. Many patients with HF, especially older
adults with disabilities and those living in rural communities often have
difficulty attending in-person visits due to very poor exercise tolerance,
inadequate transportation and difficulty in transporting oxygen, among
other barriers. For these patients, VVs are certainly more convenient;
likewise for their caregivers, who sometimes have to take time off from
work to take their family member to the appointment
Distant health technologies that align with VVs, including biosensing
wearables and other diagnostic tools, may be increasingly adopted.
Whether the use of VVs can improve adherence, decrease no-show rates,
decrease office overhead, improve transitions of care from the inpatient
to outpatient setting, or prevent emergency department visits and hospital
admissions and readmissions for patients with HF is yet unknown.

Rafael Vidal Pérez
Rafael Vidal Pérez
https://onlinelibrary.wiley.com/doi/10.1002/ejhf.1915

Rafael Vidal Pérez
Rafael Vidal Pérez
Circ Heart Fail. 2020;13:e007219

Rafael Vidal Pérez
Rafael Vidal Pérez
https://secardiologia.es/covid-19

Rafael Vidal Pérez
Rafael Vidal Pérez
http://secardiologia.es/images/secciones/riesgo/recomendaciones-rehabilitacion-cardiaca-SEC-2020-COVID19.pdf
No podemos olvidar la reestructuración de la
asistencia en nuestros programas, buscando
soluciones innovadoras para ofrecer programas de
orientación personalizada y seguimiento remoto.
Además, se debe promover la reanudación de
servicios de RC tras la crisis, especialmente para
aquellos pacientes que hayan experimentado
retrasos en el manejo de sus cuidados
cardiovasculares

Rafael Vidal Pérez
Rafael Vidal Pérez
http://secardiologia.es/images/secciones/riesgo/recomendaciones-rehabilitacion-cardiaca-SEC-2020-COVID19.pdf

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.revespcardiol.org/es-pdf-S030089322030172X

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.reccardioclinics.org/es-pdf-S2605153220300339
Como es lógico, no todos los pacientes podrán ser atendidos de
forma telemática, por lo que proponemos algunos criterios que se
deben considerar al hacer una visita presencial en hospital de día o
en los ingresos directos en planta, evitando la estancia en urgencias

Rafael Vidal Pérez
Rafael Vidal Pérez
REC 2020, in review

Rafael Vidal Pérez
Rafael Vidal Pérez
https://salud-digital.es/guia-basica-de-recomendaciones-para-la-teleconsulta/

Rafael Vidal Pérez
Rafael Vidal Pérez
https://elpais.com/economia/2020-05-09/las-
zonas-oscuras-de-la-telemedicina.html
Esto genera un doble problema. Por un lado,
los pacientes pueden ver mermada la
protección de sus datos sanitarios,
considerados legalmente como
especialmente sensibles. Por otro, la
inseguridad jurídica de las empresas, que
puede limitar el desarrollo y la innovación en
el sector, o exponerlas a elevadas
sanciones. Hay que recordar que el
Reglamento General de Protección de Datos
(RGPD) cuenta con un severo régimen de
infracciones, permitiendo multas de hasta 20
millones de euros o del 4% de la facturación
global de la compañía en los casos más
graves.

Rafael Vidal Pérez
Rafael Vidal Pérez
1. El principio general de la inmediación física (el cara a cara; cuando si cuando no) (donde las
excepciones, la primera consulta debe ser presencial; la continuación asistencial la comunicación de
resultados pruebas puede ser factible): Absolutamente necesaria en medicina clínica en diagnóstico y
seguimiento. Código Deontológico OMC (tiene traducción legal- norma a cumplir LOPD). No hay
norma que regule estas cuestiones (digitalización sanitaria).
2. Todo sistema de digitalización requiere identificación entre médico y paciente (de forma fiable y
segura). Garantizar la adecuada identificación.
3. El paciente digital lo tiene que ser por convicción no por obligación. Es una opción/alternativa, no se
le puede obligar, hay que convencerlo de que es lo mejor. Previo al uso de herramienta informática
hay que asegurarse de que el paciente es idóneo para llevarlo a cabo (dejar constancia de ello-incluir
en consentimiento informado).
4. Tiene que haber seguridad en las comunicaciones (esta en Ley de protección de datos y estándares
europeos).
4 reglas generales E-salud

Rafael Vidal Pérez
Rafael Vidal Pérez
https://www.acpjournals.org/doi/10.7326/G20-0033

Rafael Vidal Pérez
Rafael Vidal Pérez
http://www.medicosypacientes.com/sites/default/files/INFORME
%20E%20CONSULTA_CCD_10_06_2020%20%281%29.pdf

Rafael Vidal Pérez
Conclusiones
Telemedicina
• La telemedicina llevaba mucho tiempo entre nosotros pero NO estaba implementada
• Suponía excelentes oportunidades
• Permite a los pacientes tener un papel más activo en el sistema sanitario
• Facilita la colaboración / comunicación paciente – médico
• Supone un potencial para aprovechar inteligentemente cada byte de datos → más personalización, mejor
información, una mejora general de las prestación sanitaria
• Prometedores resultados en prevención cardiovascular
• Evidentemente su organización es todo un reto para el sistema sanitario sobre todo en tiempos de una pandemia
• Impedir su mal uso con un potencial importante de sobrecarga del sistema
• Usabilidad, precisión de los datos, validación de sus resultados…
• Regulación de su uso / Resistencia al cambio

Rafael Vidal Pérez
@rafavidalperez
rafavidal@hotmail.com

¿Qué sabíamos de telemedicina y qué nos han propuesto durante la pandemia de COVID-19?

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¿Qué sabíamos de telemedicina y qué nos han propuesto durante la pandemia de COVID-19?