COVID-19 pandemic has posed unique challenges to the healthcare delivery systems due to problems caused by lockdowns as well as need to maintain social distancing to decrease exposure . With the imposition of lockdowns and restricted patient movement across cities as well as disruption of routine outpatient department care, hematology patients were at a receiving end and would have a high risk of disease recurrence/relapse if regular medical advice is not provided. Our study showed encouraging data of feasibility of telemedicine services. More than 75% of tele-appointments were successfully attended. We started from scratch and physical visits were restricted to emergency or daycare only. A study from New York hospital reported that around half of their patients who could not be attended on site were contacted by telemedicine visits in early 2020 . In a global survey about oncology practice during COVID-19 pandemic, over 80% participants were using telemedicine in some form or another . Both the above studies highlight the virtual non-existence of telemedicine services prior to pandemic and rapid expansion over last few months.
Around one third (37%) patients required re-appointment in the form of either physical or repeat call. The reasons of re-consultation were to review of investigations, dose alteration or side effects of medications and related to disease course like progression of disease or other complaints of patients. Some of the patients required hospital visit after successful teleconsultation for treating physician signature for their medications and reimbursement related like government beneficiaries etc. All such physical visits can be triaged using telemedicine and patients can be directed to emergency ward, COVID screening area, daycare facility or pharmacy etc. depending on the inputs from teleconsult .
Those patients, who need to travel a long and tiring journey, can easily approach their physician for follow up issues related to disease & treatment without any exposure risk. E-prescription through message, email etc. can be sent to them thus avoiding physical visit. This will save on man hours, decrease office/school holidays as well as avoid over-crowding at busy government hospital outpatient services. Telemedicine-based care is easier in certain group of patients such as patients with long term oral medications e.g. chronic myeloid leukemia, chronic lymphocytic leukemia, chronic immune thrombocytopenia etc. and patient in complete remission and on maintenance therapy for their disease e.g. acute lymphoblastic leukemia, multiple myeloma, aplastic anemia etc. These patients are less likely to have active complaint during their treatment; drug modifications are easier and hence less likely to need physical outpatient department visit, as reflected in our data. More than one third of acute leukemia or myelodysplasia, myeloma, lymphoma and undiagnosed patients who consulted on phone were requested for physical consultation, as reflected in our data.
Challenges in drug availability were expected, as many patients living in second/third tier cities or villages were not able to procure medicines. Similar problems have been reported in an Italian CML study, where Imatinib was easily accessible but other medicines delivery issues were faced by 36% physicians for their patients . Our patients who underwent stem cell transplant < 6 months ago, were constantly in touch with us and always required to visit daycare facility for assessment. Only long-term follow-up transplant recipients were considered for teleconsultation. An Italian study showed that 58% of their long term follow up patients were seen by teleconsultation. Forty nine percent long term patients were contacted by teleconsultation for disease specific information and services available .
Patient feedback by google form provided good insights into overall success of teleconsultation services. Overall satisfaction with teleconsultation was present and it was heartening to see that patient understand the importance of teleconsultation in COVID era and its role in preventing virus spread. Their suggestions on improving the services are easy to implement and we are in process to doing so.
One of the limiting factors for telemedicine is lack of physical examination. We suggest any patient whose symptoms or reports warrant physical examination should be called to visit nearby health care facility. In present pandemic and through telemedicine, it is difficult to break bad news in comparison to pre-COVID time. We need to develop skill and art for breaking bad news when the patient initial diagnosis is made as well as at relapse or other major complication . Through telemedicine facilities patient, caregiver and relatives, staying at different places, can be counseled on a single platform as well as treatment plan formulated by treating physician and distantly staying specialist . Video based consultation should be the preferred modality in urban and educated areas, especially with resurgence of online video platforms like zoom, Google meets, teams etc. But availability of basic infrastructure including smart phone, internet and proper surroundings for communication and education level of patients are major barrier for integration into practice. Patients of acute leukemia during induction/consolidation cycles, high grade lymphoma patients on chemotherapy, transplant recipients in early post-transplant period etc. need more supervision. Even if consulted by telemedicine, they will require physical consultations more often so that complications are managed effectively.
To conclude, with the emergence of COVID 19, many cities under partial lockdown with restricted movement of people and fear of contacting virus, we can clearly see the advantages as well as feasibility of telemedicine services for our patients. With the possibility of long persistence of COVID-19, we feel that telemedicine is here to stay and both health care providers as well as patients need to be well versed with these technologies. Various advantages associated with telemedicine and potential applications make it a feasible approach even during the non COVID times. This expansion achieved on an urgent basis could be harnessed in the future to provide comprehensive and integrated care to patients suffering from various hematological disorders.