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RANZCR: Clinical Medicine in a Pandemic
Practising Clinical Medicine under a Mask and at a Distance
Utilising Available Technologies, Developing New Ones
The demands of the pandemic have fast-tracked the uptake of digital health and the development of new technologies, or simply new ways of utilising existing technologies.
The integration of digital health into our healthcare systems needs to go beyond the ‘emergency fix’ and be set against the long durée of its implementation in a complex system with the accompanying set of puzzles regarding access, security, privacy, workflow integration.
It remains to be seen which technological innovations will outlive the pandemic and whether, for instance, populations will still be as willing to relinquish as large a degree of privacy as they have been during the crisis.
Whether e-prescriptions are here to stay, whether wearables can continue to be adapted and repurposed for diagnosis as well as tracking.
Whether telehealth is reimbursed at parity.
What to do about an app that is manufactured for collection of health data by a company that falls outside the regulatory sphere that encompasses healthcare providers themselves.
Whether a deep learning based model to detect and classify COVID-19 cases from X-ray images can be used in remote places in countries affected by COVID-19 to overcome a shortage of radiologists.*
The pandemic has not miraculously delivered a perfectly formed digital health system, however the exigencies of providing care ‘under a mask and at a distance’ have meant that data have been shared across the globe, as seen in the collaborative work of Dr Yuranga Weerakkody, and carers have come to be involved in consultations despite geographical distance as highlighted by Dr Sid Baxi.
The necessary social distance of a clinical consultation during COVID-19 has been offset by the time and effort saved for patients in getting to appointments, the reduction in exposure to the risk of COVID-related illness for clinicians and medical staff, greater access to more complete health metrics provided by wearables and apps. There has been increased adoption of lifestyle and wellbeing apps in 2020, perhaps leading to ‘more prevention, less cure’ in a future where their use is commonplace.
We spoke to Dr Sid Baxi, Genesis Cancer Care, about his experience as a radiation oncologist in the past year.
What has been your experience practising your profession during the pandemic?
During the pandemic we have had to tackle a number of unique challenges not faced by us in the past. We have had to tackle patient fears of coming for treatment and patient fears of contracting the virus in high-risk hospital environments.
We have had patients cancel and delay treatment, trying to balance up the relative seriousness of their tumour versus the risk of COVID-related illness.
We have had to keep our staff safe and consider their safety with patients coming in and out of hospital from various regions and states.
Having been part of a practice on the border, the cross-border issues and the closure and opening of borders ad hoc and quickly has resulted in us needing to be nimble and working out how to get our patients access to care when they lived across the border.
Practising clinical medicine under a mask and at a distance has been challenging, practising it over the phone and via video consultations has been challenging.
What has been most difficult?
Two aspects have been most difficult for me.
Number one—trying to get patients across border closures in a timely fashion when medical care was needed and only available across the border has been a great source of stress for the patients and our clinic.
Trying to practise clinical medicine where you needed the patient in the room but were unable to get that option available at the peak of the pandemic was significantly challenging, when examination holds so much in the clinical assessment of a patient.
Have there been any unexpected upsides?
I think there have been a number of upsides including understanding in what aspects of health care we can use telehealth and video consultations so that patients don’t have to drive, park, wait for quick consults that can be done quite safely over the phone.
It has expedited the government’s roll-out of digital strategies which has been just brilliant. This includes item numbers for video consultations and telephone consultations and the use of e-prescription technologies and e-referral technologies.
What are the specific challenges of practising near a state border?
I think the two significant challenges were: the communications piece of aligning the states on either side of the border, their regulations versus the hospital and the clinic’s policies; and messaging that to the patient in a timely and effective fashion when such changes happened, very quickly and often on the weekend.
Is there a particular story/experience that you encountered during the pandemic that stays with you?
I have had an experience, not a pleasant one, that does stay with me. During a sudden lockdown, we had an ambulance vehicle turned away at the border and told to return to its point of origin. At which point it had to be redirected to the nearest health centre that could look after the patient which was much further away and it certainly wasn’t a patient-centred outcome.
This was, unfortunately, the didactic application of policy without context and had to be followed in a black and white manner as we were working out how to grapple with the nuances of state border jurisdictions not aligning all the time and being nimble and contextual in their approaches.
What would you do differently in a similar public health crisis in the future?
The one thing I would do is make actionable changes in how we operate in a more contextual manner, rather than too rapidly and impulsively, as I think we approached the problem early in the pandemic, March 2020, with an extreme reaction that was not needed nor warranted at that time.
Having been through it now, there are grades of responses and we’re better off, we’re better positioned now to respond to any levels of emergency, depending on the crisis level.
What would your message be now—to clinicians, to patients?
To clinicians, I would say we have proven that our strategies, everything from social distancing to hygiene, masks and so on, have been very effective at keeping Australians, and Australians in the healthcare setting, safe. And so we need to trust those measures.
Reference 1. Ozturk, Tulin et al. “Automated detection of COVID-19 cases using deep neural networks with X-ray images.” Computers in biology and medicine vol. 121 (2020): 103792. doi:10.1016/j. compbiomed.2020.103792
New Technologies to Distinguish COVID-19 from Other Lung Diseases
Dr Yuranga Weerakkody
Our congratulations go to FRANZCR Dr Yuranga Weerakkody for the successful development of a COVID-19 imaging educational app awarded runner up “best new radiology software” for 2020 by Auntminnie.europe.
Together with Prof Kay-Geert Hermann, Professor of Radiology, Charité Medical School, Berlin and Dr Fabio Macori MD, Radiologist Ospedale Santo Spirito, Rome, Dr Weerakkody helped design the app as a multicentre collaborative effort between Western Australia, Germany and Italy during the initial COVID-19 outbreak in Europe in early 2020.
The app drew on the programming expertise of the noted BerlinCaseViewer team and clinical radiology experience from the three radiologists and some of their clinical and technical support staff.
It was designed as a question-and-answer case-based interactive teaching tool with links to important radiology journal publications embedded up to the level initial release (April 2020). These cases are presented as easily scrollable stacks with annotations as the user progresses through a case.
Data from a large number of COVID-19 positive cases in Italy, which was an epicentre at the time, were generously made available by lung radiologist Dr Macori. These were then selected and mixed with several mimic cases to help imaging professionals and relevant frontline clinicians realise the differences and similarities with certain overlap of non-COVID-19 conditions on imaging.
The app can be accessed from BerlinCaseViewer.de or any app store.
*www.berlincaseviewer.de/covid-19-onct-scans/
Do you have a story to recount where technology has succeeded, or been problematic, in the delivery of care during a public health crisis? We’d love to hear it: editor@ranzcr.edu.au
