Is the COVID-19 Pandemic an Opportunity to Enlarge the Telemedicine Boundaries? (Re: Telemed J E Health 2020;26:571–573)

Dear Editor:

We write in regard to the recent editorial entitled, “Telemedicine and the COVID-19 Pandemic, Lessons for the Future” by Bashshur et al.¹ recently published in Telemedicine and e-Health,¹ with the aim both of sharing our thoughts with you and to ask for the authors’ feedback on our position regarding a possible evolution of the boundaries of telemedicine caused by the COVID-19 pandemic.

There is no doubt that telemedicine as a diagnostic, monitoring, and treatment tool is showing, as highlighted in the editorial, potentialities to fight the epidemic, to avoid the risk of contagion and to ensure continuity of treatment.

As researchers in this discipline who have been working for about 20 years in this area, we have greatly appreciated the editorial that summarizes what we scholars are feeling right now. We are convinced that all of us, working in this field are asking the questions on Table 1.

We would like to list and share our personal reply to each one of these questions.

We have reflected on the first question and we believe that, compared with before, unprecedented conditions of technological availability and exceptional circumstances have been created. One aspect that drove this boom was certainly the vastness of the pandemic, the most terrible of the past century; but the real engine of the boom in telemedicine, during the epidemic for the SARS-CoV-2 virus of 2019, compared with the SARS-CoV epidemic of 2003, is certainly the mobile technology and in particular the smartphone with its enormous potential; such as the possibility of installing apps for communication, digital tracking, availability and integrability with sensors, and ease of interaction with multimedia content. During the epidemic of 2003, the smartphone was not yet widespread and to make a message with the mobile phone using the SMS one had to write “s” by typing the “7” key of the composer four times!

To the second question, we answer that we noticed that many factors contributed to this boom and a great role in this moment was played by social networks and video communication apps, in all of the telemedicine sectors, from the mental health to the ophthalmology.^2–5 The use of these systems is very often disseminated in smartphones and was allowed in telemedicine in derogation of regulations (that prohibited their use before the pandemic in telemedical applications due to limits in confidentiality and privacy). We will have to see if after the pandemic it will still be possible to use them in telemedicine applications.

To the third question, we believe that the editorial has responded widely. During the pandemic, exceptional changes have happened in the health care. As an example, we laud the regulatory derogation in the United States in telepsychiatry with regard to the possibility of selling online drugs through telemedicine architectures. Psychiatrists hope that this will be possible even when the pandemic is over; however, as highlighted in the editorial, in general it is important that quality in care must be the guiding principle and that abuse must be avoided.

As for the fourth question, we answer both as researchers and as European and Italian citizens. We do not think this boom has been identical across the world. Different regulations and a less enlightened and more conservative political approach in some cases have in many cases hampered the spread of telemedicine. Just to cite a first example, whereas in the United States the system based on medical insurance has clearly defined the reimbursement procedures, in Italy and in Europe this has not happened so explicitly. For example, think of the derogations to law for the use of messaging and video communication systems that have occurred in the United States: even on this issue, Europe has not clearly made explicit derogations to current regulations.

To the fifth and final question, we want to answer in an articulated way and also report our personal experience during the pandemic. One of us works at the Istituto Superiore di Sanità (ISS), the Italian National Institutes for Health. At the outbreak of the pandemic, 21 working groups were created at the ISS on various topics, from epidemiology to telemedicine and scientific updating. While reviewing the publications of telemedicine for one of these groups, we realized that new potentialities are weakly emerging in telemedicine. The pandemic has generated conditions of enormous stress, for example, due to the severe restrictions on social life, home isolation, and the fear of being contaminated. Stress and reduced motor activity are certainly leading to an increase in various pathologies (not only in borderline subjects), from cardiovascular to metabolic ones (such as diabetes), to anxiety and depression also in subjects who did not have any never suffered. Telemedicine, currently during the COVID-19 pandemic, is used for remote care, monitoring, diagnosis and rehabilitation.

In our opinion, the aforementioned considerations show that telemedicine should also be used as a tool for mass preventive investigation, widening its limits, becoming also a preventive type tool for the pathologies listed earlier and beyond. However, in the scarcity of resources, as a first step it would be at least necessary to hypothesize simple solutions, based on mobile-technology capable of, at least acting in the health sector as self-awareness tools. In the field of psychology they could be useful for (a) verifying the extent and presence of problems of anxiety and/or depression; (b) identify the factors that influence (also positively) the psychological sphere; (c) offer tools for self-awareness of one’s state of health and, for example, be a trigger to suggest a subsequent visit; (d) also offer suitable exercises for the self-therapy. Certainly, the mobile-survey (m-survey) tool⁶ administered through mobile technology, sent, for example, with social networks, could contain psychological tests on self-awareness anxiety/depression, a self-reported quality of life questionnaire, and investigate other factors that influence these problems for subjects, and respond to monitoring aspects (a–c). Tools such as those proposed by Bäuerle et al.³ could play a self-therapy role. At the ISS, we have proposed a tool to investigate (a–c), with also the curiosity to explore the role of the pet during the lockdown (a newer tried experience before).

The tool, based on an m-survey, has been designed using Microsoft forms. The tool is arranged into three sections (Fig. 1: Contents on the m-health tool): (1) this section was dedicated to the characterization of the subjects involved in the study (all subjects with history of psychological problems were excluded); (2) the second section was dedicated to the relationship with the pet; and (3) the third section included an anxiety self-assessment scale.^7,8 The m-survey was submitted through the social networks and the messaging tools (English version of the link: https://forms.office.com/Pages/ResponsePage.aspx?id=DQSIkWdsW0yxEjajBLZtrQAAAAAAAAAAAAZAAOUXdFhUQUNQWTFTTlBYRk1aOVhBNVRWVEEzTVlJNi4u; QR code in Fig. 1).