Letter to the Editor. Limitations of telemedicine in low- and middle-income countries

Ivo Kehayov MD, PhD1, Petar Uchikov MD, PhD1, Tanya Kitova MD, PhD, DMSc1, and Borislav Kitov MD, PhD2
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  • 1 Medical University of Plovdiv, Bulgaria
  • | 2 Sv. Georgi University Hospital, Plovdiv, Bulgaria
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TO THE EDITOR: We read with great interest the editorial by Servadei and Zaed (Servadei F, Zaed I. The role of telemedicine in countries with limited facilities: which peculiarities? Editorial. Neurosurg Focus. 2022;52[6]:E6).1 We fully agree that the COVID-19 pandemic has catalyzed the utilization of telemedicine services in the field of neurosurgery in countries with limited facilities and thereby confirmed the significance of these services for routine clinical practice. The vast availability of free cutting-edge software for distant video communication (Skype, Messenger, Viber, WhatsApp, etc.), in addition to state-of-the-art mobile devices with high-speed internet connection, provide excellent opportunities for real-time, high-quality online neurosurgical consultations, education, and exchange of medical knowledge around the globe.2,3

On the other hand, telemedicine services have certain limitations in countries with limited facilities, such as the lack of adequate legislation for guaranteed payment of the accomplished consultations and invested expenses, the lack of detailed neurological examination, issues with the protection of shared personal information and data, the absence of eye-to-eye intercommunication between the physician and patient, insufficient regional development of technologies, and inadequate judgment of the severity of the particular neurosurgical disease.4 Underutilization of telemedicine in neurosurgery originates from its uneven coverage, the absence of international licensing and universal software, and the lack of legalized responsibility for misdiagnosis and omissions.5

Despite recent advancements in telemedicine, the majority of physicians and patients in countries with limited facilities still prefer the traditional methods for consultations and medical care, which necessitates the introduction of widespread informational campaigns to clearly explain the pros and cons of telemedicine services.6 The latter cannot substitute for conventional eye-to-eye contact between physicians and patients; however, it can be of real benefit to differentiate between elective and emergency cases, as well as to provide patient follow-up during the postoperative period.

Strict and clear legislation is absolutely necessary to guarantee the ongoing utilization of telemedicine services in the aftermath of the COVID-19 pandemic. Such legislation should address the scope of telemedicine coverage, issues with personal data sharing, fair payment for accomplished medical services, and the legal definition of responsibility for misdiagnosis and medical omissions.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Servadei F, Zaed I. The role of telemedicine in countries with limited facilities: which peculiarities? Editorial. Neurosurg Focus. 2022; 52(6):E6.

  • 2

    Szmuda T, Ali S, Słoniewski P; NSurg4WL Group. Telemedicine in neurosurgery during the novel coronavirus (COVID-19) pandemic. Neurol Neurochir Pol. 2020; 54(2):207208.

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  • 3

    LoPresti MA, McDeavitt JT, Wade K, et al. Telemedicine in neurosurgery—a timely review. Letter. Neurosurgery. 2020; 87(2):E208E210.

  • 4

    Kahn EN, La Marca F, Mazzola CA. Neurosurgery and telemedicine in the United States: assessment of the risks and opportunities. World Neurosurg. 2016; 89:133138.

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  • 5

    Rahman M, Azam G, Bohorquez-Rivero J, et al. Telehealth and telemedicine in the COVID-19 era: a world of opportunities for the neurosurgeon. Letter. World Neurosurg. 2020; 142:541542.

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  • 6

    Wootton R. Telemedicine support for the developing world. J Telemed Telecare. 2008; 14(3):109114.

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  • 1 IRCCS—Humanitas Research Hospital, Rozzano, Milan, Italy
  • | 2 Humanitas University, Pieve Emanuele, Milan, Italy
  • | 3 ASST Ovest Milanese, Legnano Hospital, Milan, Italy

Response

We read with great interest the letter from Dr. Kehayov and colleagues, and we appreciate their interest in our editorial. We reported the effects of the 2-year-long COVID-19 pandemic on improving the number of users of telemedicine-related services in countries with limited resources. Despite recent advancements, we rightfully highlighted the current limitations in those countries that, according to Kehayov and colleagues, are present at several levels, such as the lack of a legislative body that can allow payments for consultations, the lack of a proper neurological examination, issues related to protection of personal data, and the difficulty of properly assessing the severity of the patient’s conditions.

The assumption that most patients still prefer a face-to-face visit was not confirmed by the report from Kumar et al.,1 who used post-visit interviews to show high patient satisfaction. During the pandemic period, we discovered that some (but not all) in-person visits can be avoided. It is now the responsibility of the neurosurgical community to solve the issues related to telemedicine. In our opinion, the solution is not to go back to in-person clinic visits but to couple remote visits with low-cost, easy-to-use informatics devices and smartphones to provide quick feedback.

Telemedicine in neurosurgery, both now and in the future, does not have the pretense to be a substitute for the traditional ways of delivering neurosurgical consultations and procedures, but it should be seen as a new, powerful instrument that allows neurosurgeons to reach their patients in an easier, more reliable, and cheaper way, despite global or geographical situations.

In low- and middle-income countries, one of the main issues is clinical follow-up of patients.2 The distance to travel to the hospital is often prohibitive, in addition to transportation and other related costs. Therefore, many papers from these countries are not scored properly because of the absence of adequate outcomes of the surgical procedures performed. The use of a validated telemedicine system would obviously help to overcome these difficulties.

In conclusion, we surely need to better organize our remote consultation systems, which have exploded in use during the pandemic and very often without any rules. But, we do not need to stop this experience, which will be extremely useful for the future of neurosurgical care all over the world and in particular in low- and middle-income countries.

References

  • 1

    Kumar N, Katiyar V, Praneeth K, et al. Challenges and prospects of neurosurgical teleconsultations in a developing country: a reality check. Neurosurg Focus. 2022; 52(6):E5.

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  • 2

    Clark D, Joannides A, Adeleye AO, et al. Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study. Lancet Neurol. 2022; 21(5):438449.

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Captain Benny Brandvold stands "at the ready" outside of Dhahran, Saudi Arabia, during the early phase of Operation Desert Shield, fall of 1990. © Benny Brandvold, published with permission. See the article by Martin et al. (E16).

  • 1

    Servadei F, Zaed I. The role of telemedicine in countries with limited facilities: which peculiarities? Editorial. Neurosurg Focus. 2022; 52(6):E6.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Szmuda T, Ali S, Słoniewski P; NSurg4WL Group. Telemedicine in neurosurgery during the novel coronavirus (COVID-19) pandemic. Neurol Neurochir Pol. 2020; 54(2):207208.

    • Search Google Scholar
    • Export Citation
  • 3

    LoPresti MA, McDeavitt JT, Wade K, et al. Telemedicine in neurosurgery—a timely review. Letter. Neurosurgery. 2020; 87(2):E208E210.

  • 4

    Kahn EN, La Marca F, Mazzola CA. Neurosurgery and telemedicine in the United States: assessment of the risks and opportunities. World Neurosurg. 2016; 89:133138.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Rahman M, Azam G, Bohorquez-Rivero J, et al. Telehealth and telemedicine in the COVID-19 era: a world of opportunities for the neurosurgeon. Letter. World Neurosurg. 2020; 142:541542.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Wootton R. Telemedicine support for the developing world. J Telemed Telecare. 2008; 14(3):109114.

  • 1

    Kumar N, Katiyar V, Praneeth K, et al. Challenges and prospects of neurosurgical teleconsultations in a developing country: a reality check. Neurosurg Focus. 2022; 52(6):E5.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Clark D, Joannides A, Adeleye AO, et al. Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study. Lancet Neurol. 2022; 21(5):438449.

    • Crossref
    • Search Google Scholar
    • Export Citation

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