INTRODUCTION

Telemedicine can be defined as the application of information and communication technologies to medicine. Telemedicine development began in the middle of the last century, but it was not until 2 decades ago that it started to be implemented in healthcare systems ¹.

Telemedicine is based on the provision of remote medical services, and increasingly, they are part of the service portfolio of many health services. There are several modalities of telemedicine applied in clinical practice such as teleconsultation, telediagnosis, or telemonitoring. Telemedicine is currently used in many clinical specialties and in many healthcare settings, ranging from patient-centric mobile applications to complex interactions between physicians in tertiary hospital reference settings ². The reasons for deciding to turn to this practice seem to be linked to a high volume of demand for a specific medical service ³.

Telemedicine as a screening and referral system for patients from primary care (PC) to the hospital level is effective not only in pathologies with a high impact due to their severity, but in others that, due to their high prevalence, represent a significant healthcare burden ^{4 5-6}.

There are few studies on the interrelation of primary care through e-consultation with pain units (PU). In this sense, the Canadian group Champlain BASE (Building Access to Specialists through eConsultation) observed a great interest of primary care physicians (PCP) in teleconsultation as a way of relating to PU specialists, praising its bidirectional nature and highlighting the interest of its use for patients with chronic pain attended in primary care ^{7 8 9-10}; The Canadian system, like ours, is characterized by having public management and being universal for citizens in Canada.

Since 1999, the e-interconsultation solutions of the Galician Health Service (SERGAS) allow communication between professionals in health centers (CS) and professionals in hospital centers, facilitating patient access to specialized care. In 2014 and in the context of the Chronic Pain Care Plan, promoted by SERGAS ¹¹, the first pilot experience applied to PU was launched. For its start, the Organizational Structure of Integrated Management (EOXI) of Vigo (Spain) was chosen, which includes, under the same management, the hospital management of the area, the regional hospitals that exist in it and the primary care. Within this EOXI, the PU of the University Hospital Complex of Vigo (CHUVI, Complexo Hospitalario Universitario de Vigo) and its associated primary care centers were selected as a pilot center ^11,12. In its initial phase, this experience was only available for a small number of healthcare centers, to later be exported to the entire healthcare area and the rest of Galicia.

MATERIAL AND METHODS

A retrospective longitudinal descriptive study was performed.

Scope of study: the Vigo EOXI provides health care to a population of 565,764 inhabitants, of which 20.8 % are over 64 years old and 3.2 % are over 84 years, indicating an aging target population.

Analyzed sample: all teleconsultations sent to the PU from January 1, 2015 to December 31, 2018.

The protocol of all the phases of the teleconsultation is as follows (Figure 1):

Fig. 1. Flow chart of the e-consultation. PCP: primary care physician. 

RESULTS

Teleconsultations conducted during the implementation test phase in 2014 (n = 114) have been excluded from the statistical analysis because the process and platform were adjusted during this period.

A total of 2,218 teleconsultations were requested at the EOXI in Vigo between January 2015 and December 2018 (Figure 2).

Fig. 2. Number of teleconsultations solved in the Vigo EOXI from 2015 to 2018. 

The 42 healthcare centers, which represent the total number of healthcare centers of the EOXI, made teleconsultations to the PU.

A total of 49 % out of the 2,218 teleconsultations received were preferential. Figure 3 shows the distribution of teleconsultations. A decrease over the years was found, reaching a plateau phenomenon in recent years.

Fig. 3. Distribution of teleconsultations according to the degree of priority. 

Regarding resolution capacity, Figure 4 shows the distribution of patients per year and the relationship between patients scheduled or discharged. The data indicate that, in total, 26 % (586) of the patients are discharged electronically and 74 % (1632) were scheduled for a visit to the PU for face-to-face assessment. Distributed by years, the percentages were: 36 % (176) of the e-consultations sent were resolved as discharges in 2015, 20 % (89) in 2016, 26 % (160) in 2017 and 24 % (161) in 2018.

Fig. 4. Discharges in teleconsultation (patient without face-to-face appointment) and patients scheduled for a face-to-face visit to the pain unit (patient with face-to-face appointment). 

The average response times for the period studied were: 21 days for preferential teleconsultations and 22 for ordinary teleconsultations. When analyzed by years, we obtained the following results: average times for ordinary and preferential teleconsultations in 2015 were 24 days and 21 days, respectively; 41 days and 38 days, respectively, in 2016; 17 days and 18 days, respectively, in 2017; and 7 days for ordinary and preferential in 2018 (Table 1).

Table 1. Average response time to teleconsultations in days, (mean ± standard deviation) 

DISCUSSION

Modern telecommunications in health services allow, in environments of high healthcare demand and where waiting lists are accumulated, to perform an agile, decisive and efficient service, sharing a limited number of resources among a large number of users ^13,14.

The explosion of telemedicine in medical practice responds to the decrease in health professionals and the increase in the average age of the population, with the consequent increase in patients with chronic diseases ^15,16. Thus, we found that in the Vigo EOXI 20.8 % of its population is over 64 years old and 3.2 % is over 84 years old. The implementation of Teleconsultation in Pain in Galicia began in Vigo on a pilot basis in 2014 and since its beginning until today the number of teleconsultations has been on the rise and it has become generalized in other medical-surgical specialties.

With this study we aimed to explain the telemedicine work performed for 5 years in the PU and to describe the efficacy of this technique based on the variables described in the material.

The efficacy parameters analyzed to assess this potential usefulness have been:

Since the introduction of teleconsultation in our center, significant advantages from the organizational and healthcare point of view and from the point of view of quality of patient care have been found. An evident improvement in the prioritization of consultations has been achieved, so minimum waiting times have been obtained for preferential patients, such as those with neuropathic or oncological pain. In addition, with this tool we can implement consensual treatments with the PCP and improve pain management until the time of the first visit, and serve as support in the control of patients with chronic pain who have no indication at the current time of an appointment in our pain unit. A fundamental part of all this process is the protocolization of all the phases of the teleconsultation, to achieve a uniform and standardized way of working in all the centers using this service. To maintain this dynamic, it is necessary to periodically perform awareness campaigns to improve the referral system, report changes in the service portfolio and update the protocols.

CONCLUSIONS

The teleconsultation contributes to making the coordination between different healthcare levels known and improved, avoiding unnecessary referrals to face-to-face consultation, improving patient accessibility and decongesting hospital services.

The increase detected in the rate of patients admitted for physical consultation shows the importance of a agreed referral protocol between primary care and our PU, and the periodic awareness campaigns of our healthcare center.

It allows to detect communication deficiencies between PCP and PU and to initiate corrective actions.