The prospects of telemedicine in respiratory rehabilitation: interview with Paolo Banfi

Paolo Banfi is head of the Intensive Pneumatological Rehabilitation Unit of the IRCCS “S. Maria Nascente” (Don Carlo Gnocchi Foundation) in Milan. 

Q. Dr Banfi, what telemedicine projects were you carrying out before the COVID-19 outbreak?

PB. Before the COVID-19 outbreak, we were carrying out a telemedicine project called SIDERA^B which received, among other things, funding from the Lombardy Region. The SIDERA^B research project was born to create and validate a platform for the continuity of care at home supported by innovative technologies and addressed to patients with chronic diseases of particular relevance for the National Health Service (SSN) and Regional Health Service (SSR), such as chronic obstructive pulmonary disease (COPD), Parkinson’s disease and chronic heart failure (CHF).

The primary objective of the research project is the construction of a platform where several integrated devices (i.e., advanced telemonitoring systems, non-wearable sensors, tools for video-calling with clinicians) will manage patient care, monitoring and engagement in a personalised way. In this project, the sleep and motor activity (i.e. in COPD, the re-adaptation to the effort through exercise bikes and other exercises in the lower and upper limbs) of patients suffering from chronic pathology will be monitored, the motivational support at home of the patient and also of the caregiver will be guaranteed, in the logic of “taking care”. The project has been going on for a couple of years, and in June 2020, we will start to analyse the results. The primary outcome is the 6 Minute Walk Test (6MWT) – which in respiratory rehabilitation is a coarse outcome, in my opinion. However, still today, it is considered as the most used in respiratory rehabilitation. The number of visits required outside the routine check-ups, the number of visits to the emergency room and admissions during the study period represent the secondary outcomes.

Q. How do we preserve empathy and the humanisation of care in telemedicine?

PB. I believe – but this is my personal observation – that, depending on how the previous relationship with the patient has been set up, this can be perpetuated in telemedicine as well. One of the possibilities of telemedicine is that patients see on the other side the doctor or physiotherapist who takes care of them for a specific time, just to maintain that relationship of humanised medicine which is extremely important, just as it is crucial to see, to make a face correspond to a voice, to know that that face is of “my” doctor, of “my” physiotherapist, to see that they will follow me and that I will be able to have a feedback from them.

To give an example, we also follow patients with Amyotrophic Lateral Sclerosis (ALS), a disease characterised by the fact that patients often experience a sense of abandonment and loneliness. During this period it was impossible to assess them in the outpatient clinic for all the problems related to the COVID-19 outbreak, so we established an audio and video contact via WhatsApp or other platforms, and I must say that we got – I could make or accept calls from patients – positive feedback from them: they needed answers about the evolution of their disease or specific treatments for specific problems that arose. In this way, they felt more reassured because their caregiver was on the other side.

Q. Can you give us a concrete case of how a telemedicine visit is conducted? Could you provide some practical advice on the subject?

PB. I bring a weighty concrete example of an ALS patient in terminal palliation. Now, after the diagnosis of ALS, everything shared with the patient is palliation, but there is then a period of terminal palliation. In this case, the patient had to decide whether to do a tracheotomy or follow an accompanying path. Clearly, it is a path that we usually do de visu, i.e. we talk to the patient and share the pathway he has chosen, without trying to interfere in his choice.

In this case, it was impossible to meet at the hospital or at home, so we opened an audio-video channel and talked with him and his family. We gave each other schedules, and every night we systematically spoke about this and other problems related to the therapy. He asked a lot of questions, also through his family, who in turn asked a lot of questions. In the end, the patient chose freely to not do the tracheotomy. He decided it without hesitation. Without being influenced by anyone. The burden of the pathology was too excessive. A crucial thing was also the acceptance by the family of that choice: wife and daughter experienced, from an emotional point of view, a significant impact in this sense, because the choice of the husband/father was strong. We followed this case by talking to everyone: the evening meeting was everyone’s, everyone accepted the path, and we began the journey with a palliative therapist who guided us through the pharmacological pathway always shared.

The only thing the patient asked us was not to feel respiratory ambivalence or pain. We started a path that lasted a couple of weeks, and in the end, the patient died peacefully. I also saw the daughter, who was distressed at first, become serene. And above all, his wife became more peaceful, seeing that we were always in contact, that whenever she needed us, she could count on us (in audio-video presence).

This is extremely important and – in my opinion – is also another way of doing telemedicine: beyond the evaluation of parameters or therapeutic corrections, there was a lot of empathy on both sides.

Q. What future prospects do you see in telemedicine after the COVID-19 emergency?

PB. I think that the COVID-19 outbreak has given us great opportunities to reset medicine. I agree with Dr Marini’s article published in Sole 24 Ore Sanità, where she explains that in this emergency territorial medicine has been lacking, especially in the Lombardy Region. This emergency gives us an excellent opportunity to restructure General Medicine, where it will also be possible for the doctor to come into empathic contact with the patient without the need for a mere visit. We will have to think a lot about this because I don’t know how many general practitioners will be willing to make such a choice, but I know many who will undoubtedly consider it. This is an alternative way of doing local medicine and staying in touch with the patient at all times, and in my opinion, this is a future perspective. In fact, we will also have to reconsider ADI (Assistenza Domiciliare Integrata, Integrated Home Care), not as a passive executor of care managed by a tired and under-resourced general practitioner, but add the possibility of managing patients even with pathologies that deserve home monitoring.

Rehabilitation in telemedicine represents another perspective: there are fragile patients, for example, those suffering from COPD, who for different reasons cannot provide outpatient rehabilitation care, why not carry it out at home? In Lombardy telemedicine is not included in the DRG system: maybe after the SIDERA^B project we could start a reflection in this sense, it would be crucial.

The possibility to carry out respiratory rehabilitation inside a room, through a tablet or a smartphone to control the patient also practising educational interventions of therapy management, to reinforce the assumption of therapy to improve adherence is now a practice that should be consolidated.

Q. There are now many publications on telemedicine as a tool for managing people as if the clinic had moved into the home context. What do you think, and what absolutely must be preserved in such a visit?

PB. As for the examination, I have strong doubts that telemedicine can be carried out in this sense. In my opinion, the initial assessment is challenging to make in telemedicine, if not impossible. But I believe that the follow-up, subsequent actions and rehabilitation can be carried out in a home environment.

There are many scenarios. I am thinking of a significant example, the patient who works and needs respiratory rehabilitation: why lose hours of work, if we can offer him/her a telerehabilitation in the workplace? Especially in chronic structural pathologies, many patients have the problem of losing hours of work. I think that in this way, we would be able to solve the problem and the company itself would have to be involved through the occupational doctor, it would have all the convenience.

Q. How can elderly persons be literate in the use of telemedicine?

PB. The underlying problem is that we have to sensitise general practitioners, who are the ones who keep the ranks of all this also through the ADI: educating them means to make them understand that there is an alternative way of doing medicine, which is not that of visiting or filling the prescription and that is enough, but that is to take care of the patient. It is unthinkable that the opening hours of a general practitioner’s office should be 3-4 hours a day. Still, we must arrive at a study time such that all clinical-assistance activities are guaranteed. At this point, we must, in my opinion, start a new path, in which tablets must be considered, and the general practitioner must instruct his most fragile patients (who are not necessarily elderly) in their use. Clearly, it must be a simple technology, but it could open a new channel and could be the subject of new startups.

As I said, I agree with Dr Marini’s article: in Lombardy, local medicine has been completely aborted. After the Balduzzi law, more could be done. A hospital-centric medicine was preferred, but this did not produce the results they had set themselves, also because clearly the accredited private hospitals chose the best options (heart surgery, neurosurgery, orthopaedics) and developed them so that hypertrophic gains were obtained from carefully selected and exploited DRGs. The public system has been reduced staffing levels, closed resuscitation beds and, above all, the ratio of beds/citizens has been reduced. When there was a real need for treatment in an epidemic/pandemic context, it was impossible to guarantee it. The final message is that territorial medicine is critical, has its own raison d’être and is vital for the NHS/SSR, and COVID-19 has amply demonstrated this.

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