The current need to redistribute economic, infrastructural, and medical resources to the assistance of patients with SARS-CoV-2 is changing the common practice of several medical specialties, like urology, which is not involved in the management of respiratory diseases. Outpatient and elective surgical activities have been postponed to save facilities and resources. On the other hand, health systems in which staff had to be quarantined at home because of unprotected exposure to COVID-19 patients, have experienced an important decline in their in-site capabilities, which means having totally asymptomatic health care workers at their homes.
For these reasons, most hospitals and healthcare providers in critically affected areas are changing their on-site activity to telehealth medicine and trying to reserve hospital visits to the minimum necessary.1,2 In this context, telemedicine, particularly video consultations has been promoted and scaled up to reduce the risk of transmission.
Telehealth medicine allows healthcare workers to provide assistance to patients utilizing electronic communication tools and has shown to be helpful in previous outbreaks, including former coronavirus outbreaks such as SARS-CoV (severe acute respiratory syndrome-associated coronavirus) and MERS-CoV (Middle East respiratory syndrome coronavirus), or PHEICs related to Ebola and Zika viruses.3
The aim of telehealth is to decrease the burden of care, as well as unnecessary travel for medical consultations or relative urgencies, to limit the number of individuals grouping in waiting rooms, to screen or detect suspected patients, and to continue the follow-up of mild confirmed cases from home.4–6
Equipment and resources for telehealth medicine:
Telehealth medicine is not new for urology. It has been used and described in the literature as a good resource with special benefits for underserved and isolated populations and in cases of workforce shortage.7–9
Each health system is responsible for providing its staff with adequate electronic medical record (EMR) software for managing consultation agendas, writing notes, accessing test results such as laboratory and images, and being able to generate new orders. Modern telehealth modalities include electronic messaging within patient portals, video calls, and telephone calls.10
The ideal place in which a telehealth consult should be conducted is a closed, private location, such as an in-office or even at home. Hospital administrators should provide remote access to VPN (virtual private networks) for allowing physicians to work from home and avoid mobilization as much as possible.
A successful telehealth practice must include an entire team of secretaries, nurses, technicians, and urologists. Moreover, communication with other specialists is crucial for the correct management of complex patients, as in the case of multidisciplinary committees. We must keep in mind at all times, no matter our relationship with other specialists, that the best way for maintaining the privacy of patient’s information is to use institutional email accounts and avoid instant messaging apps or regular email. Online conference applications and platforms which allow maintaining multidisciplinary committees should be considered.
The most interactive, and possibly the most familiar way to do teleconsulting is a video call. It allows for better contact and improves the patient-physician relationship. It could even provide a limited physical examination done by the patient with the physician’s guidance. Limitations for video calls include training clinicians and patients to use software, providing physicians with video equipment at their homes, and the need for a fast internet connection that allows for a good quality video image. Unfortunately, some video visits have had to be switched to more user-friendly but non-regulated for telemedicine platforms such as FaceTime, Hangouts, Zoom, or Skype.10 We cannot recommend the use of these platforms, which are not compliant with privacy regulations, although due to the huge size of coverage needed, institutions like the U.S. Department of Health & Human Services have recently declared that will not enforce compliance rules.10,11 Some platforms that incorporate EMR have developed capabilities to deliver virtual clinics, such as EPIC® (EPIC, Verona, USA), used successfully in the United States, or NHS Attend Anywhere ® in the United Kingdom.2
Some platforms that meet the strict HIPAA (Health Insurance Portability & Accountability Act) compliance specifications in the United States are embedded within the EMR software of the health center including Zoom for Healthcare, Skype for Business, Doxy.me, Updox, VSee, Microsoft Teams, Google G Suite, and Hangouts Meet. All these mentioned platforms include a facile audio and visual component and can be used in any device with a microphone and a camera, such as desktop computers, laptop computers, tablets, or smartphones. They can even allow for multiple guest participation, which is extremely useful in cases we need the involvement of family members, another health provider or even language interpreters.12 A summary of the most important information and platforms is provided in Table 1.
Although video calls from a secure platform with all the capabilities we have mentioned seem to be the best possible way to do telemedicine, the reality is that not all patients will have the required devices or capabilities for a video call. In such cases, we have to change to the more traditional telephone call.
The hospital or healthcare system should provide patients with all resources needed to schedule their visits, these including websites, telephone calls, mobile applications, and electronic messages within patient portals. Previous calls from the administrative or nursing team, text messages, emails, or application alerts should be provided to remember patients of the schedule’s appointment.
Considerations for telehealth consults:
Probably the most important thing during this scenario is to detect patients with COVID-19 symptoms which need to be diagnosed and later admitted to the hospital or kept at home in quarantine maintaining special precautions within their household. Then, we believe that the cornerstone of a urology telehealth consult is a good triage. We should be able to classify patients into groups according to their priority. This will help us to define which patients are in urgent need of attention and should come to the emergency department immediately for a prompt physical examination, laboratory tests, and imaging. Simonato et al. provide excellent algorithms and recommendations for the management of the main urological emergency conditions during the COVID-19 era in the emergency department: 1) upper urinary tract obstruction (with or without sepsis), 2) acute or chronic urinary retention, 3) gross hematuria and 4) genitourinary trauma and acute scrotum.13
Gadzinski et al. recommend conducting a mock visit before conducting a real video call with a patient, so providers can familiarize with the various capabilities of the software, such as initiating a visit, terminating a visit, managing audio and video functions, and the possibility of screen sharing to show radiologic findings or even relevant diagrams.12
Notes on patients’ EMR, when a teleconsult is made, should be carefully documented in compliance with privacy and data protection regulations. A note should include all information possible. A good recommendation is to begin the note with a title such as: “Teleconsult due to COVID-19 outbreak with the consent of the patient”. Reports, as well as the results of complementary tests, should be sent to the patient via regular mail or encrypted email.
During this exceptional situation, we should limit orders for complementary diagnostic exams as much as possible, and act rationally, to avoid unnecessary mobilization of patients. Consider that many outpatient diagnostic centers (laboratory and radiologic) can be closed due to the situation.,
In order to facilitate follow-up teleconsults, before discharge, patients should be fully informed and trained for complete autonomous care of indwelling catheters, such as nephrostomy tubes, suprapubic catheters, and transurethral catheters. Photographic and/or video tutorials could be useful for easy home care of urinary stomas for patients and relatives.13 Nursing staff should be available for improvised teleconsults regarding issues with catheters and/or stomas. Due to the current scenario, it may be understandable that follow-up visits in which not crucial decision will be taken (e.g. non-oncologic) can be postponed.
Working from home can be challenging, as physicians are not used to it and many distractions can come up while doing teleconsultation. It is encouraged to maintain self-discipline, avoid distracting factors as much as possible, make lists of activities and schedules, and work in an area with a good internet connection and having available video call hardware. Keeping enthusiasm with the rest of the team members, as well as maintaining healthy routines, habits and correct nutrition helps with productivity.14
Billing for telehealth medicine is a conflictive issue in systems that are not used to this format. Every health provider should discuss this issue with the administrative responsible for avoiding further issues.
Telehealth for education in urology:
The current COVID-19 pandemic is affecting graduate and postgraduate education in a tremendous way, with disruption of rotations, delay of residency examinations, suspension of elective surgeries, clinical rounds, and academic activity.15
As an effect, this COVID-19 pandemic is uneven through countries and individual regions and each hospital is responding in an own individual way to cope with its affected population. Although urology departments must keep a resident and a consultant on call for emergencies, it is no clear whether they would be at home or physically in the hospital.16 Many residents may face uncertainty regarding the location and aim of their daily activities, thus generating an even more stressful environment.17 Some residents and/or consultants indeed will be directed to alternative activities and/or locations to cope with the needs of the system due to the pandemic, meaning in most cases suspension of residency examinations.
Despite international events such as the European Association of Urology (EAU) and the American Urological Association (AUA) annual meetings have been physically canceled and have converted to virtual, these associations are maintaining efforts to keep their members updated and share recommendations via webinars, publications and, email alerts.
The current situation of isolation is giving us unique opportunities to dedicate time to academic topics, personal growth and wellness, and to explore new ways of virtual learning or “smart learning” thanks to web-based technologies.18,19
Webinars are gaining a lot of popularity within urology departments and associations, which have already proved useful for learning.20 Some webinars are being open to the general public and announced on social media. For this purpose, we recommend the platform LogMeIn (https://logmeininc.com) which offers the possibility of organizing webinars and virtual congresses. Other alternatives, with a broad range of capabilities (depending on the user limit, and time allowance) are Zoom, Skype, Facebook, Instagram, or YouTube, in which attendants can participate actively and ask questions. Social media channels such as Twitter, Facebook, Instagram, are releasing lots of useful information regarding published papers and experiences from physicians all over the world. In our experience, we have established a successful online education program to continue with our academic goals. We have interactive lectures given by consultants in their field of expertise once to twice per week using the platform Zoom.
Podcasts and pre-recorded videos of lectures and surgical procedures offer an enormous library and have the benefit of being available on-demand, so residents and consultants can organize their time better.
The European Association of Urology recommendations:
The recommendations given by Rodríguez-Socarrás M et al4 can be summarized in the following:
- Keep up to date on strategies and tools that allow communication with patients and with other team members.
- During teleconsultation, to have a quiet and private environment.
- Offer advice to perform a guided physical examination if possible.
- Hospital phones should be used for phone calls.
- Triage patients properly.
- Comply with the privacy and billing regulations in your country and region.
- Keep yourself updated academically.
- Try to generate and share quality content for the population and patients.
These tools and recommendations are useful during this outbreak and probably are here to stay since everything seems to suggest that face-to-face consultation is going to be partially restricted for an indeterminate period of time. It is our duty to enhance telemedicine programs for the benefit of our patients.
Conclusions: What have we learned about the implementation of telehealth medicine?
The COVID-19 pandemic poses a great challenge to specialties like urology, which has to continue working and adapt their services to remote assistance. The key is establishing a good triage, so we can identify patients who need to come urgently to the hospital or can continue with teleconsulting.
While telemedicine has been around for several years, the current situation will serve for establishing more advanced criteria of efficiency in managing certain pathologies and follow-ups entirely by a telehealth method.
We must prioritize the safety of both patients and staff and try to use as much telehealth medicine as we can during these difficult times.
Guidelines of telehealth medicine in urology are lacking, so we must adhere to current available general guidelines issued by our authorities.
Public and private healthcare systems need to regulate all the details for the correct practice of telehealth, as well as billing and coding.
Hospitals need efficient and modern EMR software that allows an easy telecommunication circuit between the secretaries, the physicians, nurses, laboratory, radiology departments, and patients.
Virtual telehealth medicine practice is evolving by the day, better services are being developed, as well as physicians are growing experience in managing complicated situations by phone or video call.
In our experience, patients understand this situation and are grateful to receive a teleconsult by telephone.
We believe after this pandemic is over, urologists and patients will value more the telehealth medicine services for assistance.
Table 1: Summary of important information regarding telehealth medicine and telehealth education.
Table 2: Recommendation on the management of the most prevalent visits to the ourology outpatient clinic.
*BC: Bladder cancer; BCG: Bacillus Calmette-Guérin; TURBT: transurethral resection of bladder tumor; RC: radical cystectomy; RIRS: retrograde intra renal surgery; PCNL: percutaneous nephrolithotomy; BPH: benign prostatic hyperplasia
Written by: Juan Gómez Rivas,1 Irene de la Parra,1 Diego M Carrión2
- Department of Urology, Hospital Clinico San Carlos. Madrid, Spain.
- Department of Urology, La Paz University Hospital, Madrid, Spain.
- Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol 2020. https://doi.org/10.23736/S0393-2249.20.03846-1.
- Connor MJ, Winkler M, Miah S. COVID-19 Pandemic - Is Virtual Urology Clinic the answer to keeping the cancer pathway moving? BJU Int 2020. https://doi.org/10.1111/bju.15061.
- Ohannessian R, Duong TA, Odone A. Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action. JMIR Public Heal Surveill 2020;6:e18810. https://doi.org/10.2196/18810.
- Rodriguez Socarrás M, Loeb S, Teoh JYC, Ribal MJ, Bloemberg J, Catto J, et al. Telemedicine and Smart Working: Recommendations of the European Association of Urology. Eur Urol 2020. https://doi.org/10.1016/j.eururo.2020.06.031.
- Carrión DM, Gómez Rivas J, Rodríguez-Socarrás ME, Mantica G, Esperto F, Álvarez-Maestro M, et al. Implementación de la teleconsulta en la práctica urológica durante la era Covid-19: ¿qué hemos aprendido? Arch Esp Urol 2020;73:345–52.
- Gómez Rivas J, Rodríguez-Serrano A, Loeb S, Yuen-Chun Teoh J, Ribal MJ, Bloemberg J, et al. Telemedicine and smart working: Spanish adaptation of the European Association of Urology recommendations. Actas Urol Esp 2020;44:644–52. https://doi.org/10.1016/j.acuro.2020.08.010.
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- Miller A, Rhee E, Gettman M, Spitz A. The Current State of Telemedicine in Urology. Med Clin North Am 2018;102:387–98. https://doi.org/10.1016/j.mcna.2017.10.014.
- Ellimoottil C, Skolarus T, Gettman M, Boxer R, Kutikov A, Lee BR, et al. Telemedicine in Urology: State of the Art. Urology 2016;94:10–6. https://doi.org/10.1016/j.urology.2016.02.061.
- Mehrotra A, Ray K, Brockmeyer DM, Barnett ML, Bender JA. Rapidly Converting to “Virtual Practices”: Outpatient Care in the Era of Covid-19. NEJM Catal 2020;1. https://doi.org/10.1056/CAT.20.0091.
- HHS Press Release. OCR Announces Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency | HHS.gov n.d.
- Gadzinski AJ, Ellimoottil C, Odisho AY, Watts KL, Gore JL. Implementing Telemedicine in Response to the 2020 COVID-19 Pandemic. J Urol 2020:101097JU0000000000001033. https://doi.org/10.1097/JU.0000000000001033.
- Simonato A, Giannarini G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Pathways for urology patients during the COVID-19 pandemic. Minerva Urol Nefrol 2020. https://doi.org/10.23736/S0393-2249.20.03861-8.
- Dubin JM, Wyant WA, Balaji NC, Ong WLK, Kettache RH, Haffaf M, et al. Telemedicine Usage among Urologists during the COVID-19 Pandemic: Cross-Sectional Study. J Med Internet Res 2020;22. https://doi.org/10.2196/21875.
- Pang KH, Carrion DM, Rivas JG, Mantica G, Mattigk A, Pradere B, et al. The Impact of COVID-19 on European Health Care and Urology Trainees. Eur Urol 2020;78. https://doi.org/10.1016/j.eururo.2020.04.042.
- Carrion DM, Gómez Rivas J, Esperto F, Patruno G, Vasquez JL. Current status of urological training in Europe. Arch Esp Urol 2018;71:11–7.
- Marchalik D, C Goldman C, F L Carvalho F, Talso M, H Lynch J, Esperto F, et al. Resident burnout in USA and European urology residents: an international concern. BJU Int 2019;124:349–56. https://doi.org/10.1111/bju.14774.
- Porpiglia F, Checcucci E, Amparore D, Verri P, Campi R, Claps F, et al. Slowdown of urology residents’ learning curve during COVID-19 emergency. BJU Int 2020. https://doi.org/10.1111/bju.15076.
- Campi R, Amparore D, Checcucci E, Claps F, Teoh JYC, Serni S, et al. Exploring the Residents’ Perspective on Smart learning Modalities and Contents for Virtual Urology Education: Lesson Learned During the COVID-19 Pandemic. Actas Urol Esp 2021;45:39–48. https://doi.org/10.1016/j.acuro.2020.08.008.
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