Expert Opinion: Hybrid Telehealth Model is the Way Forward in the Post-Covid World

Telemedicine, the provision of healthcare from afar, may provide safe, patient-centered care. In recent years, it has gained significant momentum and popularity, especially in response to the COVID-19 pandemic. Success using telemedicine was reported across diverse groups of patients for a variety of diagnoses, including older adults and gynecology patients.

In urogynecology, virtual care is growing, along with a growing body of evidence in the literature that supports this way of providing care. However, there are still many limitations that need to be overcome before it could be widely adopted in my clinical environment. These limitations include medical, organizational, infrastructural, financial, legal, and ethical issues.

Israel is a multicultural country and the southern region, The Negev, consists of two main populations: Hebrew-speaking Jews and Arabic-speaking Bedouin-Arabs. I work at the Soroka University Medical Center (SUMC), a tertiary teaching hospital, located in Beer Sheva, the central city of southern Israel. It serves as the major referral center for the vast majority of the population in the Negev.

The Bedouins in the Negev are a Muslim minority comprising approximately 10%-15% of the population. This population is experiencing a rapid transition from a semi-nomadic to a sedentary way of life. About 80% of the population live in permanent settlements and the remainder hold a traditional, semi-nomadic lifestyle in small groups of tents or shacks without proper infrastructure, electricity or running water.

Bedouin women are usually very religious, most of them are married, and there is a substantial underuse of health care services (including prenatal care) among this group. Most women are poorly educated and do not have access to employment outside the home. In addition, this underuse of prenatal care may be explained by underlying cultural gaps, distrust of the service providers, geographical distance to healthcare services including available prenatal care services, and patriarchal restriction of female autonomy. Public transportation is limited to the main Bedouin towns, and many semi-nomadic Bedouins live in remote locations with no paved roads, making what is perceived as unnecessary use of health services a burden on the population.

The future should address the existing limitations by enabling hybrid telehealth models. The widespread use of the Internet and smart phones is common among young people who were born into a different technological world. The older generation, including most of the women suffering from urogynecological problems do not utilize even basic technologies freely.

Despite the common assumption that the Internet is a space that allows women to be presented as equals and may provide a window to the outside world, this space is also subject to social and political pressures. The way women use it is subject to the standards set for them by society. A recent survey found that only 39.8% of women feel safe sharing personal information and photos on social media (compared to 56.2% of men), and they censor themselves online.

While we are witnessing an era of transition into a new technological environment, the optimal use of a hybrid model for providing healthcare in general, and specifically gynecological care, seems to be yet unreachable.

These limitations include:

Medical issues – not all medical services can be provided via telemedicine. When physical examination is needed, a physical visit should be scheduled. Telehealth visits could be appropriate for follow up after symptoms, recording treatment outcome and adverse effects, adjustment of medications and patient satisfaction with treatment.

Organizational and financial issues – how should these visits be reimbursed? How to overcome patient literacy and illiteracy? How to overcome technological literacy and illiteracy?

Infrastructural issues – internet access to all areas. Appropriate tools – computers, laptops, iPads, smart phones, etc.

Ethical issues – provision of equitable health care to all groups. Is medico-legal liability different?

We are not yet there. These issues will need to be addressed in the future if we want to adapt a hybrid telehealth method.

The COVID-19 pandemic is challenging health care systems all over the world. Specific circumstances such as avoiding personal contact between health care providers and patients to avoid spreading the virus, have induced the adoption of safe alternatives such as telehealth medicine.

Patients with urogynecologic problems often recognize their symptoms as a bothersome loss of quality of life rather than a “real disease.” As a matter of fact, this group of patients has been particularly subjected to postponement or even cancellation of consultations and surgical therapies during the pandemic. In addition, most older women, considering themselves as a vulnerable group, opted for delaying their consultation until the pandemic had abated.

As in many other fields of medicine, diligent medical history taking is crucial in urogynecologic patients, probably as important as gynecologic exam, ultrasound, urodynamic testing, and other imaging techniques. This is true especially for women with lower urinary tract symptoms (LUTS), overactive bladder syndrome and stress urinary incontinence. Although sometimes a descending anterior vaginal wall can have negative effects on bladder function, often the anatomy of LUTS patients can be normal. Therefore, this specific group might be suitable for telehealth consulting, at least as a first step. In women with pelvic organ prolapse, gynecologic exam might be more important to determine which compartment and level of support is involved to get a clear diagnosis. In addition, ultrasound examination is important in these women to assess post void residual and rule out hydronephrosis.

In settings in which rescheduling patients for follow-up visits is common, telehealth might be a very good alternative. Health care providers and patients can meet online and discuss success or failure of the therapy initiated. This is especially reasonable in women with LUTS, including overactive bladder syndrome or stress urinary incontinence. The success of conservative treatment can be assessed easily in an online appointment, even in a telephone call.

Therefore, telehealth can be a safe alternative to conventional medicine even beyond the pandemic.  Many older patients might appreciate the opportunity to have an online conversation rather than a personal visit to avoid traveling long distances to access care at a hospital.

For women who have had surgery either for pelvic organ prolapse or for urinary incontinence, telehealth appointments can identify complications early and can offer a good opportunity to counsel patients early. Whether or not an in-person consultation is necessary at all can be discussed online.

So why could both patients and health care providers have an interest in teleconsultation in the post-pandemic era? There are a few reasonable answers to this question: First, urogynecology patients are often elderly people who might appreciate less traveling. Second, even in younger patients (e.g., women in the postpartum period) teleconsultation can result in higher acceptance due to reasons of convenience. And third, sometimes comorbidities might restrict the ability to travel. In addition, heath care providers might consider telehealth as a more comfortable and less time-consuming way of taking care of their patients, especially if both know each other already.

In summary, the rapid adoption of telehealth medicine due to the pandemic should be continued and further consolidated even in a post-covid world. However, questions of reimbursement have to be clarified. In addition, protection of data privacy using e-mail or video software needs to be addressed appropriately.

The COVID-19 pandemic had a great impact on Obstetrics and Gynecology health services all around the world including in Indonesia. Since most Urogynecological disorders need elective non-emergency care and only influence the quality of life without any impact on mortality (like in oncology), the number of cases that were referred to our health center during the first year of the pandemic were significantly less.

However, telehealth did not prove to be an ideal solution because all Urogynecology problems could not be managed only by online consultation. Physical examination is often necessary. Also, it is not ethical to send photos of abnormal vulva appearances in Urogynecology patients virtually to Urogynecologists unlike what could be done in regular dermatology practice with respect to other skin lesions.

Hybrid telehealth has been recently developed to answer the problem. Logically, a combination of online and offline interaction between patients and doctors is promising as it can potentially cover all parts of service delivery effectively even post pandemic. However, there were some obstacles that we faced in organizing the method. The availability of online telehealth itself was the issue as we could not ensure equitable distribution of the solution throughout the country. Telehealth is not a simple and cheap technology; it needs good online connectivity which must be built and spread widely to the entire country. This in general could be done efficiently only in our private health sector, which has modern facilities. All our government health services are still struggling with conventional services without any opportunity to develop online telehealth services. Most of our patients who access government health servicecould not use any online telehealth programs. Only a small fraction of our Urogynecology patients who access the private sector could take advantage of hybrid telehealth models.

The other problem related to this issue is that Indonesia is a country formed from thousands of islands which is an inherent obstacle in building the necessary infrastructure needed for good online connectivity between the various islands. Our government has tried various measures, from using satellites to building a network of underground wire lines. However, despite such efforts, only the big cities have good connectivity and several provinces, especially the remote ones, still lag behind.

In conclusion, in countries like Indonesia, hybrid telehealth is not yet an optimal method for providing comprehensive Urogynecology care for a significant proportion of the population.