Telemedicine has been strongly advocated as a useful tool to relieve pressure on the overwhelmed Health Systems during the COVID–19 pandemic. The urge to implement e-health systems in this critical phase can turn into an opportunity to reduce structural barriers, especially in disadvantaged areas. The Sardinia island, with its 1,6 million of citizens spread on a 24,100 km2, is the second Mediterranean island and the third Italian Region for extension and ranks third last in terms of regional population density.
In this context, we felt that a rapid implementation of a telemedicine service would represent a valid answer to the service disruption that the COVID–19 pandemic has imposed to our Bariatric Surgery Center activity. Nevertheless, preliminary results of this approach showed that patients could find difficult to adapt to such a system.
Telemedicine offers clear opportunities to abolish barriers of distance and to save time and direct costs. Also, in the field of bariatric surgery there is a growing interest in the application of e-health systems in the pre- and post-operative period. In the context of the COVID–19 pandemic, facilitating healthcare access maintaining the strict individual protection provisions became a priority to ensure safety for patients and healthcare professionals, and to allow the continuation of specialist medical services.
However, e-health technologies are not yet widely adopted and many centers had to implement telemedicine services without the appropriate technical knowledge and without the time to train their own staff and to properly educate the users.
The results of the initial phase of telemedicine in our Bariatric Surgery Center reflect these difficulties. Several patients didn’t consider video-counseling a useful opportunity and preferred to wait until the end of the mobility restrictions to attend in person to the clinic. Unfortunately, it is not possible at present to predict when this is possible and is likely that the use of digital technologies will be a necessity, more than a choice, for a long period.
Moreover, Italian National Health Service don’t recognize telemedicine as an essential level of care and there is a lack of a regulatory framework that may allow integration of e-health platforms into existing electronic medical record system.
Free video-communication solutions (for example, WhatsApp, Skype, or Facetime) raise questions about privacy and security requirements.
Technological improvements and cost reduction of video communication solutions combined with both the high-speed internet and mass spread of smartphones make possible to offer e-health services to a large audience but high-speed Internet is not equally available to everybody (digital divide).
The annual report on Internet availability drafted by the Italian National Institute of Statistics (ISTAT) showed that in 2019, 76.1% of households had Internet access and 74.7% had a broadband connection, but only 67,9% used the Internet in the past 3 months prior to the interview. Moreover, only 29.1% of the internet users between the ages of 16 to 74 years have high digital skills. Most Internet users, on the other hand, have low (41.6%) or basic (25.8%) digital skills. Furthermore, there is a minority of Internet users (3.4%) who have no digital skills which equals, however, to a large number of people (1,135 million). Most households without home Internet access indicate the lack of computer skills as the main reason (56.4%) and 25.5% do not consider the Internet a useful and interesting tool; economic reasons follow. Another discriminating factor is the educational qualification; 94.1% of families with at least one graduate component has a broadband connection against 46.1% of those families whose members had attended only high school. Disparities are also evident between municipalities of different demographic amplitudes: in metropolitan areas, broadband access rates reach 78.1% while in municipalities up to 2,000 inhabitants this share drops to 68.0%.
Data from Sardinia (only available until the year 2018), do not differ significantly to the national ones.
This initial experience, although anecdotic, suggests that the absence of basic computer skills and the lack of confidence with video call systems may be important patient-specific barriers for the implementation of telemedicine between the most vulnerable social groups of the Italian population.
Although it is not statistically significant, in consideration of the small sample size, we found a greater presence of residents in urban areas in the group of participants, compared to the group of non-participants (57.9% vs 42.8% respectively).
Regarding structural barriers, it must be noted the lack of an electronic system able to integrate telemedicine software with hospital medical records which may resolve privacy and security issues and of a dedicated Internet portal where patients may obtain operative instructions. In fact, our satisfaction survey reported lowest result at the questions regarding clarity and usefulness of the instructions received (Table 3).
Messiah et al in a recent review of eHealth strategies for metabolic and bariatric surgery patients, analyzed 38 published articles between 2011 and 2019 that varied widely in terms of study design and presented several limitations. Despite this, the authors reported overall positive results in terms of feasibility, acceptability and preliminary efficacy of eHealth delivery of pre- and post-operative educational materials, knowledge exchange and social support.
In accordance with our preliminary experience, the Authors concluded stating the importance to take into account key constructs from the socioecological framework including not only intra/interpersonal and developmental factors, but also those of the system or setting that provides the eHealth strategy. In this setting, the relationship between care providers and rural areas is crucial because is right there that patients are more exposed to social, geographical and economical burdens and that they are less inclined to access to e-health services, as we observed in our preliminary experience.
Patient education is time- and resource-consuming and yet a critical key to implement telemedicine and one must consider that there is an initial investment of time and effort to effectively present the option of a telemedicine consultation and then train the patient to the use of the necessary software for the first time, as it is extensively elucidated by Smith et al in their interesting recent paper published on this Journal. The authors, suggesting an Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program during the COVID–19 Pandemic,highlight 8 necessary elements: among these, an electronic medical record system infrastructure, adequate and flexible audiovisual platforms, patient education, patient and caregiver participation are the same issues we faced up in our preliminary experience.