ENDO2020 Insights: COVID-19 is Helping Telemedicine Grow

Telemedicine is here to stay

With Gary Hammer, MD, PhD, Martin Reinke PhD, Ravinder J. Singh PhD, Alberto M. Pereira MD, PhD, and Sophie Leboulleux MD

Medical professionals are using digital methods to meet with colleagues as well as patients.

The ENDO2020 session, Telemedicine in the Age of COVID-19, was moderated by Endocrine Society President Gary Hammer MD, PhD and Martin Reinke PhD, the incoming president of the European Society of Endocrinology. Introducing the sessions, Dr. Reinke said,

“We are all affected by the pandemic, and as endocrinologists, we have to deal with situations with patients who have special needs or are at special risk for the virus. Therefore we thought that having a symposium on telemedicine would be the right place to discuss problems around endocrinology in the current pandemic. The virus is the same, the problems in every healthcare system are different, and it is important to cover a broad spectrum of speakers from different areas.”

Point of Care Testing is still growing

Ravinder J. Singh, PhD, DABCC, Co-Director of the Endocrinology Laboratory and professor of Laboratory Medicine and Pathology at Mayo Clinic, Rochester, MN, presented on the current state of affairs in lab testing with an emphasis on point of care testing (POCT).

The benefit of POCT is that, ideally, that it can be done in outpatient clinics, patient rooms, ambulances, pharmacies, and places of work, schools, and homes. POCT can reduce the need for access to large centralized testing facilities for some types of testing. Cortisol, glucose, A1C, cholesterol, pregnancy/ovulation, HIV, and drugs-of-abuse are the most common types of home testing. POCT is turning into a multimillion dollar industry.

As it has been practiced in the past, lab testing started with the primary care physician ordering the test and ended with result interpretation and presentation to the patient. In between though, were multiple steps that prolong the lab testing process, including collection, transportation, preparation, processing, analysis, review, and finally reporting.

POCT can streamline many of these intermediary steps, by allowing testing to occur virtually anywhere by anyone, as in the case with glucose monitoring or cortisol testing.

Using cortisol saliva testing as an example, Dr. Singh points out some of the pros and cons of POCT when samples can be collected practically anywhere. Saliva is a cheap, easily obtained, non-invasive sample which can be taken across multiple time points. It is ideal for 3rd world and challenging environments, and poses minimal risk to healthcare workers.

Unfortunately there is little standardization for collecting saliva in a POCT situation. Patients often fail to treat sample collection as a biohazard, using ungloved hands to touch sampling devices and materials. In the case of salivary cortisol testing, cortisol-loaded creams and ointments used by many patients can transfer from the ungloved hand to the sampling device, unknowingly invalidating the sample.

More importantly though, Dr. Singh points out, is our limited knowledge about the dynamics of transportation of biomolecules across blood capillaries and salivary glands.

Many POCT samples, saliva and blood spots, have substantially lower hormone concentrations compared to blood levels. Many smaller POCT devices lack the power to reliably detect these small concentrations.

Furthermore, testing standards for cortisol, glucose, A1C, cholesterol, etc. have been validated using blood samples measured in large scale medical testing facilities. To translate those standards to saliva, blood spots, or microsamples can be a challenge. As an example, Dr. Singh discussed the now-defunct Theranos medical testing device which was plagued by inter- and intra-sample variability, as well as non-equivalent results compared to standard testing.

Dr. Singh finished by saying, “It’s good to be back to the patient and physician discretion on lab testing. That does not mean the approach to take testing back to the lab is not continuing though.”

The European reference networks (ERN): standardized care and increased healthcare equality

ERN is a group of virtual healthcare networks bringing specialized health centers and disease experts across different European Union (EU) countries into a collaborative effort to provide meaningful standardized healthcare regardless of country. It was made possible by the EU Article 12 directive regarding patients’ rights in cross-border healthcare.

The benefit of ERN is that the virtual networks link centers of expertise and specialists in different regions to other healthcare systems that may have insufficient expertise, sharing their knowledge and collaborating to the benefit of the patient, which is especially beneficial in those with rare or ultra-rare endocrine disorders.

Details on the ERN network related to endocrine disorders, Endo-ERN, were provided by Alberto M. Pereira MD, PhD, professor of Medicine and head of the Division of Endocrinology at the Leiden University Medical Center, the Netherlands. Endo-ERN is the largest ERN network with more than 25 EU member states. Endo-ERN provides expert multidisciplinary care from birth to senesce and covers eight thematic groups:

  • Adrenal
  • Disorders of calcium and phosphate homeostasis
  • Genetic disorders of glucose and insulin homeostasis
  • Genetic endocrine tumor syndromes
  • Growth and genetic obesity syndromes
  • Pituitary
  • Sex development and maturation
  • Thyroid

This virtual network has the ability to quickly respond to unmet or time-sensitive needs, as in the recent pandemic. Dr. Pereira said that in response to COVID-19, Endo-ERN put together a webinar for the European Commission hosting a panel of international endocrine experts covering the risk of COVID-19 to those with endocrine disorders.

EU directives have made cross-country healthcare access possible, and ERN has simply enhanced the benefits. However, there are still challenges to overcome. A system for adequate reimbursement needs to be approved by all EU countries.

Endo-ERN also suggests a “CPMS first” policy where, for any rare or complex disease, patients are initially seen by a specialist through a virtual consultation using the clinical patient management system (CPMS). This saves resources and reduces costs.

Dr. Pereira reported that 80% of rare disease patients could have been seen by an initial virtual consultation using the Endo-ERN network and did not need to be seen in person. This would lessen the burden of endocrine patients if they did not need to travel to have in-person consultation by an expert in another country or region.

National Tumor Boards in France could not be stopped by COVID-19 lock-down

Sophie Leboulleux MD, head of the Thyroid Cancer Multidisciplinary Team in the department of Nuclear Medicine and Endocrine Oncology, Institut Gustave Roussy, France spoke about the benefits and challenges of France’s national and regional tumor boards that were brought to light during the COVID-19 quarantine.

The goal of tumor boards is to provide care locally and with the same quality to all patients in in France. There are two national expert rare tumor networks and 24 regional centers, including island constituents in Polynesia and West Indies. Briefly, each board is comprised of a multidisciplinary group of experts from different specialties including endocrinology, nuclear medicine, pathology, radiology, oncology, radiation oncology, and surgery.

The National Refractory Thyroid Cancer Tumor Board (TUTHYREF) is a national virtual meeting which has been occurring every two weeks since 2008. They use a simple Adobe software system to screen share the presentations.

Dr. Leboulleux says, “The plus of this approach is that it is simple. It’s for everybody. We’ve never had any problems from any firewall from any hospital.” However, she also points out that the simplicity of this particular software system limits the depth and breadth at which CT images can be viewed. Another challenge is time. Participation from overseas tumor boards, ie. Martinique and French Polynesia, in different time zones make can meetings difficult to attend at the scheduled time.

Since France implemented a COVID-19 lock-down on March 18, TUTHYREF was able to continue meeting with little to no loss in participation or in patient case presentation through May 11, when restrictions were lessened. The continuity of national tumor board meetings was attributed to the fact that they had already been meeting virtually prior to COVID-19, and the software and hardware needed to do so was simple and already in place.

In contrast, regional board participation dropped since most meetings occurred in-person at the regional institution. The transition to virtual meetings was hindered because home laptops did not have the institutional IT approved software to access patient records and bandwidth on local servers fluctuated as others in the home also used the internet.

Based on the recent pandemic, Dr. Leboulleux gave the following insights:

  • Physicians easily adapted to the new way of participating in virtual tumor boards and many were enthusiastic about continuing virtual meetings at least part time.
  • Regional, national, and even international tumor boards are time saving, cost efficient, and have a beneficial carbon footprint.
  • Local tumor boards are possible, though it can be more difficult as local participants who are used to in-person team collaborations and brainstorming learn the dynamics of “one person talking at a time.”
  • Institutions also need to allow healthcare providers access to medical software programs from outside the institution (ie. home). To do this, IT departments need to be involved so that patient medical anonymity can be safe-guarded.
  • All virtual tumor boards suffer from “multitasking,” as at some point in the meeting participants begin to check emails and answer phones.

Conclusion

Telemedicine in the time of COVID-19 seems to have validated the use of those systems already using virtual technology to collaborate between medical specialties, such as Endo-ERN and TUTHYREF. It has also highlighted areas that need additional attention.

Regional boards will need to come up to speed on virtual interactions. POCT, as indicated by Dr. Singh, needs additional testing and validating before we can circumvent the large scale medical testing facilities, even for routine tests. 

Drs. Bjugstad, Pereira, Singh, and Reincke report no conflicts with regard to discussing these studies. Dr. Leboulleux has association with Bayer Inc. and Lilly. Dr. Hammer is the founder of Millendo Therapeutics and Vasaragen.

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