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ISICO Telemedicine described in a recently published article

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ISICO’s use of the telemedicine approach during the COVID-19 emergency and the data collected in relation to that experience are the focus of a new article by our team, Feasibility and acceptability of telemedicine to substitute outpatient rehabilitation services in the COVID-19 emergency in Italy: an observational everyday clinical-life study, which has just been published in Archives of Physical Medicine and Rehabilitation.

“This is a hugely important publication,” remarks Prof. Stefano Negrini, scientific director of ISICO, “as it testifies to the work done by ISICO right at the beginning of the COVID-19 crisis when, in our daily clinical work, we switched to the telemedicine modality in order to avoid having to interrupt the care and treatment of many of our patients”.

Here are a few figures: the article examines data collected over a 15-day telemedicine period, during which 325 teleconsulations and 882 telephysiotherapy sessions were provided. Instead, over the entire lockdown period, the remote sessions numbered 3,231 in total, i.e. 2317 telephysiotherapy sessions and 914 teleconsulations. These are impressive numbers, especially if we consider the high level of patient satisfaction recorded (2.8/3).

ISICO has longstanding experience in caring for and monitoring young scoliosis patients (children and adolescents) living all over Italy and also abroad. Precisely for this reason, i.e. in order to find a way of allowing farther-flung patients to travel to the centre less often, it has already experimented with various telemedicine tools. 

In fact, over the years, ISICO patients, some even living in other continents (such as Australia and the USA), have been able to follow long-term treatment programmes, thanks to the availability of online consultations.

Therefore, our temporary recourse to online consultations and treatments following the COVID outbreak and during the subsequent lockdown did not constitute a completely new experience, but rather a speeding up of a process that was already under way. 

“This strategy aims to decrease the heavy impact on the health systems and allow hospitalisation and intensive care of the huge number of patients in need, thereby reducing the overall mortality” explains Prof. Negrini. But “the COVID-19 emergency is hitting hard not only infected patients, but also all the others. In many countries, outpatient services have been fully closed due to the need for physicians to treat COVID-19 patients, and also to reduce the risk of infection linked to travelling. This has left outpatients are on their own and mostly self-managing. This is not acceptable for diseases that can still show sudden, important progressions, even in the space of a few months, and it is even less acceptable in children.”

How did telemedicine at ISICO work? The telemedicine services consisted of teleconsultations and telephysiotherapy sessions, which lasted as long as usual interventions. They were delivered using free teleconference apps, caregivers were actively involved, and interviews and counseling were performed as usual. 
Teleconsultations included standard, but adapted, measurements and evaluations by video and using photographs and videos prepared according to specific tutorials and sent in beforehand.  During telephysiotherapy sessions, new sets of exercises were defined and recorded as usual.

In the article, we considered 3 phases: the first covers the usual services delivered, over a period of  30 working days (January 7th to February 23rd), prior to the discovery of the spread of COVID-19 the second phase (February 24th to March 14th) was the one in which COVID-19 began to impact  on our usual services, but before we started using the telemedicine approach; finally the last data analysed refer to the 15 working days from our introduction of exclusively Telemedicine consultations (starting from March 16th)

What came out of the study?

That “Telemedicine is feasible and allows us to keep on providing outpatient services that meet with patients’ satisfaction. In the current pandemic,” Prof. Negrini concludes, “telemedicine has been shown to be effective in specific areas of care, particularly where technology is involved. To our knowledge there are no published results about the application of telemedicine to patients with spinal deformities,” and the publication of this article shows that “this strategy can provide a viable alternative to closure of many outpatient services”.

Telemedicine: patients’ feedback

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While Isico has organized to reopen in total safety its clinics throughout Italy (the reopening was on May 11th ), our work never stopped thanks to the Telemedicine, started two months ago. Weeks later, we are sure that it was the best choice for this specific moment we are experiencing because it allowed us to stay close to our patients and carry out the therapies. We have passed 3000 consultations, and many patients not only from Italy but also from abroad declared that they are fully satisfied with the solution proposed.
Like Simone from Germany and Laurie from Switzerland, both of them having their daughters treated in Isico. 

Here is their feedback.

The Telemedicine visit with Isico was fantastic. Isico was perfectly prepared and communicated to us exactly what we needed to do far in advance of the visit. Their videos explained everything very clearly in Italian and English and the upload of the requested data was easy to accomplish. We wouldn’t hesitate to do this again in the future, if needed. Thank you, Isico, for ensuring continued patient care, even during this challenging time!
Laurie, Swizterland

I always wanted to have the possibility to use telemedicine. Even if the current circumstances are not the circumstances I wished for, I was very happy for the offer from ISICO to try Telemedicine. I knew that it would require some hours of preparation at least for the first time, so I procrastinated for at least two or three weeks. But then I decided to force myself through the whole process. I was very astonished about the tool “weTransfer”, it is possible to send huge data. It took me about 20 minutes to send the x-rays and I just made sure that my computer didn’t turn off during the transmission. ISICO helped me before to find the right documents on the CD. Taking pictures was very easy with the explanations from ISICO. For the video I bought a scoliometer through Amazon. The cheapest one costs 20 € and a very professional one 98 €. My husband took the video and I made the measurements with the scoliometer. The consultation with the doctor and afterwords with the therapist were more than great. It was above our expectations. Our doctor could fully assess the current brace and we spoke about the further treatment. Our therapist gave my daughter a full set of new exercises. He really saw even the tiniest movements to correct. This kind of consultation is much more comfortable for us than the long travel with flights and train and metro from Munich to Milan. We definitely want to proceed this way and we are very thankful that we got the chance to use Telemedicine.
Simone, Germany



	Telemedicine in response to Covid-19 emergency: the first results				
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“I have appreciated being able to have continuity of treatment and the certainty that I can go on being supported by my doctor and therapist even in an emergency, like the one created by the coronavirus outbreak”. This is one of many anonymous comments collected by ISICO through quality assessment questionnaires that patients are filling in, voluntarily, to give us their personal feedback on our telemedicine service. 





The first results show a very high level of satisfaction among patients (mean overall satisfaction rating 2.8/3). Dozens of them clearly feel reassured by the fact that the telemedicine modality guarantees them continuity of care. As well as considering the modality worth recommending to others (mean satisfaction rating 2.8/3), they also feel that the information they have received is clear and exhaustive (mean satisfaction rating 2.99/3). 





As you know, on March 16th, after 13 days of constant and increasing cancellations due to travel restrictions (50% of bookings), ISICO launched its telemedicine initiative. 





It was clear to us, here at ISICO, that we needed to find a way of guaranteeing our patients ongoing care while at the same time removing the need for them to travel and physically access health facilities, thereby protecting them from possible contact with the virus.





Over the 12 days since the introduction of this new system, we have provided more than 1000 medical consultations or physiotherapy sessions in telemedicine mode, and cut face-to-face interventions to just 0.5% of the total. 





“This is a viable solution allowing us to continue providing services to patients, while eliminating the risk of infection associated with the need (both for patients and healthcare providers) to travel and access health facilities” explains Prof. Stefano Negrini, medical and scientific director of Isico.  





Organizing the service





The ISICO staff worked together, in teleconferences, to identify the tools necessary to conduct examinations remotely, i.e. via Skype or WhatsApp video call. The sensitive data are not recorded on these channels, but only in the internally used and protected file storage.





To be able to conduct examinations in telemedicine mode, we requested the collaboration of parents, sending them tutorials on how to photograph their children in a way that would allow us to do the measurements necessary to evaluate the state of their scoliosis.





We also had to explain to parents how the patient should be positioned in relation to the video camera. “Of course, measurements obtained in this way are slightly less reliable than those taken directly, but the photos/videos we are sent before the actual examination are generally of good quality” Prof. Negrini adds.





Parental support is also essential for delivering rehabilitation in telemedicine mode. “Fortunately, parents are always there in the gym, and so they are familiar with the work we do with their children” says Michele Romano, director of physiotherapy at ISICO. “We therapists have also sent written instructions and tutorials to explain how to perform simple tests of musculoskeletal function, and how to make their own simple measurement tools, which then help us to obtain reliable data. We are able to do, remotely, 70% of what we would normally do at the center”.





Consultations include adapted measurements and evaluations, which are done both “live” and from the photos/videos received. During physiotherapy sessions, new sets of exercises are defined and recorded. In both these settings, interviews and counselling are performed as usual.





It is worth recalling that treatments provided by ISICO are mostly based on home practice. Patients exercise at home 10/20 minutes per day, and individual physiotherapy sessions are provided every 30-90 (deformities) or 7-15 (pain) days. 
During the sessions, physiotherapists perform evaluations, update and teach exercises (video recorded by parents), and provide patients with cognitive-behavioural therapy and counselling. An App, synchronised with the individual patient’s file, is used to manage treatment plans, provide exercise programmes and videos, promote compliance (with motivational tools) and encourage contact between patients and physiotherapists.





In conclusion, our early results are extremely positive. The telemedicine approach, which has been well received both by the patients and the professionals involved, has given us a means of providing uninterrupted outpatient services. In the current pandemic, this approach, reducing the need for travel and face-to-face contacts, can offer a viable alternative to closure for many outpatient services.


	Isico launches Telemedicine: home treatment and care for the duration of the coronavirus emergency				
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Dear Patients and Families,





The most difficult periods we face in life are the ones when we most need to be courageous and decisive, and look to the future.





We are living through a dramatic time, in which the health of every single one of us must take priority over every other consideration. And at a time like this, we, as a clinical institute, are acutely aware of our mission as doctors, therapists and specialists: a whole team working to support you, our patients. Because you have shown faith in us, by putting your health in our hands.





Over recent weeks, we have tried to keep all our outpatient clinics running, always in full compliance with the different regulations that have, progressively, been issued. Many of our patients in this period have had to go without examinations and treatments. 





Scoliosis, however, is a condition that goes on evolving all the time. Therefore, even in the midst of the present coronavirus emergency, it is crucial to ensure that treatments are not interrupted.





With the dual aim of guaranteeing our patients continuity of care while at the same time taking steps to drastically decrease the risk of infection, on Monday 16 March, we introduced a radically new way of operating. This has been done in order to limit the movements of our staff members, to limit the clinical activities performed in our dozens of centres throughout Italy, and thus to reduce, as far as possible, the risk of the virus being spread during examinations and treatments. However, for us, limiting does not mean not being there for our patients: we are still providing examinations, prescriptions and treatments, but we are adapting our activity to the rigorous restrictions imposed by our country. In recent days we have been working harder than ever, racing to find new approaches and solutions, in order to continue repaying your faith in us.





Isico is now ready to activate a new method for providing examinations and treatments, in all situations in which this is feasible. This approach, called Telemedicine, is a hugely important opportunity for patients. The patients we see are ones whose condition requires or can require





 a long and difficult course of treatment, and this is a way of preventing their hard work and sacrifices from going to waste. This new approach also reflects our determination to do all we can to reduce the burden on our National Health System, which is wrestling with the emergency, and also to do our bit for our country and for the many families facing unexpected economic hardship (we will be offering examinations and treatments at reduced rates). Obviously, these services will remain unchanged in terms of duration, timing and quality.





As one of our physiotherapists, Marta Tavernaro, wrote on the Facebook page aimed at our scoliosis patients: “I am not worried about this approach. We therapists already use it to follow young patients abroad, and for some time now our doctors have been studying an approach that might allow us to reach youngsters the world over. However, this emergency has hit everyone with catastrophic speed, and we have had to work day and night to come up with an adequate solution. Personally, in my 30-year career as a physiotherapist I have never experienced as many emotions, or had so many thoughts running round in my head as I have in recent days. Never before have I found it so hard to advise those who called me asking for advice, in this case on what they should do about their planned examinations and treatments. Now, however, with Isico Telemedicine, we have found the solution. And the fact that we have managed to do this is, believe me, yet another Isico miracle! At last, I have some peace of mind: in addition to being able, as a private citizen, to play my part in tackling this dreadful situation, I am now confident, as a professional, that I can go on giving our young patients the support they need without exposing them to the slightest risk”. 





Should we have been looking for further confirmation of the value of our approach, in recent days the New England Journal of Medicine published an editorial entitled Virtually Perfect? Telemedicine for Covid-19, which remarks that”disasters and pandemics pose unique challenges to health care delivery. Though telehealth will not solve them all, it’s well suited for scenarios in which infrastructure remains intact and clinicians are available to see patients”.





Isico has equipped itself to be, until the emergency ends, a digital institute.





Together we can get through this difficult time.