Covid-19: The rapid growth of telemedicine in France

By Florence Rosier

Hard to admit, but the pandemic has had at least one positive fallout. It allowed doctors to test teleconsultation, even in an emergency … Health insurance in France made the same observation: “The Covid-19 crisis has led health players to innovate and to shake up patient management methods. Teleconsultation has been the subject of massive use, thus becoming an essential component of healthcare provision on the land”. Between February and April 2020, the number of teleconsultations has multiplied by more than 100.

However, “this service remained quite limited: only a few doctors used it,” says Nathalie Quenel-Tueux, specialist doctor at the Bergonié Institute. The pandemic occurs, which imposes lockdown in March. Everything changes. She adds: “In one to two weeks, 35 doctors from the Bergonié Institute started teleconsultation. Doctors of all ages and all specialties: oncologists, surgeons, anesthesiologists, radiotherapists … ” And she concludes that it worked very well, the patients were reassured by these teleconsultations because they were aware of their vulnerability to Covid- 19. This remote monitoring allowed to keep the link and to see if it was necessary to bring patients in.
The definition of telemedicine acts in French regulations:
Decree n ° 2010-1229 of October 19, 2010 (published in the OJ of October 21) determines as falling within the scope of telemedicine “medical acts, carried out remotely, by means of a device using information and communication technologies. ”. Five types of acts are thus concerned:

• teleconsultation: a doctor provides a remote consultation to a patient, a health professional or a psychologist can be present with the patient and, if necessary, assist the doctor during this act;

• tele-expertise: a doctor remotely requests the opinion of one or more of his colleagues because of their training or their particular skills, based on the information related to the health care of a patient;

• medical telemonitoring: a doctor remotely interprets the data necessary for the medical follow-up of a patient and, if necessary, makes decisions relating to his care. The recording and transmission of data can be automated or carried out by the patient himself, or by a healthcare professional;

• medical tele-assistance: a doctor remotely assists another health professional during the performance of an act;

• the medical response provided within the framework of the medical regulation of emergencies or on-going care.

During lockdown, Medical insurance points out, teleconsultation represented one in four consultations. “Today, more than one in two doctors use it, it affects patients of all ages, not just urban youth. Knowing

that Medicare has reimbursed teleconsultation acts since September 2018 and tele-expertise acts since February 2019. On one condition; that the attending physician, who knows the state of health and the history of his patients, has to be consulted first. But telemedicine has been slow to take off. It took the pandemic to emerge, as brutal as it happened, to release that brake. From the start of the lockdown, reimbursement conditions for teleconsultation were relaxed. And their reimbursement went from 70% to 100%.

An asset in medical deserts
In fact, the four major issues of telehealth have found, “a general resonance” with those of the health crisis, according to the health insurance. It is about facilitating access for all to a quality health care throughout the country; to simplify the follow-up of patients especially in the face of the burden of chronic diseases; to improve their quality of life by avoiding unnecessary visits; and to promote access for all to the opinions of medical specialists.
“Tele-expertise can be a real asset in areas of medical deserts”, estimates Dr. Didier Simon, general practitioner practicing in the Landes. For example, he had made remote appointments between a rheumatologist and one of his patients, in whom he suspected an inflammatory rheumatic disease. “By video communication, we presented together to this rheumatologist the results of the examinations already carried out: blood tests, radiology, ultrasound. The diagnosis was confirmed, and this person was able to benefit from background treatment without delay instead of waiting 3 to 6 months before consulting physically this specialist.
According to Pauline d´Orgeval, co-founder of the site, the pandemic has doubled the number of users of the platform. “Our opinions have sometimes been the only solution for patients whose hospital consultation, which has been awaited for months, has been canceled or postponed due to Covid-19,” she said.

“Lost enough” patients
The request, most often, comes from the patient himself, who must complete a questionnaire, collect and download the elements of his medical file, then transmit everything to the site, in a secure manner. The specialist’s opinion is therefore based exclusively on the patient’s medical record, without clinical examination.

Outside of the usual course of care, this notice is therefore not reimbursed by health insurance. But it is offered as part of the health contracts of certain supplementary insurance funds, provident funds or brokers, “which to date cover 16 million people,” says Pauline d’Orgeval. For her, this is “a solution to reduce inequalities in access to medical expertise in France”. But the assertion raises an immediate question: what about those who are not covered by these health contracts?
What about the lack of clinical examination? “Of course, a second opinion on the Internet is not the same as a face-to-face consultation. But the files consulted are very complete and, in many pathologies, patients receive differing opinions: they are quite lost” testifies Professor Jérôme Allain, orthopedic surgeon, who is one of the experts on the Deuxiemeavis.fr platform. “With this site, they receive the perspective of an expert selected for his skills in a very specific area. In surgery, this advice does not come from the doctor who will eventually operate on the patient. For them, it is a guarantee of a very reassuring neutrality. ”
Beware of deviations from the system, however, which has alerted many players in the field. “While it is funded by national solidarity, patient care cannot be done through “off the ground” consultations, where the patient-doctor link is weak, or even non-existent,” said Nicolas Revel, Director of Health Insurance, in the bulletin relative to the National Council of the Order of Physicians (CNOM) of July-August 2018.

Telemedicine should not be “a commercial response to a demand for care,” adds Dr. Simon today. Doctors must know their patient perfectly, their medical history, all their illnesses and treatments, as well as their social environment and mental state. Otherwise, it is a source of insecurity.”

A clarification of the legislation
An opinion shared by Professor Vincent Renard, President of the National College of General Teachers (CNGE). “For telemedicine to improve the medical service provided, it must be integrated into the coordinated patient care pathway. “Conversely,” he continues, “market platforms based on telemedicine divert the patient from such a path. They are the caricature of what should not be done ”

(*) Florence Rosier is a freelance journalist at the newspaper ‘Le Monde’ (France).
https://www.lemonde.fr/le-monde-evenements/article/2020/10/20/covid-19-l-essor-fulgurant-de-la-telemedecine_6056664_4333359.html