An App-Based Telemedicine Program for Primary Care and Specialist Video Consultations During the COVID-19 Pandemic in Mexico

Introduction

On March 11, 2020, the World Health Organization declared the novel coronavirus disease 2019 (COVID-19) outbreak a pandemic.^1,2 As of January 27, 2021, the COVID-19 pandemic has caused >100 million confirmed cases and >2 million deaths worldwide. The situation in Mexico has not been dissimilar, with >2 million confirmed cases and >170,000 total deaths reported.³

Telemedicine is the provision of remote clinical services through real-time two-way communication between patients and the health care providers, using electronic, audio, and visual means.⁴ Teleconsultations contribute with multiple modalities in the case of a pandemic, reducing unnecessary visits to emergency departments and allowing the evaluation and follow-up of outpatients who do not require face-to-face assessments.⁵ During the COVID-19 pandemic, the use of video consultations has become a widespread practice in many primary care and specialist services,^6–8 providing patients with access to health care services without leaving home or work, reducing travel costs, and saving time.⁹ Fortunately, governments are starting to strongly promote digital-first care, arguing that it will improve access and convenience for patients while also increasing efficiency.¹⁰

Sofía is a Mexican health care and technology startup founded in 2018, which focuses on changing how people approach and cultivate their health, leveraging technology to build a complete product, with services ranging from primary care with a video consultation to treating severe illnesses or accidents with a major health insurance. Since its foundation, Sofía developed an app (also named Sofía) that allows teleconsultations, exchange of medical prescriptions, and requesting follow-up consultations. The video consulting service launched in March 2020 with nine internal medicine specialists providing medical attention on a daily basis; from March to September of 2020. Seven versions of the app were released with >400 video call tests conducted.

Materials and Methods

On March 23, 2020, the Mexican Ministry of Health declared the beginning of the national emergency period of social distancing.¹¹ In response to the pandemic, Sofía implemented its video consultation service in Mexico City and the metropolitan area, offering free-of-charge mobile-based consultation services by physicians specialized in internal medicine, with expertise in providing medical care by video consultation. On April 30, the service was extended to the entire country, and on June 11, pediatric consultations were added. This program was called Coronaid. Informed consent was obtained for all participants through the mobile application and IRB review was waivered.

PROGRAM DEVELOPMENT AND PROCESS

The Coronaid was developed by Sofía's medical department and included a medical guideline for remote assessment in suspected COVID-19 cases, based on recommendations from the World Health Organization, the Centers for Disease Control and Prevention, and the General Directorate of Epidemiology. This guideline was reviewed by an infectious disease specialist physician.

Video consultation services were provided through Sofía's mobile app by internal medicine physicians on a daily basis, from 8 am to 9 pm. Pediatric consultations were scheduled and evaluated distinctly. Once consultations were finished, patients received a prescription on the app, including follow-up indications if necessary. Patients were able to successfully solve common questions related to previous consultations through the app's chat. Medical information collected in the consultations was registered in Sofía's electronic medical record. And while video consultations were conducted by internal medicine specialists, they facilitated clinical care and reference to other specialists when needed, based on direct communication with other clinical specialists in the medical team.

PARTICIPANTS

All patients who were assessed in teleconsultations through Sofia's mobile app were included in this study. There were no restrictions regarding age, gender, or comorbidities. Anyone >18 years could request a video consultation for any reason to receive medical assessment and treatment. Patient satisfaction was measured on a 1–5 Likert scale after utilizing the teleconsultation services. Participants' flow of the telemedicine program is shown in Figure 1.

During this period, video consultations were also offered for pediatric patients. These video consultations were scheduled during the pediatrician's office hours and were also included in our statistical analysis.

STATISTICAL ANALYSIS

All patients with a complete medical record that used Sofía's video consultation services were included in the analysis, patients with incomplete or missing data were excluded. We performed a descriptive statistical analysis of the baseline demographic characteristics of all patients and reported them in frequencies and percentages for nominal and ordinal variables. For numerical variables, means and standard deviations were calculated. Microsoft Excel 2020 and SPSS v.25 (IBM) were used for data collection and analysis.

Results

A total of 2,585 video consultations were provided through the Sofia mobile application in the period from March 23 to September 4, 2020, and were available for anyone >18 years in Mexico. Most consultations (71.8%) were taken by patients located in the Mexico City Megalopolis (which includes Mexico City and the metropolitan area surrounding it). The geographic distribution of the Coronaid services is located in Figure 2.

The total number of patients were 1,545, but 19 were excluded due to incomplete data. Only 1,526 patients were included in the analysis. Of these patients, 46% were female and 54% male and the mean age was 34.8 (SD = 14.6). Fifty-four pediatric video consultations were provided (2% of total). The mean body mass index was 26.49 kg/m² (SD = 5.21 kg/m²). The main comorbidities among the population were diabetes (4.6%), hypertension (7.7%), and obesity (20%). Other common comorbidities were asthma, anxiety, gastroesophageal reflux disease (GERD), and hypothyroidism, among others. All baseline demographic characteristics are described in Table 1.

The chief complaints were classified by organs and systems (Table 2). 1,148 (44.4%) of the consultations were associated with respiratory symptoms and the rest of them were related to other medical conditions. Respiratory chief complaints were mainly associated with COVID-19-related symptoms, but other reasons for consultation included asthma exacerbations, allergic rhinitis and the common cold. Among the main reasons for consultation within the other organs and systems were abdominal pain, diarrhea, and GERD in gastrointestinal, symptoms related to urinary tract infections in genitourinary, anxiety and insomnia in psychiatry, and muscle/joint pain in the musculoskeletal system.

PATIENT SATISFACTION

Regarding patient satisfaction, patients were asked to fill out a survey to express their opinion about the quality of the whole service when they were discharged, starting from the app, the consultation, and the treatment delivered. Three different platforms were used for this evaluation and the results are as follows: in the first platform the final score was 4.2 out of 5 (84% of patient satisfaction), in the second 4.3 out of 5 (86%), and in the last one 5 out of 5 (100%). Notes were taken from reviews to promote continuous improvement.

Discussion

During the COVID-19 pandemic, medical care related and not related with COVID-19 has endured many changes, many of which involve implementation of technological advances to clinical practice to maintain and improve patient's overall health and improve survival. The Coronaid program provided safe and remote health care to 1,545 patients in Mexico during the pandemic. This encouraged patients to implement public health preventive measures and introduced them to telemedicine clinical practice, which was widely accepted in the vast majority of the patients.

Our patient sample was composed of a younger demographic than other telemedicine programs^12,13; this can be attributed to the fact that Sofía's Coronaid Program was implemented using a smartphone mobile application, which is often more commonly used by a younger patient sector.¹⁴ Other studies have shown that younger patient demographics, specifically in patients with Type 1 Diabetes Mellitus, have good follow-up outcomes, and are widely accepted.¹⁵

Regarding patient satisfaction, patients who received video consultation services during the COVID-19 pandemic rated a satisfaction score >80%. Other telemedicine programs have reported high patient satisfaction levels as well, this can be attributed to significant cost, time and distance savings,¹⁶ and in the case of the COVID-19 pandemic, other safety benefits can be achieved by remote care telemedicine services like Sofía's Coronaid such as reducing virus spread and decreasing contagiousness. Also, other studies have shown that video consultation services, which provide a face-to-face interaction with the patient are more likely to be accepted than other telehealth services such as telephone-based or text messaging services.¹⁷

Owing to the COVID-19 pandemic, telemedicine services have gained more usage among health care workers in all areas of medicine, including gastroenterology,¹⁸ pediatrics,¹⁹ oncology,²⁰ urology,²¹ ophthalmology,²² endocrinology,²³ and even palliative care.²⁴ Sofía's Coronaid was mainly focused on primary care consultations, including internal medicine and pediatrics. COVID-19 positive patients who required only ambulatory care were also assessed through video consultations.

During pandemics and epidemics, telemedicine has been used as a powerful tool to maintain patient health and provide consultations to patients minimizing the risk of infections such as SARS, MERS, Ebola, and in this case, COVID-19.²⁵ This has generated further interest in improving telehealth technologies for them to be more widely available to all patient demographics and greater country coverage.

Conclusion

Telemedicine has been proven to be a useful, safe, and effective tool to improve patients' overall health. This effect has been boosted by the COVID-19 pandemic. The use of mobile applications, such as Sofía, is a versatile and convenient tool to manage health care remotely, especially in a younger population. The use of an app-based telemedicine program can encourage patients to seek help to improve their health and well-being due to many factors, including the elimination of commuting time to the physician's office, on-demand health care assistance, and many others, leading to high levels of patient satisfaction.

Authors' Contributions

All authors included in this article meet the criteria for authorship, as defined by the International Committee of Medical Journal Editors.

Disclosure Statement

All authors are currently employed by Sofía Salud S.A., a technology and health care startup based in Mexico City.

Funding Information

This research was supported by Sofía Salud S.A.