Zeel Shah, MD; John R. Maese, MD, MACP; Donna Seminara, MD, MACP; Anita Szerszen, MD, FACP
Calamity catalyzes change. With the emergence of the COVID-19 outbreak, Americans are quickly realizing their health care system is overdue for a digital revolution. Medicine is a profession that is slow to change. In the past it would take several years for a new treatment or therapy to become main stream [1]. The era of the internet allows for faster dissemination of information through multiple lines of communication whereas in the past, medical innovation was primarily distributed through academic journals. The diagnostician of the future will need to be facile and adaptable to new technologies. The days where the stethoscope was the most advanced piece of equipment are long behind us. The availability of data to monitor, treat and change the outcomes will be game changing. In this pandemic we are seeing the way telehealth via cell phones have become indispensable in monitoring patients and providing care.
Although telemedicine has been around for decades, it was in this pandemic that the cellphone has catapulted itself into the role of a mobile critical service. Using a cellphone allows for instantaneous communication with patients while maintaining the fabric of healthcare by decreasing the transmission of COVID-19 and preserving limited personal protective equipment (PPE) [2]. U.S health care systems have responded swiftly and have leveraged 21st century telemedicine innovations to respond to the COVID-19 crisis seemingly overnight.
The value of telemedicine has been well-documented throughout former infectious outbreaks [3]. Telemedicine has been used in the past for teleconsultation of asymptomatic individuals and of symptomatic cases requiring isolation. Teleconsultation of asymptomatic individuals includes home-based individuals living in an epidemic-affected location or individuals that are identified as case contacts.
The role of teleconsultation was to dispatch emergency medical services when suspicious symptoms were detected. These sessions were conducted using text, audio, and/or video to permit efficient triage [3]. Teleconsultations were set up by the Ministry of Health in Guinea through the National Ebola Hotline in 2014 during the Ebola virus outbreak to triage suspected cases to the isolation ward at Donka Hospital in Conakry [4, 5]. Similar initiatives were set up in Liberia and Sierra Leone while the doctors were based in Indonesia and Nigeria [6]. Telemonitoring has been utilized since 2014 in Guinea and West Australia. Those exposed to the virus were monitored via text message twice a day to identify the health status of patients including their temperature [3]. Telemonitoring of symptomatic patients requiring isolation allows for decreased exposure between healthcare worker and an infectious patient to facilitate improved disease control by mitigating healthcare-associated infections [3]. This technique has been used since the 2003 SARS-CoV outbreak in Taiwan in a hospital quarantined SARS-positive patient [7,8].
U.S health care systems are currently incorporating telemedicine to respond to COVID-19 by focusing on “forward triage” where patients are sorted prior to their arrival into the emergency department [9]. This allows healthcare workers to safely provide efficient and patient-centered care. Not only is telemedicine a useful tool to mitigate the spread of infection, there is a desire for these services amongst the US population as the number of COVID19 cases rise. Despite the increased interest in telehealth, a correlated increase in the proportion of hospitals providing telehealth services was not found [10]. This has changed with the advent of COVID19. While former acceptance of telemedicine was genuinely skewed towards younger patients, the fear of contracting the virus has opened previously closed minds to the use of this technology.
Some health systems have incorporated automated screening algorithms into the telehealth intake process and utilized local epidemiologic information to standardize screening and practice patterns across providers. These include Jefferson Health, Mount Sinai, Kaiser Permanente, Cleveland Clinic, and Providence [9]. This direct-to-consumer telemedicine protects patients, clinicians, and the community from exposure by providing care while maintaining self-quarantine. It facilitates communication between patients and physicians through smartphones or webcam-enabled computers [9]. As hospitals and outpatient clinics scale up and acclimate to the marrying of telemedical innovation with traditional modes of patient delivery, there is hope that regulators will relax regulation so that patients and physicians will be able to flourish by using telemedicine to effectively treat and prevent active disease as well as improve patient compliance with treatment algorithms. Telemedicine in a meaningful and economically viable way can use innovation to do more for a patient. There will be a growth of home use technologies so that critically ill patients can be monitored effectively and safely with the data being transmitted to the doctor in real time. This data can be as simple as text messaging or more complex based on the technology available.
In Singapore, an infectious tracing system has been developed using an application called “Trace Together”. This technology uses a Bluetooth signal along with an application. Application communicates information on your cell phone to another cellphone with the same application. The phones exchange anonymous codes through Bluetooth signal that are stored in an encrypted form on each phone. These codes are stored as a list of anonymous IDs that have been in close proximity in the past 14 days. In the case of COVID19, a positive patient will have to make a note of their infectious status in the application on their phone. The list of anonymous codes is then sent to the health department so that the phone users that were in close proximity can be notified of their exposure and provides the appropriate advice on how to proceed. The information is anonymous and no geolocation of personal data is collected. Currently in the United States to technological giants Alphabet and Apple are developing similar technology that meet the privacy standards required in the United States but at the same time allows COVID-19 contacts to be tracked [11].
Technological innovations are an absolute necessity in the fight against COVID19. The increase in testing has caused a nationwide shortage in nasopharyngeal (NP) swabs that are required to collect samples. To deal with this problem, 3D printing promises to be a viable solution. USF Health faculty researchers in Departments of Radiology and Infectious Disease in collaboration with Northwell Health have developed nasal swab prototypes using Formlabs’ 3D printers and biocompatible, autoclavable resins. These swabs are currently being produced after tests showed that 3D printed nasal swabs were as good as or better than traditional swabs using for NP specimen collection [12]. Doctors in the future will need to be skilled in 3-D printing, so that when supply chains are disrupted critical medical supplies can be replicated, so that care can continue.
Despite the darkness and tragedy that has accompanied the COVID-19 pandemic, there is an opportunity for healthcare delivery. Now is the time to revolutionize healthcare and set up an infrastructure to provide care using technology not just in the pandemic but for long-term use so that access is expanded throughout the country and patients can get needed medical help without the burden of extensive travel. We need regulatory relief and appropriate compensation so that we can innovate and use technology in a meaningful way to improve outcomes and decrease healthcare disparities in all clinical situations. Doctors need to be trained in Computer Science so that they can innovate as needed to meet patient care demands. As history has shown us with past pandemics, the emergence of a new infectious disease is just around the corner and it is up to us to decide how prepared we wish to be. The proactive implementation of technology is more likely to generate greater benefits in the long-term and can effectively manage emergency situations in the future [13].
References:
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