Harnessing The Power Of Digital Health In Responding To COVID-19 And Beyond
Harnessing the Power of DigitalHealth in Responding to COVID-19and BeyondK2P COVID-19 SERIES
AuthorsMathilda Jabbour, Linda Matar, Nour Hemadi,Clara Abou Samra, Fadi El-Jardali*CitationJabbour, M., Matar, L., Hemadi, N., Abou Samra,C., El-Jardali, F. K2P COVID-19 Series: Harnessingthe Power of Digital Health in Responding toCOVID-19 and Beyond, Knowledge to Policy (K2P)Center, Beirut, Lebanon, May 8, 2020*senior authorK2P Harnessing the Power of Digital Health
2Key MessagesThe rapid spread of the COVID-19 pandemic has currently infected more thanthree million person globally and has surged the need and demand for healthcareservices beyond the capacity of some healthcare systems. Digital health, thatincludes big data, e-health and technologies such as artificial intelligence,has emerged as a fundamental tool for governments, healthcare providers andhealthcare institutions to effectively respond to this public health crisis.Technologies leveraged upon in the COVID-19 Response Online platforms were leveraged to perform various functions including, raisingawareness, educating personnel, sorting and monitoring patients, enabling virtualcare, and informing decision-makers and the public. Machine learning and artificial intelligence played an important role in contacttracing, effective design of diagnostic technologies, identification of drugs thatcan be re-purposed for COVID-19 treatment, and enhacement of epidemiologicalforecasts. Blockchain technology was used to allow immediate payments for hospitals andconnect healthcare providers to new vendors. Robots and drones were utilized for preventing disease transmission, screening,diagnosis, and minimizing human-to-human contact.Advancing the Agenda of Digital Health in the Eastern Mediterranean Region Leverage on digital health to respond to public health emergencies such as theCOVID-19 Promote the utilization of big data to advance and support digital healthtechnologies in informing and supporting the response to COVID-19 and beyond Invest in robust national health information systems (HIS) Harness the utilization of virtual technology to respond to the continuous increasein demand for health services that is not limited to public health emergencies butalso extends to everyday practice. Enable public engagement and enrollment in digital health interventionsK2P Harnessing the Power of Digital Health
3PreambleOn March 11, 2020 the World Health Organization (WHO) declared the novelcoronavirus as a pandemic. Since then the number of confirmed COVID-19 casesreached over three million overwhelming healthcare systems around the globe andchallenging economies. In addition to strict measures that escalated from socialdistancing to complete lockdowns, governments that have succeeded so far incontaining the virus, heavily invested in digital health that includes technologiesand big data.Digital health encompass the utilization of electronic health, advancing computingscience such as big data and leveraging on artificial intelligence (AI). Digital healthdraws on various technologies including phones, applications, telemedicine,wearable devices, robotics, drones, virtual reality and AI to support tasks and informdecision making. Digital technologies provide opportunities to address health systemchallenges, and enhance the coverage and quality of health practices and services,particularly in outbreaks (WHO, 2019; WHO, 2020).Governments and international organizations mobilized digital technology duringthe Ebola crisis for numerous functions including awareness, education, outreach,coordination, surveillance, and planning. For instance, mobile technologies wereleveraged to raise public awareness on disease prevention, educate healthcareworkers on best practice, and provide infected individuals and those living in hard-toreach regions with essential needs and financial support (Dahiya et al., 2016; Oza etal., 2017; Tambo et al., 2016). Mobile-based applications in addition to dashboardsalso helped front-line healthcare workers and management carry out various taskssuch as information coordination, surveillance and reporting, real-time notifications onnew cases, prompt results sharing and strategic planning (Tambo et al., 2017).As the COVID-19 pandemic spreads to nearly every country around the world includingthe most developed, the role and scope of digital health stretched beyond thatobserved in the Ebola epidemic.K2P Harnessing the Power of Digital Health
Selection ProcessA search of the literature was undertaken to identify articles-systematic reviews and single studies- addressing the use oftechnology in COVID-19 response. A combination of free wordand controlled vocabulary to combine the following concepts:“Pandemic” AND “Technology”; “COVID-19” AND “Technology”;“Epidemic” AND “Technology”; “Digital” AND “Health” AND“COVID-19”; “Digital” AND “Health” AND “Technology” wereused to search the following databases: Medline/Pubmed,Health Systems Evidence, and Cochrane Library. GoogleScholar and grey literature were also reviewed. Last search wasdone on the 4th of May, 2020.While this document does not evaluate the impact of thecomponents of digital health, it provides insights basedon evidence and experience during the COVID-19 on howdigital health can harness and enable health systems torespond to the COVID-19 pandemic and other public healthemergencies in the Eastern Mediterranean Region.K2P Harnessing the Power of Digital Health4
5E-healthE-health which is “the use ofinformation and communicationstechnology in support of health andhealth-related fields” (WHO, 2019),covers a broad range of tools includinghealth information systems (HIS),Electronic Health Records (EHR)and telemedicine (Kierkegaard,2013). Robust HIS are particularlyimportant E-health tools as they arepre-requisites for the provision ofinformation essential for evidenceinformed decision making, propermanagement and planning, and healthsystem monitoring and evaluation(Alwan et al., 2016).It is essential to assess the state ofE-health in the EMR to determine theregion’s preparedness to leverageadvanced technological applications.The socioeconomic and culturalvariations among countries in theEMR reflect a wide array of challengesrelated to e-health preparednessespecially in low-to-middle incomecountries (Al Shorbaji, 2008).Countries in this region vary in termsof wealth which results in a hugedisparity in the level of networkedreadiness (Al Shorbaji, 2008). Forinstance, whereby countries such asUAE, Qatar and Bahrain are the topthree leading countries in the EMRin terms of the networked readinessindex, Yemen and Algeria have scoredmuch less (Portulans Institute, 2019).Other challenges include lack ofstandardized policies for health datamanagement, lack of sustainablefunding, poor E-health publicprivate partnerships, lack of skilledhuman resources, lack of politicalcommitment, underdeveloped healthinformation systems (HIS), poor policyand legal frameworks and cultural andmultilingual challenges (Al Shorbaji,2008, Alwan et al., 2016).E-health preparedness depends on fourkey pillars including (1) network readiness,(2) standardization policies, protocols, andprocedures, (3) user access and accessibility,and (4) government regulations and roles(Wickramasinghe et al.,2005)K2P Harnessing the Power of Digital Health
6Big DataBig data describes a large, complexand fast data that is difficult to beanalyzed using traditional methods.Big data can be used for informationextraction, machine learning andartificial intelligence, predictivemodeling, and advanced analytics(Rouse, 2020). The opportunitiesrevealed from big data includequality improvement, population andhealth management, early detectionof disease, data quality, structure,and accessibility, improved decisionmaking, and cost reduction (Kruse etal., 2016; Mehta et al., 2018).Evidence showed that big dataapproaches that include analyzingsocial media data, such as posts,likes and comments, can be used todetect outbreaks. (Xie, et al., 2013). ACanadian artificial intelligence startup called “Bluedot” was able to alertthe world of the novel coronavirusoutbreak 9 days before WHO releasedinformation. The start-up used big dataand artificial intelligence to processinformation from different sourcesincluding statements from publichealth organizations, digital media,airline ticketing, livestock healthreports and population demographicsto detect and forecast the size of theoutbreak (CNBC, 2020).Lessons learned from previousepidemics showed that active casefinding and prompt treatments arecrucial in the reduction of diseaseincidence (Yuen et al., 2015). TheTaiwanese government leveraged bigdata to actively find and test highrisk individuals. This was done byintegrating the travel and customsdatabase with the national healthinsurance database and patients’travel histories and incorporatingthis information into the individuals’medical records. This allowedclinicians to receive real-time alertsto investigate COVID-19 infectionfor those who report with flu-likesymptoms and have recently visitedendemic regions (Wang et al., 2020a).Nonetheless, the use of big datashould consider the data structure,security, data standardization, storageand transfers, and data governanceto mitigate the negative impact of bigdata and enhance its benefits (Kruseet al., 2016).K2P Harnessing the Power of Digital Health
7Digital Health TechnologiesUtilized for COVID-19 Response01 Online PlatformsRAISING PUBLIC AWARENESSEDUCATING AND TRAININGHEALTHCARE WORKERSAuthorities are leveraging on socialmedia to efficiently reach the public withaccurate and comprehensive information.For instance, the Singaporean authoritiesestablished chatbots and a nationalWhatsApp channel to raise awareness onCOVID-19 (UNDP, 2020). Nevertheless,social media has also been the platformfor the fast and overwhelming spread ofinformation, which created an infodemic,making it harder for people to distinguishcredible from fake information (Wonget al., 2020). To mitigate the spread ofmisinformation, WHO collaborated withsearch companies and social mediagiants to track fake-news and ensurethat the information published by WHOappears on the top of the search resultswhen people search for information onCOVID-19 (Bullock et al., 2020).WHO launched a list of online courses toeducate healthcare workers on how toprotect themselves and take better careof COVID-19 patients (WHO, 2020). Chinaalso trained healthcare workers throughgovernment-supported online coursesand live teleconferencing sessionspresented on mobile platforms (Li et al.,2020).K2P Harnessing the Power of Digital Health
8Online Platforms wereleveraged to raise publicawareness, educatehealthcare workers, sortand monitor patients,enable virtual care, andinform decision-makersand the public during theCOVID-19 pandemic.TRIAGE, MONITORING AND PROVISIONOF ROUTINE CAREINFORMING DECISION MAKERS ANDTHE PUBLICVirtual healthcare emerged as a keystrategy to manage demand on hospitalcare as well as reduce the exposureand potential spread of the virus amonghealthcare professionals, patients andtheir communities (Greenhalgh et al.,2020). Several governments, such as theChinese and the British governments,resorted to virtual consultations toprovide initial patient screening and“forward triage” (Dorsey and Topel,2020; Greenhalgh et al., 2020; Hollanderand Carr, 2020). Additionally, virtualconsultations and COVID-19 specificmobile applications were used to supportand monitor suspected cases andpatients with mild symptoms, therefore,decreasing the demand on healthcare(Ohannessian et al., 2020). Severalcountries such as the United States andAustralia have also shifted non-COVID-19related consultations online to ensurethe continuous provision of routine carewithout the risk of exposure in busy andcontaminated hospitals (Smith et al.,2020; Leite et al., 2020).National, regional and international livedashboards were established to providedecision-makers and the public withup-to-date information. For instance,John Hopkins developed an interactivedashboard that allows people to trackcases around the globe in real-time (Donget al., 2020).On the national level, numerous countriesincluding Lebanon and the UnitedKingdom established country-specificdashboards. Some dashboards expandedto include key information that can helpcoordinate efforts, assess the impactof interventions and direct the flow ofresources (Digital Health, 2020).K2P Harnessing the Power of Digital Health
902 Machine Learning andArtificial IntelligenceCONTACT-TRACINGDIAGNOSISSeveral countries resorted to technologyto automate the contact-tracing processwhilst encountering the fast spreadof the COVID-19 disease (Ferretti etal., 2020). For instance, the Chinesepublic health authority developed anapplication that collects real-time data onpeople’s geolocation and latest COVID-19diagnosis to generate a green or a red QRcode that is scanned at the entrance ofpublic spaces, transportation systems,malls and hotels. A red code would denyentry to its holder and would indicatethat the individual either tested positivefor COVID-19 or came into proximity toanother person who has recently testedpositive (Ferretti et al., 2020). Singapore,traced the digital signature of people whotested positive with COVID-19 to identifythe people they came in contact with, totest and isolate them accordingly (UNDP,2020).Evidence suggests that machine learningcan be potentially used for COVID-19diagnosis as machines can be trainedto identify particular radiologicalsignatures associated with COVID-19on CT-Scans (Ai et al., 2020; Wang etal. 2020b) or identify an abnormallyrapid breathing pattern associated withCOVID-19 through footage from kineticdepth cameras (Cascella et al., 2020;Wang et al., 2020c). Other approachesinclude using mobile phones to diagnoseCOVID-19 through embedded sensorsor through a questionnaire that canfilter high-risk patients based on theirresponses (Maghdid et al., 2020; Rao &Vazquez, 2020).K2P Harnessing the Power of Digital Health
10Machine learning andartificial intelligence playedan important role in contacttracing, effective design ofdiagnostic technologies,identification of drugsthat can be re-purposedfor COVID-19 treatment,and enhacement ofepidemiological forecasts.TREATMENTEPIDEMIOLOGICAL RESEARCHArtificial intelligence can be used toidentify the structure of the proteinsassociated with viruses, identify drugsthat can be re-purposed for the treatmentof this infection, and propose new drugsthat provide the potential for treatment(Zhavoronkov, 2018). For instance,Richardson et al. (2020) used anartificial intelligence technique to identifyBaricitinib, a drug which is commonlyused to treat arthritis, as a potentialdrug that can be used for the treatmentof COVID-19. Beck et al. (2020) used amachine learning approach to identifyAtazanavir as a potentially effective drugfor the treatment of COVID-19.Explaining the spread of the virus, andits effect on different demographicsand geographic locations is crucial toinform policy decisions. Given the rapidprogression of COVID-19, researchersleveraged models with machine learningcapabilities to provide real-time forecasts(Bullock et al., 2020). For instance, Huet al. (2020) used data compiled by WHOto develop a dataset of cases in China.This dataset was then used to train amodified auto-encoder to provide realtime forecasting of new cases.K2P Harnessing the Power of Digital Health
1103 BlockchainSTREAMLINING INSURANCEOPERATIONSADDRESSING SUPPLY CHAIN ISSUESBlockchain technology can be usedto securely store patients’ medicalrecords (Chen et al., 2019). Using thistechnology, an insurance companyin China was able to get data directlyfrom hospitals, track history of patienttreatment, the tests they received,and the physicians that treated themin a secure manner ensuring no datatampering. The company also usedsmart contracts to automate insurancepayments to issue immediate paymentsupon discharge (Field, 2020).The rapid spread of COVID-19 resulted ina drastic increase in demand for medicalsupplies (i.e. PPE). Many non-traditionalsuppliers, such as apparel companies,shifted their activity to address thisshortage, yet connecting these suppliersto health authorities and health providerswas still a time-consuming task. In theUnited States, IBM launched a blockchain based network to connect healthauthorities and healthcare providers withnon-traditional suppliers which allowedthem to quickly identify and verify newvendors (Landi, 2020).K2P Harnessing the Power of Digital Health
12Blockchain technology wasused to allow immediatepayments for hospitalsand connect healthcareproviders to new vendors.K2P Harnessing the Power of Digital Health
1304 Robots and DronesPREVENTING DISEASE TRANSMISSIONSCREENINGAutonomous disinfection using UV Robotscan be more efficient and effective ascompared to manual disinfection whichrequires workforce mobilization andincreases the exposure risk of cleaningworkers (Yang et al., 2020).Similarly, China and Spain adapteddrones that were originally designedto spray pesticides for agriculturalapplications to spray disinfectingchemicals in public spaces. Drone spraycan be fifty times more efficient thanhand spray and can help reduce thetransmission mechanisms of the novelcoronavirus (Pan, 2020; Yang & Reuter,2020).Mobile robots that incorporate thermalsensors and vision algorithms technologycan increase the efficiency and coverageof screening in public areas and portsof entry (assisting with border controls).China deployed mobile robots to thermallyscan large crowds and detect suspectedcoronavirus carriers; these robots livestream temperature readings to controlcenters and send alerts when necessary(Ng, 2020; Yang et al., 2020).K2P Harnessing the Power of Digital Health
14Robots and dronescontributed to theCOVID-19 response inareas related to preventingdisease transmission,screening, diagnosis, andminimizing human-tohuman contact.DIAGNOSISMINIMIZING HUMAN-TO-HUMANCONTACTRobots can come in handy in performingnasopharyngeal and oropharyngealswabbing to test for COVID-19, thusspeeding up the diagnostic testingprocess, reducing the risk of infection andfreeing up staff for other tasks (Yang etal., 2020; Caixiong, 2020).Robots have been used for the deliveryof medications and meals for people inhospitals and quarantine zones in Chinato minimize human-to-human interactionand prevent the spread of COVID-19(Okyere et al., 2020). Also, China hasbeen utilizing drones to deliver medicaltesting samples which significantlyreduced unnecessary human contactthroughout the transport cycle andspeeded the feedback for critical testsby cutting delivery time by more thanhalf (Yang & Reuter, 2020). Drones arebeing used in China and Spain to patrolpublic spaces and track non-complianceto quarantine directives (Onyango, 2020;Pan 2020).K2P Harnessing the Power of Digital Health
15EthicalConsiderationsPrivacy, cybersecurity and data misuseVarious technology applications described throughout require the collection andanalysis of a large amount of citizens’ data. For instance, some contact tracingsolutions require that the geolocation of every citizen at any point in time be storedin a central server. This raises significant concerns around privacy, cybersecurityand data misuse, especially when the utilization of the collected data shifts from itsoriginal purpose (Cho & Yu, 2020). Failing to address these concerns in public healthemergencies may undermine public trust and result in public resistance to followgovernment recommendations (Ienca & Vayena, 2020).Social inequityThe use of technology in the provision of healthcare raises a concern of social inequity.Barriers such as poor digital literacy, financial constraints, and poor infrastructuremay result in inequitable access to digital healthcare (O’Connor et al., 2016). Forinstance, the younger generations are expected to have good digital literacy, olderadults still struggle with the use of technology (Levine et al., 2016). Additionally, thecost of acquiring technology and poor internet access may prohibit certain groups fromaccessing digital healthcare especially those living in low-to-middle income countries(O’Connor et al., 2016; Yamin et al., 2011).K2P Harnessing the Power of Digital Health
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17Advancing the Agenda ofDigital Health in the EasternMediterranean RegionThe COVID-19 pandemic provides an opportunityfor countries in the EMR to advance digitalhealth to proactively develop and implementevidence-informed decisions for effective andefficient response to the pandemic and beyond.Insights derived from the global response to theCOVID-19 pandemic highlight the importance ofadvancing the digital health agenda for betterresponse. Key strategies were developed basedon international best practices and specificexamples from the response to COVID-19.01LEVERAGE ON DIGITAL HEALTH TO RESPOND TO PUBLIC HEALTHEMERGENCIES SUCH AS THE COVID-19 (MAHMOOD, 2020; SCOTT, 2013;WHO, 2019) Assess the current state of digital health in the country and identify the nationalneeds to integrate the utilization of digital health modalities within the system Develop a national partnership across multiple sectors to align investments,resources and efforts; therefore ensuring sustainability of digital health effortsand enabling growth Ensure data interoperability by complying with health data standards. This canallow the seamless flow of data among different stakeholders Develop and implement a national and context-specific E-health vision andstrategy based on local needs Ensure the availability of adequate and sustainable financial resources Develop a digital infrastructure that can support digital transformation Build health workforce capacity including skills related to leadership andgovernance as well as technology-related skills Develop laws and policies to ensure compliance with ethical standardsK2P Harnessing the Power of Digital Health
1802PROMOTE THE UTILIZATION OF BIG DATA TO ADVANCE AND SUPPORTDIGITAL HEALTH TECHNOLOGIES IN INFORMING AND SUPPORTING THERESPONSE TO COVID-19 AND BEYOND (VAYENA ET AL., 2018; GUPTA ETAL., 2018; KRUSE ET AL., 2016; SAMUEL & DERRICK, 2020). Identify big data sources that can be used to support digital health technologiesand information mining Promote interoperability of data sources Develop an intricate governing framework to address concerns related to (1)data minimization, (2) privacy and security, (3) transparency, and (4) consent Ensure that big data is leveraged for the public goodK2P Harnessing the Power of Digital Health
1903INVEST IN ROBUST NATIONAL HEALTH INFORMATION SYSTEMS (HIS) (WHO,2007; WHO, 2008; WHO, 2014). Updating HIS policies laws and regulations Improving national coordination, planning and accountability and integratingboth public and private providers. Ensuring availability of adequate human, financial and technical resources Optimizing data generation, quality assurance, monitoring and flow Building capacity of users on the utilization of the health information systems Strengthening data and information dissemination, such as translating datainto information through dashboards and issuing alerts based on outbreakidentification using the HIS Conducting a periodic assessment of additional health information needs04HARNESS THE UTILIZATION OF VIRTUAL TECHNOLOGY TO RESPOND TOTHE CONTINUOUS INCREASE IN DEMAND FOR HEALTH SERVICES THAT ISNOT LIMITED TO PUBLIC HEALTH EMERGENCIES BUT ALSO EXTENDS TOEVERYDAY PRACTICE (SMITH ET AL., 2020). Ensure sustainable financing and appropriate remuneration for service provision Train healthcare workforce on new methods required for virtual healthconsultations Redesign the existing model of care by adopting a whole-system approach andembedding virtual health within the health system Develop policies and procedures for virtual health Ensure adequate infrastructure to support virtual technology (that can bescaled-up during emergencies)K2P Harnessing the Power of Digital Health
2005ENABLE PUBLIC ENGAGEMENT AND ENROLLMENT IN DIGITAL HEALTHINTERVENTIONS (O’CONNOR ET AL., 2016) Raise public awareness on the role of different digital health interventions, theirbenefits, and potential risks. Consider incorporating two-way communication platforms where users caninteract with healthcare providers or peers with similar health issues. Obtaining endorsement from respected healthcare providers or instructions onthe digital health technologies utilized to promote additional user sign up andengagement Market the digital health interventions by targeting not just the patient but alsohis wider support network, such as his peers and his healthcare providers Develop user-friendly and easy access and sign up digital interventions Invest in upgrading network capacity and technical infrastructure Invest in digital upskilling which would allow users to gain the skills needed toutilize the digital solutions Provide funding models that can ensure equity Inform the public of potential security threats and develop regulations to addresssecurity and user privacy and ensure the anonymity of information gatheredK2P Harnessing the Power of Digital Health
21Further InsightsAs the COVID-19 pandemic unfolds, technologicalapplications are emerging as fundamental tools forgovernments, healthcare providers and healthcareinstitutions to effectively respond to public healthcrisis and to improve access to healthcare. There isno one-size-fits-all when it comes to digital health yetthis advancement will require extensive assessments,localizing validated solutions and commitment toenable it.While COVID-19 is a public health crisis, it is also anopportunity for the EMR governments, healthcareproviders and healthcare institutions to harness,invest and capitalize on digital health technologies tostrengthen evidence-informed decision-making duringoutbreaks and to address global and national healthchallenges.K2P Harnessing the Power of Digital Health
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K2P Harnessing the Power of Digital Health 4 While this document does not evaluate the impact of the components of digital health, it provides insights based on evidence and experience during the COVID-19 on how digital health can harness and enable health systems to respond to the COVID-19 pandemic and other public health
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