Use of digital technology in Hospital(Non-ICU)COVID-19 patients

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                                Use of Digital Technology in Hospitalized (Non-ICU) COVID-19 patients

Introduction:

Any patient requiring hospital admission due to a suspected or confirmed COVID-19 diagnosis is isolated immediately upon arrival to the emergency department. They are placed on a high-risk respiratory unit, with strict no visitor policies. Families are restricted from visiting as they pose a risk to themselves, to the staff, and the public.

Communication:

“Need for a human connection, loneliness, clinicians overstretched for time and only further slowed by the don on and don off protocols, an effort to conserve the much-needed PPE”, (p3)1 an attempt to reduce healthcare provider exposure time to this highly contagious patient population makes communication even more challenging. Isolation without family contact can be daunting causing severe patient anxiety and psycho-social distress.2 If the patient’s prognosis is poor, having sensitive goals of care conversations can be overwhelming for patients as well as the healthcare provider.

Goal:

Attempt to optimize communication between patients, family members, and the health care staff. This is done by appropriate integration of telehealth into workflows, in a simple, clear, secure manner, using readily available, low cost, and easy to use video conferencing tools.4

Tools:

Real-time audio-video tools connecting patients and healthcare workers,by utilizing interactive videoconferencing through mobile health( mHealth)applications(apps) on a computer, tablet, or a mobile device.3

Privacy:

Earlier only HIPAA compliant software was allowed for video conferencing.4 As the demand for telehealth options suddenly increased after COVID -19, the Department of Health and Human Services temporarily expanded allowable applications( apps)and stated that they, “will not impose any penalties for non-compliance with the regulatory requirement under HIPAA rules.”(p2)4
“Non-public facing remote communication products( Apple Facetime, Facebook Messenger video chat, Google Hangouts meet, Whatsapp chat, Zoom, Skype)”(p4)5 were permissible platforms as they used ‘end-to-end encryption’.
Privacy may involve “creating unique user accounts for every patient”.Only an approved contact list should be used to make calls. This ensures strangers don’t call patients. If the devices are used with multiple patients, then video capture and screenshots will need disabled. This will ensure that photos/ recordings of staff or patients are not stored in the device.4
If mobile device apps lack the ability to block call origin, it can lead to uncomfortable situations. For example, when nurses use personal devices such as in emergencies, then subsequent callbacks from family members can happen, causing distress to both parties.11

Videoconferencing :

A UK-based study compared a multitude of software platforms such as MS Teams, Cisco WebEx, Zoom, Google Hangouts Meet, GoToMeeting, and Slack.
MS teams: Highly organized, customizable, met security requirements of healthcare organizations. Personal accounts are set up free of cost. 250 users can access the meeting at once. It is however only usable in a Microsoft environment. As it is so compartmentalized, it comes with a steep learning curve.13
Cisco WebEx: Meeting uses a mobile app or a browser/ website. It is well known for its voice and video quality. “Up to 25 simultaneous video feeds can be supported for up to 100 participants.”(p4)13 It is also optimal for use in healthcare. But it allows only one presenter per license.13
Zoom: User-friendly, widely used for social networking. It has built-in-messaging features, easy to set up, and can accommodate 49 videos on a single screen. But there are privacy concerns with end-to-end encryption.13
Google Hangouts: User-friendly, easy to use, compliant with data security. It can accommodate 150 users at once. But this platform is not tailored to the health care system.13
GoToMeeting: It has a smartphone-friendly application. Additional software needs to be downloaded on the computer. It can allow 250 participants. It does not support third-party applications, so its use in healthcare is limited.13
Slack: Has a good third party application. It is healthcare compliant but allows only 15 logins per call. “The Microsoft integration was not as seamless with Slack.”(p3)13
A US-based article compared FaceTime, Google Duo, Google Hangouts, Skype, Zoom.
FaceTime: Easiest to set up, but it is not ‘cross-platform’. That means it is not available on multiple different operating systems and devices. Only Apple devices have to be used. But the setup is easy and it comes preinstalled.4 Facetime is the “only free app that hides app and device settings from patients and provides a full restriction.”(p7)4
Google Duo: Does not restrict contacts, so a new account or password needs to be generated at each encounter.
Google Hangout, Skype, and Zoom: Even though the apps restrict contacts, patients can remove the restriction within the app, if the app settings are not hidden.4
Facetime and Google Duo generate call logs from typed chats. So the call logs, contacts list, and typed chats all need to be deleted after every video call. They both use E2EE(a most secure form of encryption, where a third party cannot decrypt any transmitted data).”(p6)4

Device Costs:

Tablets pose an upfront cost burden on hospitals, ranging from $50 to $500.“Most common tablets run one of three operating systems( Android, Windows, IOS).”(p3)4 Community donations of used tablets is another option.4

Uses:

  1. Video conferencing provides a more personal touch.
  2. Participants can better assess non-verbal cues.4
  3. Decreased use of PPE.
  4. Limits avoidable health care exposure.
  5. Clerks, case managers, social workers do not require to enter the room.4
  6. In a teaching hospital, the entire teaching team does not need to enter the room.4
  7. Palliative care consults can be done for the end of life care to patients and families.12
  8. Can be extrapolated to any airborne or droplet precautions setting.

Limitations:

Approximately,41% or more of Medicare patients have no computer access with a strong internet home connection. 41% don’t have a smartphone and a wireless data plan, and 26% or more don't have access to either.(p1387)15,14 “Unreadiness was more among patients 85 years or older, unmarried, men, Black or Hispanic, lived in rural areas, and who had less education, lower-income and worse self-reported health.”(p1387)15,14
  1. Increased training burden on the providers, patients, and their families.
  2. Patients who do not speak English4,7, and families living outside the United States.
  3. Clinician unwillingness to improve digital literacy.6,10
  4. Financial reimbursement concerns from insurers.10
  5. Lack of ability to keep a digitally secure list of patient and family contacts that is readily available to the clinical team. So, overworked clinical staff needs to locate, confirm, and re-enter phone numbers or email addresses.”(p2)11
  6. Cannot be used in the ICU setting with critically ill, highly infectious, intubated, and sedated patients.9
  7. Cannot be used for patients with cognitive impairment, delirium, hearing or visual loss, unmotivated patients, or other co-morbidities that affect the ability to use technology effectively.12

References:

  1. Srinivasan SR. Tele-ICU in the Age of COVID-19: Built for This Challenge. The journal of nutrition, health & aging. 2020;24(5):536-537. doi:10.1007/s12603-020-1376-6
  2. Bains J, Greenwald PW, Mulcare MR, et al. Utilizing Telemedicine in a Novel Approach to COVID-19 Management and Patient Experience in the Emergency Department. Telemedicine and e-Health. 2020. doi:10.1089/tmj.2020.0162
  3. Karen S. Rheuban MD. Telemedicine. Telemedicine | Technology and Finance | AMA STEPS Forward | AMA Ed Hub. https://edhub.ama-assn.org/steps-forward/module/2702689. Published October 7, 2015. Accessed October 23, 2020.
  4. Fang J, Liu Y, Lee E, Yadav K. Telehealth Solutions for In-hospital Communication with Patients Under Isolation During COVID-19. Western Journal of Emergency Medicine. 2020;21(4). doi:10.5811/westjem.2020.5.48165
  5. https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf
  6. Poncette A-S, Mosch L, Spies C, et al. Improvements in Patient Monitoring in the Intensive Care Unit: Survey Study (Preprint). 2020. doi:10.2196/preprints.19091
  7. Abad C, Fearday A, Safdar N. Adverse effects of isolation in hospitalized patients: a systematic review. Journal of Hospital Infection. 2010;76(2):97-102. doi:10.1016/j.jhin.2010.04.027
  8. Arneson SL, Tucker SJ, Mercier M, Singh J. Answering the Call: Impact of Tele-ICU Nurses During the COVID-19 Pandemic. Critical Care Nurse. 2020;40(4):25-31. doi:10.4037/ccn2020126
  9. Dhala A, Sasangohar F, Kash B, Ahmadi N, Masud F. Rapid Implementation and Innovative Applications of a Virtual Intensive Care Unit During the COVID-19 Pandemic: Case Study. Journal of Medical Internet Research. 2020;22(9). doi:10.2196/20143
  10. Smith AC, Thomas E, Snoswell CL, et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). Journal of Telemedicine and Telecare. 2020;26(5):309-313. doi:10.1177/1357633x20916567
  11. Rose L, Cook A, Casey J, Meyer J. Restricted family visiting in intensive care during COVID-19. Intensive and Critical Care Nursing. 2020;60:102896. doi:10.1016/j.iccn.2020.102896
  12. Ramsetty A, Adams C. Impact of the digital divide in the age of COVID-19. Journal of the American Medical Informatics Association. 2020;27(7):1147-1148. doi:10.1093/jamia/ocaa078
  13. Khincha PP, Chauhan V, Ekwobi CC. COVID-19: the impetus for change—sustaining healthcare team communication in times of social distancing. European Journal of Plastic Surgery. 2020;43(5):523-526. doi:10.1007/s00238-020-01702-3
  14. Eric T. Roberts PD. Assessment of Disparities in Digital Disparities Among Medicare Beneficiaries. JAMA Internal Medicine. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2768771. Published October 1, 2020. Accessed October 24, 2020.
  15. https://www.ama-assn.org/practice-management/digital/why-so-many-patients-still-can-t-connect-doctors-telehealth

Submitted by (Sunita Mall)