by Tarneem Darwish, MD; Samuel Korouri, BA; Mia Pasini, RN, MSN; Maria Veronica Cortez, RN; and Waguih William IsHak, MD, FAPA
Drs. Darwish and IsHak and Mr. Korouri, Ms. Pasini, and Ms. Cortez are with the Department of Psychiatry and Behavioral Neurosciences at Cedars-Sinai Medical Center in Los Angeles, California. Dr. IsHak is also with the Department of Psychiatry at the David Geffen School of Medicine in Los Angeles, California.
FUNDING: No funding was provided for this study.
DISCLOSURES: The author has no conflicts of interest relevant to the content of this article.
ABSTRACT: The COVID-19 pandemic presents a significant challenge for providing adequate healthcare services in the context of patient isolation.
Discussion. The ability of our current healthcare system to cope with the current situation is mainly dependent on advanced health technology, such as telehealth, chatbots, virtual reality (VR), and artificial intelligence (AI). Telehealth can be a novel tool for improving our current healthcare system and allowing for greater delivery of healthcare services during global crises (i.e., the COVID-19 pandemic). Technology, such as chatbots, VR, and AI, could be utilized to reduce the burden of both communicable and noncommunicable diseases, as well as to build a patient-centered decision-making healthcare system.
Objectives. Understanding the various methods of enhancing healthcare services using advanced health technology will help to develop new applications that can be integrated into regular healthcare and in time of healthcare crises.
Conclusion. Advanced health technology is a main tool to face a pandemic that decreased the burden on physicians and patients as well as the entire healthcare system.
Keywords: Health technology, telehealth, health system, COVID-19, pandemic
Innov Clin Neurosci. 2021;18(1–3):
Health systems all over the world face an unprecedented challenge with the novel coronavirus (COVID-19), which originated in late 2019.1 The COVID-19 pandemic presented additional threats to the fragile relationship between community health, medical care, and health technology.2 By the end of November 2020, the number of positive COVID-19 cases surpassed 59 million worldwide, with 1,397,000 deaths; it is approaching 12.5 million in the United States (US), claiming 261,387 deaths.3 A national emergency was declared in the US followed by a stay-at-home government order on March 20, 2020, prompting the implementation of social (physical) distancing measures to slow the spread of the virus. This was a strategy that negatively impacted the economy, social life, and healthcare, as it has reduced access to support from family and friends; it has degraded social support systems and has thus increased the risk for anxiety and depressive symptoms.4 It raised the challenge of providing adequate healthcare services in the context of patient isolation, prompting the implementation of protocols that address both the physiological and psychological needs of patients and providers.4 Furthermore, it has increased the need for more medical staff to face this pandemic, including bringing back retired physicians, many of whom fall into the high-risk categories.5
The healthcare system had utilized telephone triage and advice to prioritize high demand and facilitate access to appropriate services.6,7 Previous studies have shown that patients’ compliance with triage advice varied according to the patient’s need, where higher compliance was reported in patients receiving advice to attend the emergency department compared to those advised to seek primary care.8 The healthcare system has been introduced to new and compelling innovations created in the past few years following the significant recent advances in technology, such as telehealth.9–11 Telehealth can play an important role in facing the current situation.
A variety of options to assist telehealth implementation include phones, computers (laptops and desktops), and tablets. Many virtual formats became available recently such as chatbots, embodied conversational agents, and three-dimensional avatars.12 Moreover, telehealth, particularly video consultations, has been promoted to reduce both the risk of infectious transmission and the workload on medical staff, especially those in the United Kingdom and the US.13–15 Furthermore, telehealth services, in particular for mental health, have been expanding in China and Australia as well.16,4
Compared to telephone triage, online video consultation enables a feeling of presence between patients and providers and enhances nonverbal or body language communication. Research has shown psychologist and psychiatrist satisfaction with providing telehealth by being able to read patients’ body language cues.17 Participants were also satisfied with the feeling of presence during their online psychotherapy sessions.18 Moreover, studies reported satisfaction and improved chronic disease management when patients used home telehealth system, which empowered them to participate in their own health management.19 Results from semi-structured interviews with patients with diabetes using telehealth for disease management reported patients’ appreciation of the continuity of monitoring and care, which boosted their comfort and sense of security.20
Understanding the challenges facing telehealth, in general, will help to identify ways to improve upon it and to thus make it available for everyone sooner rather than later, especially with the increased need for effective telehealth services during the COVID-19 pandemic. The use of telehealth to provide mental health services still has a lot of drawbacks to successful application.21 Such barriers are sometimes technological, as well as cultural both for patients and mental health professionals.22
The fast progress in telehealth might soon replace the traditional face to face practice in our daily life. A 2010 meta-analysis argued that computer therapy for anxiety and depressive disorders was effective, acceptable, and practical healthcare tool.23 Since that time, many researchers worked on this field till in 2018, when Andrews et al23 published a meta-analysis of 4,423 abstracts. The results had shown that face-to-face cognitive behavioral therapy (CBT), iCBT, and bibliotherapy are equally effective for anxiety and depressive disorders treatment, but face-to-face CBT is more time consuming while iCBT has higher rates of satisfaction, acceptability, and moderate adherence. iCBT is more privileged by being more convenient to use and more private form or treatment. The iCBT needs more standardization, as the current available forms are diverse and the content varies according to the diagnosis; moreover, the range of topics are different, which might affect the quality of the service. When it comes to medication prescription, this process becomes more complicated.23
A detailed and practical telehealth experience was presented during the COVID-19 outbreak in Italy using free applications.24 According to this experience, the challenges of implementation included technology unavailability, breakdowns, poor connections, privacy concerns, informed consents, payment-related problems, and human diffidence.25 On the other hand, the successes of implementation included a reduction in patient isolation, reduced costs of healthcare services, and increased overall patient and health professional satisfaction.25
Telehealth challenges also include privacy concerns despite significant efforts to overcome such a problem. In 2017, a software platform called Epharmix was developed by Washington University in St. Louis, Missouri, with unique high data security protecting both patient and provider’s privacy. It was designed to have a built-in combination of security measures including “identifier removal, clinically relevant surveys, clinical data reporting, voluntary opt-out, toll-free messaging, customizable message frequency, consent confirmation, and time tracking.”26 Privacy regulations during the COVID-19 pandemic were challenged in the face of barriers to medical care access, resulting in the government decision to waive Health Insurance Portability and Accountability Act (HIPAA) business associate agreements for the provision of telehealth services.27 It is interesting to note that commonly used apps such as Skype are not HIPAA compliant, and thus might not provide a high level of security.28 However, Zoom still meets the necessary HIPAA specifications for access and audit control, integrity, person or entity authentication, and transmission security.29 An important standard practice for providers using telehealth to deliver services is to notify patients that these third-party applications might introduce privacy risks.27
Additional telehealth challenges include the inability to perform a proper physical examination, inability to engage certain patient age groups especially at upper and lower limits of age, and physician communication skills.30,31 One of the successful experiences that overcame some of these challenges is the TeleBurn app in the Medical University of South Carolina, which helped patients with burns to heal faster and comply with the treatment better than face-to-face treatment. It involved major collaborations of experts from different fields including burn care, nursing, health communication, information technology (IT), public health, and clinical psychology.32
The multimodal, multifunctional, recently developed conversational agents (also known as chatbots) can be of great help to the general public, patients, and physicians through automation of a diverse range of health-related activities. Understanding the psychophysiological mechanisms underlying the virtual patient-agent interaction that is a hallmark of telehealth interactions is a great point of interest among researchers.33 It was suggested that a positive and congruent response by a virtual agent can overcome the belief that the agent is a computer program, hence enhancing such an interaction.33 Chatbots analyze user inputs by using natural language and respond via auditory or textual methods using human language, a process that mimics human interaction.34 They are designed to offer the ability to learn as they go, in addition to the ability for shifting in conversation structure and flow, while addressing the variability of language, which can help in understanding the described health-related needs.35 Amazon’s Alexa is a good example of a widely used voice recognition application used in daily life in many households.36 These conversational agents can perform vital tasks including triage, diagnostics, counseling, health promotion, and training of health care professionals, which decreases the burden on the current healthcare system and enables populations with limited access to these services.12 Though its use requires tolerance for imperfection and postrelease improvement, it performs mundane tasks in predictable fashion, which offers it a unique ability to handle the level of variation and complexity in medical questions arising in the time of pandemic.37
Since 2018, Buoy Health and the Boston Children’s Hospital have been collaboratively working on a web interface-based system that provides advice to parents for their ill children by answering questions about medications and whether symptoms require a doctor visit.36 In January 2020, Herriman et al outlined the creation of a Penn Medicine Chatbot, which was collaboratively created with Verily, Google Cloud, and Quantiphi, a Google Cloud strategic partner. They started by analyzing incoming patient questions, then designing the chatbot as a symptom checker with the ability to transform information into desired patient actions (after creating a system for ongoing answer verification) while responsibly managing constrained resources.38
Predictive modeling tools that can improve patient safety and outcomes, as well as supporting clinician and patient decision-making capacity, can be developed using the rapidly growing electronic healthcare record (EHR) data, artificial intelligence (AI), and machine learning (ML) approaches.39 Furthermore, the interaction between AI and patients can be based on physical signs of interpretation by conversational agents. The input channels have recently developed to allow body and eye movement perception and analysis of gesture, which collectively get integrated into multimodal signals as in the case of human-human interaction, which might therefore enhance the user-agent interaction.12 Patient temperature can be collected through a remote assessment of the patient’s body temperature.40 Patient anxiety can be assessed as well through a newly recommended technique to investigate cortisol dynamics in human sweat using a graphene-based wireless health system, which can be used as one of the parameters in the predictive model.12,41 The implementation using digital biomarkers coming from smartphones, wearable sensors, and smart homes. Both physicians and patients need to integrate these programs into routine care as means for increasing empowerment, improving health literacy, and reducing disease burden.
Research into virtual reality (VR) has rapidly developed this method as a possible contribution to therapeutic value in mental health, particularly for anxiety disorders.21 These conversational agents became more developed and have personalization features integrated, which improved user satisfaction, engagement, and dialogue quality; this can collectively allow more patients involvement in their healthcare, decision making, and helping to provide patient-centered care.12
In conclusion, advanced health technology, such as telehealth, chatbots, VR, and AI, could be utilized to reduce the burden of both communicable and noncommunicable diseases, as well as to build a patient-centered decision-making healthcare system. Understanding the various methods of enhancing healthcare services using advanced health technology will help to develop new applications that can be integrated into regular healthcare and in time of healthcare crises.
- Grange ES, Neil EJ, Stoffel M, et al. Responding to COVID-19: The UW medicine information technology services experience. Appl Clin Inform. 2020;11(2):265–275.
- McCullough PA, Eidt J, Rangaswami J, et al. Urgent need for individual mobile phone and institutional reporting of at home, hospitalized, and intensive care unit cases of SARS-CoV-2 (COVID-19) infection. Rev Cardiovasc Med. 2020;21(1):1–7.
- The Centers for Disease Control and Prevention site. Coronavirus disease 2019 (COVID-19). Mar 2020. https://covid.cdc.gov/covid-data-tracker/?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-updates%2Fcases-in-us.html#cases_casesper100klast7days. Accessed 02 Mar 2021.
- Zhou X, Snoswell CL, Harding LE, et al. The role of telehealth in reducing the mental health burden from COVID-19. Telemed J E Health. 2020;26(4):377–379.
- Thomson E, Lovegrove S. Let us help’- why senior medical students are the next step in battling the COVID-19 pandemic. Int J Clin Pract. 2020;74(8):e13516.
- St George I, Cullen M, Gardiner L, Karabatsos G. Universal telenursing triage in Australia and New Zealand – a new primary health service. Aust Fam Physician. 2008;37(6):476–479.
- Nagree Y, Cameron P, Gosbell A, Mountain D. Telephone triage is not the answer to ED over crowding. Emerg Med Australas. 2012;24:123–126.
- Tran DT, Gibson A, Randal D, et al. Compliance with telephone triage advice among adults aged 45 years and older: an Australian data linkage study. BMC Health Serv Res. 2017;17:512.
- Gulshan V, Peng L, Coram M, et al. Development and validation of a deep learning algorithm for detection of diabetic retinopathy in retinal fundus photographs. DR JAMA. 2016; 316(22):2402–2410.
- Coudray N, Ocampo PS, Sakellaropoulos T, et al. Classification and mutation prediction from non-small cell lung cancer histopathology images using deep learning. Nat Med. 2018;24(10):1559–1567.
- Esteva A, Kuprel B, Novoa RA, et al. Dermatologist-level classification of skin cancer with deep neural networks. Nature. 2017;542(7639):115–118.
- Baptista S, Bellei E, Tanaka H, et al. Effectiveness of conversational agents (virtual assistants) in health care: protocol for a systematic review. JMIR Res Protoc. 2020;9(3):e16934.
- Greenhalgh T, Wherton J, Shaw S, Morrison C. Video consultations for covid-19. BMJ. 2020 Mar 12;368:m998.
- Hollander JE, Carr BG. Virtually Perfect? Telemedicine for Covid-19. N Engl J Med. 2020;382:1679–1681.
- Dorsey ER, Topol EJ. Telemedicine 2020 and the next decade. The Lancet. 2020;395(10227):859.
- Liu S, Yang L, Zhang C, et al. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry. 2020;7(4):e17–e18.
- Williams A, Larocca R, Chang T, et al. Web-based depression screening and psychiatric consultation for college students: A feasibility and acceptability study. Int J Telemed Appl. 2014;2014:580786.
- Guillén S, Arredondo MT, Traver V, et al. Multimedia telehomecare system using standard TV set. IEEE Trans Biomed Eng. 2002;49(12):1431–1437.
- Rahimpour M, Lovell NH, Celler BG, et al. Patients’ perceptions of a home telecare system. Int J Med Inform. 2008;77:486–498.
- Lee, PA, Greenfield, G, Pappas, Y. Patients’ perception of using telehealth for Type 2 diabetes management: a phenomenological study. BMC Health Serv Res. 2018;18:549.
- Aboujaoude E, Gega L, Parish MB, Hilty DM. Editorial: digital interventions in mental health: current status and future directions. Front Psychiatry. 2020;11:111.
- Negrini S, Kiekens C, Bernetti A, et al. Telemedicine from research to practice during the pandemic. “Instant paper from the field” on rehabilitation answers to the Covid-19 emergency. boldrinip. eurjphys rehabilmed. Eur J Phys Rehabil Med. 2020;56(3):327–330.
- Andrews G , Basu A, Cuijpers P, et al. Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: an updated meta-analysis. J Anxiety Disord. 2018;55:70–78.
- Negrini S, Ferriero G, Kiekens C, Boldrini P. Facing in real time the challenges of the Covid-19 epidemic for rehabilitation. Eur J Phys Rehabil Med. 2020; 56(3):313–315.
- Medicare site. Telehealth. https://www.medicare.gov/coverage/telehealth. Accessed 02 Mar 2021.
- Som A, Patel K, Sink E, et al. Novel patient engagement platform using accessible text messages and calls (Epharmix): feasibility study. JMIR Form Res. 2017;1(1):e2
- Gorodeski EZ, Goyal P, Cox ZL. et al. Virtual visits for care of patients with heart failure in the era of COVID-19: a statement from the heart failure society of America. J Card Fail. 2020;26(6):448–456.
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