key: cord-278672-pxzsntfg
authors: Milenkovic, Aleksandar; Jankovic, Dragan; Rajkovic, Petar
title: Extensions and Adaptations of Existing Medical Information System in Order to Reduce Social Contacts During COVID-19 Pandemic
date: 2020-06-16
journal: Int J Med Inform
DOI: 10.1016/j.ijmedinf.2020.104224
sha: 
doc_id: 278672
cord_uid: pxzsntfg

OBJECTIVE: The main objective of this paper is the reduction of the COVID-19 pandemic spread by increasing the degree of social distancing by using and upgrading the existing Medical Information System (MIS). MATERIAL AND METHODS: The existing MIS MEDIS.NET, currently used in the largest health center in the Balkans, has been adapted and further developed. RESULTS: During the adaptation of existing MIS MEDIS.NET 4 new and 9 existing modules were developed. A quick questionnaire for the smart triage of patients was also implemented. DISCUSSION: The adapted MIS successfully influenced the reduction of social contacts within the Health Center Nis. The need for the arrival of children and their parents to receive appropriate health certificates for the school enrolment is reduced. The therapy of chronic patients has been prolonged for 6 months via an electronic prescription. An online service for the communication between patients and the chosen physicians is provided. Possible social contacts and exposure to the viral environment of patients are reduced by making appointments in extended slots and at determined physical locations. Patients are notified per SMS or email about the availability of chosen and physician on duty. The social distancing of patients and physicians is also established by sending laboratory analyses per email or SMS. Keeping the central registry for COVID-19 is enabled throughout the country. CONCLUSION: The smart adaptation of MIS, and its collaboration with other state systems can significantly influence the reduction of social contacts and thus mitigate the consequences of COVID-19 pandemic.

The emergence and rapid expansion of major epidemics, besides the influence on the daily lives of people through changing health, economic, working style, social and political routines, also has a significant impact on existing information technology (IT) products, with a great emphasis on large-scale information systems (IS) which are exploited on a daily basis. During outbreaks, especially those with a pandemic character, the following key activities [1] which are updated with COVID-19 strategy [2] have been identified whose strict implementation has an impact on the reduction of number of infected people and suppression of the spread of epidemic: 6 . Isolation of persons who are suspected to be infected with the virus [6] (the persons not yet diagnosed with the disease), 7 . Monitoring persons during home isolation in order to check whether they follow the rules of self-isolation, 8 . Make as many digital (government, administration, health such as telehealth [7] ) online services as possible available to people to reduce their need to exit and be exposed to the infectious environment.

The main problem that naturally arises is the efficient suppression of the rapid spread of epidemic i.e. reducing the number of persons who could be exposed to the infection through the proposed key activities. The reduction of disease transmission is most efficiently conducted by socially distancing people from each other and reducing their contacts [8] . Additionally, educational campaigns which strengthen the understanding of the outbreak and adhere to mitigation strategies need to be conducted in order to raise awareness about the COVID-19 disease and its consequences. Some epidemics have the characteristic of rapid pathogen spread, which causes them with the high incidence of hospitalized and severely ill patients. Emerging of an enormous number of patients, suffering from the disease which causes the epidemic, within a short period of time, can become a major problem for the whole healthcare system of a country especially with an emphasis on the secondary or tertiary protection level. Even well-developed countries with the most sophisticated healthcare systems can easily experience the healthcare collapse during epidemics [9] (e.g. Italy [10] , USA [11] , Spain [12] , UK [13] ). The primary healthcare system in such circumstances needs to undertake significant steps in early diagnosing of ill patients and reducing the degree of contact in order to avoid the collapse of secondary and tertiary level. Besides engaging healthcare resources to combat the epidemic, the need emerges for an intensive use of IT solutions. This paper presents the adaptation and extension of existing medical information system (MIS) as an efficient response to the rapid COVID-19 epidemic spread, mostly through influencing the reduction of social contacts and earliest possible identification of potentially infected persons.

The objective of this paper is increasing the degree of social distancing (decreasing unnecessary physical contacts in a healthcare institution and city in general) which is accomplished by adapting the existing MIS MEDIS.NET [14] .

The implementation of social distancing is based on the following relationships: patient to patient and patient to healthcare worker. The adjusted MIS gave an efficient response to the rapid spread of pandemic caused by COVID- 19 . By adapting MIS MEDIS.NET a software support is granted to the Healthcare Centre Nis (HCN) to combat the J o u r n a l P r e -p r o o f fast-spreading disease COVID-19. The software support is provided to the following key proposed activities: 1, 4, 5, 6, 8.

The novel coronavirus appeared by the end of 2019 and is named SARS-CoV-2 [15] . It was discovered in China by the end of 2019 in the city of Wuhan, the province of Hubei [16] . The disease caused by the virus SARS-CoV-2 is named COVID-19. For COVID-19 the World Health Organization (WHO) assigned the urgent ICD-10 diagnosis U07.1 [17] . Since its emergence, COVID-19 is the center of attention of many researchers. One recent study [18] reviewed the virology, origin, epidemiology, clinical manifestations, pathology and treatment of COVID- 19 showed bilateral patchy shadows or ground glass opacity in the lungs [19] . The COVID-19 disease in most of the cases affects older men with comorbidities and can lead to severe as well as life-threatening respiratory diseases. The average age of these patients infected by new coronavirus in Wuhan was 55.5 years (SD 13.1) and 51% of them had some chronic disease [20] . The most vulnerable patients have chronic diseases such as diabetes, hypertension and cardiovascular disease with possible complications, which include acute respiratory distress syndrome (ARDS), RNAaemia, acute cardiac injury and secondary infection [21] .

The Fig. 1 shows the exponential growth of the affected and deceased people worldwide infected by COVID-19

[22]. Due to prolonged lockdown and fear of infection, COVID-19 adversely affect the mental health of the general The first case of the affected by the virus in the Republic of Serbia (RS) was recorded on March 6, 2020. The exponential growth of patients affected by COVID-19 is recorded in RS [25] .

The Government of RS formed on April 3 the COVID-19 IS [26] . The aim of this IS is to carry out epidemiological surveillance related to COVID-19. Due to the exponential and easy spread of the highly contagious COVID-19 disease, it was necessary to rapidly adapt the existing MIS during the beginning of the COVD-19 pandemic.

Due to the exponential growth of the COVID-19 disease it is crucial to develop triage protocols in order to identify and isolate patients suspected of having the COVID-19 infection in COVID-19 temporarily hospitals or special departments in existing health institutions for the isolation of patients. In this way the disruption of normal medical care would be mitigated. A successful protocol for triage during a pandemic requires a more detailed planning, which involves a constant data collection: about the patient (demographic and medical data), data about availability of healthcare resources [27] . A patient portal-based COVID-19 self-triage and self-scheduling tool was created and it was made available to all primary care patients at the large academic health system at the University of California, San Francisco (UCSF) Health [28] . Based on the results, during first 16 days of use symptomatic patient triage dispositions were as follows: 193 emergent (24%), 193 urgent (24%), 99 nonurgent (12%), 329 self-care (40%) and sensitivity for detecting emergency-level care was 87.5%. According to the research findings the integration of patient self-triage tools into electronic health record (EHR) systems has a great potential in improving the triage efficiency and preventing unnecessary visits during the COVID-19 pandemic.

The estimate of effects of physical distancing measures on the progression of the COVID-19 epidemic was conducted [29] . Synthetic location-specific contact patterns in Wuhan were used and adapted in presence of school and workplace closures as well as the general reduction in mixing in the community. Using an age-structured susceptible-exposed-infected-removed (SEIR) model the authors simulated the ongoing trajectory of the epidemic.

They fitted the latest estimates of epidemic parameters and investigated the age distribution of cases. Lifting of the control measures, such as allowing people to return to work in a phased-in way was also simulated. The effects of returning to work at the beginning of March or April were investigated. Based on the results, physical distancing measures showed to be most effective if staggered return to work happened at the beginning of April, which reduced the average number of cases by more than 92%. The authors summed up that if restrictions maintained until April, they would delay the peak of epidemic. Sudden lifting of measures could provoke an earlier secondary peak. Such a scenario can be avoided by relaxing the measures gradually.

The tools and methods developed for the identification of possible patients who suffer from some chronic disease show that the automatic summarization would help identify all patients with at least one record related to the diagnosis usually marked as chronic, with the final approval of medical professionals [30] . The results show that depending on the data filter definition, the total percentage of newly discovered patients with a chronic disease is between 35% and 53%, as expected. It is important to mark chronic patients during the regular physician's visit during the COVID-19 pandemic in MIS MEDIS.NET since they belong to the vulnerable and high-risk groups.

The use of smart technologies has been the focal point of many researches worldwide. Especially in recent times the researchers are focusing on developing phone applications which track infected and potentially infected people in order to suppress the spread of COVID-19. The Pan-European Privacy Preserving Proximity Tracing (PEPP-PT) [31] is a platform on whose development works a team of 130 researchers from 8 European countries. On the basis of this software national authorities remain free to decide how to inform persons that they were in contact with someone who was tested positive. World-renowned companies such as Apple and Google [32] are developing a smartphone platform that tracks the spread of COVID-19 by using proximity capabilities built into Bluetooth Low Energy transmissions, which enables the actual tracking of physical contacts of phone users who agreed to participate. The user who is tested positive for COVID-19 can enter the result into a health department-approved application. All other participating phone users who recently had a contact at the distance of approximately six feet with the infected user will be contacted by the application. During the largest Ebola epidemic in West Africa (2014 -2016) researches developed an Ebola J o u r n a l P r e -p r o o f contact tracing (ECT) application for tracing contacts [33] . The authors compared results of the application developed with the existing paper-based system. Based on their research, the app-based contact tracing recorded 63% of contacts of laboratory-confirmed cases, whereas paper-based contact tracing achieved the result of 39% with often incomplete data. The developed smartphone application is linked to an alert central system to notify the District Ebola Response

Centre of symptomatic contacts. The authors agreed that despite many challenges the use of application had benefits, such as improved data completeness, storage and accuracy.

The development of smart healthcare system is a highly important factor from the perspective of patients (e.g. better health self-management, timely and appropriate medical services can be accessed when needed), healthcare employees (e.g. reduce costs, relieve personnel pressure, achieve unified management of materials and information, and improve the patient's medical experience) and research institutions (e.g. reduce the cost of research, reduce research time, and improve the overall efficiency of research) [34] . The researchers emphasized the importance of new generation of information technologies, such as internet of things (IoT), mobile Internet, cloud computing, big data, 5G, microelectronics, and artificial intelligence in order to build smart healthcare. Furthermore, Big Data Computational Epidemiology is a new and exciting multidisciplinary area that uses computational models and big data for identifying and controlling the spatiotemporal spread of disease through populations (e.g. the H1N1 influenza) [35] .

In today's era of informatization many health care institutions are facing the need to rapidly improve their IT infrastructure to meet the challenges of modern times, such as the outbreak of COVID-19. The health facilities need to be prepared for the exponential growth of patients [36].

On the territory of RS as MIS several solutions are used among which are, during the last 10 years, the most (Table   1 , Table 2 ), as well as the development of additional software modules, which help healthcare workers to proactively act in the suppression of pandemic. Before the beginning of COVID-19 pandemic MIS MEDIS.NET did not have specifically developed software functionalities (modules, subsystems) which would help healthcare workers and patients to combat seasonal and exceptional pandemics. 

In the Fig. 2 

Due to the COVID-19 pandemic the state service of COVID-19 Republic IS [26] was urgently developed and put 

Smart EHR Module enhances MIS MEDIS.NET making it a more advanced version. One of the functionalities of the module is the clustering of patients based on the demographic and medical data by using the DNN [41] . Logistic regression [42] , Random Forest [43] and DNN are used for the implementation of subsystem for the smart identification and assessment of patients who will not come to the appointment with the chosen physician or/and to expensive diagnostic examinations for which a patient needs to wait, sometimes even for several months. This system has enabled patients to make appointments in overlapping slots [44] during the COVID-19 pandemic. For chronic patients [30] during a pandemic, a special submodule is used which suggests to general practitioners a possible therapy with the amounts of a medicine and the periodicity of taking a medicine, as well as possible referrals for specialist examinations [45] . Due to the use of new medicines during the treatment of infected patients with the COVID-19

infection, a subsystem is used as an assistance, which warns the physician whether the prescribed therapy corresponds to the established diagnosis. The subsystem also informs about the possible contraindications with other medicines the patient is using. A smart mobile reminder for taking the prescribed therapy [46] helps elderly and chronic patients during the pandemic not to forget to take the therapy at the predefined time. The developed subsystem for the use of existing data from MIS MEDIS.NET in the education of students at the Faculty of Medicine and newly employed workers, as well as for medical research [47] , enables tracking and studying the COVID-19 disease at this stage. Open Data Service is used for obtaining the demographic data from available open data sets in Serbia [48] .

Scheduling Module is responsible for recording scheduled/cancelled appointments of patients for an examination with chosen physicians/diagnostic devices. The centralized management of arranged checkup appointments and J o u r n a l P r e -p r o o f diagnostic procedures of patients was accomplished by integrating Scheduling module with the service/application "Moj doktor" IS [49] .

Mail Notification Modul is responsible for providing service information to patients and health center employees via email. SMS Notification Module enables providing service information via SMS [50] . During the pandemic these modules were used for sending information to health care employees and patients.

In order to receive updated demographic data for each patient during the pandemic Reporting Modul was connected to OpenData available services of the RS [48] . 

In the Fig. 5 and Fig. 6 a significant decrease of the arrival of patients during pandemic weeks at HCN is presented after the implementation of additional modules developed during the COVID-19 pandemic. From the 12 th pandemic week, the number of patients who received referrals for specialist examinations decreased notably (Fig. 6 ). Out of all the patients who came to the HCN, the patients who were referred to specialist examinations were predominantly chronic patients. In most of the cases those were the patients with diagnosed I10 -Essential (primary) hypertension and E11 -Type 2 diabetes mellitus. The reduced number of patients at the HCN also influenced the decrease in the laboratory referrals. The Fig. 6 . presents also the most frequent diseases for which prescriptions, referrals and laboratory orders were used.

All the patients who visited the health center showing some symptoms of COVID-19 went through the triage algorithm. Despite the lower arrival of patients ( Table 3 ) the number of patients who were forwarded to the Clinics of Infectious Diseases and Pulmonology was higher in comparison with last years. Taking into consideration that the number of arrivals of patients at HCN was in general reduced (Fig. 5, Fig. 6 ), the increase of such referrals was significant. COVID-19 as a significant manifestation had a rapid change of health condition on the lungs of a patient, J o u r n a l P r e -p r o o f so patients were after completing triage urgently referred to already mentioned external clinics for urgent further diagnostics. were patients who could be in home isolation, patients who were tested and not diagnosed with COVID-19, although they showed some infection symptoms or were in contact with infected or potentially infected persons. Patients with a Yellow priority had a clear picture of disease and were hospitalized in temporary COVID-19 hospitals. Patients with a Red priority were confirmed COVID-19 cases who also had some chronic disease and belonged to highly vulnerable groups (Table 1) . These patients were hospitalized and required constant monitoring. Patients with a Blue priority needed to be hospitalized and were directly transported from home to COVID-19 hospitals. 

One The most significant decrease of arrivals of patients at the HCN was recorded during the 13 th , 14 th and 15 th pandemic

week. It was influenced by the developed modules which were distributed to the HCN as they were developed and adapted. The greatest decrease so far was recorded in the 14 th week of 2020 (Fig. 5, Fig. 6 ). During the 13 th pandemic

week the integration with COVID-19 IS was completed so patients started to significantly communicate online with chosen physicians. At the same time, the number of their arrivals at the HCN decreased, which means that contacts and the stay in the environment with high virus presence incidence were reduced.

The age structure of patients who were coming the most during pandemic weeks was from 35 to 65 years of age were the data about the persons who were coming to physicians for examinations, during the period when the physicians were infected, and who were later diagnosed with the presence of COVID-19 (14-28 days before registering the disease). These data were provided by COVID- 19 analyses, which can be accepted or denied by the physician. The authors argue that the EHR is a necessary tool in supporting the clinical needs of a health system during the COVID-19 pandemic management.

One of the limitations of this study is that the top 10 chronic ICD-10 diagnoses did not include psychiatric illnesses such as depression. Psychiatric patients were deprived of psychiatric care and resulted in more severe levels of depression and anxiety during COVID-19 pandemic [52] . Workers are reluctant to taking time off work to attend hospital/clinic during COVID-19 pandemic [53] and the MIS MEDIS.NET may help them to book appointment.

Future research is required to extend the application of MIS MEDIS.NET to psychiatric patients and workers.

Furthermore, MIS MEDIS.NET can work with smartphone applications to deliver counselling [54] , rehabilitation [55] , support caregivers [56] and monitor symptoms [57] .

Since the coronavirus has potential for long lasting global pandemic with huge mortality rates and overloaded health systems, currently the only possible prevention is case isolation, contact tracing and quarantine, physical distancing, and hygiene measures [58] . A key approach to avoid the exceeding of health care capacities is by successfully implementing social distancing as a measure to control the spread of COVID-19. In order to achieve this, prolonged social distancing might be required until 2022 [59] . The 

The following contributions are made by the authors:

-Aleksandar Milenkovic, Dragan Jankovic and Petar Rajkovic made initial design of system functionalities;

-Aleksandar Milenkovic and Dragan Jankovic lead the system development and later deployment to the production environment;

-Aleksandar Milenkovic and Petar Rajkovic extracted the data and performed analysis and data interpretation;

-Aleksandar Milenkovic and Petar Rajkovic made a literature review;

-All the authors made initial article draft;

-All the authors revised and made a final approval of the submitted version.

Medical information system MEDIS.NET, whose usage overview is presented in the submitted work, is a result of a joint project of the Laboratory of Medical Informatics and Health Center Nis. As a commercial product, it is sold to other public health centers in the Republic of Serbia.

Aleksandar Milenkovic and Dragan Jankovic received personal fees as full members of Laboratory of Medical Informatics.

During the conduct of this research, Petar Rajkovic received no financial compensation, but was allowed to use statistically processed data for other researches.

This work has been supported by the Ministry of Education, Science and Technological Development of the Republic of Serbia (Project number: ON174026).

J o u r n a l P r e -p r o o f use the real medical data for the research that is presented in this paper. The assistance provided by Slavica Cvetkovic for language editing and proofreading is greatly appreciated.

What was previously known on the topic:

-Social distancing is one of the most significant measures in suppressing the spread of a virus during epidemics and pandemics (such as the current COVID-19 pandemic).

-Initially, medical information systems were not created for the purposes of social distancing.

-The adequate adaptation and upgrading of medical information systems can significantly increase social distancing by reducing patient to patient and patient to healthcare worker contacts.

-By customizing the medical information system social contacts can be significantly reduced and the spread of the virus slowed down without severely disrupting people's lives.

-The accurate triage is essential when there are not enough tests and when the laboratory capacities for samples processing are limited.

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The authors would like to offer their special thanks to all the staff at the Laboratory of Medical Informatics at the Faculty of Electronic Engineering in Nis. The special thanks are extended to the Health Center Nis for enabling the