key: cord-0696058-23q9gzg8 authors: Syed, Fibhaa; Hassan, Muhammad; Shehzad, Aamir; Shafi Koul, Salman; Ali Arif, Mohammad; Susan Dewey, Rebecca; Khaliq, Tanwir title: The establishment of a telemedicine center during the COVID-19 pandemic at a tertiary care hospital in Pakistan date: 2021-11-15 journal: Clinical eHealth DOI: 10.1016/j.ceh.2021.11.002 sha: 52dc58122768d8313ebd3cb29c1cc30f5ae36d41 doc_id: 696058 cord_uid: 23q9gzg8 Background Telemedicine involves the innovative application of technology to provide remote patient healthcare services especially those relating to emergency care and contagious disease spread. Telemedicine is less developed in low-and-middle-income countries like Pakistan and there is little published literature on its function and efficiency. Our institution was established to triage patients with COVID-19 symptoms to ease the load on emergency departments. Objective To conduct an analysis of the first month of function of a telemedicine/tele-triage center in Pakistan. To determine in which ways it was beneficial to hospital management during the COVID-19 pandemic. Methods This study was carried out at the newly established telemedicine/tele-triage center at the Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU) in Islamabad Pakistan between the 26th March and the 25th April 2020. Data were collected over telephone interview using a proforma to provide each caller with a C-Score (a C-score of <3 indicated observe at home 3-5- indicated home isolation with confirmatory testing and >5 indicated testing and transfer to hospital) representing their COVID-19 risk and informing the nature of the advice given to them. Data were presented using descriptive statistics. Results The center received total of 857 calls. Fever cough dyspnea and flu were present in 327(38.2%) 268(31.3%) 107(12.5%) and 124(14.5%) callers respectively. Based on the completion of the proforma 774(90.3%) callers had a C-Score of <3 75(8.8%) callers had a C-Score of 3-5 and 8 (0.9%) callers had a C-Score of >5. We recommended COVID-19 testing in 83 patients (9.68%) based on C-score. Out of these 83 patients 64 underwent testing and only 1 tested positive for COVID-19. Conclusion In a one-month period the center was able to support patients by providing a triage service thereby preventing numerous unnecessary hospital visits and helping to protect healthcare professionals during a global pandemic. Telemedicine has great potential to help patient populations in low-and-middle-income countries. The World Health Organization (WHO) have reported that telemedicine provides an economical use of ICT in healthcare services, facilitating the provision of emergency care, health monitoring, education, and research (2) . To contribute to the response to extraordinary events in the future, the WHO launched an eHealth Strategy at the 58th World Health Assembly in May 2005 (4) . Telemedicine has the capacity to provide and improve healthcare services in areas where access to healthcare is inadequate (5) . A reported 65% of smartphone users in the US have downloaded at least one medical app (6) , indicating that the public are open to online healthcare solutions (7) . Telemedicine is often used in the fight against infectious diseases, and be implemented at great pace and scale, making it a frontline tool. While the effectiveness of telemedicine is already broadly accepted, this article outlines the largest trial to date of patients-clinician interactions in the e-health setting. With remote monitoring of chronic health problems and good quality access to existing network infrastructure, the high-income countries are already benefitting from this technology, but in low-and-middle-income countries, the health infrastructure is less developed (8.9) . Further, there is little literature surrounding the development of such service platforms in countries such as Pakistan, highlighting the need for the present study. The development and introduction of ehealth services in low-and-middle-income countries requires a broad acceptance and efficiency of the relevant technology, as well as a minimum level of knowledge and understanding among users, and a working environment conducive to the adoption of novel technology. The goal of this research was therefore to analyze the function of a telemedicine center in Pakistan through assessing callers' COVID-19 symptoms, management, and follow up. The triage system implemented in the present study was different from those reported previously, such as a virtual medicine counselling system (VMCS) (10) , and as such, the function of a system implemented in this way has not been previously assessed. The objectives of the study were to conduct an analysis of the first month of function of a telemedicine/tele-triage center in Pakistan and to determine in which ways it was beneficial to hospital management during the COVID-19 pandemic. The Pakistan Institute of Medical Sciences (PIMS), in Islamabad, is associated with the Hospital of Shaheed Zulfiqar Ali Bhutto Medical University. PIMS is the country's premier postgraduate medical center, housing 1,254 hospital beds, and 32 medical and surgical specialties. The telemedicine center was established during the COVID-19 pandemic following a large investment in e-health in accordance with the HIPAA (Health Insurance Portability and Accountability Act) of 1996. This was the first telemedicine center established in Islamabad, capital of Pakistan just like the tele-triage center established in USA (11) . This cross sectional, retrospective study period comprised the first month of the facility opening, 26 th March to 25 th April 2020. All calls made to the center in this period, relating to COVID-19 symptoms and management, formed the study sample. Data were retrospectively extracted from the register of all callers to the center. Data extraction was completed by the authors. Information was captured from callers including demographic information, any COVID-related symptoms, recent travel, contacts, and their occupation (Table 1 ). This information was then used to categorize callers based on the number of risk factors they answered "yes" to, and their total score. C-score was devised by many local experts after various meeting and it was neither validated nor accredited. Callers were subsequently followed up by telephone call to determine whether they received a COVID test, whether it was positive, and whether their symptoms had abated. Callers were segregated based on the region from which they were calling: Pakistan as Punjab, Sindh, Baluchistan, Khyber Pakhtunkhwa, Azad Kashmir, and Islamabad Capital Territory (ICT). Data were analyzed using Statistical Package for Social Sciences (SPSS) version 22. Categorical variables were presented as frequencies and percentages. Descriptive statistics were used to estimate rates of telemedicine calls related and unrelated to COVID-19. Exposure to a known COVID-19 patient Yes=3, No=0 Family or friends with fever, flu or cough Yes=1, No=0 Are you a health worker? Yes=1, No=0 Resulting C-Score: Advice given: Less than 3 Less likely Observe at home Score 3-5 Suspected Home isolation and confirmatory test needed Score 6 or more Strong suspicion Testing and hospital transfer During the study period, the center received 857 calls relating to COVID-19 symptoms and management. The demographic information of callers is summarized in Table 2 . Using the scoring system outlined in the proforma, in Table 1 , frequencies of each item are given in Table 3 . Fever, cough, dyspnea, and shortness of breath were present as an indicator of COVID-19 symptoms in 327 (38.2%), 268 (31.3%), 107 (12.5%), and 124 (14.5%) callers, respectively. History of travel to an affected area, and contact with a COVID-19 patient were reported by 26 (3%) and 8 (0.9%) callers, respectively. Table 3 also shows callers' C-Scores, whereby 774 (90.3%) callers had a C-Score of less than 3, 75 (8.8%) callers had C-Score of between 3 and 5, and 8 (0.9%) callers had a C-Score greater than 5. The rates of callers taking various medications are also given in Table 3 . Table 4 . During the COVID-19 pandemic, it has been necessary to control and limit the spread of the virus, and to protect doctors, nurses, and other healthcare workers. E-health programs, including telemedicine, can contribute to limiting the spread of infection by allowing patients to receive medical advice from their homes. Such telemedicine programs are common in higher-income countries, especially China (upper-middle income group). This study demonstrates the effectiveness of telemedicine in providing patients with information and preventing unnecessary hospital visits. The ability of telemedicine to provide this service while protecting healthcare professionals demonstrates its usefulness as a clinical tool. This study showed that there was uptake of the telemedicine service, with 857 patients calling the center for matters related to the symptoms and management of COVID-19 in a one-month period. There is currently little published literature on the field of telemedicine. The absence of disseminated information outlining the implantation of telemedicine may in itself act as a deterrent preventing others from taking the leap themselves (9) . Awareness of the existence of telemedicine is likely to be a significant facilitator in the adoption of telemedicine, particularly among healthcare providers (12) . As such, there is a need for training in telemedicine to be provided to healthcare professionals in Pakistan. Recent studies conducted in low-and-middleincome countries have reported that doctors are receptive to the idea of telemedicine (12) (13) (14) (15) . A study conducted in Karachi demonstrated that doctors were able to understand the technology, and learn to use it correctly without the rigorous training that is sometimes needed in the consumer population (15) . The introduction of telemedicine system has provided a vital safety measure and decreased the impact of the pandemic on the emergency care setting. The use of telemedicine in non-urgent services has demonstrated that effective care can still be given while social distancing. Further, the use of telemedicine has facilitated quarantined/self-isolating/shielding but asymptomatic clinicians to provide treatment and consultation from their home, thereby reducing pressure on the system. Telemedicine has been reported to minimize "White Coat Syndrome", and the impact of reducing the frequency of hospital visits through the use of interactive medical videos and emails reduces patient anxiety. Further, telemedicine provides an ideal platform for monitoring and follow up in communicable diseases such as tuberculosis (13) . Moving patient consultation online increases the chance of a breach of patient privacy, creating a potential threat to the principle of protection (12) . In low-and-middle-income countries, telemedicine is still an emerging field, and there is little knowledge, experience, or guidance on frameworks for its implementation (16) . As mentioned previously, the triage system implemented in Pakistan was different from that of a VMCS, in that it involved greater financial investment in labor and video conferencing equipment, and also made provision for taking online consent, providing appointment reminders, and reports on numbers of pharmacists etc. (11) . Meanwhile, patients in Pakistan were not well-equipped electronically, and had a generally lower level of knowledge about ICT and telemedicine systems. As highlighted by a recent study in Karachi, the absence of financial support, reliable network access, and public familiarity with ICT act as significant barriers to public understanding of the value of telemedicine. However, many countries' healthcare sectors have already taken the first steps in the direction of e-health (5) . This was a single-center study that aimed to address the lack of existing evidence around the implementation of telemedicine in Pakistan, however, being a single-center study, it may not be generalizable to different settings. Further, the duration of the study was too short to fully assess the impact of telemedicine on hospital practice more generally, and the lack of follow-up of individual patients may further reduce the generalizability of the findings. Many aspects of investigation were beyond the scope of this study, for example the reason for the low uptake of COVID-19 testing once offered, patients' access to conventional healthcare, and the impact of religious or cultural factors, and the political environment. Longitudinal studies covering multiple centers will be needed to understand how telemedicine can most effectively be used moving forward.  Telemedicine may be a barrier to insurance companies' reimbursement, inter-state medical permits, and hospital credentials. This should be addressed to ensure a good uptake of the service.  Issues around privacy of patient data should be addressed.  Further study should be conducted into factors such as access to smartphones, access to and stability of communication networks, and ICT literacy rates of clinicians.  Further study is needed to forecast the future demand for telemedicine in Pakistan. These findings indicate that remote telemedicine services can be introduced in Pakistan with great success a promising level of uptake from the local population. An economic assessment must first be made, and then the appropriate tools can be introduced into the COVID-19 pandemic plan for implementation. Ethical Approval: Not required Recent advances: Telemedicine Opportunities and Developments in Member States: Report on the Second Global Survey on eHealth 2009 Teledentistry and its applications in paediatric dentistry: A literature review Resolutions and decisions annex Knowledge and Attitude Regarding Telemedicine Among Doctors in Karachi Health App Use Among US Mobile Phone Owners: A National Survey Questionnaire study of electronic weartime tracking as experienced by patients and parents during treatment with removable orthodontic appliances Health App use among US mobile phone users: analysis of trends by chronic disease status Evaluation of knowledge and perception of Malaysian health professionals about telemedicine Interactive virtual medication counselling in outpatient pharmacy: An accessible and safe patient counselling method during the COVID-19 pandemic COVID-19 and gastrointestinal endoscopies: Current insights and emergent strategies Successes and challenges in the implementation and application of telemedicine in the eastern province of Saudi Arabia Diffusion of ehealth innovations in 'post-conflict' settings: a qualitative study on the personal experiences of health workers Prospects for mobile health in Pakistan and other developing countries Application of ethics for providing telemedicine services and information technology Improved access to subspecialist diabetes care by telemedicine: cost savings and care measures in the first two years of the FITE diabetes project Muhammad Hassan Formal Analysis, Writing-Original Draft, Editing and Review Muhammad Ali Arif Supervision, Writing-Editing and Review We gratefully acknowledge the work of past and present members of our telemedicine team.