key: cord-0735683-57dzw4rm
authors: Eslami, Parisa; Niakan Kalhori, Sharareh R.; Taheriyan, Moloud
title: eHealth solutions to fight against COVID-19: A scoping review of applications
date: 2021-04-01
journal: Med J Islam Repub Iran
DOI: 10.47176/mjiri.35.43
sha: 58b0a62bfb48d84294f00c25a846fd6a6399d54d
doc_id: 735683
cord_uid: 57dzw4rm

Background: eHealth has a notable potential to help in prevention, diagnosis, treatment, screening, management, and control of the COVID-19 pandemic. Since ehealth is considered here broadly, as an umbrella term, it also covers subsets like telehealth and mhealth. This study aimed to review the literature to identify and classify subdomains of eHealth solutions that have been utilized, developed, or suggested for the COVID-19 pandemic. Methods: A comprehensive literature search was performed using the PubMed, Scopus, Embase, and Cochrane library databases in April 2020, with no time limitation. The search strategy was built based on 2 concept domains of eHealth solutions and covid-19. For each concept domain, the search query comprised a combination of free text keywords identified from reference papers and controlled vocabulary terms. Obtained results were classified, graphically presented, and discussed. Results: Of the 423 studies identified initially, 35 were included in this study. From related papers, general characteristics, study objective, eHealth-related outcomes, target populations, eHealth interventions, health service category, eHealth solution, and eHealth domain were extracted, classified, and tabulated. Most publication types were ideas, editorials, or opinions (46%). The most targeted populations were people of the community and medical staff (80%). The most implemented or suggested eHealth solution was telehealth (63%), followed by mhealth, health information technology, and health data analytics. Most of the COVID-19 ehealth interventions designed or suggested for improving prevention (48%) and diagnosis (48%). Most of the studies applied or proposed eHealth solutions for general practice or epidemiological purposes (48%). Conclusion: eHealth solutions have the potential to provide useful services to help in COVID-19 pandemics in terms of prevention, diagnosis, treatment, screening, surveillance, resource allocation, education, management, and control. The obtained results from this review might be used for a better understanding of current ehealth solutions provided or recommended in response to the COVID-19 pandemic.

Since december 2019, a novel human coronavirus was identified and expanded to the world. This was the start point of the most severe type of coronavirus disease (1-3). COVID-19 or corona virus disease 2019 is a viral disease, which was caused by SARS-CoV-2. It is classified as a B type of infectious disease and has a long incubation period (1) . According to a study conducted by Lauer et al, the median incubation period for COVID-19 estimated 5.1 days (95% CI, 4.5-5.8 days) and "this implies that under conservation assumptions, 101 out of every 10 000 cases will develop symptoms after 14 days of active monitoring or quarantine." This means direct communication or contacts spread the virus rapidly (3) . Thus, most of the countries that identified the prevalence of COVID-19 set quarantine and warned people to avoid crowds and stay home (1) . In such a situation, information and communication technologies (ICT), emerged as a solution to ease the difficulties and solve some problems. The ICT technology, which is applied in the health area, is called eHealth. The scope of eHealth is more than just technology. "eHealth" is a broad term and defines as "an emerging field in the intersection of medical informatics, public health, and business, referring to health services and information delivered or enhanced through the Internet and related technologies." (4) It consists of finding, applying, registering, managing, transmitting, interpreting, and inferencing information in making medical decisions in supporting health care and many other purposes (5, 6). This technology particularly has various applications in this pandemic control; it is due to the contagious nature of this virus and the need for physical distancing to reduce the transmission rate. As a response to this need, several papers have been published in the recent months on usage or implementation of eHealth solutions to aid combat this global health crisis. Some studies were not implemented and were just as ideas or recommendations for the future. Our research aims to explore the subdomains of eHealth solutions, which are utilized or recommended to help against COVID-19 pandemic in terms of prevention, diagnosis, treatment, management, and control. The results can be used to determine where future research endeavors in this area might best be directed.

This scoping review was designed and conducted according to the principles of the preferred reporting items for systematic reviews and meta-analyses (PRISMA-SCR) guidelines (7, 8) . All phases of data collection are displayed in the PRISMA flow diagram (Fig. 1 ). This study aimed to investigate the subdomains of eHealth solutions, which are mostly used or recommended to conquer COVID-19.

This review was conducted on the published articles up to April 14, 2020 . A comprehensive literature search was performed using 4 databases of PubMed, Scopus, Embase, and Cochrane library. The search strategy was built based on 2 concept domains of eHealth solutions and COVID-19. For each concept domain, the search query comprised a combination of free text keywords identified from reference papers and controlled vocabulary terms (ie, Mesh for PubMed) ( Table 1) . 

After the removal of duplicate papers with EndNote reference management software, the articles were imported to the Rayan platform, which is a systematic review web application designed to help reviews in the systematic review blind screening process (9) . Through this platform, all documents were initially screened at the title and abstract level by 2 reviewers (P.E. and M.T). At the first level, screening disagreements were resolved by consensus. At the second level for disputes cases, a third reviewer made the final decision (S.R.N.K.).

Two reviewers thoroughly investigated the full-text of relevant papers, and for each document, 9 information categories were extracted using a data extraction form. The extracted data items included first author and publication year, country, study type, target population, aim of study, eHealth related outcomes, eHealth Intervention, eHealth Service category, eHealth solution, and e-Health domain. Two authors independently extracted data, and any disagreement was solved through discussions between the 3 authors.

The electronic searches resulted in 423 records. After the removal of duplicates, 294 articles remained. We used the Rayyan web application for a systematic review blind screening process (43) . Conducting screening based on title and abstract of articles, we defined 4 categories: Included (n = 30 papers), Maybe (n = 13 papers), Excluded (n = 232 documents), and Conflicts (n = 19 essays). After reaching an agreement for Maybe and Conflict categories, we studied 62 records in full-text and included 35 studies only. A variety of variables were extracted from the included studies. Extracted variables are categorized and presented in Tables 2 and 3 . "Tele telehealth" OR "telehealth" OR "telemedicine" OR "tele-medicine" OR "telemonitor" OR "tele-monitor" OR "telecare" OR "tele-care" OR "teleconsult" OR "tele-consult" OR "telecommunication" OR "tele-communication" OR "remote" OR "metry" OR "sensor" OR "sensing" OR "wearable" OR "Artificial intelligence" OR "Artificial intelligent" OR "neural network OR "Computational intelligence" OR "AI" OR "Machine inteligen*" OR "Machine learning" OR "Deep learning" OR "mining" OR Big data" OR "Pattern recognition" OR "Image processing" OR "analytics" OR "data mining" OR "mobile" OR "m-health" OR "m health" OR "mHealth" OR "mobile based" OR "app" OR "mobile application" OR "phone app" OR "smart phone" OR "mobile health" OR "e-health" OR "ehealth" OR "e health" OR "digital health" #2 "COVID-19" OR "COVID 19" OR "SARS-CoV-2" OR "2019-nCov" OR "Coronavirus" OR "Coronavirus" OR novel corona virus" OR "novel coronavirus" OR "corona virus" OR "nCov" OR COVID 2019" Search #1 AND #2 Given the many clinical, technical, organizational, and policy questions raised by the telehealth solutionss, the implementation process of this promising technology is likely to be complicated and resource intensive. It will need both national and local strategic leads. It should be championed by respected opinion leaders, with attention paid to the overall narrative or "organizing vision" within which the change is framed. 

All studies were published in 2020. Included publications were from the USA (n =1 ), China (n = 9), UK (n = 4), Italy (n =1), Iran (n =1), Sultanate of Oman (n = 1), and Taiwan (n = 1). In 7 studies, the authors from more than 1 country collaborated.

Based on the extracted information, we categorized the study type variable into 5 groups. Ideas, Editorials, or Opinions reflect the author's views, opinions, or recommendations on the application of eHealth-related interventions in response to COVID-19 pandemic (46%). Case reports are reporting adaptation of eHealth interventions as tools to aid combat COVID-19 pandemic (26%). Prac- Describe a deep learning approach to augment chest radiographs with a color probability overlay to improve the diagnosis of COVID-19 pneumonia.

The proposed deep learning approach may have utility in early diagnosis and longitudinal followup of suspected pneumonia, including patients with COVID-19 pneumonia. In viral epidemics such as COVID-19, which place a significant strain on the healthcare system, deep learning approaches may provide a mechanism of workload relief and earlier advanced interpretation. Jiang, X. et al.,2020 (13) China

Case Report -Medical staff (mental health professionals) -People of the community Introduce a two-pronged approach (onsite and remote) implemented at the national and provincial level to support timely psychological crisis intervention in response to mental disorders resulted from the COVID-19 pandemic.

Because of substantial shortcomings with remote consultation, remote psychological consultations services, cannot replace face-to-face onsite services. Therefore, in to improve efficiency and optimal use of limited medical resources in an epidemic situation such as COVID-19, implementation of the twopronged approach (onsite and remote) for psychological crisis interventions at the same time can minimize risks of cross-infections Direct-to-consumer telemedicine could lead to a substantial decline in unnecessary patients visits and the risk of clinicians' exposure to infections, promoting self-isolation, and reducing emergency department overuse. This approach provides early screening and remote monitoring of COVID-19 patients during incubation and post-discharge period, which is a crucial step in containing the outbreak. By investigating included studies, we identified 6 target groups for eHealth interventions: people of the community (n = 28), medical staff (n = 28), Health policymakers and planners (n = 8), Health enterprises leadership (n = 4), health care researchers (n = 4), and academic medical organizations (n = 1). Telemedicine has the potential to help patients and health providers by permitting them to give and get supportive care while minimizing their exposure to potentially infected people. Rao Describe the rapid development and implementation of the EHR based tools essential for optimizing COVID-19 outbreak management and discuss its associated challenges within a broad regional public, academic health center.

The electronic health record and associated technologies are essential tools in supporting the clinical needs of a health system managing the COVID-19 pandemic and should be leveraged to their full potential.

Smith, A. C. et al., 2020

Australia, Denmark, and the USA Ideas, Editorials, Opinions -Medical staff -People of the community To outline critical requirements to ensure that the value of telehealth is fully realized, not only in emergencies (such as COVID-19 pandemics) but also, in everyday practice.

For telehealth to be useful as part of a global or national emergency response as well as an everyday practice, it first needs to become a routinely used part of every health system. Szperka 6 Figure 2 shows the classification of included publications based on eHealth solution subdomains suggested or used for the COVID-19 pandemic. We broke down eHealth domain into 4 subdomains. The most implemented or suggested subdomain was telehealth, followed by mHealth, health information technology, and health data analytics. Thirty one out of 35 studies used, proposed, or implemented telehealth and mhealth solutions alone or in combination with other eHealth solutions. Eleven out of 35 studies applied or suggested health information technology solutions. The last implemented or proposed eHealth solution was health data analytics. Only 9 out of 35 studies implemented or suggested this eHealth solution.

By investigating the publications, we identified 11 categories as the aim of eHealth interventions, including prevention, screening, triage, diagnosis, treatment, prescription, monitoring, reporting, health resources allocation, To share a national experience of using health-related technology approaches for case identification, containment, and resource allocation to protect the public health in case of the COVID-19 pandemic.

Given the continual spread of COVID-19 around the world, understanding the action items and health relates to technological tools that were implemented quickly in Taiwan and assessing the effectiveness of these actions in preventing a largescale epidemic may be instructive for other countries. Wind 7 education, and outbreak surveillance. Figure 3 demonstrates the frequency ratio of these health service categories. Most of the studies were applied or suggested eHealth interventions were for prevention and diagnosis. We also break down the included publications regarding the health domain to be covered by digital interventions they applied or suggested, including general practice, medical specialty, epidemiology, medical research, and medical education. As shown in Figure 4 , most of the studies applied or suggested eHealth solutions for general practice or epidemiological purposes, followed by medical specialty. In 2 studies, interventions were designed or rec- 8 ommended to cover the health research domain, and in 1 study eHealth interventions were utilized for medical education. 9

At the beginning of the prevalence of novel coronavirus, most of the countries in the world applied seriously infec-tion-control solutions to protect people of the community as well as the medical workers from COVID-19 infectious (44) . The application of these solutions drew global 

Mobile-phone online survey for data collection, Machine learning algorithms for data analysis 10 attention to eHealth solutions as a cost-effective and secure approach for outbreak management. As a result, several studies have been performed considering application or suggestion of technology to support different aspects of pandemic control (1, 10, 13, 20, 24, 28, 34, 35, 38) . Some studies are national or organizational case reports on the utilization of eHealth solutions, and some studies also have been done to create guidelines or frameworks on how to use technology in medical workflow with the lowest contacts (1, 10, 13, 19, 20, 24, 28, (34) (35) (36) 38) . A majority of publications discuss potential applications for using different subdomains of eHealth solutions along with their challenges and opportunities. A smaller number of studies conducted practical research with the implementation of 11 more innovative eHealth technologies, such as machine learning or artificial intelligence-based solutions (3, 12, 14, 20, 21, 23, 28, 34, 42, 45, 46) . By investigating extracted information from selected studies, we identify significant eHealth subdomains solutions, including telehealth, mobile health, health information technology solutions, and Health data analytics, which are explained briefly in the following sections.

Telehealth is a subcategory of ehealth solutions that are used for medical information exchanged from 1 site to another through electronic communication to deliver health-related care, diagnosis, consultation, treatment, intervention, monitoring, and education at a distance (47, 48) . The primary response strategy included self-isolation and mandatory quarantine to avoid direct contacts and decrease the risk of transmission (47) (48) (49) . This strategy creates a need to replace another communication approach, such as telehealth. Our included studies investigated different aspects related to the integration of telehealth services in 3 pillars of modern-day medical practice, including clinical practice, medical research, and education during the COVID-19 crisis. Potential applications, the possibility of implementation as well as benefits and barriers of applying this technology in different aspects of today's medical practice are discussed in included studies. In 1 study, an updated conceptual framework for telemedicine implementation to conquer the COVID-19 pandemic presented (19) .

Our included studies applied telehealth in both general practice and specialized medical services. A notable portion of studies highlights the use of telemental health ser-vices for analyzing and managing mental health issues (13, 29-31, 33, 34) . Some studies suggested telehealth services for chronic disease management, such as migraine or diabetes (26, 40) . Some studies recommend the use of telehealth services for more vulnerable populations, such as frontline health workers or older patients and practitioners (18, 31, 32) . Telehealth also can be used as a valuable tool for animal care during the COVID-19 crisis (39) . Telehealth was also applied in remote drug delivery (38, 39) . Medical institutions across China have launched remote pharmacy services for online drug prescribing, drug consultation, drug delivery, and drug shortage management (38) . Telehealth can be used for conducting health research during COVID-19 (18) . Nicol, G. E. et al. recommend clinical researchers working with vulnerable populations like older adults to remotely perform and continue research studies by using telehealth platforms (18) . Telehealth is also suggested as a substitute method of delivering medical education in the time of the COVID-19 pandemic. A study conducted in a national medical college used tale teaching via online platforms (35) . Most of the studies did not indicate a specific platform to deliver telehealth services. Among included publications, video consultation, and video-conferencing were the most applied or suggested approaches for health care professionals and clinicians to communicate and share experiences. Most of the included studies, which used telehealth services, found that as an effective way to deal with and control the COVID-19 pandemic (11, 35, 39) .

Mobile health or mHealth is a subcategory of eHealth solutions that are used for the practice of medicine and public health supported by mobile devices. Increasing the use of smartphones coupled with the increasing availability of other mobile and wearable devices make it possible to utilize mobile technology in health care delivery. Inbuilt geographic information systems (GIS) in mobile devices enabled the tracking of the COVID-19 epidemic and associated events (27, 42) . Using location-based technologies raises some issues regarding privacy. Yasaka, T M, et al developed a contact tracing smartphone application for tracing possible routes of COVID-19 transmission. They present a novel solution that respects user privacy by not collecting location information or other personal data (32) . mHealth solutions can also be used for proper management of self and mandatory isolation or resource allocation (16, 24, 28) . In a study related to Taiwan crisis management, a geographical tracking application used to track suspicious people during the incubation period to ensure mandatory isolation (28) . The entry of COVID-19 had a negative impact on the countries' economic status. Mashamba-Thompson, T. P. et al. developed a low-cost blockchain and artificial intelligence coupled mobile-linked self-testing and tracking system for accurate diagnosis and electronic surveillance of COVID-19 in underserved populations. They suggested that their proposed structure help curb the spread of COVID-19 and the related mortalities and alleviate the burden on the health system, particularly in resource-limited settings (14) . Valsalan P. et al proposed a remote patient health monitoring framework using IoT servers and wearable sensors as a solution for remote disease diagnosis during the COVID-19 pandemic (27) . mHealth technology can also be used to facilitate health researches during the COVID-19 pandemic (15) . Zhenyu Li et al performed a study to evaluate psychological stress caused by the COVID-19 pandemic in hospital nurses (37) .

Health information technology solutions are eHealth tools designed to support health information management to improve integration, quality, and efficiency of health care work processes and provide real-time communications of health informatics among health care professionals (50, 51) . In the health domain, health information systems and electronic health records are applicable tools that have a significant role in health care management. UW Medicine, a national health care organization, utilized information technology solutions to support their clinical response to the COVID-19 pandemic. Their experience demonstrated that information technology solutions and IT-based solutions could play an integral role in responding to COVID-19 public health emergencies (10) . Taiwan's national experience in response to COVID-19 demonstrated that the integration of national health insurance, immigration, and custom databases helps Taiwan decision makers to manage the crisis (28) . J Reeves, J. J. et al highlighted the application of health information technology solutions to support the outbreak response in an academic health system. They built multiple COVID-19-specific tools against the outbreak. Based on their study, the electronic health record and associated technologies are essential tools in supporting the clinical needs of the health system managing the COVID-19 pandemic and should be leveraged to their full potential (24) .

Data and information are valuable resources. Health data analytics as a subcategory of eHealth tools utilize techniques to infer or recognize patterns or extract rules. These tools are mainly used by health professionals to improve clinical decision making in complex situations (45, 46) , such as the COVID-19 pandemic. Machinelearning methods, such as deep learning, are nowadays widely applied in the field of radiology for medical image processing (52, 53) . In the case of COVID-19, Hurt, B. et al proposed a deep-learning approach to improve the diagnosis and longitudinal follow-up of COVID-19 pneumonia. They concluded that in viral epidemics such as COVID-19, deep learning approaches might provide a mechanism of workload relief and earlier advanced interpretation (12, 53) . Artificial intelligence (AI) is another innovative technology to fight against COVID-19. This technology plays an essential role in detecting the cluster of cases and to predict where this virus will affect in the future by collecting and analyzing all previous data (54) . Pirouz, B. et al developed a neural network algorithm for calcification of COVID-19 confirmed cases. Their study demonstrated the suitable performance capacity of AIbased techniques in COVID-19 related investigations (21) . Some studies suggested the integration of health data analytics with other eHealth solutions such as mHealth. Rao, A. S. R. S. et al proposed an AI framework coupled with a mobile phone-based survey for COVID-19 preliminary screening and early case identification. They concluded that AI and mHealth technology could assist in healthrelated data collection and faster identification of possible cases of COVID-19 to bring timely interventions (23) . Another valuable approach in this area is big data analytics. This could potentially help to understand the nature of the new coronavirus through processing and visualization of massive and unstructured data, such as medical images, patient records, social networks, and other sources, and thus facilitating prevention and treatment process during COVID-19. In a study related to Taiwan's response to COVID-19, big data analytics were utilized for analyzing national and regional databases to help identify suspicious cases for the track (28). Liu, S. et al, in their study to highlight online mental health, discussed the use of big data analytics for psychological crises intervention during COVID-19 epidemic. The program they mentioned recognizes individuals at risk of suicide during the COVID-19 pandemic by analyzing and monitoring massages people post on china national social network called Weibo and alert designated volunteers to act accordingly (34) .

Our research results had a limitation of databases we accessed, as we searched in PubMed, Scopus, Embase, and Cochrane databases, and more databases such as Web of Science could be considered for further reviews.

eHealth solutions have the potential to provide useful services to help in pandemics in terms of prevention, diagnosis, treatment, screening, surveillance, resource allocation, education, management, and control. The obtained results from this scoping review might be used for a better understanding of current ehealth solutions provided or recommended in response to the COVID-19 pandemic. It is also recommended to identify the possibility of implementation in different settings as well as the benefits and barriers of applying this technology in various aspects of today's medical practice.

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The authors declare that they have no competing interests.