key: cord-0784311-t6lose0l
authors: Perez-Alba, Eduardo; Nuzzolo-Shihadeh, Laura; Espinosa-Mora, Jaime Eugenio; Camacho-Ortiz, Adrián
title: Use of self-administered surveys through QR code and same center telemedicine in a walk-in clinic in the era of COVID-19
date: 2020-04-13
journal: J Am Med Inform Assoc
DOI: 10.1093/jamia/ocaa054
sha: 40e20b3a439bad6426827a13bd0ac2312de990b0
doc_id: 784311
cord_uid: t6lose0l

nan

COVID-19; SARS-CoV-2; Telemedicine; QR code; Telehealth.

Author contributions: All authors contributed significantly and equally.

Funding source: This study was supported by internal funding.

As COVID-19 continues to challenge healthcare systems worldwide, we read with great interest Turer's et al. approach on telemedicine for COVID-19 in the U.S and we would like to share our center's experience to complement the view from a middle-income country's perspective. (1) Since a complete telemedicine program can't be created overnight, we faced the fact that it hasn't been a priority at our public hospitals to strengthen telemedical innovations. As such, we had to develop health informatics tools for the attention of patients potentially infected with SARS-CoV-2 as the pandemic developed.

We faced the same realities that most physicians are struggling with at first. Wearing personal protective equipment (PPE) complicates audio communication with patients.

Furthermore, registering patient's information and medical history requires time and materials that could potentially become fomites facilitating transmission (i.e. pens, pencils and paper).

As a solution we decided to create a survey using Google Forms® and transformed the link for sharing it into a Quick Response (QR) code. As patients arrive at the waiting area of the walk-in clinic, they see posters with instructions detailing how to use their smart device to access a self-administered questionnaire (Figure 1-A) . Data gathered included symptoms, risk factors for severe disease and prior medical history. This provides real time information for the ID staff and fellows to analyze at an adjacent, but isolated room were stratification and prioritization of patients is done and and creates an automatic queue for the rest of the patients.

After being called via interphone, the patients are asked to access a room where a computer has a pre-established Skype® connection (as Turer et. al have previously suggested). (1) . This way, one of the doctors from the ID team runs a telemedicine consult where the patient can see the physician's face and get into details about their chief complaint. The physician has the opportunity to ask any further information needed and, if necessary, explain the swabbing procedure (Figure 1-B) . Afterwards the doctor calls one of his or her peers that is waiting fully dressed in PPE at another room to discuss the goals of the next encounter: swabbing, prescribing, assessing for more detailed physical examination signs. Thereby, the exposure of the healthcare worker (HCW) in PPE to the potentially infected patient, and vice versa, is ideally reduced to a minimum.

In brief, patients enter the clinic, scan a QR code, fill the questionnaire and are consulted through same center telemedicine, all without physical contact with the HCW. https://mc.manuscriptcentral.com/jamia

The ID team then considers whether it is necessary to undergo a swab or other procedures reducing the exposure to an average time of 5:43 min per patient.

As Hollander and Carr suggest, we found that webconferencing software was easily implemented in our center to diminish unnecessary contact with between high-risk patients and HCW.(2) This allows a safe, comfortable and humane one-on-one interaction for both parties and created our very own electronic personal protective equipment as per Turer's definition. (1) In our case, adapting this system came at little to no cost since the software used was free to access and use. This raises the question to whether such platforms comply with ethics and local general data protection regulation. Since the transmission of the data is encrypted by the software used, these authors' opinion is that the potential benefits in the current pandemic outweigh the recognized risks for a system that can't allow the privilege to outsource telehealth systems. What may normally seem as a disadvantage in low-and middle-income countries, the lack of strict billing and regulatory laws play as an advantage in COVID-19 times when it comes to telehealth regulation.

One of our main concerns was that the patients may not be comfortable or able to answer the self-administered survey using smart devices. This was facilitated by the fact that most of the current smartphones only require for the camera app to point to at a QR in order to access the link. Out of the 1009 patients cared in this model, 874 (86.6%) completed the task successfully. Fifty patients from the database were randomly selected and were asked to answer an e-mail satisfaction survey in which 90% felt like they had enough time with their doctor to solve their doubts and 80% reported that it was easy to use and fill the QR based survey. The latter is consistent with the conclusions of a systematic review where self-administered questionnaire responses collected using smart devices might improve data completeness, acceptability, and time taken to complete over paper surveys. (3) Even though we live in a middle-income country, we have adequate infrastructure to stablish the mentioned strategies, this may not be the case for all the hospitals in developing countries and certainly not to the least developed countries. Despite the fact that we didn't achieve scripted triaging as with novel electronic health records,(4) it's these author's opinion that we may have accomplished electronic check-in, real-time data analysis, and telemedicine capabilities. We share our model so that it may encourage others to adapt technologies according to their resources. 

Electronic Personal Protective Equipment: A Strategy to Protect Emergency Department Providers in the Age of COVID-19

Virtually Perfect? Telemedicine for Covid-19

Comparison of self administered survey questionnaire responses collected using mobile apps versus other methods

Rapid Response to COVID-19: Health Informatics Support for Outbreak Management in an Academic Health System