key: cord-0970128-0mryrfjk authors: Hunt, Richard C.; Struminger, Bruce B.; Redd, John T.; Herrmann, Jack; Jolly, B. Tilman; Arora, Sanjeev; Armistad, Amy J.; Dezan, Amanda M.; Bennett, Celine A.; Krohmer, Jon R.; Brown, Lawrence H. title: Virtual Peer-to-Peer Learning to Enhance and Accelerate the Health System Response to COVID-19: The HHS ASPR Project ECHO COVID-19 Clinical Rounds Initiative date: 2021-04-17 journal: Ann Emerg Med DOI: 10.1016/j.annemergmed.2021.03.035 sha: 542718460eac85b3dc74b2cde838032c62465728 doc_id: 970128 cord_uid: 0mryrfjk Tasked with identifying digital health solutions to support dynamic learning health systems and their response to COVID-19, the U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response partnered with the University of New Mexico's Project ECHO and more than two dozen other organizations and agencies to create a real-time virtual peer-to-peer clinical education opportunity: the COVID-19 Clinical Rounds Initiative. Focused on three "pressure points" in the COVID-19 continuum of care—(1) the prehospital / EMS setting, (2) emergency departments and (3) inpatient critical care environments—the initiative has created a massive peer-to-peer learning network for real time information-sharing engaging participants in all 50 U.S. states and more than 100 countries. One hundred twenty five learning sessions had been conducted between March 24, 2020 and February 25, 2021, delivering more than 58,000 total learner-hours of contact in the first eleven months of operation. Disease 2019 (COVID-19) [1] [2] [3] continues to challenge the health care community. [4] [5] [6] [7] How can health care systems, clinicians, administrators and policy makers quickly learn what is necessary to face these unprecedented and evolving challenges? Expanded use of digital health technologies has been suggested as one strategy for supporting learning health systems during a pandemic. 8 This paper describes the realization of one COVID-19-specific digital health solution: COVID-19 Clinical Rounds. First developed in 2003, Project ECHO-"Extension for Community Healthcare Outcomes"-is a non-profit telehealth initiative that uses a case-based collaborative learning approach to promote real-time, peer-to-peer, multi-directional learning among primary care teams, specialists, care managers and public health practitioners. [9] [10] [11] The idea is for clinicians to learn from each other, just as they do every day on the wards, but on a regional, national or international scale. The Project ECHO model has been used to improve care and outcomes for both chronic and acute conditions throughout the United States and around the globe. 12 Our understanding of COVID-19 remains incomplete, and the continuing knowledge gaps underscore several important concepts: • None of the information shared through COVID-19 Clinical Rounds should be adopted as dogma. This is shared information, not evidence. • It is important to regularly revisit issues and discussions. For example, in early April 2020 one emergency department rounds presenter described how his institution embedded mental health support for doctors, nurses and other staff into their emergency J o u r n a l P r e -p r o o f 7 department. Four weeks later, that presenter returned to report that the strategy had failed and the department was now trialing a "buddy system" for peer support. • COVID-19 Clinical Rounds must be able to evolve and adapt. Building on the success of COVID-19 Clinical Rounds, additional pandemic response learning networks have been developed to focus on 1) implementation of telemedicine in ambulatory care settings, and 2) outpatient therapeutics including monoclonal antibody therapy. • The COVID-19 experience is diverse, but there is value in learning about experiences even in dissimilar settings. As one participant put it in a chat entry: "Great presentations today and very valuable to see the responses from the poll. … One observation I'd like to share. The Covid-19 experience is very different for each of us, based on geography and other factors. It is clear however, that all of us need to be vigilant … and have the right policies and procedures in place for the foreseeable future." • Finally, COVID-19 is not constrained by national boundaries. With participation from more than 100 countries, COVID-19 Clinical Rounds has facilitated international knowledge-sharing between and across nations, helping to support an effective global response to both the patient care and public health challenges of the pandemic. Relationships have been key to the success of COVID-19 Clinical Rounds. A pre-existing relationship between federal agencies and Project ECHO set the foundation for the initiative. Relationships among the participants have been critical to building and expanding the three learning communities. There are challenges and limitations to the COVID-19 Clinical Rounds initiative. First, by design, the rounds do not necessarily present evidence-based medicine. Indeed, COVID-19 Clinical Rounds was conceived at a time when evidence was limited, and for the express purpose of panelists sharing individual experiences. The real-time chat and Q&A functions enable participants to share similar or conflicting experiences, essentially crowd-sourcing knowledge in the absence of evidence. Nonetheless, developing evidence is included in the presentations. For example, early discussions around steroids were generally driven by anecdote and opinion, but once the RECOVERY 18 trial was completed an internist from the U.K. was invited to discuss those findings. Second, COVID-19 Clinical Rounds is a resource-intense undertaking, requiring both time, technical expertise and funding. Once the COVID-19 pandemic has passed, ongoing support will be required to ensure continued readiness. Third, virtual peer-to-peer learning was new to almost all of the presenters, panelists and participants, and adaptation took some time. Future technological advances will likely necessitate additional adaptations. Finally, the dependence on existing relationships to identify speakers and panelists is both a strength and limitation of COVID-19 Clinical Rounds. Existing relationships allowed planners to quickly J o u r n a l P r e -p r o o f identify clinicians with experience managing special pathogen outbreaks, and provided access to ever-expanding networks of additional potential speakers and panelists. However, there is also some risk that clinicians with important experiences worthy of sharing are excluded simply because they are not known by or referred to the planners. When the COVID-19 Clinical Rounds initiative has served its purpose and is no longer useful in its current form, the platform can be stood down as quickly as it was stood up. It can also be transitioned to focus on preparedness for the next emergency. Epidemics and pandemics, natural and manmade disasters, and the impacts of global warming and climate change are just a few examples of potential future crises. Whenever and whatever that next disaster is, COVID-19 Clinical Rounds provides a new model for multi-directional peer-to-peer learning at scale. Investing in and maintaining a platform, the expertise and-most importantly-the relationships necessary to quickly establish virtual networks that support dynamic learning health systems should be a priority for public health and disaster-oriented agencies and organizations. In the meantime, anyone interested in participating in upcoming COVID-19 Clinical Rounds sessions, or reviewing resources from prior sessions, can find more information at . J o u r n a l P r e -p r o o f Epidemiological and clinical characteristics of 99 cases of Novel Coronavirus pneumonia in Wuhan, China: A Descriptive Study A novel coronavirus from patients with pneumonia in China Characteristics of and important lessons from the Coronavirus Disease 2019 (COVID-19) outbreak in China: Summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention World Health Organization. COVID-19 Weekly Epidemiological Upate COVID-19) Update: FDA Issues Emergency Use Authorization for Potential COVID-19 Treatment (press release) Coronavirus breakthrough: Dexamethasone is first drug shown to save lives Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study Roundtable Report -Leveraging digital health technologies during large-scale epidemics Building virtual communities of practice for health Project ECHO (Project Extension for Community Healthcare Outcomes): A national and global model for continuing professional development Leveraging telehealth to improve health care access in rural America: it takes more than bandwidth Outcomes of treatment for hepatitis C virus infection by primary care providers Creating a public health community of practice to support American Indian and Alaska Native communities in addressing chronic disease Building physician networks as part of the Zika response Implementation and evaluation of a Project ECHO telementoring program for the Namibian HIV workforce Extension for Community Healthcare Outcomes (ECHO) National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury Dexamethasone in hospitalized patients with Covid-19 -preliminary report