key: cord-0994094-i2bnrf07
authors: Kumar, Anirudh; Patel, Divyang R.; Nissen, Steven E.; Desai, Milind Y.
title: Never Let a Crisis Go To Waste: Implementing Virtual Innovations during the COVID-19 Pandemic for a Better Tomorrow in Healthcare
date: 2020-05-19
journal: JACC Case Rep
DOI: 10.1016/j.jaccas.2020.05.014
sha: a6562708b0f4d23a2d68af68fff6d4d5a7e62d3a
doc_id: 994094
cord_uid: i2bnrf07

Abstract The coronavirus disease (COVID-19) pandemic has necessitated adjustments within our healthcare infrastructure, many of which have been virtually mediated, in order to facilitate preservation of patient care, education, and research. In this commentary, we discuss how these virtual innovations can be applied to improve healthcare delivery in the post-COVID-19 era.

Stanford economist Paul Romer once stated "a crisis is a terrible thing to waste." The tragic events of World War II led to the development of rockets that resulted in massive technological innovations including communications, weather, and television satellites that shape our modern world. In the midst of the unprecedented coronavirus disease pandemic, our nation has been mired in a crisis unlike any we have previously faced. From a medical standpoint, healthcare communities, despite insufficient resources, have scrambled to provide appropriate patient care to both infected and non-infected patients while also protecting healthcare personnel. Considerable debate, from national news broadcasts to social media platforms, coupled with massive federal deregulation, has spawned rapid adjustments to attempt to preserve the important principles of medicine -patient care, education, and research. With this crisis, a call for the emergence of virtual applications has been echoed (1). In the current commentary, we discuss how the medical community can use this time of peril to implement virtual changes in healthcare delivery to strive for a better tomorrow.

In response to the COVID-19 pandemic, the Centers of Medicare and Medicaid Services significantly loosened regulations to minimize barriers to effective patient care, including offering reimbursement for telemedicine services (2) . While these measures represent temporary accommodations during this public health crisis, the experience and resulting innovation can permanently improve healthcare delivery, bringing care to millions currently underserved.

Consider a patient who requires a chest pain evaluation. In a new reality utilizing virtual medicine, the patient has a virtual "e-consult" with an invasive and non-invasive cardiologist who can virtually utilize a "Heart Team approach" and order all necessary testing prior to a face-to-face visit with the patient. The virtual process is streamlined for the patient and can mitigate weeks to months traversing multiple appointments, reduce unnecessary testing prior to formal consultation, and allow the patient to minimize lost productivity due to absence from work.

Following coronary revascularization, similar virtual platforms can be utilized to improve adherence to cardiac rehabilitation (3), an important intervention which remains substantially underutilized despite robust data supporting its use. Virtual exercise routines can be applied broadly with far-reaching applications, including insurance premium "rewards" for the general public who meet recommended exercise goals. The economic and health implications of this more efficient approach are potentially transformative.

Reports have described a significant reduction in patients presenting with acute myocardial infarction, stroke, and other medical emergencies coinciding with an 800% increase in cardiac arrest deaths at home in New York City (4). A contributing explanation may be that symptomatic patients, afraid of possible COVID-19 exposure or wary of long wait times, choose to endure worrisome symptoms at home rather than seek care. Virtual triage, a role that might be staffed by personnel who may otherwise be furloughed, could be used to help patients determine if urgent care is necessary and/or to divert "persons under investigation" to hospitals dedicated to care for COVID-19 patients. In the future, these systems can be maintained to significantly reduce costs associated with unnecessary Emergency Department care and improve ambulatory access. Moreover, as much of medical decision making is cognitive, virtual medicine may also be applied to other aspects of acute care, including tele-intensive care units (5) and remote robotic-assisted percutaneous coronary intervention (6) . Accordingly, virtual applications in acute care can be used to improve access, resource allocation, protection of healthcare personnel and patients, and reduce treatment delays. Similar innovation is feasible when communication is required between the healthcare team and a patient's immediate family, including procedure consent. Frequently, care is delayed and hospitalizations are prolonged due to inability of the care team to contact an appropriate power-of-attorney or families to reach consensus on care plans for critically ill patients. By utilizing virtual communication, the healthcare team may be better equipped to provide an accurate description of prognosis, answer questions amongst family members present and not present, and create a sense of trust and collaboration between all parties. In a system in which end-of-life spending is a major component of aggregate medical expenditure, this measure may potentially reduce overall costs while improving the opportunity for all family members to participate in decisions.

In the wake of this pandemic, formal medical student and trainee didactics were disbanded to allow for social distancing. Additionally, several states expedited graduation of senior medical students for work pool expansion. This left educators scrambling to find other avenues to foster learning despite pressing needs of patient care and risks of healthcare personnel becoming infected. In spite of these obstacles, many training programs rapidly implemented virtual curriculums including lectures, noon conferences, and formal grand rounds. Experience using these virtual platforms can be used in the future to further expand the educational mission and distance learning.

The advantages of virtual didactics are, including promoting social distancing, that lectures can be easily recorded and disseminated to those who are unavailable at the time of initial presentation. While lecture streaming has been in place for many years, allowing for live interaction, questions, and debate can enhance the overall learning experience. In the future, more academic sessions for trainees can be performed in this fashion. Some medical schools have already created virtual anatomy laboratories that do not require access to the limited resource of cadavers. Similar platforms may be utilized to enhance grand rounds and other departmental educational forums. While there are important benefits of continuing many inperson invited lectures, virtual education involving global experts could allow for a much greater reach, including academic collaboration between widely dispersed institutions.

Virtual didactics may also be used to redefine continuing medical education (CME).

Historically, CME aims to strengthen and update the knowledge of healthcare personnel in their area of specialization. However, the COVID-19 pandemic has resulted in many healthcare personnel being thrust into clinical scenarios they did not previously encounter in day-to-day practice. While these efforts are heroic and truly encapsulate the ideals of medicine, it highlights how truly specialized caregivers have become. As such, the value of healthcare personnel with a diversified set of skills beyond their scope of practice has never been more evident. The benefits of having a workforce with diverse skills can outreach this pandemic, including application of novel care systems, innovation, and research.

In light of the hardships and pressure placed on the medical system during the COVID-19 pandemic, the research endeavor has widely flourished. Institutional review boards have rapidly approved protocols for registry work and randomized controlled trials. Data has been readily shared in an effort to educate different ecosystems of COVID-19 characteristics and disease manifestations. Journals of all tiers have placed calls for articles and rapidly performed peer review to allow for dissemination of knowledge. In times like these, collaboration and communication across medical communities is as important as ever. Dissemination of knowledge and perspective, particularly in a timely manner, is paramount and serves as an invaluable tool both in medical care as well as policy formation. While institutional review boards are essential for safety of patients and conduct of ethical research, it may be beneficial to the system as a whole to minimize bureaucratic hoops and obstacles that defeat the intellectual curiosity of research itself.

In addition to increasing opportunities for collaboration as discussed above, virtual platforms have far reaching applications to research endeavors. Prior to the COVID-19 pandemic, a burgeoning interest in ambulatory monitoring was developing traction using technology such as wearable devices, smartwatches, and other novel technology (7) . Moreover, machine learning algorithms are increasingly applied to risk prediction and stratification of cardiovascular patients. Combining these technologies with virtual visits as discussed above could potentially be used to improve enrollment in clinical trials and personalize therapeutics.

Lastly, in light of the COVID-19 pandemic, a number of major congress meetings were cancelled and replaced with a virtual symposium. While there are some advantages to traditional meetings that should not be ignored, the potential reach of a virtual meeting could significantly increase attendance and as such collaboration, networking, and transfer of ideas. Perhaps, while initially appearing to stunt that mission, COVID-19 may have opened the doors for an innovative future where conference medium can be conducted live and virtually spread around the world to all interested parties and thus greatly increase the scientific impact.

As a global pandemic, COVID-19 will cause massive changes to our way of life.

However, it also uniquely offers an opportunity to reexamine the strengths and deficiencies of our healthcare system. The emergence of virtual medicine has allowed our community to unite through the sharing of ideas and ideals. Together, we must use this historical moment to promote a wave of change in healthcare delivery and aim for a better tomorrow. A crisis is a terrible thing to waste.

Covid-19 and Health Care's Digital Revolution

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