DOI: https://doi.org/10.21203/rs.3.rs-23906/v1
Purpose The outbreak of coronavirus disease-19 (COVID-19) is a public health emergency of international concern. Telehealth is effective option to fight COVID-19 outbreak. The aim of this systematic review was to identify the role of telehealth services during COVID-19 outbreak.
Methods This systematic review was conducted through searching five databases including PubMed, Scopus, Embase, Web of Science and Science direct. Inclusion criteria included studies clearly defined role of telehealth services in COVID-19 outbreak, published from December 31, 2019, written in English language and published in peer reviewed. Two reviewers independently assessed search results, extracted data, and assessed quality of included studies. Quality assessment was based on the Critical Appraisal Skills Program (CASP) checklist. Narrative synthesis was undertaken to summarize and report the findings.
Results Eight studies met the inclusion out of the 142 search results. Currently, healthcare providers and patients who are self-isolating, telehealth is certainly appropriate to minimizing the risk of COVID-19 transmission. This solution has the potential to avoidance of direct physical contact, provide continuous care to the community and finally reduce morbidity and mortality in COVID-19 outbreak.
Conclusions The use of telehealth improves the provision of health services. Therefore, telehealth should be an important tool in caring services while keeping patients and health providers safe as the COVID-19 outbreak.
Coronaviruses, a genus of the coronaviridae family, which may cause illness in animals or humans (1, 2). In humans, several coronaviruses are known to cause respiratory infections ranging from the common cold to more severe diseases. The most recently discovered coronavirus causes coronavirus disease-19 (COVID-19) (1). The disease originated in Wuhan, China, and has spread widely to other countries (3). Early symptoms of COVID-19 include fever, dry cough, difficulty breathing and tiredness (4, 5). Older people and those with underlying medical problems such as hypertension, heart problems and diabetes are more likely to develop the disease in its most severe form (1). This global event has been announced a pandemic by the World Health Organization (WHO) (6). A major factor in slowing down the transmission of the virus is the "social gap" that is made possible by the reduction of person-to-person contact (7, 8).
For reduce transmission, travel restrictions have been established around the world and most cities have been quarantined (9). But, people who are not infected with the COVID-19, especially those who are at greater risk of developing the disease (e.g. Elderly people and those with underlying disease), should receive daily care without the risk of exposure to other patients in the hospital (7). Also, under strict infection control, unnecessary personnel such as clinical psychiatrists strongly refuse to enter ward of COVID-19 patients (10, 11). Natural disasters and epidemics pose many challenges in providing health care (12). As a result, unique and innovative solutions are needed to address both the critical needs of patients with COVID-19 and other people who need medical care, that technological advances provide new options (13). Although the ultimate solution for COVID-19 will be multifaceted, it is one of the effective ways to use existing technologies to facilitate optimal service delivery while minimizing the risk of direct exposure person-to-person (7, 14). Telemedicine use in epidemic conditions (COVID-19 outbreak) has the potential to improve epidemiological research, disease control and clinical case management (7, 14, 15).
The use of telehealth technology is a 21st century approach that is both patient-centered and protects patients, physicians and others (16, 17). Telehealth is delivery of health care services by health care professionals, where distance is a critical factor, using information and communication technologies (ICT) for the exchange of valid information (18). Telehealth services are delivered using real-time or store-and-forward techniques (19). With the rapid evolution and downsizing of portable electronics, most families have at least one digital device, such as smartphones (20) and webcams, that provide patient and provider communication (21). Video conferencing and similar television systems are also used to provide health care programs for people who are hospitalized or in quarantine to reduce the risk of exposure to others and employees (7). Physicians who are in quarantine can cover these services to take care of their patients remotely (8, 22). Covering multiple sites with a tele-physician can address some of the challenges of the workforce (8, 23).
There are several benefits to using telehealth, especially in non-emergency / routine care and in cases where services do not require direct patient-provider interaction, such as providing psychological services (24). Remote care reduces the use of resources in health centers, improves access to care, while minimizing the risk of direct transmission of the infectious agent from person to person (25). In addition to being useful in keeping people safe, including the general public, patients and health workers, another important advantage is providing access to care givers widely. (12). Therefore, this technology is an attractive, effective and affordable option (14, 26, 27). Patients are eager to use telehealth, but barriers still exist (28, 29), the barriers to implementing these programs also largely depend on payments, accreditation and insurance (8). Furthermore, some physicians are concerned about technical and clinical quality, privacy, safety and accountability (23, 30).
Telehealth can become a basic need for the general population, health care providers and patients with COVID-19, especially when people are in quarantine, enabling patients in real time through contact with health care provider for advice on their health problems. Thus, the aim of this review was to identify and systematically review the role of telehealth services during COVID-19 outbreak.
This systematic review was conducted based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. A systematic review method was selected to allow a robust and reproducible approach to structure a critical synthesis of existing current evidence. Considering the urgency of the matter and limited available evidence on the topic, we did not register the systematic review protocol.
Five online databases included PubMed, Scopus, Embase, Web of Science and Science direct were searched to identify relevant and published studies. A preliminary search in March 26, 2020, identified a range of available evidence on the role of telehealth services during 2019 novel coronavirus (COVID-19) outbreak. A subsequent search was conducted on April 3, 2020 to update the results. The combination of keywords and Medical Subject Headings (MeSH) were used: COVID19, COVID-19, Coronavirus, Novel coronavirus, 2019-nCoV, Wuhan coronavirus, SARS-CoV-2, SARS2, Tele*, Telemedicine, Tele-medicine, Telehealth, Tele-health, Telecare, Mobile Health, mHealth, Electronic health, ehealth. The Boolean operators (AND, OR and NOT) were used to combine terms. A librarian was consulted during this phase to ensure that the search strategy was satisfactory. The search in each databases was adapted. For example, the search strategy in the PubMed database was executed as follows:
(COVID-19 OR COVID19 OR Coronavirus OR Novel coronavirus OR 2019-nCoV OR Wuhan coronavirus OR SARS-CoV-2 OR SARS2) AND (Telemedicine OR Tele-medicine OR Telehealth OR Tele-health OR Telecare OR Mobile health OR mHealth OR Electronic health OR eHealth).
Manual search in web-based resources was performed on Google, Google Scholar, journals which published key articles and through searching specific website (WHO, https://www.who.int, Centers for Disease Control and Prevention, https://www.cdc.gov, National Institute for Health and Clinical Excellence, https://www.nice.org.uk, National Health Commission of the People’s Republic of China http://www.nhc.gov and National Administration of Traditional Chinese Medicine http://www.satcm.gov.cn). In additional, we reviewed the references of the selected articles in order to identify additional studies or reports not retrieved by the preliminary searches (reference by reference).
All studies that primary sources of evidence and reporting the role of telehealth services in COVID-19 was included. In fact, studies were included if they clearly defined function type of telehealth in diagnosis, management, prevention and treatment of COVID-19, Published from December 31, 2019 to April 3, 2020 literature, written in English language and published in peer reviewed journals were included to obtain additional relevant studies. The reason for choosing December 31 was because of the COVID-19 emerged in Wuhan, Hubei Province, China. Actually, studies that illustrate the any use of telehealth tools by all aspect of health care (primary, secondary or tertiary level health care) to provide clinical services, diagnosis of clinical education, assessment of symptoms, triage of patients, consultation services and training or supervision of clinicians were included. Studies about other technologies (e.g. Internet of Medical Things or IoMT), duplicate publications, review articles, opinion articles and letters not presenting original data were excluded, as well as studies reporting with incomplete information.
Two authors (A.H. and E.M.) who performed the literature search also independently following the application of the inclusion and exclusion criteria screened the studies based on the title, abstract. After initial screening, full-text of studies were obtained and examined to ensure eligibility for develop the data extraction form.
Data were extracted for all papers rated as eligible for the review. The following data were extracted and analyzed: first author, date of publication, country, design of study, type of telehealth used, key outputs of studies and effects of telehealth.
To assess the quality of included studies, Critical Appraisal Skills Program (CASP) checklist was used. The CASP tools were developed to teach people how to critically appraise different types of evidence (31). For scoring the quality of the included studies, they were divided into three categories poor, medium and good quality.
For expressing and synthesizing the results of included studies, narrative synthesis of overall evidence was undertaken by comparing and contrasting the data. Three stages of the narrative synthesis were developing a preliminary synthesis, exploring relationships within and between studies; and determining the robustness of the synthesis (32). Data of included studies was qualitatively described and presented. The authors met frequently to discuss consensus of findings.
The details on the literature search and screening processes are shown in Fig. 1. Following removing the duplicate search records and screening of titles and abstracts, we evaluated 46 relevant studies in full text. From the remaining studies, 39 articles did not meet inclusion criteria leaving. Finally, one study was added after reference screening and 8 full studies included for evidence synthesis.
Some summary characteristics of included studies were reflected in Table 1. The included studies that were published in different journals between February 17, 2020 and Apr 9, 2020, were mostly done in USA. Eight studies were performed from 6 countries: USA (n = 5), China (n = 2), UK (n = 2), Canada (n = 2), Iran (n = 1) and Italy (n = 1). Five studies were cross-sectional, two were case studies and one was case-control. In included studies, most of telehealth and social media channels were used during pandemic of COVID-19 including live video conferencing, telephone and email.
Table 1: Summary characteristic of included studies in systematic review.
Our review included 8 studies that were assessed using the CASP tool. The quality of the assessed studies were generally high level that way six (75%) studies had good quality and two (25%) had medium quality. No studies was excluded on the basis of the level of evidence or quality assessment.
We identified eight studies that reported data on the telehealth in status of patients infected with COVID-19. Telehealth has the ability to unite several medical organizations and situations into one virtual network, led by the central clinic. This network can include different physical locations: central and remote clinics, state and private clinics, rehab centers and prevention centers, physicians’ private offices and all registered patients within their locations. By using virtual care for much regular, necessary medical care, and deferring elective procedures or annual checkups, we free up medical staff and equipment needed for those who become seriously ill from COVID-19. Additionally, by not congregating in small spaces like waiting rooms, we thwart the ability of the virus to hop from one person to another. Keeping people apart is called “social distancing”. Keeping healthcare providers apart from patients and other providers is “medical distancing”. Telehealth is one strategy to help us accomplish this.
Telehealth can mobilize all aspects of healthcare potential to: reduce transmission of disease, safety of online health services, direct people to the right level of care, protects of patients, clinicians, and the community from exposure infection and finally decrease the burden on the healthcare system. Some of the telehealth usage cases for patients were control and triage during spread of COVID-19, self and distance monitoring, treatment, patients after discharge (follow-ups) and implemented of online health services. These methods have the potential to reduce morbidity and mortality. For health workers: clinicians with mild symptoms can still work remotely with patients, facilitate rapid access to medical decision making, second opinion for severe cases, cross-border experience exchange, teleradiology and online trainings for health workers. To provide continued access to essential health services, telehealth should be a key weapon in the fight against the COVID-19 pandemic.
The aim of this systematic review was to identify the role of telehealth services to manifestation and diagnosis, prevention, treatment and control during COVID-19 outbreak. We described the benefits and implications of several telehealth tools that aimed to improving this management of COVID-19 infection. At this moment, for the general population there is no vaccine preventing COVID-19 disease and the best strategy to prevention is avoid being exposed to the coronavirus (41). A series of measures have been suggested to infection preventive and control (IPC) that may reduce the risk of exposure including use of face masks, covering coughs and sneezes with tissues, regular hand washing with soap or disinfection n with hand sanitizer containing at least 60% alcohol, avoidance of contact with infected people and maintaining an appropriate distance as much as possible, and refraining from touching eyes, nose, and mouth with unwashed hands (42). Healthcare providers can communicate with patients by telehealth and other remote of triaging, assessing and caring for all patients to reducing the number of those who seek face-to-face care (43). Telehealth uses live video conferencing, or even a simple mobile call, to allow medical staff to ask specific questions and gather information, give consultation and triage of patient, or if a person can continue to self-monitor symptoms at home while recovering. It can also be used for regular check-ins such as blood pressure, oxygen level and respiratory rate, as needed (34).
During the COVID-19 outbreak in china, online mental health surveys with communication programs, such as WeChat, Weibo, and TikTok have enabled mental health professionals and health authorities to provide online mental health services during the COVID-19 outbreak (44). Chinese government, to ensure the ongoing provision of mental health services and reduce the risk of cross-infections, implemented a remote consultation network where telephone or internet consultations can be carried out in a safe setting (45). The National Health Commission of China have published several online guideline documents and free electronic books on COVID-19 that lead to helping the development of Chinese public emergency interventions, improve the quality and effectiveness of emergency interventions (10). In addition, telehealth can provide mental health services in the context of patient isolation, to reducing the mental health burden from COVID-19 and share information about symptoms of burnout, depression and anxiety (14).
Greenhawt et al suggested telehealth has several advantages in delivery allergy and immunology services are including limit exposure of healthcare to potentially infected patients and provide access to rapid evaluation for COVID-19 infection (38). Apart from the commonly methods used in diagnosing OVID-19, one study in Iran identified novel screening and triage strategy during deadly COVID-19 epidemic. Iranian Society of Radiology (ISR) to response the shortage of on-site thoracic radiologists, through a social media massager delivered teleradiology services and provide teleconsultation for triage of COVID-19 infection (33). In addition to taking actions to protect the health and safety of patients, staff should also take mobile health technology to develop staffing plans and conducted billing of patients (39).
Our results show that to management the COVID-19, there are many potentials in video consulting, which are not difficult to set up. Live video conferencing can lead to avoidance of direct physical contact, thus diminishing the hazard of exposure to respiratory secretions, preventing the potential transmission of infection to physicians and another health staffs (34). Also, for patients consulting about covid-19, video could be useful for people with heightened anxiety, in-person visit include chronic disease reviews, some medication checks, and triage when telephone is insufficient (23). In order to halt the spread of the COVID-19 outbreak, telephone and video consultations follow up is possible in multiple cancer settings including endometrial, prostate, lung, and colorectal (37).
Based on study was conducted in USA, phone calls and electronic health record (EHR) can facilitates screening or treating a patient in an ambulatory and urgent care setting without the need for in-person visits and improve decision making process among healthcare team (35). Overall, the impact of telehealth tools during the COVID-19 pandemic in preventing morbidity and avoid mass from high-risk areas such as hospital grounds was significant. Also, elderly people can access health services by using electronic devices (36). At moment, the major barrier to large-scale telehealth for management of COVID-19 infection including appropriate adaptation of local systems with changes, programs are related to payment and coordination of services (8). We are hope with training for health providers and patients on how to make the most of telehealth tools, revisiting traditional definitions of clinical practice and using closed online platforms COVID-19 were prevention and control.
The biggest challenge for future research in use of telehealth, is probably defining the obstacles and facilitators in health providers and patients. Future research that suggested were specify effects of telehealth solutions in the efficiency indicators and hospital performance. Also, further global research is required for determine how to set up telehealth in primary care. Researchers can also examine the effectiveness of using telehealth approaches in different health areas, especially in the field of nursing home elderly who are high-risk people in the community. It is also highly recommended to use this technology in the field of psychiatry as it does not require in-person visits. Other future research that evaluate the satisfaction of patients and providers with telehealth services.
Our systematic review holds three limitations. Firstly, it is possible that related articles have been published in nationality language (e.g. china language) that is outed from our study. Second, was inaccessibility to some other databases such as CINAHL and PsycINFO. Third, there may be other reported studies that we did not identify, despite our search strategy being comprehensive and covering a broad range of evidence across world.
This study has provided a comprehensive systematic review in this area that solely focusses on potential telehealth during the COVID-19 pandemic. In response to WHO’s call for studies on the COVID-19 infection and present the most recent evidence published in this early period of the outbreak for health care providers, this study was performed to identify the role of telehealth during COVID-19 outbreak. As the COVID-19 epidemic scales exponentially across the worlds, calls for expended use of telehealth, innovative solutions and optimization of life-saving critical care hospital beds clearly highlight unmet needs in the world healthcare system. Telehealth has the potential to address many of the key challenges to providing health services in during COVID-19 outbreak. Telehealth can be avoidance of direct physical contact and minimizing the risk of COVID transmission and finally provide continuous care to the community. At present, we suggest for clinicians and patients, telehealth approaches are certainly appropriate to prevent COVID-19 infection.
COVID-19: Corona Virus Disease 2019, CASP: Critical Appraisal Skills Program, WHO: World Health Organization, MeSH: Medical Subject Headings, IoMT: Internet of Medical Things, IPC: Infection Preventive and Control, HER: Electronic Health Record, PUI: Persons Under Investigation.
Acknowledgements
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Declaration of interests
None.
Authors' contribution
AH and EM developed the design and involved in the study selection, data extraction, quality assessment, evidence synthesis and developing the first draft of the manuscript. Two authors read and approved the final draft of the manuscript.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Availability of data and materials
Datasets are available through the corresponding author upon reasonable request.