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Telehealth for global emergencies: Implications for coronavirus disease 2019

(COVID-19)

Article  in  Journal of Telemedicine and Telecare · March 2020

DOI: 10.1177/1357633X20916567

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LEADER: Focus

Journal of Telemedicine and Telecare

0(0) 1–5
Telehealth for global emergencies: ! The Author(s) 2020
Article reuse guidelines:
Implications for coronavirus disease 2019 sagepub.com/journals-permissions
DOI: 10.1177/1357633X20916567
(COVID-19) journals.sagepub.com/home/jtt

Anthony C Smith1,2,3 , Emma Thomas1 ,

Centaine L Snoswell4 , Helen Haydon1 , Ateev Mehrotra5 ,
Jane Clemensen2,3 and Liam J Caffery1,4

Abstract
The current coronavirus (COVID-19) pandemic is again reminding us of the importance of using telehealth to deliver
care, especially as means of reducing the risk of cross-contamination caused by close contact. For telehealth to be
effective as part of an emergency response it first needs to become a routinely used part of our health system. Hence, it
is time to step back and ask why telehealth is not mainstreamed. In this article, we highlight key requirements for this to
occur. Strategies to ensure that telehealth is used regularly in acute, post-acute and emergency situations, alongside
conventional service delivery methods, include flexible funding arrangements, training and accrediting our health work-
force. Telehealth uptake also requires a significant change in management effort and the redesign of existing models of
care. Implementing telehealth proactively rather than reactively is more likely to generate greater benefits in the long-
term, and help with the everyday (and emergency) challenges in healthcare.

Keywords
Telehealth, telemedicine, pandemic, emergency, disaster management, sustainability, coronavirus, COVID-19
Date received: 8 March 2020; Date accepted: 12 March 2020

Introduction
convenient access to routine care without the risk of
The number of cases of coronavirus disease 2019 exposure in a congested hospital or in medical practice
(COVID-19) is increasing rapidly and, as of 11 waiting rooms.
March 2020, the World Health Organization has However, for telehealth to be effective during the
declared that this can be characterised as a pandemic.1 current COVID-19 pandemic and future events, we
Governments are preparing for the worst, quickly real- must ensure that telehealth is appropriately integrated
ising the impact that COVID-19 is having on health into our health service, and treated as a ‘business as
services and the global economy. Amidst the avalanche usual’ modality. The aim of this article is to outline key
of reports concerning the spread of the virus, there is
also recognition (again) that telehealth ‘could’ play a
critical role in the global response. 1
Centre for Online Health, The University of Queensland, Australia
Of course, telehealth is ideal for the management of 2
Hans Christian Andersen Children’s Hospital, Denmark
3
communicable diseases. A key factor in slowing the Centre for Innovative Medical Technology, University of Southern
transmission of a virus is ‘social distancing’2 thus Denmark, Denmark
4
Centre for Health Services Research, The University of Queensland,
decreasing person-to-person contact. For patients Australia
with COVID-19, or those concerned that they might 5
Department of Health Care Policy, Harvard Medical School, USA
be infected, telehealth can help with remote assessment
(triage) and the provision of care. For people not Corresponding author:
Anthony C Smith, Centre for Online Health, Centre for Health Services
infected with the COVID-19 virus, especially those at Research, The University of Queensland, Ground Level, Building 33,
higher risk of being affected (e.g. older adults with pre- Princess Alexandra Hospital, Woolloongabba, QLD, 4102, Australia.
existing medical conditions), telehealth can provide Email: asmith@uq.edu.au
2 Journal of Telemedicine and Telecare 0(0)

requirements to ensure that the value of telehealth is MBS funding, claims data shows only four telehealth
fully realised, not only in emergencies (such as pandem- visits were provided in the first three months.
ics) but also in everyday practice.
Barriers to the use of telehealth and
Previous use of telehealth in emergency strategies to address them
situations Outside of emergency situations, the overall uptake of
Telehealth has a number of key strengths that can telehealth has been slow and fragmented.14,15
enhance an emergency response when environmental Substantial efforts have gone into scaling-up the rou-
or biological hazards present. During infectious disease tine use of telehealth, often with limited success. In
outbreaks, telehealth can enable remote triaging of care Australia, despite the introduction of generous finan-
and provide rapidly accessible information through cial incentives for specialist videoconsultations, tele-
technology – such as chatbots, as seen in Singapore health represented less than 1% of all specialist
during COVID-19.3 Telehealth can also assist with dis- consultations provided.16 The experience in the USA
ease diagnosis via video consultations with health pro- has been similar, where less than 1% of people living
fessionals. Various applications exist for providing in rural areas have ever experienced telehealth. Reasons
ongoing care as demonstrated by a hospital in the for the low uptake of telehealth are multifaceted and
USA where physicians are currently using telehealth diverse, but factors such as clinician willingness, finan-
to care for COVID-19 patients remotely.4 cial reimbursement and (re)organisation of the health
Additionally, telehealth can enable people to navigate system may be to blame.
the health system and access routine care during an
infectious disease outbreak. Clinician willingness and acceptance of telehealth
The current COVID-19 event is not the first time
The limited uptake of telehealth services is mostly
that government agencies and healthcare providers
attributable to clinician’s unwillingness to adopt tele-
have turned to telehealth in response to disaster situa-
health.17 A timely telehealth response to emergencies
tions. The North Atlantic Treaty Alliance (NATO) (an
such as the COVID-19 outbreak, calls for a health
intergovernmental military alliance between 29 mem-
workforce that is skilled and capable of switching deliv-
bers including North American and European coun-
ery modes, as required. Relying just on sporadic uptake
tries), developed a Multinational Telemedicine System
of telehealth, as in times of emergency, is problematic.
in 2000 that has been deployed with their military
Why the unwillingness to adopt telehealth?
forces during various crises.5 Through solutions such
Telehealth is disruptive,18 complex19 and requires clini-
as person-deployable portable telemedicine kits and
cians to learn new methods of consulting.20 Clinician
satellite linkage, areas in need have received health sup-
acceptance of telehealth relies on them perceiving tele-
port from medical experts located in other countries.6
health as effective, safe and normal.17 Clinicians may
During hurricanes Harvey and Irma,7 private telemed-
not be knowledgeable and aware of telehealth, 21 which
icine companies provided care to victims relocated
is not surprising given there is limited telehealth train-
from their homes and primary care providers.
ing in medical, nursing and allied health pre-
Following the Severe Acute Respiratory Syndrome
registration curricula.22
(SARS) pandemic in 2003, China began exploring tele-
Regular telehealth practice leads to more sustainable
health and integrated electronic medical systems for use
models of care,23 and a telehealth-ready workforce.
in similar situations in the future.8 During severe pro-
Ensuring the health workforce is telehealth-ready will
longed droughts in Australia, the health department
require telehealth to be included in training and educa-
introduced new funding through the Medicare Benefits
tion.24 Therefore, it is imperative to include telehealth
Schedule (MBS) to allow clinicians to provide additional
in curricula and to mandate post-graduate telehealth
mental health services via videoconferencing.9 In 2019,
accreditation. This will send a clear message to current
similar mental health services were also offered to
and future healthcare professionals that telehealth is a
people affected by the bushfires.9
legitimate part of usual care. Furthermore it may
Whilst the potential benefits of telehealth are
increase readiness to use telehealth in every day prac-
clear,10–12 the uptake of telehealth in emergency situa-
tice, and in times of emergency.
tions has been limited. As an example, the funding pro-
vided by the Australian government to support the
delivery of online (videoconference) mental health serv- Reimbursement
ices to people affected in the bushfire crisis seems to Appropriate remuneration is needed for all telehealth
have had little impact.13 Despite the availability of services. Traditionally, the lack of funding has been
Smith et al. 3

blamed for the slow uptake of telehealth.25 Constraints Multiple resources are available to support disaster
for funding associated with geographical location and preparedness and response strategies. For example, the
service type have also limited expansion of telehealth in American Telemedicine Association Emergency and
city locations. For example, in Australia, funding is Response special interest group has developed a frame-
predominantly focused on medical consultations deliv- work and infrastructure checklist that could be used at
ered by videoconference for patients in rural and local, regional and national levels during disaster
remote locations. This is problematic because tele- events.30 The NATO Multinational Telemedicine
health is just as useful for people living in metropolitan System (described above) resulted in the development
locations. In the case of COVID-19, city locations are of a system, supported by guidelines and technology
most at risk because of greater population density.26 In solutions, which is able to interconnect various nation-
other emergencies, certain communities may be affect- al telemedicine capabilities for use during disasters.5
ed and therefore require increased access to specialist In the absence of any formal telehealth strategy, it is
health services, hence the importance of telehealth important to make telehealth guidelines available to
capability, irrespective of rurality. assist with co-ordination and delivery of telehealth
Temporary funding methods may be an appropriate services during an emergency event. This information
way of dealing with ad-hoc emergencies such as needs to suit all stakeholders, including patients, clini-
COVID-19. Depending on the nature of the emergen- cians, health service providers and funders.31
cy, prioritising telehealth funding for specific services International health agencies such as the World
or for a selected patient group (such as older people Health Organization, national centres for disease con-
with a respiratory illness) could help address high-risk trol, and health departments have been disseminating
and high-demand situations. This funding could be real-time information about COVID-19 via their web-
authorised by the government at short notice and sites and social media outlets32,33 and have a very
decommissioned after the emergency. important role to play in advocating for the use of
Countries have begun to address the reimbursement telehealth via these channels. These organisations can
barriers associated with COVID-19. In March 2020, increase awareness of telehealth, provide specific rec-
emergency supplemental funding legislation for coro- ommendations on effective telehealth use, and validate
navirus was passed in the USA which allows the federal the importance of telehealth’s role in the healthcare
government to expand telehealth to patients in metro- sector.
politan areas and also allows physicians to care for
patients in their homes.27 In Australia, there have
been similar calls to relax restrictions on general- Conclusion
practitioner-provided telehealth consultations.28 While we may not be able to accurately predict the
Whilst remuneration for telehealth services is an impor- timing of natural disasters and infectious pandemics,
tant requirement, a focus on funding alone will not we can be sure that they will present again in the
generate an effective telehealth service. Other critical future. The COVID-19 experience is not a first, and
factors need to be considered. nor will it be the last. Telehealth does have a critical
role in emergency responses. Advantages of telehealth
Organisation of the healthcare system include the ability to: rapidly deploy large numbers of
Dependency on individual clinicians to lead telehealth providers; facilitate triage so that front-line providers
is not a sustainable approach to the expansion of tele- are not overwhelmed with new presentations; supply
health. Telehealth adoption requires a whole-system clinical services when local clinics or hospitals are dam-
strategy. Embedding telehealth into routine service aged or unable to meet demand; and decrease the risk
delivery, by all healthcare providers, is the most effec- of communicable diseases which are transmitted by
tive way of ensuring telehealth can be readily used person-to-person contact.
during emergencies. This requires operational tele- There are also limitations to the use of telehealth.
health networks, telehealth policies and procedures, Some consultations require physical examinations that
and technology infrastructure that can be scaled-up may be difficult to perform remotely (e.g. auscultation)
during times of disaster. Telehealth is a disruptive pro- and diagnostics (e.g. imaging, cultures) which cannot
cess, so there is a need for effective change- be done remotely. It is important that clinician training
management strategies to support clinicians with highlights the limitations of telehealth and informs of
limited telehealth experience. Furthermore, simulated alternative methods of information gathering that can
testing of telehealth applications for emergency situa- be used in these situation. These situations also high-
tions is also a useful way of ensuring that workflow light the importance of providing care via telehealth to
processes are clear and effective.29 non-infected people during an infectious pandemic.
4 Journal of Telemedicine and Telecare 0(0)

This can reduce contamination when it is necessary to March 2020, https://www.who.int/dg/speeches/detail/wh

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