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César Morcillo et al. Medical Research Archives vol 8 issue 8. Medical Research Archives
Copyright 2020 KEI Journals. All Rights Reserved
Digital health solutions implemented by Sanitas hospitals to
maintain continuity of care during COVID-19 pandemic.
Authors
* César Morcillo Serra 1, Daniel Tizon Galisteo 2, Domingo Marzal Martín 3, José Francisco
Tomás Martínez 4.
Affiliations
1 Medical Director, Sanitas Digital Hospital. Internal medicine, Sanitas Cima Hospital.
2 Information technology systems and artificial intelligence, Sanitas Hospitals.
3 Medical Director, Sanitas Hospitals.
4 Managing Director, Sanitas Hospitals.
Correspondence Author
César Morcillo Serra, Pg Manuel Girona 33. 08034 Barcelona, Spain. T 935522700, F
935522792, cmorcillo@sanitas.es
RESEARCH ARTICLE
César Morcillo et al. Medical Research Archives vol 8 issue 8. August 2020 Page 2 of 12
Copyright 2020 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra
Introduction
The irruption of technology in healthcare is
an increasingly evident reality, driven by
the rise of digital transformation. From this
convergence between health and digital
technology is born the so-called digital
health, which not only provides us with a
toolbox that supports the development of
innovative patient-centered care models,
promoting accessibility, quality, safety and
efficiency in all areas of health, but it is a
cultural transformation of traditional
medical care, through disruptive
technologies such as telemedicine, mobile
Abstract
Introduction: Digital health facilitates patient-centered, accessible, safe, and more
efficient care, through technologies such as telemedicine, big data, bots, artificial
intelligence, and other technologies. Undoubtedly, its implementation has been
accelerated thanks to the COVID-19 pandemic, where they have demonstrated their
effectiveness, by maintaining continuity of care and facilitating early interventions
thanks to the analysis of data and the deployment of bots, telemonitoring and virtual
care platforms.
Objective and methods: Prospective observational study to describe the digital health
solutions implemented by Sanitas hospitals, a health insurance company with around
2 million costumers, 5 teaching hospitals and many outpatient health care facilities
throughout Spain, to maintain continuity of care during COVID-19 pandemic. We
outline the results of using the Sanitas telemedicine platform (video consultations and
Connected Health application) and chatbot.
Results: During the first 2 months of the COVID-19 outbreak, we have experienced
an exponential increase in the number of video consultations, coming from an average
of 300 a day before the COVID-19 crisis to around 5000 a day, going from 27.058
virtual visits made during 2019, to 114.598 in the first 5 months of 2020. The
Connected Health mobile phone application allowed to remote monitoring 95 patients
after hospital discharge for COVID-19 infection, measuring vital signs with a
connected pulse oximeter, answer health questionnaires daily, and alert the medical
team who received alerts for pain from 80% of patients and a decrease in oxygen
saturation in 12% of cases. Bots has also helped to fight the COVID-19 crisis, making
information available by providing the best answer to patients whenever they want it
24/7. Our bot SanIA has experienced 16.858 consultations about COVID-19 during
the first 2 months of the outbreak.
Conclusions: Digital health, throughout video consultations, telemonitoring platform
and bots, has helped to maintain continuity of care during the COVID-19 crisis. The
COVID-19 pandemic has brought a sudden change in the adoption of digital health
strategies, which will undoubtedly continue in the long term, and has served us, both
health staff and the population, to be better prepared for this next digital age.
Key Words: Digital Health, Telemedicine, Bot, Artificial Intelligence, COVID-19.
César Morcillo et al. Medical Research Archives vol 8 issue 8. August 2020 Page 3 of 12
Copyright 2020 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra
health, applications, artificial intelligence
(AI), bots, sensors and other devices, which
we will discuss below (1).
These new digital technologies allow
building a different relationship with the
patient, focused on their needs, transparent,
agile and continuous 24 hours a day, where
the user enjoys much more information,
participation and autonomy. They have the
potential to simplify both administrative
and healthcare processes, to improve the
quality and reduce the cost of medical care.
Telemedicine and internet of things
Mobile devices and applications create the
digital channel, where healthcare can be
delivered anywhere. The video
consultation is a clear example of this,
being very useful for disease control,
follow-up after discharge from the hospital,
and in emergency services, where it has a
high resolution capacity, reducing waiting
time.
The Internet of Things is simply the
networking of physical devices over the
Internet, providing them with connectivity
and facilitating a great exchange of high-
quality data. This allows patients to use
connected sensors that measure all kinds of
physiological variables, medication
adherence, and perceived health status,
making it easy for physicians to remotely
monitor a patient's health in real time. This
has led to the creation of connected health
platforms, which allow telemonitoring of
patients with wearables linked to mobile
applications that support behavior
modification through behavioral
techniques and gamification. The data is
managed in the cloud by software that
allows alerting healthcare personnel of a
clinical deterioration and thus acting early
(2). There is sufficient evidence that
telemedicine reduces healthcare costs,
improves the health of the population and
the customer experience in health care (3).
Artificial intelligence
AI is intended not only to change the way
we diagnose and treat, but to redesign
health care, impacting on three levels: in
doctors with fast and accurate image
interpretation; in healthcare systems, by
improving workflow and the possibility of
reducing medical errors; and in patients, by
allowing them to process their own data to
promote their health (4).
AI can help the insufficient number of
doctors to treat the growing number of
patients more efficiently, through digital
diagnosis and monitoring of diseases,
through interaction with sensors, facial
recognition, voice analysis and use of
interactive virtual assistants, which can be
implemented on mobile phones around the
world and facilitate universal access to
low-cost, predictive, personalized
healthcare 2.0 (5).
Another great application of AI is the
chatbot or conversational bot (shortened
form of robot), which is a programme that
simulates having a conversation with a
human being. It is able to process messages
in natural language, issued by the user
through keyboard or audio systems and it
generates responses sent again to the user.
These automated voice conversation virtual
assistants are useful for managing tasks
with minimal human-machine interaction,
or for health problem management, such as
helping to improve weight loss or gain (6)
or helping depression (7) or to deal with
César Morcillo et al. Medical Research Archives vol 8 issue 8. August 2020 Page 4 of 12
Copyright 2020 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra
COVID-19 crisis. Bots can make
information available at a scale well
beyond telemedicine approaches due to
automation and this can provide support for
people who cannot afford care, who can’t
communicate well in English, or who
prefer anonymity. These approaches can be
developed to tie to institution-specific
resources and that will enhance customer
service by providing the best answer to
patients whenever they want it, without
having to wait and without variability
based on who answers the phone (8). They
are accessible any time, allowing patients
to obtain answers 24/7 and to avoid wait
times on hold before reaching a human.
Bots have a higher handling capacity than
any human. A single chat bot can
simultaneously have conversations with
thousands of people no matter what time of
day. Regardless of the volume of calls,
every question may be answered
immediately.
The objective of AI is not to replace doctors
but to expand our skills, since its greatest
potential lies in the analysis of large
amounts of data that will allow replacing
part of the doctor's routine work. Therefore,
AI will not displace doctors, but those who
embrace its advantages will end up
displacing those who do not use it (9).
Big data and Real world data
Big data is a large data set that can be
computerized to uncover patterns, trends,
and associations, particularly those related
to human behavior and interactions. The
development of new AI algorithms and the
increase in the number and quality of the
data allow the analysis of unstructured
biomedical texts and in turn extract
information from sensors and notes from
the electronic medical record. Although
there is an ethical obligation to protect the
privacy of patients, they express their
willingness to provide their data to medical
records if they are kept confidential.
Real World Data (RWD) is data related to
the health status of the patient and / or the
provision of health care collected on a
routine basis, which can be obtained from a
wide variety of sources with various uses in
the clinical practice. There is a need for
clear RWD documentation and
communication between patients and the
medical team. Patients provide information
that is complementary but different from
the adverse events classified by the doctor,
since these tend to underestimate the
symptoms of the patients, having shown
that severe symptoms are not reported in
clinical trials in up to 76%. The data
suggests that RWDs are more sensitive to
differences in treatment-related toxicity
than clinically classified adverse events,
reflecting the importance of proactive
symptom management in high-quality
healthcare. Incorporating RWD into
clinical care can improve outcomes over
standard care. Numerous trials have shown
that outpatient symptom monitoring
improves communication between the
patient and the medical team, quality of
life, symptom management and survival
(10), and in turn the satisfaction of the
medical team (11) and clinical decision
support. Efforts for this integration of
RWD must include the perspectives of all
stakeholders, including patients, families
and providers.
Digital health in the covid-19 pandemic
César Morcillo et al. Medical Research Archives vol 8 issue 8. August 2020 Page 5 of 12
Copyright 2020 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra
Digital health offers significant
opportunities to reshape today's healthcare
systems. From the adoption of electronic
medical records to mobile health
applications and other disruptive
technologies, digital health solutions have
promised better quality of care at a more
sustainable cost. At times like this
pandemic, the most adverse scenarios often
provide an opportunity to develop and test
the ability of these digital health
technologies to increase the efficiency of
healthcare systems.
While clinical staff remain on the front line
to protect citizens from the pandemic,
healthcare system managers reduce the
infection rate by deploying digital
healthcare solutions, to avoid nonessential
patient contact with the health care system
and to improve the control and diagnosis of
COVID-19 (12).
Methods
This is a prospective observational study
with the digital health solutions
implemented during the COVID-19
pandemic by Sanitas hospitals, a health
insurance company with around 2 million
costumers, 5 teaching hospitals and many
outpatient health care facilities throughout
Spain, to maintain continuity of care during
COVID-19 pandemic. We outline the
results of using the Sanitas telemedicine
platform (video consultations and
Connected Health application) and chatbot
between March and May, 2020.
For the analysis of the data, usual
descriptive statistical techniques have been
used.
Results
This is a prospective observational study
with the digital health solutions
implemented during the COVID-19
pandemic. Some examples of these
strategies deployed in our company have
been: Facilitate the registration of citizens
in personal health platforms by using a
mobile application for appointment
management; Expansion of the virtual visit
system that allows the doctor to make a
videoconference with the patient directly
from the electronic medical record;
Establish a synchronous and asynchronous
communication channel between the
citizen and the health professional;
Develop chatbot for self-evaluation of the
disease COVID-19; Enable web access to
the electronic medical record through
virtualization technologies that ensure that
health professionals can continue their
work, including medical visits, from home
(telework) during the period of
confinement; Reduction of bureaucratic
barriers in medical care processes by
allowing patients online access to their
medical reports and pharmacies to
treatment plans through electronic
prescription systems; Or managing the
emotional state of citizens through the
implementation of chatbots, applications or
web services that allow self-assessment and
identify risk cases to contact them
proactively.
This supposes the creation of a new
communication channel that guarantees
equity in access, a change in the model of
care provision with a reduction in personal
visits and training of clinical personnel
with adaptation to new technologies. It also
implies the design of new financing models
César Morcillo et al. Medical Research Archives vol 8 issue 8. August 2020 Page 6 of 12
Copyright 2020 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra
such as the recognition of virtual visits as a
billable service.
Its benefits are to establish a formal and
secure communication channel between the
citizen and the health professional,
decrease non-essential visits to health
centers by citizens, thus reducing the risk of
infection for both citizens and health
professionals and ensure continuity of care.
During the first 2 months of the COVID-19
outbreak, we have experienced an
exponential increase in the number of video
consultations, coming from an average of
300 a day before the COVID-19 crisis to
around 5000 a day, going from 27.058
virtual visits made during 2019, to 114.598
in the first 5 months of 2020 (Figure 1).
Figure 1. Number of video consultations during the first 2 months of the COVID-19
outbreak.
The Connected Health telemonitoring
platform is a mobile phone application
connected to a pulse oximeter and the
medical team. It has been used by 95
patients (64% male with a mean age of 54
(SD 26-81) years) after hospital discharge
for COVID-19 infection. The mobile phone
application, allowed to measure vital signs
and answer health questionnaires daily, and
alert the medical team that could be
contacted by video consultation. The
application allowed the detection of alerts
for pain (80% of patients) and a decrease in
oxygen saturation (12%). No patient
required hospital readmission or presented
complications. The application allowed
strict monitoring of symptoms and quality
of life. The main symptom was severe pain
(59% of patients) followed by anxiety or
depression (25%).
César Morcillo et al. Medical Research Archives vol 8 issue 8. August 2020 Page 7 of 12
Copyright 2020 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra
Figure 2. Connected Health application: screenshots
Figure 3. Alerts detected by the Connected Health application.
Bots has also helped to fight the COVID-
19 crisis, making information available by
providing the best answer to patients
whenever they want it 24/7. Based on our
experience with 16.858 consultations
about COVID-19 to our bot SanIA, during
the first 2 months of the outbreak in Spain
(Figure 2), most of the questions were
about health insurance coverage and
COVID-19 symptoms (Figure 3).
0 10 20 30 40 50 60 70 80 90 100
Severe Pain
Heart Rate >120x'
Oxygen Saturation <90%
% Patients
César Morcillo et al. Medical Research Archives vol 8 issue 8. August 2020 Page 8 of 12
Copyright 2020 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra
Figure 4. Number of bot consultations about COVID-19 during the first 2 months of the
outbreak.
Figure 5. Reasons for querying the Bot SanIA (16.858 consultations)
As we have seen, all this advances in
wireless technology, smartphones, and the
Internet of Things have facilitated new
ways to collect RWD in real time during
hospital visits and in daily life (Table 1 and
2). These can generate very large data sets
capable of big data analysis. The
integration of these electronic medical
records and biometric data will allow the
digital phenotype of the patient to be
created and its integration in research and
clinical care.
César Morcillo et al. Medical Research Archives vol 8 issue 8. August 2020 Page 9 of 12
Copyright 2020 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra
Table 1: RWD generated by the patient.
Self-reported medical data: personal or family
history, lifestyle habits, risk factors, treatments and
their completion.
Self-reported outcomes: disease symptoms,
treatment side effects, and quality of life.
Biometric or wearable data: heart rate, blood
pressure, blood glucose, temperature, physical
activity, sleep, location, ambient level of light and
noise, weight, falls ...
Table 2: RWD Benefits
Developing Personalized Medicine: targeted therapies based on the history and genetic information
of the patients.
Decision making: provide healthcare professionals with specific data and biostatistics information.
Variable analysis: they allow variables to be interrelated, being able to find probable events that
until now were not related or to screen the information based on specific needs.
Analysis of treatments and quality of care: efficiency, safety and measurement of results.
Early diagnosis: and introduction of specific therapies for initial stages of the disease.
Optimization of resources: reduction of waiting lists, detection of poorly controlled or poor
adherence patients, hospitalization, consultation time…
Discussion
Digital health, throughout video
consultations, telemonitoring platform and
bots, has helped to maintain continuity of
care during the COVID-19 crisis.
Thanks to the implementation of digital
strategies such as video consultation, a
strong change has been observed in face-to-
face visits to virtual consultations. Even
after the outbreak of COVID-19, an
César Morcillo et al. Medical Research Archives vol 8 issue 8. August 2020 Page 10 of 12
Copyright 2020 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra
increase in the adoption of digital health
solutions has continued to be observed.
Many barriers to adoption have
disappeared, at the same time that the
general population and professionals are
increasingly demanding technologies.
The high pressure on the health care system
in a situation of extreme crisis has been a
surprising engine of change. The lessons
learned in the pandemic by COVID-19
have helped define future steps.
This study also demonstrates the efficacy
of the Connected Health platform for the
remote monitoring of patients after hospital
discharge by COVID-19. The application
has facilitated the measurement of oxygen
saturation, symptoms and has allowed the
detection and management of alerts by the
medical team through video consultation.
Other studies have shown that remote
monitoring of patients to control COVID-
19 symptoms at home is effective and safe,
improving engagement and health
education, while minimizing exposure to
COVID-19 and the use of face-to-face
medical care (13), specifically after
hospital discharge, making early hospital
discharge possible, reducing the hospital
stay, the use of protective materials and
healthcare costs (14).
A long-term digital health strategy and a
robust health system have proven to be the
foundation of the accelerated change
process, such as a unique electronic health
record system, fostering a rapid
deployment of innovations. Digital health
tools have been shown to be the main driver
for reducing bureaucratic processes related
to health, which has saved time for
professional staff, avoided non-essential
visits by citizens to health centers, and
decreased risks of infection for both
citizens and health professionals. In
addition, financial barriers to the adoption
of digital solutions must be removed,
payment systems must be adapted to
facilitate their adoption, and deployment
must be accompanied by incentives for
healthcare providers (15).
In addition, it is essential to bear in mind
that for digital health to be implanted in the
long term, a true digital transformation of
medicine will be required, which involves
adapting multiple processes, such as the
ability to obtain informed consent, the
terms and conditions of use, verification of
the identity and location of the patient and
the use of secure platforms, among others.
It is not just about digitizing the
conventional, but creating a new innovative
digital system, a profound change in the
healthcare model necessary to take
advantage of the benefits that technology
offers us at this time.
It will require closer collaboration between
health and social care services, especially
with social health centers, and improve it
through a stronger deployment of digital
solutions, such as a single electronic
medical record and telemonitoring and
virtual care platforms.
The need created by the pandemic and the
current acceptance of digital health
solutions has opened a window to further
implement the model in a system that has
traditionally preferred face-to-face contact.
Although evaluating the efficiency of
adopting these long-term implemented
digital health solutions is of utmost
importance, the satisfactory experience
will undoubtedly create great expectations
about the convenience and accessibility of
César Morcillo et al. Medical Research Archives vol 8 issue 8. August 2020 Page 11 of 12
Copyright 2020 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra
virtual care, which will be difficult to
reverse once the crisis COVID-19
decrease. Similarly, the regulatory changes
invoked to support the widespread use of
telemedicine can be equally difficult to
reverse.
Beyond the clinical benefits, the changes
generated by the COVID-19 pandemic
have probably irreversibly altered the
position of telemedicine in the health
system. When speculation about
telemedicine's potential primacy over in-
person care previously seemed futuristic, it
is now a reality practiced in multiple
healthcare systems around the world. Using
telemedicine platforms, healthcare
personnel and patients are forced to a new
normal that includes communicating with
each other through video and audio. For
physicians, this means rapidly developing
skills in virtual relationship building,
empathy, physical video exams, diagnosis
and counseling, as study plans must be
developed to train the medical team in these
new skills and modalities to ensure the
quality.
We must harness the power and ingenuity
of the technology sector to combat these
disease outbreaks, but keep in mind that
when these digital technologies are
implemented to combat a pandemic,
especially with regard to digital
surveillance, it must be through a
thoughtful and transparent process (16).
The COVID-19 pandemic has brought
about a sudden change in the adoption of
digital health strategies, which will
undoubtedly continue in the long term.
Conclusion
The past decade has seen unprecedented
progress in digital health, accelerated by
the COVID-19 pandemic, allowing for
closer contact with patients. Digital health,
throughout video consultations,
telemonitoring platforms and bots, has
helped to fight the COVID-19 crisis. We
have the opportunity to create new
approaches based on data to identify and
intervene early in clinically significant
events, and thus improve both the quality
and quantity of life.
It is necessary to work to ensure that we are
better prepared for the next pandemic, but
this has undoubtedly helped us, both health
personnel and the population, to be better
prepared for this next digital age.
César Morcillo et al. Medical Research Archives vol 8 issue 8. Medical Research Archives
Copyright 2020 KEI Journals. All Rights Reserved
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