Thursday, August 6, 2020

Top ten COVID-19 impact on Healthcare Imaging and IT.

The onslaught of the COVID-19 virus has impacted many from an emotional and financial perspective and dramatically changed the way healthcare is being delivered. From a personal emotional perspective, a few of my family members were diagnosed positive, some of my friends had their loved ones hospitalized, and I recently lost a good friend and colleague due to the virus.
However, out of a “bad thing” usually “good things” happen as there is a sense of urgency and focus to 
deliver healthcare faster and better while keeping social distance. We did not only find out what worked in this environment, but also what did not work and where are the gaps that need to be filled to be ready for the COVID-19 aftermath and for potential future pandemics. 

Here are my observations:

1.       When there is a need, there is a way to change policies – To quote Christopher Roth, Vice-Chair of Radiology at Duke, who said during one of the many excellent SIIM webinars, “this pandemic was as dramatic and life changing as the implementation of a new EMR, but with the difference that instead of taking 2-3 years, it had to be done in less than a month. Therefore there was no time for committee meetings, no time for training and planning, but instead practitioners had to learn and make changes as-you-go.”

New uses for modalities were invented, for example, instead of bringing a COVID patient to a radiology department to perform an exam, with the result that a cleanup crew has to take half an hour to clean and disinfect it again for the next patient, it might be better to take a chest X-ray with a portable unit at the bed-side in the ICU or ER or patient room. Federal guidelines for reimbursement of non-standard procedures, which under normal circumstances would not be reimbursed were quickly changed and adapted.

2.       POCUS use has sky-rocketed – The emergence of hand-held ultrasound (Point Of Care Ultrasound, or POCUS) over the last 2 years could not have come at a better time. These systems are relatively affordable as the cost ranges between $2k and $6k, and as they connect to either a standard phone or dedicated phone-size screen or tablet, a healthcare practitioner can carry one in his or her pocket and make an assessment on the spot.

Uploading the images that a physician wants to keep as part of the electronic health record has been a challenge that has been addressed by the standards community in the form of an “Encounter Based Imaging” IHE profile. As a recent JACR study showed, its usage did not impact downstream ultrasound volumes which is good news for those who feared that it would cannibalize the “standard” ultrasound procedures.

3.       Telemedicine has shown a massive increase – Telemedicine takes place in three modes: 1) Synchronous where a patient is talking real-time to a healthcare practitioner, 2) A-synchronous where the communication takes place in the form of texts, emails, uploaded documents, etc.,  and 3) Telemonitoring or Virtual Observation.

Telemonitoring does not only include monitoring a patient at home but also monitoring inpatients such as in the ICU. The less a practitioner has to interact physically with an infected patient, the lower the risk of spreading the infection and the lower the need for PPE usage.
Estimates for telemedicine business range between a 7 to 10 fold increase over the next 5 years. If you consider an individual practitioner, the increase could be dramatic from having virtually no telemedicine consults to converting more than 70% of their practices to remote consults. This increase became the ultimate test of the scalability of the platforms that are being used. It can only be expected that when the pandemic wanes there will be a certain percentage of those applications kept in place.

A positive effect also has been that tele-visits are now chargeable because of changed regulations, let’s hope that some of these “emergency rules” by CMS will stay in place as there is no reason for a patient to show up in a doctor’s office for simple things that can be dealt with remotely.

4.       The cyber security attack surface has been greatly enlarged – Many non-clinical healthcare workers have been working from home, clinical workers might be working from home as well, and last but not least, because of teleconsultations, patients are now also directly connected to providers. This is especially challenging for smaller providers who might not have the IT resources to deal with this.

5.       Patients have become users of an organization technical infrastructure – According to a survey, most of the telehealth consultations used commercial applications such as Zoom (23%), Facetime (17%) and Skype (9%) with telehealth platforms (34%) in the minority. One cannot assume that every patient is familiar with the functionality of these tools, and some of them are definitely more user-friendly than others. Who is the patient going to call if they cannot get into the tele consult application? IT support had to ramp up significantly to support patients as well as their remote employees.

6.       Telemedicine extended beyond COVID calls – The same survey showed that only 14% of visits were related to COVID symptoms. The other 86% of the calls ranged from urgent care to scheduled visits, behavioral health, chronic illness management (diabetes, cardiac, others…), and surgical follow ups. Again, the social distancing requirement showed that a significant percentage of routine visits can be done equally well remotely.

7.       Artificial Intelligence (AI) has proven not to be a panacea (yet) – As most AI algorithms are based on deep learning it requires a significant amount of training data which was certainly in the beginning not readily available. It is getting better as many institutions make their data available to researchers. Many AI vendors were “reprogramming” their algorithms from existing applications, such as pneumonia, for COVID which has proven not to work as well. In addition, it was and is still not clear what modality is the best to diagnose COVID, is it a chest X-ray, a CT, an ultrasound or other modality? The advantage of imaging is that it is almost real time, or at least has a much faster turn-around time than having to wait for a lab test result.

8.       Digital pathology is a major laggard – With tele consults and teleradiology being widely available it is definitely frustrating to see how it is currently challenging if not impossible to exchange a digitized pathology slide, especially in the US due to a lack of regulatory approvals and interoperability. Some countries, notably the Netherlands already have a nationwide digital pathology exchange set up to for this. There is no reason why this kind of implementation could not be deployed in the US, as a matter of fact this is the main topic of an upcoming seminar on this subject.

9.       How to get access to all of the records is still very challenging – Just from anecdotal experience, after one of my good friends had arranged for her scheduled in-person visit to be changed to a telehealth visit with a major institution for a second opinion, the physician did not have access to the most recent X-rays. The fact that my friend had the CD did not really help as there was no upload mechanism for them in the platform/portal they were using. Having all the information in a timely and complete manner is even more of a challenge with these telehealth consults.

10.   A major workflow redesign is needed – I was rather impressed with the new workflow when I had an in-person appointment with my specialist. I was instructed to text my arrival to the front-desk, upon which a nurse came to my car with a wireless tablet to confirm my identity, take my temperature, ask basic questions and when I “passed,” escorted me to the clinic straight into an exam room using a path that would limit any close encounters with other patients or practitioners. Similarly, hospitals now have a special dedicated entrance for suspected COVID cases. 


In conclusion, the pandemic has had a major impact on healthcare IT and accelerated some of the “dormant” applications to a degree that will very likely stay, most of it for the better. I recall the last visit of my spouse with the surgeon one week after she was discharged following a minor surgery, upon which the surgeon took a quick look at her scar and determined in a matter of seconds that all was OK. There is no reason for that type of visit to be in person as she could simply take a picture with her phone and email it or during a synchronous telehealth session point her phone to the incision to show it. Telehealth is in many cases more efficient and creates less of a burden for patients and has the potential to lower costs as well, let’s hope that the result of many of these COVID impacts will remain for the better.