Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development

Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development
Published online: 2021-04-21

    © 2021                       IMIA and Georg Thieme Verlag KG

    Primary Care Informatics Response to
    Covid-19 Pandemic: Adaptation, Progress,
    and Lessons from Four Countries with High
    ICT Development
    Siaw-Teng Liaw1, Craig Kuziemsky2, Richard Schreiber3, Jitendra Jonnagaddala1, Harshana
    Liyanage4, Aliasgar Chittalia5, Ravninder Bahniwal6, Jennifer W. He7, Bridget L. Ryan8,
    Daniel J. Lizotte9, Jacqueline K. Kueper7, Amanda L. Terry8, Simon de Lusignan4
      WHO Collaborating Centre on eHealth, UNSW Sydney, Australia
      MacEwan University, Edmonton, Alberta, Canada
      Penn State Health Holy Spirit Medical Center, Camp Hill, Pennsylvania, USA
      Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
      Family Practice Center, Mountaintop, Pennsylvania, USA
      Schulich Interfaculty Program in Public Health, Western University, London, Canada
      Graduate Program in Epidemiology and Biostatistics, Western University, London, Canada
      Centre for Studies in Family Medicine, Department of Family Medicine, Western University,
      London, Canada
      Department of Computer Science, Western University, London, Canada

     Summary                                                              Results: All countries responded rapidly. Common themes              change. However, the lack of coordinated national strategies and
     Objective: Internationally, primary care practice had to transform   included rapid reductions then transformation to virtual visits,     regulation, assurance of financial viability, and working in silos
     in response to the COVID pandemic. Informatics issues included       pausing of non-COVID related informatics projects, all against a     remained limitations. The potential for primary care informatics
     access, privacy, and security, as well as patient concerns of        background of non-standardized digital development and dispa-        to transform current practice was highlighted. More research is
     equity, safety, quality, and trust. This paper describes progress    rate territory or state regulations and guidance. Common barriers    needed to confirm preliminary observations and trends noted.
     and lessons learned.                                                 in these four and in less-resourced countries included disparities
     Methods: IMIA Primary Care Informatics Working Group mem-            in internet access and availability including bandwidth limita-      Keywords
     bers from Australia, Canada, United Kingdom and United States        tions when internet access was available, initial lack of coding     Telemedicine, Primary Health Care, health policy, public health,
     developed a standardised template for collection of information.     standards, and fears of primary care clinicians that patients were   severe acute respiratory syndrome coronavirus 2
     The template guided a rapid literature review. We also included      delaying care despite the availability of televisits.
     experiential learning from primary care and public health            Conclusions: Primary care clinicians were able to respond to the     Yearb Med Inform 2021:44-55
     perspectives.                                                        COVID crisis through telehealth and electronic record enabled

    1 Introduction                                                        nication technology (ICT) developments
                                                                          and telehealth were “fast-forwarded” to
                                                                                                                                               privacy and ethical issues, participants’ lit-
                                                                                                                                               eracy, cost, reimbursement, and regulatory
    Primary care informatics (PCI) is the sci-                            support the rapid and ongoing response to                            barriers [3]. Despite a lack of evidence for
    ence that underpins digital health in the                             the COVID-19 pandemic [2].                                           the access, equity, utility, safety and qual-
    community, empowering patients, carers,                                   Primary care had to deal with managing                           ity of telehealth, it quickly became policy
    citizens, health professionals and health or-                         personal protective equipment (PPE), pub-                            (Box 1) [4]. The scope to develop PCI
    ganisations in the delivery of safe, effective,                       lic health guidelines such as hand hygiene                           and digital health to support primary care
    and integrated patient-centred care.                                  and social distancing, and contact tracing                           during COVID-19 cannot be separated from
        Global progress towards digital health                            apps, and informatics issues including tech-                         policy, human resources and other system
    maturity [1] was slow until the COVID-19                              nical issues (network connectivity & user                            limitations [5, 6].
    pandemic when information and commu-                                  interfaces), limited physical examination,

    IMIA Yearbook of Medical Informatics 2021
Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development
                                                 Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development

                                                                   countries (Australia, Canada, USA, UK)                          However, the Australian Nation-
   “Our government’s response to the
                                                                   ranked in the top 30 of 176 countries with                   al COVID-19 Primary Care Response
  pandemic brought forward a 10-year
                                                                   an International Telecommunication Union                     changed this and implemented expanded
   plan on telehealth within 10 days.”
       Australian Health Minister
                                                                   ICT Development Index [7] and provided                       access to telehealth services, training of the
                                                                   an international comparison with data from                   health workforce, 24-hour health advice,
                                                                   India (ranked 134) and Pacific Islands (Kiri-                dedicated community-based “respiratory”
  “These investments will help provide
                                                                   bati ranked 154).                                            clinics, and enhanced protection for remote
   Canadians with virtual health care
                                                                       The concepts guided the limited scoping                  communities [9].
   services that are safe and secure.”
  Canadian Federal Minster or Health
                                                                   literature review for each of the countries.
                                                                   Search terms included: primary health care,
                                                                   family medicine, general practice, popula-                   b COVID-19 Impacts on Primary Care
    “GP tele-consultations should be
                                                                   tion, health, medical, informatics, telemed-                 Delivery in Australia
      default unless reason not to.”                                                                                            Temporary telehealth items introduced in
                                                                   icine, telehealth, teleconsultation, virtual,
    United Kingdom Health Secretary                                                                                             March 2020 for 6 months significantly acceler-
                                                                   consultation, encounter, videoconference,
                                                                   COVID-19, equity, disparities, health insur-                 ated a shift from physical “in-person” consulta-
  “’Please don’t give up. Don’t despair,                           ance, health benefits, accessibility, privacy,               tions to virtual face-to-face consultations [10].
    the end is in sight,’ as opposed to:                                                                                        Telemedicine activities peaked in April, 2020
                                                                   computer security, regulatory, regulations,
  ‘Hey, we are good to go, don’t worry                                                                                          at 38% of all ambulatory visits captured in the
                                                                   risk, and various short forms with wildcards.
     about anything.’ We are not good                                                                                           Australian Medicare program [11]. In the first
     to go. We have got to continue to
                                                                       We enhanced the literature review with
                                                                   personal experiences with COVID-19 from                      40 weeks of COVID-19, a significant initial
   double down on public health mea-
                                                                   the primary care and public health perspec-                  increase in phone consultations was maintained
   Dr. Anthony Fauci, COVID advisor                                tives in our respective countries. We also                   but the small initial increase in video consul-
   to the President of the United States                           examined issues with data custodianship                      tations was not (Figure 1) [12]. Telehealth has
                of America                                         and stewardship of primary care data re-                     enabled 85% patients with COVID-19 to be
                                                                   positories in the UK and Australia. We then                  managed in the community, including patients
                                                                   summarised and synthesised the information                   suspected of SARS-CoV-2 (Severe Acute Re-
Box 1 Quotes from health system leaders about the shift towards    to identify the impacts of COVID-19 on                       spiratory Syndrome Coronavirus 2) infection
digital health                                                     primary care, how PCI adapted, and how it                    and vulnerable elderly patients at increased
                                                                   may evolve into the future and a new normal                  risk of complications [13]. At-risk older or
                                                                   for primary care.                                            quarantined GPs can continue consulting from
                                                                                                                                home, avoiding in-person consultations [14].
2 Objectives                                                                                                                        By September, 32% GP consultations
                                                                                                                                were by telehealth: 97% by phone and used
We examine the use of PCI and telehealth                           4 Results: PCI response to                                   more by women. Video was highest for the
across the COVID-19 pandemic across
countries with variable resources and levels
                                                                   COVID-19                                                     25-44 age group. About 20% specialists
                                                                                                                                billed MBS telehealth services; of these 16%
of digital health maturity. We report how                          4.1 Australia                                                were for video, compared with 3% for GPs
PCI supported the transformation of health                                                                                      [11]. While 16% is not great for nine years
systems focusing on virtual primary care en-                       a Healthcare system                                          (from 2011), it suggests video services in
counters, documenting areas of accelerated                         The Australian federated health system                       general practice are likely to increase with
progress and lessons learned.                                      is complex and fragmented, but evolving                      time, familiarity and better infrastructure,
                                                                   towards an integrated, citizen-centred, ac-                  consistent with international literature [15].
                                                                   countable and sustainable system. The My                         The MBS GP telehealth items have been
                                                                   Health Record system addressed informa-                      extended to March 2021, restricted to vul-
3 Methods                                                          tion sharing and integrated care delivery.
                                                                   There was little progress on foundational
                                                                                                                                nerable patients with an existing relationship
                                                                                                                                with the GP – defined as an in-person visit
Volunteer members of the IMIA Primary                              elements such as e-prescribing and com-                      in the past 12 months [16]. This restriction
Care Informatics Working Group developed                           puterised physician order entry (CPOE)                       has prevented some vulnerable groups from
a template to standardise the collection of                        in primary care. Whilst the Australian                       accessing telehealth services [14]. It also wor-
relevant PCI concepts and information. We                          Medicare Benefits Schedule (MBS) has                         ries many private general practices (60%) at
described the primary care system in each                          included specialist telehealth items since                   risk of non-viability as a result of COVID-19
country, then how PCI was used and adapted,                        2011 there were no general practice (GP)                     [17]. An Australian private health insurer
extent of success, and lessons learnt from                         items, apparently because of risks of fraud/                 (Medibank) has extended coverage indefinite-
each country. We present data from four                            over-servicing [8].                                          ly for allied health teleservices [18].

                                                                                                                                              IMIA Yearbook of Medical Informatics 2021
Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development
Liaw et al.

                                                                                                                                                     d Next steps: What has Australia learned
                                                                                                                                                     from COVID-19?
                                                                                                                                                     Primary care will need support to increase its
                                                                                                                                                     digital health capacity, including standards
                                                                                                                                                     for virtual health competencies, training,
                                                                                                                                                     implementing electronic referrals and CPOE
                                                                                                                                                     to enable the delivery of virtual care [24].

                                                                                                                                                     4.2 Canada
                                                                                                                                                     a Healthcare system
                                                                                                                                                     COVID-19 has accelerated the Canadian
                                                                                                                                                     health system to increase virtual care capacity
                                                                                                                                                     while respecting physical distancing [2]. The
                                                                                                                                                     challenges are significant for primary care
                                                                                                                                                     providers (PCP) as they need to deliver regu-
                                                                                                                                                     lar PC services and also manage COVID-19
                                                                                                                                                     screening and contact tracing. There was no
                                                                                                                                                     national eHealth strategy or system to support
                                                                                                                                                     the Canadian national COVID-19 response
Fig. 1 Daily charting of mode of consultations by GPs in South Eastern Australia. In person consultations declined and phone consultations           because the separate Province and Territory
increased; both after the initial surge. The low levels of telehealth (videoconsultation) remained stable. Source: Pearce C et al. The GP Insights   healthcare delivery systems developed their
Series no 7. 26 Oct 2020 ( [12]                                                                                                   own strategies and tools including telehealth
                                                                                                                                                     and virtual care [25], e-referral and intake
                                                                                                                                                     [26] and a hospital-at-home initiative [27].

c Implications for primary care informatics                                 South Eastern Australia [12]. In the first 40                            b COVID-19 impacts on primary care
Non-standardised development of digital                                     weeks of COVID-19, POLAR data showed                                     delivery in Canada
tools: Telemonitoring is increasingly being                                 marked reduction in GP presentations for                                 Canada was challenged by travel restriction
used for patients at high risk of readmission                               childhood infective illnesses (bronchiolitis,                            delays, insufficient testing, insufficient PPE
or who live in residential aged care settings                               gastroenteritis) and antibiotic prescriptions,                           supply, and difficulties with infection control
[19]. Current systems are being modified to                                 with concomitant increases in anxiety,                                   in long-term care settings [28]. PCPs started
address COVID-19, an example being the                                      depression and eating disorder-related diag-                             working in new settings such as COVID-19
Total Cardiac Care (TCC+) system which                                      noses. Other data sources showed contem-                                 screening and assessment centres. PCPs
added oximetry to its range of sensor de-                                   porary decreases in cancer biospecimens                                  were encouraged to provide telemedicine
vices [20]. TCC+ is seeking registration as                                 and pathology services [23]. A balanced                                  and virtual care, with immediate uptake of
Software as a Medical Device with the Aus-                                  approach for timely cancer diagnosis was                                 a virtual-visit-first model. In-person consul-
tralian Therapeutic Goods Administration.                                   recommended and indicates what PCI could                                 tations were limited by deferring non-urgent
COVIDSafe, a contact tracing app, has been                                  focus on [8, 23]. Mental healthcare support                              visits. Triaging protocols for virtual visits
superseded by electronic registration using                                 for isolated elderly and young people needs                              were developed [29]. Consults were primar-
QR-based technologies at public venues.                                     digital enhancement.                                                     ily by telephone, but also included email,
COVID-19 sped up electronic prescribing,                                       Unintended consequences: An Adelaide                                  video conferencing, and telemedicine ser-
allowing general practices to communicate,                                  digital health firm sent patient details and                             vices (e.g., Patients were
using a token or an active script list, with                                COVID-19 test results to wrong people.                                   generally satisfied and will continue using
local pharmacies to write and dispense an                                   Australia’s current hybrid method of contact                             virtual care, citing reasons like increased
eScript [21].                                                               tracing—manual and assisted by spread-                                   safety, convenience, and accessibility [30].
    Timely access to real-world data (RWD)                                  sheets and generic customer relationships                                    Each jurisdiction introduced similar
across the spectrum of care: Popula-                                        management solutions—raises questions                                    regulations such as adapting physician fee
tion-level data on telehealth are available                                 about safety standards, security and                                     schedules, updating practice guidelines, and
through Medicare [22]. The POLAR                                            privacy, similar to those posed to the                                   providing income stabilization [31]. Virtual
repository contains patient-level RWD                                       head of UK National Health Service                                       care billing codes were released in March
extracted from 1000 general practices in                                    (NHS) Test-and-Trace.                                                    2020 [32]; some provinces have since updated

IMIA Yearbook of Medical Informatics 2021
Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development
                                     Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development

these codes. Challenges with the new billing              Virtual care can increase or decrease ineq-               policy, with practices largely left to create
codes for virtual visits included delayed              uitable access. For Canadians living in rural                their own policies [46]. PPE other than
payments [15]. There were documented de-               or remote regions, including First Nations                   face masks, plastic aprons and gloves were
creases in the use of PC services, likely due          communities, and individuals facing barri-                   initially in short supply [47].
to patients self-isolating at home, worries            ers related to mobility, travel costs and time                   There was initially a drop in the total num-
about overstressing the healthcare system and          constraints, virtual care has been decidedly                 ber of consultations associated with a rise in
a perceived risk of COVID-19 exposure in               beneficial [41]. In contrast, PCPs worry this                non-face-to-face with a return to normal rates
healthcare settings [28]. Reductions in contact        technology may perpetuate health disparities                 of consulting within 12 weeks (Fig. 2). There
with PC have reduced routine preventative              among seniors, individuals with disabilities,                was a move to more non-face-to-face con-
care, mental health care, and delayed immuni-          populations with language barriers, and those                sulting, overwhelmingly by telephone, though
zations. Many physicians are concerned about           who cannot afford or use technology [42].                    the latter included sharing of photographs by
long-term health impacts [33]. Decreased                  Just as expectations for the continued                    email, with only a small rise in e-consultations.
patient visits and delayed payments, coupled           expansion and use of virtual care are in-                    In the week that lockdown was announced a
with the adoption of new digital workarounds           creasing, so does a need for the appropriate                 record number of patients did not attend their
have resulted in financial challenges for many         health education, clinician training, and peer               consultations (Fig. 3). In a study of people 65
practices [33]. However, despite reduced               networks [43].                                               years and older, it did not appear that the shift
practice hours, most family physicians have                                                                         to non-face-to-face increased disparities [48].
not shut down their offices [34].                      d Next steps: What has Canada learned
                                                       from COVID-19?                                               c Implications for primary care informatics
c Implications for primary care informatics            COVID-19 like any pandemic or public                         The service showed speed and adaptability.
These are positive and negative. While more            health emergency, requires integration                       A national notice allowing data sharing
care could be offered virtually [30], it is            across sectors of society. A strong primary                  over the COVID-19 pandemic has allowed
recognized this will not eliminate in-person           care-public health interface is critical. Pa-                innovations in data use including OpenSafely
visits for physical examinations and medical           tient and PCP input is important in address-                 (
procedures. The potential to increase produc-          ing equity and access for vulnerable popula-                     Coding: At the start of the pandemic there
tivity is challenged by PCPs’ preoccupation            tions. Standards for privacy and security of                 were no codes to record COVID-19 infection
with complexities such as figuring out what is         virtual care are necessary. Medical/health                   in primary care CMR systems. CMR system
essential versus non-essential care, redirecting       education and training is important to ensure                medical directors created temporary codes
patients for tests and procedures, organizing          a competent workforce. While COVID-19                        within days, later replaced with substantive
schedules, sanitizing office space, and learning       has highlighted the need for virtual care,                   SNOMED clinical terms, though the latter
new protocols and technologies [33]. There             effective implementation and adoption is                     took two iterations [49]. Subsequently these
is no one-size-fits-all solution for informatics       still a long way off [5, 44].                                had to be developed into an ontology to
support as some tasks are better support-                                                                           enable virologically confirmed, clinically
ed virtually than others. Guiding patients                                                                          likely, possible and virologically negative
through physical exam tasks such as a hernia           4.3 United Kingdom                                           cases to be differentiated in routine data [50].
diagnosis can be a challenge [35]. In contrast         a Healthcare system                                              Success of the linkage technology in
to diagnostic tasks such as cancer screening,                                                                       NHS spine: The NHS spine includes a
                                                       The UK National Health Service (NHS) pro-
mental health care and ongoing management                                                                           personal demographics service within the
                                                       vides a free service at point of care. Primary
of chronic conditions are areas where virtual                                                                       secure NHS network. This lets data about
                                                       care is a registration-based system largely
care could be particularly impactful [36].                                                                          a patient to be linked and shared. This has
                                                       delivered through independent general prac-
    Many areas of Canada had been working                                                                           been particularly important for the large-
                                                       tices, and consultations have been recorded
on telehealth solutions prior to COVID-19                                                                           scale testing offered for COVID-19 enabling
                                                       into computerised medical record (CMR)
[37, 38]. However, with the need to deploy fast                                                                     results to be filed into the relevant patient’s
                                                       systems for some years [45]. Each patient
and easy virtual care, PCPs were compelled                                                                          primary care record, and early reporting of
                                                       is registered with a single general practice.
to decide on eHealth tools on their own and                                                                         disparities in those with COVID-19 [50].
                                                       A unique personal identifier, NHS number,
learn how to use them [35]. However, the                                                                                Mortality data: Mortality data are also
                                                       links an individual’s records across the NHS.
need to develop telehealth systems that meet                                                                        shared via the NHS spine, enabling rapid
standards for secure use, communication, and                                                                        identification of the peak in mortality asso-
storage of digital health information may be           b COVID-19 impacts on primary care                           ciated with the first COVID-19 peak (Fig.
compromised as patients and physicians turn            delivery in UK                                               4). This has enabled contemporaneous data
to more user-friendly, but potentially insecure        COVID-19 had a big impact on primary care                    to report rates of mortality [51], both those
video call platforms instead of tools endorsed         delivery as there was uncertainty about what                 across the population [52] and those with
by health authorities [36, 39-41].                     constituted an effective infection control                   known COVID-19 status [53].

                                                                                                                                  IMIA Yearbook of Medical Informatics 2021
Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development
Liaw et al.

Fig. 2 Weekly consultations by GPs in UK primary care, week 40 of 2018 to week 47 of 2020. In week 12 of 2020, (202012) lockdown was announced and there was a drop in overall consulting. Home
visit rates and face to face in surgery declined, clinical administration (including text and email) and telephone consulting increased.

Fig. 3 Rate of failed encounters / did not attend in UK primary care. Week 12 of 2020 was the highest ever recorded for not attending. The rates of non-attendance have not changed with lockdown.

IMIA Yearbook of Medical Informatics 2021
                                                    Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development

Fig. 4 Mortality in week 49 of 2019 (2019-48), to week 08 of 2021 (2021-08) in people 75 years old and older. The light blue line represents this year, with the peak coinciding with the first wave of COVID-19, the dark
blue line the 5-year mortality average.

d Next Steps: what has UK learned from                                     had already increased by 154% compared                                     sitioning care into larger clinics. Staff were
COVID-19?                                                                  to 2019 [57]. One insurance plan reported                                  redeployed to primary care offices. The elec-
The implementation of digital systems ac-                                  a peak in televisits to nearly 18 visits per                               tronic health record (EHR) technical teams
celerated, and there has been a groundswell                                1000 enrolees, but with wide geographic                                    completed all configurations, templates and
of willingness of GPs to share data. The Ox-                               variation [58]. Some specialists, e.g., oph-                               phrases, billing and coding changes, and
ford-Royal College of General Practitioners                                thalmologists could not accommodate the                                    technical set-up for televisits in a few weeks,
(RCGP) Research and Surveillance Centre                                    need. By Spring many facilities reported                                   similar to experiences elsewhere in USA
(RSC), one of Europe’s oldest sentinel sys-                                that c.75% of their ambulatory visits were                                 [59-63]. Use of telehealth increased rapidly
tems, trebled its membership over the course                               virtual, including visits for patients with                                to a peak of c. 62% outpatient encounters
of the pandemic [54, 55], and created a range                              SARS-CoV-2. The US Centers for Medicare                                    (Figure 5). Use depended on technical con-
of interactive observatories [56]. This will                               and Medicaid Services (CMS) authorized                                     siderations and whether it was to manage
address the slowness of agencies involved in                               payment for both video and phone based                                     chronic care patients, which was simpler
data linkage to actually share data, even for                              televisits during COVID-19.                                                than managing acute problems that required
what have been designated high-priority pub-                                                                                                          physical examinations.
lic health studies. The four nations that make                                                                                                            The few reports regarding implemen-
                                                                           b Case study: COVID-19 impacts on                                          tation of telehealth systems in response to
up the UK have separate rules and policies.                                primary care delivery at Geisinger Health                                  the COVID-19 pandemic come from large
                                                                           System in Pennsylvania                                                     centers similar to Geisinger, including the
                                                                           COVID-19 cases in central Pennsylvania                                     University of California, San Diego [64], the
4.4 United States of America                                               peaked initially in early May, then decreased                              Veterans Administration [59, 60], Boston’s
a Healthcare system                                                        until late fall into January 2021 when                                     Children’s Hospital [65], and a few private
Telehealth in the USA prior to COVID-19                                    case numbers exceeded the spring peak.                                     practices as part of larger academic medical
was largely the province of psychiatrists and                              Telehealth enabled Geisinger to continue                                   centers [66]. However, it must be noted that
psychologists. As lockdowns occurred across                                operations during COVID-19 by decreasing                                   the Geisinger experience may not represent
the nation, televisits increased exponentially                             all nonacute visits within primary care sites,                             the experience across the USA, even for
for all clinicians. By March 2020 televisits                               temporarily closing small clinics, and tran-                               similar sized integrated health systems.

                                                                                                                                                                      IMIA Yearbook of Medical Informatics 2021
Liaw et al.

                                                                                                                                           The COVID-19 pandemic revealed exten-
                                                                                                                                        sive gaps in the ability of the US to respond
                                                                                                                                        [75]. Lacking a coherent national COVID-19
                                                                                                                                        response policy, it was left to each state and
                                                                                                                                        indeed each hospital system and clinic to de-
                                                                                                                                        velop its own operations [76]. Furthermore,
                                                                                                                                        each state licenses its clinicians, and there
                                                                                                                                        are no consistent regulations or cross-state
                                                                                                                                        agreements for care of patients living close
                                                                                                                                        to state borders [77].

                                                                                                                                        d Next Steps: What has USA learned from
                                                                                                                                        A national not jurisdictional strategy is re-
                                                                                                                                        quired to coordinate digital health laws and re-
Fig. 5 At its peak in the spring of 2020, telemedicine accounted for 62% of all outpatient encounters in the Geisinger Health System.   imbursement. Foremost among the needs is a
                                                                                                                                        national policy requiring cross-state privileges
                                                                                                                                        to accommodate both clinicians and patients
                                                                                                                                        who live close to a state border and provide
    A telemedicine app integrated with the                                 in-person physical exam beyond simply                        or seek services on both sides. Financial
Geisinger EHR system, enabled seamless                                     observing the patient virtually. Further                     and political support for high-speed internet
encounter documentation through templated                                  research of these areas is mandatory.                        everywhere is critical for sustained success
notes, shortcut phrases for routine documen-                                   Sufficient bandwidth for both audio and                  of telehealth. Addressing the challenges and
tation, and appropriate phrases to document                                video connections depends on high-speed                      making these regulatory changes will funda-
specifics of televisits per legal and billing                              internet, not available in rural areas or afford-            mentally alter primary care provision in the
requirements. Similar shortcuts were built                                 able to the poor [69]. “Last mile” connec-                   United States [78, 79]. Telehealth appears to
to communicate test results to patients and                                tions are problematic, even in urban areas.                  be firmly established in primary care, and
work excuses to employers.                                                 People may have smartphones but cannot                       adequate resources made available to sustain
    Prior to COVID-19, there was no co-                                    afford Internet access, raising problems of                  it into the post-pandemic era, including man-
herent national policy, consistent national                                finding Wi-Fi hotspots that also offer privacy               aging subsequent pandemics [80].
reimbursement or incentives to establish                                   and security. Many telehealth applications,
the informatics structure to support tele-                                 especially those tethered to an EHR, require
health. This accelerated with the pressing                                 encryption and/or compliance with the                        4.5 An International Perspective
clinical, social and public health needs from                              Health Insurance Portability and Account-
COVID-19. Telehealth practice increased                                    ability Act, which may not be compatible                     from Some Countries with Lower
exponentially across the USA [67]. Reser-                                  with cell phone use. A risk of this inequity                 ICT Developments
vations about telehealth included fear that                                is that rural PCPs will be unduly burdened                   COVID-19 triggered many similar innova-
postponed elective surgeries or unmanaged                                  with sicker patients [70].                                   tions in Indo-Pacific countries with high ICT
chronic diseases will result in more care                                      Setting up televisits was easier for PCPs                developments such as China, South Korea
requiring emergency attendances and hos-                                   with mature EHRs, especially those with                      and Singapore. A comparison with countries
pitalizations [68].                                                        available telehealth modules. The more agile                 with lower ICT developments , such as India
                                                                           clinician offices with flexible scheduling suc-              and Pacific Island Countries (PIC), will be
                                                                           ceeded early, especially if they had institution-            more meaningful.
c Implications for primary care informatics                                al support. The cessation of elective surgeries,
There are informatics, technical, and ed-                                  decreased office visits, limited reimbursement
ucational challenges. Training for a new                                   for telehealth, and patients not attending rou-              a Pacific Island Countries
technology is difficult for both providers                                 tine visits will reduce income and threaten the              At the least developed end of the ICT devel-
and patients alike. There is little to no                                  financial viability of small practices [71]. The             opment scale [7] are the small and sparsely
empiric research supporting the efficacy                                   CMS expanded telehealth payments for home                    populated PIC. Primary care is the centre of
or efficiency of telehealth, or the long-term                              health agencies [72], but payment for mental                 the health system. The digital health maturity
consequences. The literature is largely rap-                               health televisits will continue [73]. Some                   of PIC is generally low, as assessed by con-
id-cycle, non-peer reviewed articles. There                                insurance companies have already increased                   sidering four essential digital health foun-
are concerns about foregoing a regular                                     telehealth costs to patients [74].                           dations: ICT infrastructure, essential digital

IMIA Yearbook of Medical Informatics 2021
                                    Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development

health tools (e.g., Unique ID, EHRs and data          raises privacy issues with telehealth. India                 cial telehealth systems need to be monitored
quality), readiness for information sharing           and many low-and-middle-income-countries                     for compliance to technical, privacy and
(e.g., interoperability and enterprise archi-         (LMICs) are also experiencing decreased use                  security standards.
tecture) and environment to support adoption          of health services, especially for chronic dis-                  Countries where healthcare is decentral-
(e.g., capacity building, regulations) [1, 81].       ease management. A nationwide COVID-19                       ized to individual provinces, territories, or
However, telecommunication is fairly well             telephone helpline to complement telehealth                  states present different challenges than in
developed to support telemedicine with over-          services and improve patient and work-                       countries where healthcare delivery is cen-
seas medical facilities. Most are developing          force capability was not well received. The                  trally funded and delivered. The UK system
a national digital health strategy using the          WHO-ITU collaboration to directly text the                   is centrally funded with autonomy devolved
World Health Organization (WHO) and In-               public in LMICs with COVID-19 related                        to its four nations. The politics, funding,
ternational Telecommunication Union (ITU)             information was not adopted or adapted to                    models of care, and governance of health and
framework [82]. Fortunately, COVID-19 has             any significant extent [87].                                 social services are important determinants
not been prevalent in the PICT. Nevertheless,             Data quality and interoperability remain                 of variations in the COVID-19 response.
local physical and digital arrangements,              significant challenges to the development of                 Cross-country comparisons must also consid-
based on the WHO Early Warning, Alert and             an integrated system to address pandemics                    er culture and contexts. For example, Israel’s
Response System [83], are in place to deal            into the future. Data collection and manage-                 vaccine delivery model has been heralded as a
with disease outbreak in emergencies such             ment systems are often a hybrid of paper and                 successful model to emulate [88], but Israel’s
as natural disaster or epidemics as well as           digital, resulting in inefficiencies and data                centralized healthcare delivery approach and
support the vaccine strategy. These arrange-          security issues.                                             relatively small geographic and population
ments will be well and truly tested with the              There are many PCI tools readily avail-                  size (9M) can make comparisons inaccurate
recent COVID-19 outbreak in March 2021                able to address the data, information and                    and unfair, even with countries with similar
in Papua New Guinea.                                  socio-technical aspects of COVID-19. How-                    ICT developments [89].
                                                      ever, despite technical guidance from WHO                        We report our findings in two sections:
                                                      to support digital health, countries like India              the first describing how there has been
b India                                               have yet to implement policies and regulations               accelerated but patchy progress, the second
The Indian health system is a federated mod-          at state and national levels. There is an emerg-             addressing lessons for the future.
el with state and central governments having          ing and encouraging shift to a co-creation
responsibility for various aspects of health.         approach to digital health maturity assessment
There are significant urban-rural, socioeco-          to guide national digital health strategy devel-
nomic and gender divides. India aspires to            opment to address COVID-19 and its sequelae                  5.1 Accelerated but Patchy Progress
a national digital health system to facilitate        on service delivery [1].                                     Accelerated uptake of telehealth was experi-
the achievement of universal health coverage                                                                       enced across all the countries, with important
and United Nations sustainable develop-                                                                            variations in the strategies to protect vulner-
ment goals. State and central governments                                                                          able and older people. All countries shared
implemented lockdowns early, introducing
targeted COVID-19 clinics and provided
                                                      5 Synthesis and Discussion                                   the value inherent in maintaining quality
                                                                                                                   safeguards in health services [90].
PPE and infection control training to PCPs,           Table 1 synthesizes the findings into a set                      Challenges were partly due to regulatory
focusing on early detection, controlling              of seven themes, categorized into clinical                   differences between jurisdictions in digital
transmission and providing uninterrupted              and public health and informatics and data                   health, information sharing and interopera-
essential primary care services [84].                 science issues. Our analysis considered the                  bility [2]. Clinical effectiveness and safety
   Telehealth initiatives in India have been          ITU-ICT rankings of the six countries. The                   is important, but a successful response
struggling to gain momentum for many                  commonalities and variations in the PCI                      to COVID-19 requires a strong primary
years [85]. Despite high penetration, mobile          response to COVID-19 emphasises that                         care-public health interface and standardised
phones are not frequently used for health ser-        digital health maturity includes quantitative                information exchange. COVID-19, as with
vices [81]. Reimbursement for telehealth and          measures of ICT developments and other                       any public health emergency, requires a
telemonitoring services provided by PCPs              sociotechnical determinants, including                       coordinated national multisectoral response.
remain ad hoc. Telemedicine Practice Guide-           ensuring data quality, interoperability and                  Despite a strong national primary care and
lines for COVID-19 patients were issued on            readiness for information sharing, and an                    digital health system, the UK has been
March 25, 2020 [86]. However, the general             environment and culture to build capacity                    unable to limit the spread of COVID-19
fragmentation of the digital health system            and support adoption [1, 81]. Health and                     because of delayed and inconsistent poli-
and tools, including between public and pri-          digital literacy of healthcare professionals                 cy decisions on public health approaches
vate sectors, posed significant feasibility and       and citizens are also important, as is previous              based on social distancing and community
acceptability challenges. Low mobile phone            experience with epidemics such as SARS in                    testing. It may also be due to the balance of
ownership especially among Indian women               the COVID-19 context. Standalone commer-                     public and private providers in Australia and

                                                                                                                                 IMIA Yearbook of Medical Informatics 2021
Liaw et al.

Table 1 Themes for PCI response for global pandemic

                                            Theme                                                                                  International lessons
        Clinical & public health

        1              The COVID-19 pandemic onset was associated with an abrupt            Lesson: Future pandemics contingency plans need to be made so that care usually delivered
                       fall in in-person consultations.                                     face-to-face can switch to virtual. We need the technical, legislative, financing and
                                                                                            contractual frameworks to do this as standard.
        2              The “new normal” will include increased non-face-to-face             Lesson 1: We should keep the capability to step away from non-face-to-face care in future for
                       consultation.                                                        doctor, service or patient convenience.
                                                                                            Lesson 2: Where safe and convenient to patients, this as an opportunity to reset care.
                                                                                            However, both lessons need to be underpinned by research on how to do it safely.
        3              Fears of primary care clinicians that patients were delaying care    Lesson: We need robust international research as to whether this is real (likely is), what
                       despite the availability of televisits.                              exacerbated it, and what mitigated patients’ willingness to access primary care.
        4              Coordinated national programs seem to have worked better to          Lesson 1: We need empiric public health research to establish if national priorities, as
                       control spread of the disease                                        opposed to local jurisdiction, leads to reduced spread of disease and lower mortality.
                                                                                            Lesson 2: The WHO, in coordination with other international agencies, needs to develop plans
                                                                                            acceptable to the world’s nations, to control pandemics on an international scale.
        5              The digital divide in the pandemic was global.                       Lesson: We have a societal responsibility to correct uneven distribution of internet availability
                                                                                            for healthcare delivery. This should include equitable access to the internet and adequate
                                                                                            bandwidth for eHealth delivery; eHealth needs eAccess.
        Informatics and data science
        6              Inability to code SARS-COV-2 in the pandemic. There was an           Lesson 1: The WHO working with others needs to have contingencies in place that work
                       international lack of clinical terms for coding standards.           across terminologies (e.g., International Classification of Disease (ICD), SNOMED CT, and the
                                                                                            International Classification of Primary Care (ICPC)).
                                                                                            Lesson 2: We need to avoid frequent reclassification of pandemic diseases. There have been
                                                                                            three sequential reclassifications of COVID-19.
        7              Variability across regions and jurisdictions in how they recorded,   Lesson: Future preparedness needs to go beyond coding. There should be common data
                       coded, modelled, and managed key data during the pandemic,           models created to facilitate sharing data about pandemic disease spread, testing (which may
                       making lessons harder to learn globally.                             be virological or serological), vaccine coverage, vaccine effectiveness and any adverse events
                                                                                            of interest.

Canada that has enabled its health system to                                The primary care data required to success-                    These obstacles need to be overcome if we
adapt with greater speed and agility than                               fully identify, manage and monitor pandem-                        are to ever offer truly integrated care services.
systems that are mainly publicly funded                                 ics is most advanced in the UK. The use of                           Locally-based primary care organisa-
[24] or mainly privatised.                                              real-world data from GP systems and record                        tions appear to have rapidly responded by
    The equity issue and the general lack of                            linkage through the NHS spine is a model for                      adapting their services to ensure continued
evidence for safety and effectiveness of tele-                          other countries, recognising that the political                   equitable access by vulnerable populations
health compared to “in-person” encounters                               and policy environment needs to be support-                       to primary care services [42].
must be addressed. In addition to a rebalancing                         ive. Adopting international standards such as                        COVID-19 has embedded telehealth
of spending, lessons from COVID-19 to create                            SNOMED will make primary care data more                           more firmly in primary care. Virtual care
a more equitable and effective primary health                           compliant with FAIR (Findable, Accessible,                        will almost certainly find a stronger place
care system include: provide health services                            Interoperable, and Reusable) principles [92].                     within health service models and is likely
where people are, e.g., expanding the network                                                                                             to have increased acceptance among both
of community health centres including those                                                                                               patients and health care providers. How-
in schools and housing complexes; improving                                                                                               ever, it is important to recognise that each
inter-racial communication and trust includ-                            5.2 Lessons for the Future                                        country is at a different level of digital
ing culturally competent health coaches;                                Timely access to quality data has been a                          health maturity and has different health
strengthen the caregiving workforce for older                           major PCI challenge. Though different health                      priorities [1, 81].
adults including staff in nursing homes and                             systems have billing and clinical diagnosis                          PCI is key to any digital health strategy,
home-based caregiving systems; and provide                              provisions for new services during pandem-                        and we must maintain the progress made
equitable or universal health insurance [91].                           ics, provisions for data sharing are lacking.                     during COVID-19. Telehealth and EHR

IMIA Yearbook of Medical Informatics 2021
                                        Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development

systems underpinned the ability of primary                    Information Management 2019;49:343-54.                       from:
care to be flexible in-pandemic response.                 6. Jonnagaddala J, Guo GN, Batongbacal S, Marcelo                ac-care/id1437138162
                                                              A, Liaw S-T. Adoption of enterprise architecture         21. Australian Government Department of Health.
However, neither primary care nor PCI can                     for healthcare in AeHIN member countries. BMJ                Electronic prescribing. Australian Government
be considered in isolation from the wider                     Health Care Inform 2020;27(1):e100136.                       Department of Health [Internet]; 2020. Updated
health system or health policy context.                   7. International Telecommunication Union. Mea-                   13 Nov 2020. [cited 2020 Nov 15]. Available from:
                                                              suring digital development. Facts and figures      
                                                              2020. Geneva: Internatiomal Telecommunication                grams/electronic-prescribing
                                                              Union;2020.                                              22. The University of Queensland Centre for Online
                                                                                                                           Health. Telehealth and coronavirus: Medicare
                                                          8. Duckett S. What should primary care look like
6 Conclusion                                                  after the COVID-19 pandemic? Aust J Prim Health
                                                                                                                           Benefits Schedule (MBS) activity in Australia.
                                                                                                                           University of Queensland [Internet]; 2020 [cited
                                                                                                                           2020 Nov 14]. Available from: https://coh.centre.
We have conducted case studies in four                    9. Desborough J, Dykgraaf SH, de Toca L, Davis S,      
countries with well-developed ICT sys-                        Roberts L, Kelaher C, et al. Australia’s national            care-benefits-schedule-mbs-activity-australia
tems and examined reported pandemic                           COVID‐19 primary care response. Med J Aust               23. Helsper CW, Campbell C, Emery J, Neal RD, Li L,
                                                              2020;213(3):104-106.e101.                                    Rubin G, et al. Cancer has not gone away: A prima-
responses in two less-developed countries.                10. Snoswell CL, Caffery LJ, Haydon HM, Thomas                   ry care perspective to support a balanced approach
Response was accelerated but progress was                     EE, Smith AC. Telehealth uptake in general prac-             for timely cancer diagnosis during COVID-19. Eur
patchy. Improved access to good quality                       tice as a result of the coronavirus (COVID-19)               J Cancer Care (Engl) 2020;29(5):e13290.
data and a standardised approach to infor-                    pandemic. Aust Health Rev 2020;44(5):737-40.             24. Wright M, Versteeg R, Hall J. General practice’s
                                                          11. Snoswell C, Caffery L, Hobson G, Taylor ML,                  early response to the COVID-19 pandemic. Aust
mation-sharing and development of digital                     Haydon HM, Thomas E, et al. Telehealth and                   Health Rev 2020;44(5):733-6.
tools to support telehealth and virtual care                  coronavirus: Medicare Benefits Schedule (MBS)            25. Canadian Medical Association-Royal College
is foundational. Well-coordinated national                    activity in Australia. Centre for Online Health,             of Physicians & Surgeons of Canada-College of
response and governance is essential, es-                     The University of Queensland; 2020. Updated                  Family Physicians of Canada. How to navigate a
                                                              May 19, 2020 [cited 2021 Feb 7]. Available from:             virtual care visit: patient guide. Canadian Medical
pecially across the primary care and public                     Association [Internet]; 2020 [cited 2020 Nov 14].
health sectors. The informatics and digital                   navirus-medicare-benefits-schedule-mbs-activi-               Available from:
health responses to the COVID-19 pandemic                     ty-australia                                                 gate-virtual-care-visit-patient-guide
must not compromise privacy, security, data               12. Pearce C, McLeod A, Gardner K, Supple J, Epstein         26. Canadian Healthcare Technology. SK deploys
                                                              D, Buttery J. THE GP Insights Series no 7: Primary           COVID-19 e-referral and intake system. Cana-
quality and interoperability standards and                    Care and SARS-CoV-2: The first 40 weeks of the               dian Healthcare Technology [Internet); 2020.
other design issues.                                          pandemic year. Melbourne: Outcome Health; 26                 [cited 2020 Nov 14]. Available from: https://www.
                                                              October 2020.                                      
Acknowledgements                                          13. Clark M, Brewster D, Jones L, Dhaliwal JS, Teng              referral-and-intake-system/
                                                              J. Uncertainty and fear: aged care in a time of          27. Island Health. Hospital at Home - Victoria General
Patients and health providers who have al-                    COVID-19. MJA Insights+ 2020(44).                            Hospital Prototype. Island Health [Internet]; 2020.
lowed data sharing that enabled primary care              14. Baird A. Video communication for GPs and pa-                 [cited 2020 Nov 14]. Available from: https://www.
informatics organisations to contribute to the                tients. MJA Insight+ 2020(32).                     
management of the COVID-19 pandemic.                      15. Car J, Koh GC-H, Foong PS, Wang CJ. Video                    vices/hospital-home
                                                              consultations in primary and specialist care             28. Huston P, Campbell J, Russell G, Goodyear-Smith
                                                              during the covid-19 pandemic and beyond. BMJ                 F, Phillips Jr RL, van Weel C, et al. COVID-19
                                                              2020;371:m3945.                                              and primary care in six countries. BJGP Open
References                                                16. Medicare Australia. Medicare Benefits Schedule               2020;4(4):bjgpopen20X101128.
                                                                                                                       29. Bhattacharyya O, Agarwal P. Adapting primary care
                                                              (MBS) Online. Medicare Australia [Internet];
1. Liaw S-T, Zhou R, Ansari S, Gao J. Digital Health          2020. [cited 2020 Nov 8]. Available from: http://            to respond to COVID-19. Can Fam Physician 2020.
   Profile and Maturity Assessment Toolkit: co-cre-              30. Canadian Medical Association. What Canadians
   ation in the Pacific Islands. J Am Med Inform              lishing.nsf/Content/Home                                     think about virtual health care. Canadian Medical
   Assoc 2020 Nov 29:ocaa255.                                                                                              Association [Internet]; 2020. [cited 2020 Nov 14].
                                                          17. The Royal Australian College of General Prac-
2. Webster P. Virtual health care in the era of                                                                            Available from:
                                                              titioners. General Practice: Health of the Nation
   COVID-19. Lancet 2020;395(10231):1180-1.                                                                                files/pdf/virtual-care/cma-virtual-care-public-poll-
                                                              2020. East Melbourne, Vic: RACGP;2020.                       june-2020-e.pdf
3. Maldonado JMSdV, Marques AB, Cruz A. Tele-             18. Meidibank Australia. Telehealth support. Look
   medicine: challenges to dissemination in Brazil.                                                                    31. Canadian Institute for Health Information. Phy-
                                                              after your health from home with Telehealth.                 sician billing codes in response to COVID-19.
   Cadernos de Saúde Pública [Internet]. 2016 [cited          Medibank [Internet]; 2020 [cited 2020 Nov 14].
   2021 Feb]; 32(Suppl2):e00155615. Available from:                                                                        Canadian Institute for Health Information [Inter-
                                                              Available from:                    net]; 2020. [cited 2020 Nov 14]. Available from:           au/health-support/hospital-assist/covid19/tele-    
   text&pid=S0102-311X2016001402005                           health-services/                                             response-to-covid-19
4. Grönqvist H, Olsson EMG, Johansson B, Held             19. Celler B, Varnfield M, Nepal S, Sparks R, Li J,          32. Ontario Health Insurance Plan. Bulletin Number:
   C, Sjöström J, Lindahl Norberg A, et al. Fifteen           Jayasena R. Impact of At-Home Telemonitoring                 4745: Keeping Health Care Providers informed
   Challenges in Establishing a Multidisciplinary             on Health Services Expenditure and Hospital                  of payment, policy or program changes. Ministry
   Research Program on eHealth Research in a Uni-             Admissions in Patients With Chronic Conditions:              of Health [Internet]; 2020. Updated 2020 Mar
   versity Setting: A Case Study. J Med Internet Res          Before and After Control Intervention Analysis.              13. [cited 2021 Feb 7]. Available from: http://
   2017;19(5):e173.                                           JMIR Med Inform 2017;5(3):e29.                     
5. Champion C, Kuziemsky C, Affleck E, Alvarez            20. The University of New South Wales. Total Cardiac             bulletins/4000/bul4745.aspx
   GG. A systems approach for modeling health                 Care. UNSW Graduate School of Biomedical En-             33. Wong S, The Primary and Integrated Health Care
   information complexity. International Journal of           gineering [Internet]; 2020 [cited 2020]. Available           Innovations Network. Quick COVID-19 Primary

                                                                                                                                     IMIA Yearbook of Medical Informatics 2021
Liaw et al.

    Care Survey of Clinicians: Summary of the                      a cross-sectional database study in the UK. Br J        61. Sinha S, Kern LM, Gingras LF, Reshetnyak E,
    pan-Canadian survey of frontline primary care cli-             Gen Pract 2020;70(697):e540.                                Tung J, Pelzman F, et al. Implementation of Video
    nicians’ experience with COVID-19, series 6-11. In:        49. de Lusignan S, Williams J. To monitor the                   Visits During COVID-19: Lessons Learned From
    Annals of Family Medicine, COVID-19 Collection.                COVID-19 pandemic we need better quality                    a Primary Care Practice in New York City. Front
    Deepblue: University of Michigan; 2020.                        primary care data. BJGP Open 2020;4(2):bjg-                 Public Health 2020;8:514-22.
34. Ontario College of Family Physicians. Family                   popen20X101070.                                         62. Srinivasan M, Asch S, Vilendrer S, Crandall
    Doctors are Open and Here for Care, and More.              50. de Lusignan S, Dorward J, Correa A, et al. Risk             Thomas S, Bajra R, Barman L, et al. Qualitative
    Ontario College of Family Physicians [Internet];               factors for SARS-CoV-2 among patients in the                Assessment of Rapid System Transformation to
    2020. [cited 2020 Nov 14]. Available from: https://            Oxford Royal College of General Practitioners               Primary Care Video Visits at an Academic Medical                  Research and Surveillance Centre primary care               Center. Ann Intern Med 2020;173(7):527-35.
    family-medicine-news/~188-Family-Doctors-are-                  network: a cross-sectional study. Lancet Infect Dis     63. Smith WR, Atala AJ, Terlecki RP, Kelly EE,
    Open-and-Here-for-Care-and-More                                2020;20(9):1034-42.                                         Matthews CA. Implementation Guide for Rapid
35. Glauser W. Virtual care is here to stay, but major chal-   51. Joy M, Hobbs FDR, McGagh D, Akinyemi O, de                  Integration of an Outpatient Telemedicine Program
    lenges remain. CMAJ 2020;192(30):E868-E869.                    Lusignan S. Excess mortality from COVID-19 in               During the COVID-19 Pandemic. J Am Coll Surg
36. Deloitte Centre for Health Solutions. COVID-19                 an English sentinel network population. Lancet              2020;231(2): 216-222.e2
    Virtual care is here to stay. Deloitte Canada; 2020.           Infect Dis 2020 Aug 4;S1473-3099(20)30632-0.            64. Reeves JJ, Hollandsworth HM, Torriani FJ, Taplitz
37. Gagnon M-P, Julie D, Fortin J-P. A survey in               52. de Lusignan S, Joy M, Oke J, McGagh D, Nichol-              R, Abeles S, Tai-Seale M, et al. Rapid Response to
    Alberta and Quebec of the telehealth applica-                  son B, Sheppard J et al. Disparities in the excess          COVID-19: Health Informatics Support for Out-
    tions that physicians need. J Telemed Telecare                 risk of mortality in the first wave of COVID-19:            break Management in an Academic Health System.
    2007;13(7):352-6.                                              Cross sectional study of the English sentinel net-          J Am Med Inform Assoc 2020 Jun 1;27(6):853-9.
38. O’Gorman LD, Hogenbirk JC, Warry W. Clinical                   work. J Infect 2020;81(5):785-92.                       65. Hron JD, Parsons CR, Williams LA, Harper MB,
    Telemedicine Utilization in Ontario over the On-           53. Joy M, Hobbs FDR, Bernal JL, Sherlock J, Amir-              Bourgeois FC. Rapid Implementation of an Inpa-
    tario Telemedicine Network. Telemed J E Health                 thalingam G, McGagh D et al. Excess mortality               tient Telehealth Program during the COVID-19
    2015;22(6):473-9.                                              in the first COVID pandemic peak: cross-sectional           Pandemic. Appl Clin Inform 2020;11(3):452-9.
39. Bhatia RS, Falk W, Jamieson T, Piovesan C, Shaw                analyses of the impact of age, sex, ethnicity, house-   66. Sinha S, Kern LM, Gingras LF, Tung J, Pelzman
    J. Virtual health care is having its moment. Rules             hold size, and long-term conditions in people of            F, et al. Implementation of Video Visits During
    will be needed. Healthydebate [Internet]; 2020.                known SARS-Cov-2 status in England. Br J Gen                COVID-19: Lessons Learned From a Primary Care
    [cited 2020 Nov 14]. Available from: https://                  Pract 2020:bjgp20X713393.                                   Practice in New York City. Front Public Health             54. de Lusignan S, Lopez Bernal J, Zambon M,                    2020;8:514.
    rules-covid                                                    Akinyemi O, Amirthalingam G, Andrews N, et al.          67. Ranney ML, Griffeth V, Jha AK. Critical Supply
40. Appia V. What does the future of telemedicine look             Emergence of a Novel Coronavirus (COVID-19):                Shortages — The Need for Ventilators and Per-
    like in Ontario after COVID-19? [In-               Protocol for Extending Surveillance Used by                 sonal Protective Equipment during the Covid-19
    ternet]; 2020. [cited 2020 Nov 14]. Available from:            the Royal College of General Practitioners                  Pandemic. N Engl J Med 2020;382(18):e41.                    Research and Surveillance Centre and Public             68. Brodwin E. With covid-19 delaying routine care
    what-does-the-future-of-telemedicine-look-like-                Health England. JMIR Public Health Surveill                 chronic disease startups brace for a slew of com-
    in-ontario-after-covid-19-/                                    2020;6(2):e18606.                                           plications. Health Tech 2020 Apr 14 [cited 2020
41. MacLeod M. Virtual health care is ‘not the answer          55. de Lusignan S, Bernal J, Byford R, Amirthalingam            Nov 14]. Available from: https://www.statnews.
    for everything,’ critics warn. CTV News. Coronavi-             G. Seasonal influenza surveillance and vaccine ef-          com/2020/04/14/with-covid-19-delaying-routine-
    rus updates Web site [Internet]; 2020. [cited 2020             fectiveness at a time of co-circulating COVID-19:           care-chronic-disease-startups-brace-for-a-slew-of-
    Nov 14]. Available from:               Oxford-Royal College of General Practitioners               complications/
    health/coronavirus/virtual-health-care-is-not-the-             (RCGP) Research and Surveillance Centre (RSC)           69. Jaffe DH, Lee L, Huynh S, Haskell TP. Health
    answer-for-everything-critics-warn-1.4939283                   and Public Health England (PHE) protocol for                Inequalities in the Use of Telehealth in the United
42. Bhatti S, Commisso E, Rayner J. A Rapid Primary                winter 2020/21 (Preprint). 2020.                            States in the Lens of COVID-19. Popul Health
    Healthcare Response to COVID-19: An Equi-                  56. University of Oxford CIHORG. RCGP RSC                       Manag 2020;23(5):368-77.
    ty-Based and Systems- Thinking Approach to Care                COVID-19 Observatory and Coding Guidelines.             70. Summers-Gabr NM. Rural–urban mental health
    Ensuring that No One Is Left Behind. Healthc Q                 University of Oxford [Internet]; 2021. [cited 2021          disparities in the United States during COVID-19.
    2020;23(3):29-33.                                              Feb 13]. Available from:          Psychol Trauma 2020;12(S1):S222-S224.
43. Bhyat R. Canada’s ‘new normal’ must include virtu-             uk/index.php/cov-19/                                    71. Basu S, Phillips RS, Phillips R, Peterson LE,
    al care. Healthydebate [Internet]; 2020. [cited 2020       57. Koonin LM, Hoots B, Tsang CA, Leroy Z, Farris               Landon BE. Primary Care Practice Finances In
    Nov 14]. Available from:             K, Jolly T, et al. Trends in the Use of Telehealth          The United States Amid The COVID-19 Pandemic.
    opinions/new-normal-include-virtual-care                       During the Emergence of the COVID-19 Pandemic               Health Aff (Millwood) 2020;39(9):1605-14.
44. Mosnaim GS, Stempel H, Van Sickle D, Stempel                   — United States, January–March 2020. MMWR               72. United States Centers for Medicare and Medicaid
    DA. The Adoption and Implementation of Digital                 Morb Mortal Wkly Rep 2020 Oct 30;69(43):1595-9.             Services (CMS). Home health agencies: CMS flex-
    Health Care in the Post–COVID-19 Era. J Allergy            58. Patel S, Mehrotra A, Huskamp H, Uscher-Pines L,             ibilities to fight Covid-19. Washington DC: Centers
    Clin Immunol Pract 2020;8(8):2484-6.                           Ganguli I, Barnett ML. Trends in outpatient care            for Medicare and Medicaid Services; 2020.
45. Schade CP, Sullivan FM, de Lusignan S, Madeley                 delivery and telemedicine during the COVID-19           73. US Centers for Medicare & Medicaid Services.
    J. e-Prescribing, Efficiency, Quality: Lessons from            pandemic in the US. JAMA Intern Med 2021 Mar                Medicare telemedicine health care provider fact
    the Computerization of UK Family Practice. J Am                1;181(3):388-91.                                            sheet [Internet] 2020. Updated 2020 March 17
    Med Inform Assoc 2006;13(5):470-5.                         59. Reddy A, Gunnink E, Deeds SA, Hagan SL, Hey-                [cited 2021 Feb 6]. Available from: https://www.
46. de Lusignan S, Carlyon T, Lalvani A. Removing                  worth L, Mattras TF, et al. A rapid mobilization  
    the handle of the Broad Street pump: measures to               of ‘virtual’ primary care services in response to           icine-health-care-provider-fact-sheet
    slow the spread of covid-19 in primary care teams.             COVID-19 at Veterans Health Administration.             74. Robbins R, Brodwin E. As insurers move this
    BMJ 2020;369:m1841.                                            Healthc (Amst) 2020;8(4):100464-100464.                     week to stop waiving telehealth copays, patients
47. Dyer C. Covid-19: Doctors make bid for public              60. Spelman JF, Brienza R, Walsh RF, Drost P,                   may have to pay more for virtual care. STAT+.
    inquiry into lack of PPE for frontline workers.                Schwartz AR, Kravetz JD, et al. A Model for Rapid           Health Tech Web site [Internet]; 2020. [cited 2020
    BMJ 2020;369:m1905.                                            Transition to Virtual Care, VA Connecticut Primary          Nov 14]. Available from: https://www.statnews.
48. Joy M, McGagh D, Jones N, et al. Reorganisation                Care Response to COVID-19. J Gen Intern Med                 com/2020/09/29/united-healthcare-anthem-tele-
    of primary care for older adults during COVID-19:              2020;35(10):3073-6.                                         medicine-coverage-insurers/

IMIA Yearbook of Medical Informatics 2021
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