correspondence of video consultation (Fig. 1). The board during the day. The video-consultation distancing while preserving the provision of directors prioritized overcoming the pathway was tested with earlier-appointed of healthcare. limitations hindering the scaling up of video super users in the surgical department Because we believe that video consultation. The success of this process who already knew how to operate the consultation holds promise in optimizing required the immediate cooperation and video-consultation software and hardware. outpatient care in the current crisis, we feel dedication of all stakeholders together, Because the first test failed, another test was that others may benefit from our approach which are otherwise known to be important scheduled for the next morning. and efforts. By sharing this roadmap, we aim barriers to the scaling up of any innovation Day 3, the day on which everything to inspire other centers to scale up virtual within a hospital4. needed to come together, started care to cope with COVID-19. ❐ On day 1, a crisis policy team was with a stand-up meeting and a short appointed, consisting of members of the brainstorming session regarding the failed Esther Z. Barsom , Tim M. Feenstra , department heads of the intensive care test of the day before. By the end of the Willem A. Bemelman, Jaap H. Bonjer and units, clinical wards, outpatient clinics, morning, the new test was successful, Marlies P. Schijven ✉ representatives of the internet technology and the video-consultation pathway was Department of Surgery, Amsterdam Gastroenterology department, the EHR service center merged with the live environment of the and Metabolism, Amsterdam UMC, University of and chief security officers. All essential EHR. All work instructions were finalized Amsterdam, Amsterdam, the Netherlands. personnel were approached early in the and approved by the crisis policy team. ✉e-mail: [email protected] process, extra workforce capacity was The video-consultation implementation added, and time-appropriate milestones team distributed the iPads together with Published online: 14 April 2020 were formulated. Hence, the full scale of the the work instructions to all departments. https://doi.org/10.1038/s41591-020-0845-0 emergency scale up became apparent. Floor support offered just-in-time training References During the second half of day 1, existing to healthcare providers who needed extra 1. Lurie, N. & Carr, B. G. JAMA Intern. Med. 178, 745–746 (2018). technical services were expanded by support. Because all important milestones 2. Hollander, J.E. & Carr, B.G. N. Engl. J. Med. https://doi. ordering 50 extra iPads and ensuring that were achieved, patients could then be org/10.1056/NEJMp2003539 (2020). enough video-connection licenses were notified about scaling up virtual care to 3. Barsom, E.Z. et al. Surg. Endosc. https://doi.org/10.1007/s00464- 020-07499-3 (2020). available. Furthermore, at that time, all standard practice. All patients already 4. Scott Kruse, C. et al. J. Telemed. Telecare 24, 4–12 (2018). involved stakeholders were preparing for day scheduled for an appointment at the 2, the day of the development of all technical outpatient clinic received a text message Acknowledgements aspects of scaling up the integration of video with the details and directions for receiving We thank all those who have contributed to, and were part of, the video-consultation implementation and scaling-up consultation within the EHR. virtual care. A news link was placed on team before and during the COVID-19 pandemic. Day 2 began with a stand-up meeting the hospital website to inform patients with the crisis policy team and technical without a scheduled appointment at the Author contributions staff to provide a status update, identify hospital. All authors contributed extensively to the work presented possible issues and set deadlines regarding On day 4, the first video consultations in this paper. All authors reviewed and approved the final version of the manuscript. the formulated milestones. Next, all teams took place after the prerequisite stand-up worked to meet the proposed deadlines, and meeting. The virtual outpatient clinic care Competing interests the crisis policy team was updated regularly successfully began, thus facilitating social The authors declare no competing interests. A framework for identifying regional outbreak and spread of COVID-19 from one-minute population-wide surveys To the Editor — In December 2019, a novel of the disease has presented an extreme virus could serve as a strategic and valuable coronavirus was isolated, after a cluster challenge to the international community, tool for identifying such clusters and of patients in China were diagnosed with and policy-makers from different countries informing epidemiologists, public-health pneumonia of unknown cause1. This new have each chosen different strategies, officials and policymakers. We show isolate was named ‘SARS-CoV-2’ and is depending on the local spread of the virus, preliminary results from an Israeli survey the cause of the disease COVID-19. The healthcare-system resources, economic and of a cumulative number of over 74,000 virus has led to an ongoing outbreak and an political factors, public adherence, and their responses and call for additional countries unprecedented international health crisis. perception of the situation. to join an international consortium to The number of infected people is rapidly Coronavirus infection spreads in clusters, extend this concept in order to develop increasing globally2 and most probably is and early identification of these clusters predictive models. We expect such data a vast underestimation of the real number is critical for slowing down the spread will allow the following: faster detection of of patients worldwide, as infected people of the virus. Here we propose that daily spreading zones and patients; acquisition are contagious even when minimally population-wide surveys that assess the of a current snapshot of the number of symptomatic or asymptomatic3. The spread development of symptoms caused by the people in each area who have developed 634 NATURE MEDICINE | VOL 26 | MAY 2020 | 632–638 | www.nature.com/naturemedicine correspondence 1.01.8 2.63.4 4.25.0 a 1.01.8 2.63.4 4.2 5.0 were in close contact with a person with confirmed COVID-19. To obtain a real-time nationwide view of symptoms across the entire population, and since testing the entire population is not feasible, we developed a simple one-minute online questionnaire aimed at early and temporal detection of geographic clusters in which the virus is spreading. The survey was posted online (https://coronaisrael.org/) on 14 March, and participants were asked b 1.01.8 2.6 3.4 4.2 5.0 to fill it out on a daily basis and separately for each family member, including members who are unable to fill it out independently (e.g., children and older people). So that potential privacy issues that might occur can be avoided, our survey is filled out anonymously, and access to the data is restricted to only study investigators. The survey contains questions on age, sex, geographic location (city and street), Fig. 1 | Average COVID-19-associated symptoms region map. City municipal regions with at least 30 isolation status and smoking habits. completed surveys and neighborhoods with at least 10 completed surveys are shown. The color of each Participants also report whether they region indicates a category defined by the average symptoms ratio, calculated by averaging the reported are experiencing symptoms commonly symptoms rate by responses in that city or neighborhood. The values were divided into five categories, described in patients with COVID-19 by and the color of each region indicates its associated category, from green (low symptom rate) to red healthcare professionals, on the basis of the 8 (high symptom rate) (key). a, Area of Tel-Aviv and Gush-Dan with city regions. b, Area of Tel-Aviv existing literature . Several other symptoms and Gush-Dan with neighborhood regions. Map data are copyrighted by OpenStreetMap contributors that are less common in patients with and are available from https://www.openstreetmap.org. Publ. note: Springer Nature is neutral about COVID-19 but are more common in other jurisdictional claims in maps. Credit: Leaflet | OpenStreetMap contributors | CARTO infectious diseases are also included to better identify possible patients with COVID- 19. The initial symptoms included cough, fatigue, myalgia (muscle pain), shortness symptoms; prediction of future spreading 14-day home isolation. Since then, Israel of breath, rhinorrhea or nasal congestion, zones several days before an outbreak has gradually imposed several additional diarrhea and nausea or vomiting. Additional occurs; and evaluation of the effectiveness measures (Extended Data Fig. 1): symptoms, including type of cough (with of the various social-distancing measures on 9 March, the 14-day home isolation or without sputum), sore throat, headache, taken and their contribution to reducing was extended to people arriving from chills, confusion and loss of taste and/ the number of symptomatic people. This anywhere of international origin, or smell sensation, were added in a later information could provide a valuable tool and those who were in close contact with a version. Participants also report about for decision-makers in those areas in which patient with confirmed COVID-19 existing chronic health conditions and are strengthening of social-distancing measures were instructed similarly. Symptomatic asked to report their daily body temperature is needed and those in which such measures people were instructed to stay home for (Extended Data Fig. 2 presents the most can be relieved. Preliminary analysis shows 2 days after symptom resolution6. On recent version of the survey). that in neighborhoods with a confirmed 11 March, gatherings were limited to a Given that reports on the clinical patient history of COVID-19, more people maximum of 100 people; this was further characteristics of patients with COVID- report experiencing COVID-19-associated restricted to 10 people on 15 March.