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Published online: 2021-04-21

126 © 2021 IMIA and Georg Thieme Verlag KG

Telehealth and the COVID-19 Pandemic: International Perspectives and a Health Systems Framework for Implementation to Support Critical Response Arindam Basu1, Craig Kuziemsky2, Magdala de Araújo Novaes3, Araujo Kleber4, Fernando Sales5, Najeeb Al-Shorbaji6, José F. Flórez-Arango7, Shashi B. Gogia8, Kendall Ho9, Inga Hunter10, Sriram Iyengar11, Oommen John12, Sheila John13, Gumindu Kulatunga14, 15, Vije Kumar Rajput16, Prasad Ranatunga14, 15, Jai Ganesh Udayasankaran17 1 University of Canterbury, Christchurch, New Zealand 2 MacEwan University, Edmonton, Canada 3 Medical Sciences Center, Telehealth Center, Hospital, Federal University of Pernambuco, Recife, Brazil 4 Telehealth Center (NUTES), Federal University of Pernambuco, Recife, Brazil 5 and Geosciences Center, Telehealth Center, Federal University of Pernambuco, Recife, Brazil 6 eHealth Development Association of Jordan, Amman, Jordan 7 Texas A & M University, College Station, United States of America 8

Society for Administration of Telemedicine and Healthcare Informatics, New Delhi, India 9 University of British Columbia, Vancouver, Canada 10 Massey University,Palmerston North, New Zealand 11 University of Arizona, Phoenix, United States of America 12 George Institute for Global Health, University of New South Wales, Sydney, 13 Sankara Nethralaya, Chennai, India 14 Postgraduate Institute of , University of Colombo, Colombo, Sri Lanka 15 University of Southampton, Southampton, UK 16 Keele University, Staffordshire, UK 17 Sri Sathya Sai Central Trust, Puttaparthi, India

Summary in their respective countries. We then analysed their responses and systems framework extend the WHO systems model and Objectives: Telehealth implementation is a complex sys- to identify six emerging themes that we mapped to the World highlight that telemedicine usage in response to the COVID-19 tems-based endeavour. This paper compares telehealth Health Organization (WHO) model of health systems. pandemic is complex and multidimensional. Our systems-based responses to (COrona VIrus Disease 2019) COVID-19 across Results: Our analysis identified six emergent themes. (1) Gov- framework provides guidance for telehealth implementation ten countries to identify lessons learned about the complexity ernment, legal or regulatory aspects of telehealth; (2) Increase as part of health systems response to a global pandemic such of telehealth during critical response such as in response to a in telehealth capacity and delivery; (3) Regulated and unreg- as COVID-19. global pandemic. Our overall objective is to develop a health ulated telehealth; (4) Changes in the uptake and perception of systems-based framework for telehealth implementation to telemedicine; (5) Public engagement in telehealth responses to Keywords support critical response. COVID-19; and (6) Implications for training and education. We Telemedicine, telehealth, COVID-19, coronavirus, pandemic, Methods: We sought responses from the members of the discuss these themes and then use them to develop a systems health systems International Medical Informatics Association (IMIA) Telehealth framework for telehealth support in critical response. Working Group (WG) on their practices and perception of Conclusion: COVID-19 has introduced new challenges for Yearb Med Inform 2021:126-33 telehealth practices during the times of COVID-19 pandemic telehealth support in times of critical response. Our themes http://dx.doi.org/10.1055/s-0041-1726484

IMIA Yearbook of Medical Informatics 2021 127 Telehealth and the COVID-19 Pandemic: International Perspectives and a Health Systems Framework for Telehealth Implementation to Support Critical Response

human-centred design approaches, and Telehealth is a classic example of a health 1 Introduction local care delivery practices and enablers system in that that it consists of several The COrona VIrus Disease 2019 must be considered [10]. Implementing new interrelated parts that must work in unison (COVID-19) pandemic brought a trans- during a global pandemic adds for telehealth to effectively contribute to formative shift in medical care and public to the existing complexities around change healthcare delivery [21]. health delivery. When the COVID-19 pan- management, engagement, scale up, While COVID-19 has identified many demic began to spread worldwide in early prioritization of care and ensuring equity of opportunities for telehealth, it has also 2020, its infectiousness and rapid transmis- services provided. Unintended consequenc- identified challenges that the medical in- sion required countries to look for digital es are a common occurrence post health formatics community must overcome as means to deliver healthcare services that (HIT) implemen- part of developing a sustainable telehealth would provide necessary care for tation. Various unintended consequences system for supporting critical response such while also supporting physical distancing (UIC) including community, patient safety, as a global pandemic [1, 22]. Incorporating and other restrictions. As a information retrieval, individual-collabora- systems thinking into how we conceptualize result, traditional face-to-face clinical en- tive interchanges, and workflow issues have telehealth implementation would help us counters needed to be complemented with been described [6, 11–14]. UICs remind us leveraging the strengths of telehealth while digital solutions, resulting in the adoption that HIT implementation is not without risk addressing the system-based challenges of of virtual care tools such as telehealth to and expedited implementation of HIT such using telehealth during critical response. To became commonplace worldwide [1, 2]. as telehealth in response to the COVID-19 date, there is no systems-based framework While telehealth and other virtual care tools pandemic could present an increased risk for telehealth delivery. We suggest that a existed pre-COVID, the need for public of UICs. However, at the same time we system-based framework could allow us to health practices such as physical distancing want to use COVID-19 as an opportu- understand how telehealth must evolve or and a desire to keep people out of high-risk nity to learn how we might increase our be adapted for critical response such as the settings such as hospitals accelerated the capacity for telehealth delivery while COVID-19 pandemic. adoption of telehealth. The challenges of also accounting for UICs such as In this paper we describe the international the COVID-19 pandemic and disruption on and security, ethical and legal concerns, experiences in seven countries of implement- health service delivery due to lockdowns and social issues [10, 15]. Regardless of ing telemedicine/ telehealth in the context or other public health measures resulted in whether HIT adoption occurs over years of the ongoing COVID-19 pandemic. We a rapid implementation and scaling up of or weeks such as during COVID-19, it is then use the international perspectives to innovations. These solutions still a complex adoption process and we develop a health systems-based framework focused on planning, response and man- must account for implementation factors for telehealth implementation to support agement of COVID-19 including disease such as workflow, organizational, social, critical response. surveillance, patient screening, contact and ethical and legal concerns. tracing, patient diagnosis and follow-up, A high performing health system is one supply chain management, staff training, that accounts for all aspects of a health sys- and research such as predictive modelling tem and may be more resilient in response of COVID-19 spread [3–5]. As part of this to COVID-19 [16]. The World Health Or- 2 Materials and Methods digital health response to COVID-19, many ganization (WHO) model of health systems All members of the Telehealth Working countries have introduced new regulatory includes six building blocks (service deliv- Group (WG) of the International Medical frameworks, or revised existing frameworks ery, health workforce, medical products, Informatics Association (IMIA) were invited to allow telemedicine to play a vital role vaccines and technology, financing and gov- to provide their inputs and reflections on in the societal response to COVID-19 [2, ernance/leadership) and four system goals/ telehealth use in response to the COVID-19 6]. The pandemic has shown us what is outcomes (improved health, responsiveness, pandemic. The Telehealth WG consists of possible for telehealth delivery and there social and financial risk protection and approximately 100 members worldwide is global interest to sustain the COVID-19 improved efficiency) [17, 18]. The system including researchers, practitioners, and aca- facilitated increase in telehealth usage after building blocks and outcomes combined demics. The question posed to WG members the pandemic [7, 8]. with systems thinking approaches enables was “Describe how telemedicine was used in Despite the potential of telehealth for the design of interventions such as policy your country in response to the COVID-19 health professionals and health delivery or health information technology (HIT) pandemic, including pros and cons of tele- systems to extend care delivery beyond to support health system objectives [19, medicine usage”. We received data from routine care such as face-to-face delivery, 20]. The focus of our working group is on the members of the IMIA working groups implementing telehealth presents several medical informatics and more specifically in ten countries: Australia, Brazil, Canada, challenges including scale up and long-term telehealth, but we recognize that HIT is only Colombia, India, Jordan, New Zealand, Sri sustainability [9]. Telehealth implemen- one component of a health system that must Lanka, The United States, and The United tation is a sociotechnical endeavour and be aligned with other system components. Kingdom. These countries represented

IMIA Yearbook of Medical Informatics 2021 128 Basu et al.

different health system delivery models 3.1 Government, Legal or Zealand and the NZ Telehealth Leader- and perspectives and critical response to ship Group, … determined new rules for COVID-19, including variations in success Regulatory Aspects of Telehealth electronic prescribing using NZePS (NZ in response to COVID-19. The complete This theme describes government, legal or ePrescribing services) with a manual sig- text of the narratives is presented in the ac- regulatory aspects that impacted countries nature exempt temporary waiver from the companying public GitHub repository [23]. abilities to ramp up telehealth delivery in NZ Government”. “Expansion of a digital Data was collected from WG members response to the COVID-19 pandemic. national contact tracing system”. “The from September-November 2020. Starting (India): “The Government of India issued Medical Council made special provisions in mid-October the authors did an ongoing an advisory for those with chronic condi- for the return for doctors who had retired content analysis of the data to identify emer- tions to avoid visits to healthcare facilities with the last 3 years to be able to return gent themes related to telehealth use during for non-emergency consultations, resulting to practice if needed”. COVID-19. AB and CK led the content in significant challenges to those with (Colombia): “When COVID struck, Co- analysis with all authors contributing to it. chronic conditions and multiple morbidi- lombia issued an exception law, where all Disagreements in the analysis were resolved ties. These disruptions led to the acceler- face to face and elective procedures were by group consensus. ated release of the Telemedicine Practice suspended … law facilitated telemedicine We used the WHO Health System model Guidelines 2020 (TPG) which provides a and telehealth services that required di- we described earlier, and our prior work re- legal framework for delivery of rect interaction with patients” search at comparing international telehealth remotely through telemedicine services by (UK):” NHS England and NHS Im- implementation, to guide the analysis and the Board of Governors in supersession of provement (NHSEI) provide a national to identify health system considerations for the Medical Council of India which caters direction on service improvement and telemedicine use during critical response to practitioners of modern Medicine”. transformation, governance and account- [9, 17, 24, 25]. Our previous research and (India): “The Integrated Disease Sur- ability, standards of best practice, and the WHO Health System model are com- veillance Program (IDSP), which is a quality of data and information. NHSX plementary in that we identified specific nation-wide surveillance system for epi- (nhsx.nhs.uk) is responsible for driving issues related to telehealth implementation demic prone diseases has been activated digital transformation and leading policy including different models of patient-cen- by the Ministry of health and family implementation and change”. tred connected health, the need to balance welfare towards COVID response, and is (Canada):” One benefit of COVID-19 patient needs with technological capability, being further strengthened with substan- was that the rapid shift to virtual care re- and emerging privacy needs that can arise tive digital inputs” quired adapting fee schedules, from informal telehealth implementation, (Brazil): “Brazilian telemedicine law has including new billing codes and updated while the WHO model describes the broad been promulgated and it is valid as long practice guidelines. While each province concepts that comprise a health system. as the pandemic takes place”. and territory implemented their own (Brazil): “Legal authorization of telemed- billing code for virtual care, there were icine by a Federal Law [April 15th2020] many similarities across Canada . By the - Several practices have been permitted end of March 2020, all provinces and for remote consultations and prescrip- territories had some version of a billing 3 Results tions, complying to some requirements to code to support virtual care”. Our analysis identified six themes that de- provide security to the process and safety (Australia):”The federal government has scribe telemedicine experiences during the for the patients”. opened up billing codes in the national COVID-19 pandemic and the lessons learned (Sri Lanka):” the Country did not have system to allow telephone or to implement telehealth to better support any regulations or guidelines specific to consultations for virtually all types of times of critical response such as COVID-19. Telemedicine services when the pandemic consultations”. The themes were: (1) government legal or started [26]. Health Information Unit of regulatory aspects of telehealth; (2) increase the Ministry of Health, Sri Lanka made in telehealth capacity and delivery; (3) regu- a set of non-formal guidelines to assist 3.2 Increase in Telehealth lated and unregulated telehealth; (4) changes voluntary participating doctors when using in the uptake and perception of telemedicine; Telehealth services and trained them using Capacity and Delivery (5) public engagement in telehealth respons- online methods.. As for further develop- This theme describes various ways in which es to COVID-19; and (6) implications for ment the National eHealth Guidelines countries increased telehealth capacity training and education. and Standards (NeGS) are currently being and delivery in response to the COVID-19 In the sections below we describe and updated to include Telehealth services” pandemic. provide quotes to support each theme. (New Zealand):”… rapid introduction of (India): “eSanjeevaniOPD, a free online The country where each text came from is electronic prescribing … by the Ministry national OPD service from Government enclosed within parentheses for reference. of Health, the Medical Council of New of India has enabled patients to consult

IMIA Yearbook of Medical Informatics 2021 129 Telehealth and the COVID-19 Pandemic: International Perspectives and a Health Systems Framework for Telehealth Implementation to Support Critical Response

doctors from home. This real time tele- (UK) “Licences for online consultation system to help the citizens of Arizona, medicine service facilitates safe and software are purchased from a list of especially the more vulnerable and un- structured video-based consultations via accredited suppliers, via a dynamic pur- derserved populations, successfully cope web application as well as mobile app”. chasing system“. with this pandemic”. (India): United Care Development (Brazil):” several initiatives conducted by (UK):” A Digital First Primary Care Services (UCDS) an NGO in India local entities and the State Governments. approach supports patients to use online has integrated cloud telephony service The State of Sao Paulo has supported tools to access all primary care services, with a free health information systems the TeleICU Project, evolving several such as receiving advice, booking and application. This arrangement has facil- hospitals to share practices, intensive cancelling appointments, having a con- itated a two-way clinical documentation care protocols and clinical trials related sultation with a healthcare professional, exchange between the patient and the to COVID-19 pandemics”. receiving a referral and obtaining a pre- practitioner. The consultation summary (Jordan): Providing free transportation scription.” and prescription conforming with the services to patients in emergency situ- (UK):” Text messaging is used to com- Government guidelines are prepared by ation to reach to hospitals and provid- municate with patients for a range of the practitioners and sent to the patient ing hot line services. The government reasons including booking appointments, via WhatsApp. These improvisations commissioned the development of self-help web links, attaching documents/ have led to better experience for the mobile apps for contact racing, others images and flu/covid-19 campaigns”. patients seeking phone-based consul- for ePrescriptions especially for chronic (Brazil): “Chatbot or with the Coronavi- tations and professional satisfaction for diseases allowing for renewal of prescri- rus SUS application. The action aims to the medical practitioners providing this tions without having to visit physically reach 120 million Brazilians, helping the free service. the healthcare centre. Other applications early identification of people with signs (India): “In India, several health start- were developed to allow for making and symptoms of flu syndrome, vulnera- ups offered video consultations”. appointments without having to come to ble people and mapping areas of risk of (Sri Lanka):” Even though COVID case the hospital. contagion”.

rate was low in Sri Lanka, during first half (Brazil): “ a large use of WhatsApp and of 2020, the general public was unable to mobile applications (e.g., chatbots) is visit a health care facility even if it was 3.3 Regulated and Unregulated observed in Brazil for provider-provider next door due to strict movement regula- and provider-patient communication, tions. During the COVID pandemic in the Telehealth both in public and private healthcare first half of 2020, the general public was This theme describes the different telehealth service”. unable to visit a health care facility even if tools, both formal and informal, that were (Jordan): “The use of normal telephone it was next door. Alternative methods were used during the COVID-19 pandemic. lines, WhatsApp and SMS services in- needed urgently for screening of suspect- (India): “Most teleconsultations are still creased as patients asked for assistance, ed cases as well as for the follow-up of largely through WhatsApp and Telephone advice and information. These services chronic diseases who need long term care. with emails coming a distant 3rd.” have never been regulated and there is no This vacuum resulted in wide expansion (India): “Laws applicable to telemedicine medicolegal accountability as a result.” of Telehealth service providers”. in India are those governing practice of (Colombia): “Analysing the National reg- medicine and laws governing Information istry of providers we can see the explosion Technology transactions. Personal Data 3.4 Change in the Perception or of new enabled registered services. There Protection Bill, 2019 pending approval is a high concentration in „reference“ from the Parliament is expected to further Uptake of Telehealth services”. shape practice of telemedicine when it This theme looks at how the use of telehealth (Canada):” the BC Ministry of Health, in becomes an Act.” tools evolved because of the COVID-19 association with a group of health organi- (Sri Lanka): “The MyHealth Sri Lanka“ pandemic. zations including the Rural Coordination application was made to empower citizens (India): “Its use for tele-consult was large- Centre of British Columbia, First Nations with correct knowledge for correct deci- ly frowned upon but has been demand Health Authority, BC Emergency Medi- sion making” and to collaborate between driven by patients as well as forced upon cine Network, Doctors of BC, Provincial government sector and private sector [27]. by the who are themselves Health Services Authority, and Provi- (New Zealand):” The Ministry of Health vary of facing the patients directly. The dence Healthcare, set up a network of … introduced the NZ COVID Tracer App, concept of Telehealth has shifted from virtual care to support clinicians-to-clini- a digital diary using QR codes scannable remote care to a “I would rather not see cians and clinicians-to-patients telehealth on mobile phones”. a patient physically”.” services, collectively named as Real Time (United States):” AZCOVIDTXT is a (India): “The Government of India has Virtual Support (RTVS) services”. powerful bilingual (English and Spanish) included telemedicine as one of the key

IMIA Yearbook of Medical Informatics 2021 130 Basu et al.

building blocks proposed in the National 3.5 Public Engagement in Tele- 3.6 Implications for Training and Digital Health Mission (NDHM) and the National Health Authority who is the im- health Responses to COVID-19 Education plementing agency of NDHM has invited This theme looks at public engagement This theme looks forward as to what some of Proof of Concept (PoC) for telemedicine opportunities that arose because of the the lessons learned are from the COVID-19 building block.” COVID-19 pandemic. pandemic implications for telehealth training (India): The Regulatory and (India): A volunteer based network of and education. Development Authority of India (IRDAI) health focused innovators came together (India): “Delivery of ‘Train to Practice has asked the insurers in the country to on a common technology platform as Telemedicine Certificate Course’ began allow claim settlement for telemedicine Project StepOne. within ten days of the release of the tele- consultation wherever normal consulta- (India): The Telemedicine Society of medicine practice guidelines. This online tion with a medical practitioner is allowed India in partnership with the Digital course delivered as a webinar consisted in the terms and conditions of the policy Health India Association pooled a team of of four modules of 20 - 30 minutes du- contract. volunteer resource persons who designed ration each was followed by questions (Brazil): “Healthcare professionals, not an online “Train to Practice Telemedicine and answers apart from pre-course and only , have embraced remote Certificate Course”. post-course quiz”. care and a lot of fear of using technol- (India): “Telemedicine business models (India): “Ministry of Health & Family ogy has been surpassed … Self-care have been evolving from a patient-health- Welfare, Govt. of India is implementing algorithms have been adopted as an care provider model (person to person), to an eHealth project including Telemed- acceptable resource of health care by an institutional level, including, but not icine on National Medical College patients, healthcare providers and policy limited to, hospitals, , clinical Network (NMCN) for interlinking the makers”. analysis laboratory”. Medical Colleges across the country (New Zealand): “Healthcare services thus (Brazil): “NUTES-UFPE implemented with the purpose of e-Education and had 48 hours to switch service delivery a remote center for patients National Rural Telemedicine Network

from in-person to telehealth, and this was with flu-like symptoms [possible covid for e-Healthcare delivery”. over a weekend! GPs were asked to switch cases] and issues related to (New Zealand): “ New 70% of their consultations to telehealth … pandemic context. This service was, on Zealand and the NZ Telehealth Forum & Secondary care providers (hospital based the first moment, composed by volunteers Resource Centre ran webinars for health care) started to run telehealth consulta- and after some weeks,”. providers on telehealth consultations … tions in their outpatient departments”. (UK):” Volunteers have been engaged NZ Telehealth Forum & Resource Centre (UK):” In England has supporting over 2 million people at risk provided information for both health moved form 90% of face to face consulta- such as delivering food and , providers and consumers on how to run tions to 85% remote consultations mainly driving patients to appointments and telehealth consultations”. using telephone, video consultation or phone calls for the isolated. They are (UK):” Engaging healthcare profes- texting.” managed through a dedicated mobile sionals and the population regularly (Sri Lanka): Medical practitioners vol- app.” during the pandemic was essential in unteered to provide Telehealth services (Brazil):” Hundreds of volunteers have providing uniform trusted information. coordinated through the “Myhealth Sri been trained for remote guidance and Communication directly with healthcare Lanka” application. Healthcare profes- consultation. Gradually, other specialty professionals is via a central web-based sionals as well as patients attitude on agendas were opened, and the mental cascading alerting system for issuing distant care methodology changed even health agenda became the most demand- health messages and other safety critical though Sri Lankan COVID-19 case rates ed service to face mental suffering due information and guidance. Communi- were low compared to other counties. Pri- to social and distance isolation”. cation with the population is through a vate sector was eager to collaborate with (Jordan): “During COVID-19 especially government website”. government sector in sharing telehealth in lockdown and curfew times, the only (Brazil):” The Brazilian Telemedicine and platforms to provide health services for possible way to deliver health care ser- Telehealth (ABTMS) and Health Infor- the citizens. vices and information was via telehealth matics (SBIS) Societies have been pro- (Brazil):” Healthcare professionals, not support. Patients did like this method as moting actions through online seminars only physicians, have embraced remote many of them did not really need to be and courses throughout the country, with care and a lot of fear of using technology at the hospital physically. They needed emphasis on the Telemedicine University has been surpassed … Self-care algo- advice, information, follow up and/or Network (RUTE) by means of the Special rithms have been adopted as an accept- confirmation or opinion of certain health Interest Groups (SIG)”. able resource of health care by patients, status.” (Jordan): “It has become clear that the healthcare providers and policy makers”. vast majority of health care workers have

IMIA Yearbook of Medical Informatics 2021 131 Telehealth and the COVID-19 Pandemic: International Perspectives and a Health Systems Framework for Telehealth Implementation to Support Critical Response

never been exposed to such training or Table 1 Systems framework for telehealth implementation to support critical response orientation. The need for training was clearly demonstrated as physicians and nurses were unfamiliar with the appro- WHO Health System Model Telehealth Configuration in Critical Response priate procedures for documentation, Component diagnosis and follow up of cases coming to them using telehealth services.” Service Delivery ▪ Telehealth enabled virtual care delivery was provided for a significant proportion of the population, leaving in-person care for those that needed it most. ▪ Health service delivery needs evolved over the course of the pandemic and functionalities of telehealth tools needed to evolve too. Health workforce ▪ Beyond formal healthcare workers, volunteers have played a major role in working side by 4 Systems Framework for side with the governments and health systems to address the pandemic. ▪ Telehealth and other virtual care tools enabled coordination for caregivers and other Telehealth Implementation non-medical personnel to aid in care delivery. ▪ Telehealth went from being just a clinical tool to being a “care systems support tool” that to Support Critical Response was instrumental in mobilising the broader health workforce. The six themes from this paper highlight that Information ▪ System-wide networks of innovation including vendors and mobile apps have collectively telehealth delivery is a complex sociotech- enabled effective communication and flow of information necessary for pandemic nical endeavour with technical, informatics, management. human resource, financial, and governance ▪ Mobile tools and apps helped not only in dissemination of information to support care components. To provide a system framing for delivery but also educational activities, which was critical given the rapid uptake of telehealth implementation in times of critical telehealth in response to COVID-19. response such as during a global pandemic, Medical products, vaccines, ▪ Telehealth supported continuity of care for management of chronic conditions during we mapped our themes to the WHO Health and technologies lock down conditions when face-to-face encounter was not possible. It also supported System Framework [17]. Table 1 shows the peripheral tasks such as re-filling of prescription medications and provision of equipment mapping as a systems framework for tele- or other at home supports. health implementation to support critical ▪ The array of digital tools used ranged from telephone consults to formal and informal response. The systems framework provides telehealth tools. While variation in Telehealth usage was helpful in responding to guidance to assist with the conceptualization COVID-19, systems that evolve independent of formal medical informatics data standards and implementation of telehealth to support development may erode existing work on standards. critical response such as the COVID-19 Financing ▪ Governments were not the only major funders of digital innovations, but international pandemic. donor agencies and the World Bank also played a major role in keeping the funding While our framework uses the WHO streams flowing when businesses were “down”. Health Systems model, it extends the model ▪ New fee codes or billing schedules may be needed for provider compensation of telehealth by framing the system components for tele- delivery. It is essential that billing codes for virtual care remain in place after the pandemic. health delivery. A systems perspective on Leadership and governance ▪ The World Health Organisation, the telemedicine societies, and the ministries of health in telehealth provides insight that goes beyond the different countries played a major role in providing leadership and governance. clinical care aspects of telehealth such as ▪ Patients, caregivers, care providers, and other end users must be part of the planning and supporting coordination of a broader health implementation of telehealth tools. workforce as part of pandemic management and understanding the governance and fi- nancial implications of telehealth delivery. of geographical, cultural, and socioeconomic contributing to our paper with Governments contexts, as well as a variety of successes in worldwide showing flexibility in areas such responding to the COVID-19 pandemic, we as enabling remote consultations and devel- still found many similarities related to tele- oping flexible billing models. Government 5 Discussion health use during the pandemic. All countries flexibility occurred despite the different In this paper we described the international showed innovation to get telehealth rapidly health system delivery models (e.g., central- experiences in ten countries of implement- implemented in response to the pandemic. ized or decentralized) across the countries ing telehealth systems as part of managing We also saw a variation in the telehealth in our paper. For example, in Canada health- the COVID-19 pandemic. We then use tools that were used with systems ranging care is funded federally but implemented the international perspectives to develop from formal telehealth systems to tools such at the Provincial or Territory level but all a systems-based framework for telehealth as WhatsApp being used as an informal Provinces and Territories developed new implementation to support critical response. telehealth system. Legal or regulatory is- fee schedules to allow practitioners to bill While our countries represented a diversity sues were also experienced by all countries for telehealth services.

IMIA Yearbook of Medical Informatics 2021 132 Basu et al.

Public engagement was a particularly design and implementation does not come dations, and a call for papers. J Med Res interesting theme that emerged out of our at the cost of introducing unintended neg- 2020;22(6):e19284. 3. Whitelaw S, Mamas MA, Topol E, Van Spall HGC. analysis. Patient and public engagement is ative consequences into telehealth delivery. Applications of digital technology in COVID-19 necessary for any HIT initiative and many of We cannot be so fixated on agile and rapid pandemic planning and response. Lancet Digi our international perspectives talked about implementation that we ignore the need for Health 2020 Aug;2(8):e435-e440. the role that volunteers played in responding interoperable standards and privacy and se- 4. Mort M, Finch T. Principles for telemedicine and to the pandemic such as delivering food curity aspects of informatics driven systems. telecare: The perspective of a citizens’ panel. 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Thomas EE, Haydon HM, Mehrotra A, Caffery LJ, care in response to the COVID-19 pandemic, the world to become digitally connected Snoswell CL, Banbury A, et al. Building on the mo- it also increased the variation of telehealth and it is important that we do not lose the mentum: Sustaining telehealth beyond COVID-19. J Telemed Telecare 2020;1357633X20960638. tools that were used. While such diversity is new digital innovations that were developed 9. Kuziemsky CE, Gogia SB, Househ M, Petersen C, not necessarily a bad thing, it does threaten in response to COVID-19. We need to use Basu A. Balancing Health Information Exchange to erode international standard development COVID-19 as an opportunity to drive health and Privacy Governance from a Patient-Centred for telehealth delivery. Ad-hoc tools also can system innovation for informatics tools Connected Health and Telehealth Perspective: A lead to privacy or security issues as they may such as Telehealth. Telehealth delivery is Contribution from the IMIA Organizational and not have been designed to meet privacy and Social Issues and Telehealth Working Groups. very much a systems-based endeavour and Yearb Med. Inform 2018; 27:48-54. security regulations. systems thinking can help us understand all 10. Kaplan B. Revisting Health Information Technol- Critical response that extends over a the components that must be aligned in HIT ogy Ethical, Legal, and Social Issues and Evalua- significant time such as the COVID-19 pan- implementation. The main contribution from tion: Telehealth/Telemedicine and COVID-19. Int J Med Inform 2020;143:104239. demic also presents emerging challenges. this paper is a systems framework for tele- 11. Borycki EM, Kushniruk AW, Bellwood P, Brender Initial response to COVID-19 was focused health implementation that provides guid- J. Technology-induced errors. Methods Inf Med on stabilizing care delivery in the moment ance for the design and implementation of 2012;51(2):95–103. by coordinating fundamental care delivery telehealth tools to support critical response. 12. Gogia SB, Maeder A, Mars M, Hartvigsen G, Basu A, Abbott P. Unintended consequences of tele needs such as access to basic medical services One key limitation of our study is that health and their possible solutions: contribution and procurement of medications for chronic the international perspectives are all from of the IMIA working group on telehealth. Yearb disease management. As the pandemic pro- members of the IMIA Telehealth WG. As we Med Inform 2016 Nov 10;(1):41-6. gressed, telehealth needs evolved as people’s are all experts in various aspects of HIT and 13. Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in medical needs become more complex and Telehealth, as well as the broader discipline health care—an interactive sociotechnical analysis. mental health issues became a significant of health informatics, we bring a degree of J Am Med Inform Assoc 2007;14:542–9. consequence of social isolation and repeated bias to our analysis and the recommenda- 14. Kuziemsky CE, Randell R, Borycki EM. Under- lockdowns. More complex medical proce- tions from this paper. Applying and studying standing Unintended Consequences and Health Information Technology: Contribution from the dures such as cancer screening and other our systems framework in different health IMIA Organizational and Social Issues Working assessments or diagnoses that require physical systems will help to validate the framework. Group. Yearb Med Inform 2016 Nov 10;(1):53-60. touch are challenging to do virtually. Future 15. 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IMIA Yearbook of Medical Informatics 2021 133 Telehealth and the COVID-19 Pandemic: International Perspectives and a Health Systems Framework for Telehealth Implementation to Support Critical Response

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IMIA Yearbook of Medical Informatics 2021