J Islamabad Med Dental Coll 2020 79 Correspondence: Lawrence Faulkner Email: lawrence.faulkner@cure2children.org Cite this editorial: Faulkner L. Telemedicine in COVID-19 era: Lessons from Online Co-management of Bone Marrow Transplant Patients. J Islamabad Med Dental Coll. 2020; 9(2): 79-81 Doi: 10.35787/jimdc.v9i2.550 O p e n A c c e s s Telemedicine in COVID-19 era: Lessons from Online Co-management of Bone Marrow Transplant Patients Lawrence Faulkner Medical Coordinator, Cure2Children Foundation – Italy Recently, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected millions of people globally and killed hundreds of thousands. Until an effective vaccine is available, prospects of definitive control of the COVID-19 pandemic are uncertain. In fact, over 50% of the infection is being spread by asymptomatic individuals. 1,2 Both mortality and admissions to intensive care units have increased several folds over baseline seasonal rates in most severely affected regions. Pakistan might be particularly vulnerable to the COVID-19 pandemic for several reasons. The first and foremost reason is difficulty in maintaining social distancing, which is regarded as a critical prevention strategy, as many Pakistani communities live together in close quarters. Moreover, Pakistan has only 1.5 critical care beds per 100,000 population compared to 3.6 in China, 12.5 in Italy or 9.7 in Spain, respectively. 3,4 These proportions refer to physical beds and equipment, and, most importantly, to skilled personnel. In Italy, a country severely affected by this pandemic with over 30,000 deaths, more than 160 health care workers died of COVID-19, 80% of them being physicians. 5 Some of these doctors were general practitioners acting solo, but, most importantly, physicians tend to be older males as opposed to nurses who are often young women and thus at decreased risk of morbidity and mortality from COVID-19. 6 Clearly, tools capable of minimizing direct patient contact without compromising quality of care are direly needed. The potential for information and communication technology to promote effective remote intensive care has been documented, at least in high- resource settings. 7 The Cure2Children Foundation, an International Italian NGO also registered in Pakistan, has extensively applied a cloud-based platform for co-management of children undergoing bone marrow transplantation (BMT). This procedure often requires prolonged sub- intensive to intensive care, in the Indian subcontinent. 8 Since 2008, close to 700 bone marrow transplants have been performed. Of these, 170 were carried out at the Children’s Hospital, Pakistan institute of Medical Sciences (PIMS) and at Dr Akbar Niazi Teaching Hospital (ANTH) in Islamabad, Pakistan. These transplants were performed primarily in low-risk patients with hemoglobinopathies by local physicians and nurses with no previous BMT experience but assisted by daily online interactions with condition-specific BMT experts. 9 The IT system employed provided several tools including pre-transplant check lists, electronic medical record, direct connection to HL7-compliant patient monitors, automatic patient- specific treatment plans, continuing quality improvement tools, inventory and cost monitoring. 8 The quality improvement tools E D I T O R I A L J Islamabad Med Dental Coll 2020 80 included drug and transfusion administration tracking, incident reporting, clinical practice guidelines, standard operating procedures, and real-time outcome analysis. 8 Outcomes were not substantially different from those reported in high- resource settings in a comparable patient group. 10 This proof of principle is potentially quite relevant to the current COVID-19 pandemic, in as much as it shows how the physical presence of experienced physicians, presumably the ones most difficult to recruit and at highest mortality risk, may not be an absolute requirement. In fact, in units taking care of complicated patients with a single disease and a limited number of protocols and procedures which are thus amenable to focused training, professionally trained and properly supported nurses along with junior doctors can provide adequate care with online support from experienced physicians. The obvious consequence of this is the possible huge expansion of a flexible workforce of remote consultants with condition- specific expertise. Pandemics may come in asynchronous waves in different regions: for example, while it is peaking in Pakistan and India it may be subsiding in China, UK or Italy and very experienced professionals from the latter countries may be available for online consultation. 11 This approach may also have substantial cost- containment implications. Data centralization offered by a cloud-based IT platform will allow quick access for analysis, centralized protocols, and procedures and, most importantly, coordinated allocation of resources, real-time reliable medical data and well-designed clinical studies. Remote co-management models may also be relevant to future public health emergencies, including natural disasters. The experience with Fangcang shelter hospitals in China suggests that the rapid implementation of scalable and properly designed and equipped physical spaces is feasible 12 and that the bottle neck to timely scalable care might primarily be the lack of availability of skilled personnel. R e f e r e n c e s 1. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR, et al. Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. N Engl J Med. 2020. Doi: 10.1056/ NEJMoa2008457 2. Sutton D, Fuchs K, D’Alton M, Goffman D. Universal Screening for SARS-CoV-2 in Women Admitted for Delivery. N Engl J Med. 2020. Doi: 10.1056/ NEJMc2009316 3. Phua J, Faruq MO, Kulkarni AP, Redjeki IS, Detleuxay K, Mendsaikhan N, et al. Critical Care Bed Capacity in Asian Countries and Regions. Read Online Crit Care Med Soc Crit Care Med. 2020; 48(5): 654–662. Doi: 10.1097/CCM.0000 000000004222 4. List of countries by hospital beds [Internet]. Wikipedia. 2020 [cited 2020 Apr 17]; Available from: https://en.wikipedia.org/w/index.php?title=List_of _countries_by_hospital_beds& oldid=951419991 5. More than 100 doctors have now died in Italy’s coronavirus outbreak [Internet]. 2020 [cited 2020 May 12]; Available from: https://www.thelocal.it/ 20200409/more-than-100-doctors-have-now-died- in-italys-coronavirus-outbreak 6. CDC. Coronavirus Disease 2019 (COVID-19) [Internet]. Cent. Dis. Control Prev. 2020 [cited 2020 May 12]; Available from: https://www.cdc.gov/ coronavirus/2019-ncov/ COVID-data/investigations- discovery/assessing-risk-factors.html 7. Udeh C, Udeh B, Rahman N, Canfield C, Campbell J, Hata JS. Telemedicine/Virtual ICU: Where Are We and Where Are We Going? Methodist DeBakey Cardiovasc J. 2018; 14(2): 126–33. Doi: 10.14797/ mdcj-14-2-126. 8. Agarwal RK, Sedai A, Dhimal S, Ankita K, Clemente L, Siddique S, et al. A prospective international cooperative information technology platform built using open-source tools for improving the access to and safety of bone marrow transplantation in low- and middle-income countries. J Am Med Inform Assoc. 2014; 21(6): 1125–8. Doi: 10.1136/amiajnl- 2013-002594 J Islamabad Med Dental Coll 2020 81 9. Faulkner LB, Uderzo C, Masera G. International cooperation for the cure and prevention of severe hemoglobinopathies. J Pediatr Hematol Oncol. 2013; 35(6): 419–23. Doi: 10.1097/ MPH.0b013e31829 cd920 10. Faulkner L, Uderzo C, Khalid S, Marwah P, Soni R, Yaqub N, et al. ATG vs. thiotepa with busulfan and cyclophosphamide in matched-related bone marrow transplantation for thalassemia. Blood Adv. 2017; 1(13): 792–801. Doi: 10.1182/blood advances. 2016004119 11. Xu S, Li Y. Beware of the second wave of COVID-19. The Lancet. 2020; 395(10233): 1321–2. Doi: 10.1016/S0140-6736(20)30845-X 12. Chen S, Zhang Z, Yang J, Wang J, Zhai X, Bärnighausen T, et al. Fangcang shelter hospitals: a novel concept for responding to public health emergencies. The Lancet. 2020; 395(10232): 1305– 14. Doi: 10.1016/ S0140-6736(20)30744-3