How can virtual health help expand capacity in the wake of an anticipated COVID-19 surge?

The rapid expansion of the COVID-19 outbreak has illustrated cracks in healthcare systems around the world, impacting infrastructure, workforce, and equipment in every nation. In terms of infrastructure, Switzerland has currently about 1’200 medical intensive-care unit (ICU) beds. In preparing to reach a peak of seriously ill patients, Swiss hospitals and the health system have made significant efforts to free up infrastructure capacity.¹

However, even a moderate impact from the COVID-19 outbreak, assuming social-distancing and other measures from the Federal Council prove effective, could still result in about 3,200 patients in need of hospitalisation in an ICU at the same time. This would leave the country unable to respond to the potential demand.² If all existing ICU beds in Switzerland were freed up for patients affected by COVID-19, the total capacity required at peak would still call for a nearly threefold increase. Even if there are enough beds and ventilators, Switzerland has too few specialised medical staff who can care for extreme cases.³

Beside the inpatient challenges, outpatient settings such as clinics and offices are also running into many organisational and operational challenges. The Swiss patient and physician population are widely complying with guidelines set by the Federal Office for Public Health (FOPH) and rescheduled non-urgent appointments and called for telehealth consultation whenever possible. This has led to a measurable decline in the number of non-COVID medical incidents, ongoing regular visits and elective procedures. While we see other national examples of inpatient and outpatient services being overrun, in the US for example, Switzerland faces decreasing demand of outpatient medical services, forcing physician’s offices, clinics, and even hospitals to apply for government support, e.g. short-term employee and organisational benefits. Ultimately, these ‘missed visits’ will have profitability implications for treatment, medical equipment and care suppliers, and may have considerable health outcomes and wellness consequences for patients.

 

Flattening the curve: An uncontested imperative

Health officials and the FOPH have been anticipating a near-term peak in the Covid-19 outbreak and subsequently a surge in demand on health systems across the country. The FOPH recommends self-isolation, social distancing and hygiene measures to help “flatten the curve” (i.e., reduce the peak demand for health services related to COVID-19) with the hope that overall demand stays below the aggregate system capacity.⁴  The FOPH further asked telecommunication provider Swisscom to provide anonymised statistics and visualisation of Swiss population movement data to discover if people adhere to the measures. Recent results of this data show that the population have been adhering to federal guidelines. ⁵

There continues to be uncertainty about how the disease will progress in Switzerland and the extent to which social-isolation measures will be effective. It could be several weeks, possibly months, before the uncertainty is lifted.

 

Is the health care capacity line really horizontal?

The capacity of our health care system is typically seen as fixed, meaning there is a finite supply of health services that can only marginally be exceeded. This capacity - regardless of how it is calculated - is far from static. Indeed, aside from fixed assets constraints (number of beds) and supply and equipment shortages (too few masks, too few ventilators), there is a real risk for declining capacity due to workforce constraints on the frontlines. Consider the following:

• Clinicians are working over-time and facing exhaustion, which diminishes their immune response and increases vulnerability.
• Health care workers that develop symptoms and test positive for COVID-19 have to quarantine themselves for at least 48 hours. But quarantined clinicians could still play a role via virtual health.⁶
• There might be more than one health care worker in a household (e.g., married physician couple), which could multiply the effect of contagion.
• Medical personnel from other countries could be forced to return to their home country if those declare a state of emergency. For some hospitals, like the hospital of Geneva, this could mean that up to 2/3 of the medical staff will no longer be able to treat patients in Switzerland.⁷
• Furthermore, specific operational measures, protocols, and precautions in caring for COVID-19 patients could lead to less-efficient health care delivery. For example, we know from US hospital data, recovered COVID-19 patients might spend several days in inpatient facilities and critical care beds, awaiting test results before they are discharged, further decreasing capacity.^8,9

In Switzerland we have observed several short-term, quickly deployed countermeasures aimed at maintaining, or even expanding capacity. These include among others:

• Keeping nurseries open for the children of medical staff allows them to continue working.
• The state has ordered the mobilisation of up to 8.000 soldiers to support medical personnel.
• An exceptional rule allowed changing labour laws for physicians and caretakers to enable longer working hours and prohibit vacation.
• Retired and former health care workers are recruited by hospitals on a temporary basis to support the staff.

Already closed hospital wards were reopened and makeshift treatment centres are built in gymnasiums and schools to treat less severe patients.

While Switzerland has been able to rapidly scale up ICU beds from 800 to 1.200 and mobilise new forces on the Corona frontline, the clinician and infrastructure supply side may still decrease over time despite these efforts due to the above mentioned factors.

What are the implications of capacity shortages?

As we think about flattening the curve, we should account for the likely possibility that, even with proactive measures, health services capacity may indeed decline. This could mean that delays in testing and caring for patients will result in greater incidence and prevalence from undiagnosed and/or untreated individuals (see chart) and therefore greater demand over a longer period of time. On the chart, this could correspond to both increase in total number of cases (surface under curve) as well as peak demand (vertical amplitude of curve).

 

What is the role for virtual health?

Virtual health could help stabilize existing supply and increase the capacity of the health care system. Europe and Switzerland are already supporting their health care system with virtual services, such as:

• Triage and testing of potential Covid-19 patients: To decrease exposure to potentially infected patients, the FOPH and other European health offices have asked the population early on to use telehealth services before consulting a physician. In the canton of Berne a Covid-19 test centre has been established, where patients can get consulted though an online survey.¹⁰
• Europe-wide contact-tracing tracker: A European group of scientists and IT specialists has founded the Pan-European Privacy-Preserving Proximity Tracing non-profit organization and developed standards to track movement data while complying with the region’s strict data protection laws, in order to support health officials checking the adherence to self-containment measures.¹¹

Virtual health could further help stabilize supply, increase treatment capacity, and enhance transparency. Further potential use cases could be:

• Load-balance capacity: Virtual health makes it possible to tap into excess provider capacity in cantons that are not currently COVID-19 hot spots.
• Reduce workforce exposure: Virtual health visits can help reduce staff exposure and lessen the use of personal protective equipment (PPE). ER doctors, for example, can virtually drop in on emergency room visits.
• Overcome quarantine hurdles: Providers who need to self-quarantine can still attend to patients through virtual measures, which means they are not completely removed from the workforce.
• Scale scarce expertise: The capacity of scarce intensive-care physicians could be augmented by deploying e-ICU solutions in which specialists are connected remotely. This could multiply the reach of one intensivist 50 to 100 fold.
• Redeploy specialists and general practitioners (GPs): Virtual health could be an ability for GPs, specialists like psychiatrists and gynaecologists, and physicians that belong to risk groups to generate revenue as long as patients stay away. Some consultations can be done in video conferences (VC) and, using at-home-test kits or self-diagnosing tools, even certain diagnostic tests are possible. The Health Info Net (HIN) offers secure VC services for physicians.¹² 
• Stabilization of non-urgent care infrastructure: Patients that decide to stay home with seemingly non-urgent conditions can still be treated, thus mitigating the risk of potentially longer implication and consequential complications.
• Expand capacity: Virtual health can enable hospital-at-home solutions that allow for more rapid discharge of hospital patients. This can create net-new capacity “in the home” and free up inpatient hospital capacity for new cases.

In the US, federal regulators have loosened some restrictions around virtual health. Previously, telehealth services were only covered for beneficiaries living in rural areas, now they are covered for all Medicare members and comprise a broader list of services. In addition, the agency waived enforcement of HIPAA health-privacy law violations, which will make it possible to conduct virtual health visits via non-compliant social medial platforms. The relaxation of these regulations are key factors that can help accelerate adoption of virtual health.¹³ In Switzerland, the Federation of Swiss Doctors (FMH) has filed a motion to temporarily change the reimbursement regulation during these exceptional times, but is yet awaiting a response.¹⁴ 

 

In conclusion

Many predictions anticipate a surge in demand for infrastructure and, more importantly trained medical staff due to COVID-19. With potentially declining clinical workforce capacity, health systems should consider the following benefits of virtual triage and tele-medicine capabilities:

• Creating net-new capacity: Services like virtual consults, e-ICU remote rounding, and hospital-at-home can expand capacity. Through an e-ICU, for example, one intensive care physician could oversee care for 50 to 100 patients.
• Protecting the workforce and managing supplies: Virtual health can create a degree of separation between providers and patients, thus reducing the use of already dwindling PPE.
• Removing healthy individuals from a high-risk environment: Strengthening virtual triage capabilities could reduce overcrowding of in-person visits thus reducing potential for contagion at the hospital, doctor’s office or test centre itself.
•  Supporting the practice of registered physicians: Through virtual consultations or even self-diagnosing physicians can compensate for some of the revenue loss during social distancing. Regulations around reimbursement and self-testing should be (temporarily) altered to give security and clarity.

Driving virtual health could have the potential to support the burdened health care system, but implementation could prove challenging. Current infrastructure and IT capacities may not support the deployment of these measures in the very short term. The inability to use certain platforms, services and self-diagnosing tools in accordance with the law limits the possibilities and insecurities around reimbursement need to be clarified before virtual health can have a significant impact on capacity.

Switzerland has made valiant efforts to ramp up capacity and transparently communicate guidance, but depending on how long this crisis lasts, it may not be enough and new methods need to be taken into account to decrease pressure on the system.

 

Acknowledgements:
Preethi Kannan & Jana Sailer

Authors:
Felix Matthews, MD, MBA - Managing Director, Deloitte US
Patricia Gee, MPH, MBA - Director, Deloitte Switzerland
Urvi Shah, Senior Manager - Deloitte US
 

References

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8. Carilion Clinic Waiting on 100 COVID-19 Test Results after 165 Patients Tested, WSLS 10, March 19, 2020

9. Weeks Ahead of When Coronavirus Will Peak In Colorado, Hospitals Are Already Seeing Shortages, Colorado Public Radio, March 18, 2020

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