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Digital Health Technology for Remote Care in Primary Care During the COVID-19 Pandemic: Experience from Dubai

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Introduction

Coronavirus disease-2019 (COVID-19) has abruptly changed the world view of pandemics, directly impacting global health and the economy. More than 178 million cases have occurred worldwide, including more than 3.8 million deaths.1 According to statistics, the disease has spread and affected around 222 countries, with the United States and India confirming most cases worldwide.1

Due to high transmission rates, many countries have adopted strict regulations to enforce physical distancing and mass closures, thus reducing the contagious effects of the disease and preventing adverse effects till pharmaceutical solutions are ready. Due to the physical distancing and limitations this pandemic has imposed, digital health technologies have played an essential role in facilitating medical services.

During the pandemic, health care facilities remained open to the public, and patients, caregivers, and staffs were at imminent risk of being infected with the virus. Many health systems were overwhelmed,2,3 with this being more noticeable in frontline emergency and intensive care unit hospital services.4–7 Health systems were urged to promptly re-manage both human and capital resources; reorganize their clinical services to minimize the risk of health care-associated shortage; and meet public health requirements for sustained surveillance, risk alleviation, and controlling shortage of service.3

Accordingly, we as health care decision-makers faced an extraordinary challenge to adjust the usual health care services by shifting the medical care from hospitals to patients’ homes through implementation of telemedicine, a first-line tool to confront this pandemic.8,9 Digital health technologies, such as telemedicine, big data predictive analysis, and artificial intelligence (AI), have been shown to be the best tools to mitigate the effects of COVID-19 by enhancing several public health measures. Some of these digital solutions have already been piloted and deployed to address the challenges of COVID-19.9 However, there are significant challenges in the implementation of digital health solutions in health care.10,11

For telemedicine to offer true benefits, it must be fully integrated by community members. It should be used as much as possible instead of in-person hospital visits during the pandemic and in daily use. Everything that one can see in a patient physically must be seen through telemedicine. Embracing telemedicine services mandates change management in the patient care process, potentially redefining the patient physical encounter.

The present study is an appraisal of the telemedicine approach that we implemented in the Dubai Health Authority (DHA) during the COVID-19 pandemic. The objective of this study was to conduct a comprehensive assessment of the utility of telemedicine during this global emergency and to summarize its challenges, achievements, and outcomes.

Methods

STUDY DESIGN

This descriptive study was conducted on telemedicine services provided in primary health care (PHC) centers in the DHA from January 2020 until July 2021.

STUDY PARTICIPANTS

Patients of both genders, all nationalities, and all ages who received telemedicine services were included in this study. The nationalities were further grouped into United Arab Emirates (UAE) and non-UAE nationals. The age groups were further classified into newborn (0–1 month), infant (1–12 months), child (1 to 12 years), adolescent (13–18 years), adult (19 to 59 years), and senior (60 years and above). Payment processes were categorized as government insurance, private insurance, self-pay, payment through charity, and free COVID-19 test/vaccine.

STUDY PROCEDURE

The DHA is a large, academic health care provider in Dubai City, consisting of 10,000 health care providers across 6 hospitals, 9 specialty centers, and 13 PHC centers, all connected by a single Electronic Medical Record (EMR) system (SALAMA). Before COVID-19, DHA was in the process of implementing telemedicine capabilities; however, the pandemic has fundamentally accelerated this service.

The most significant investment being applied was virtual care, a fully integrated video visit experience tightly integrated into its enterprise EMR system and patient portal. Patients accessing virtual care could check in and have a video-enabled consultation with a DHA-PHC physician. DHA uses a single instance of the EMR by leveraging deep integration with the video platform to enable its virtual health services. The service is free for UAE nationals and non-UAE nationals seeking consultation for COVID-19 infection or COVID vaccine-related issues. The service is also free for non-UAE nationals who have Enaya insurance and are chronically ill, elderly, or people of determination.

DHA had decided in January 2020 to integrate telemedicine into its daily practice. This is a 24-h service, 7 days a week, including public holidays. We also identified a list of presentations that can be safely managed remotely using telephone or videoconferencing. These included repeat prescriptions; follow-up visits for stable chronic conditions, including hypertension, asthma, chronic obstructive pulmonary disease, heart failure, depression, and diabetes; and simple acute presentations, including uncomplicated urinary tract infection and osteoarthritis flares.

We developed guidelines and protocols for our front desk staff on how to screen appointment requests and select which requests can be booked directly into the family medicine physician appointment template, which should be deferred for several months (e.g., annual general checkups), and which should be triaged by an in-person clinician first. Some patients who had urgent situations were asked to come in for an examination provided that they had no COVID-19-related symptoms or contact with confirmed/probable cases. Blood tests were ordered only if necessary.

Our newly developed guidelines and their level of implementation have evolved over the 1-year period based on challenges the physicians were facing. We also implemented guidelines for collection of laboratory/imaging request forms, prescriptions, and medical off-work certificates. All prescriptions were available in DHA pharmacy systems, and patients could go to any DHA pharmacy to get their medication. Physicians were able to request blood tests and order laboratory screenings when medically indicated. Radiology orders and screening mammograms were also accessible.

However, medical reports were not ordered through telemedicine as they require clinic visits due to the need for examination and payment. Off-work certificates were also provided through the telemedicine service of care for only one working day. If imaging studies, more laboratory testing, or in-person appointments were needed to complete the diagnostic evaluation, the patient was offered an appointment in local, COVID-19, free comprehensive care centers established with additional safety procedures and environmental protection to safely care for patients awaiting test results and persons who require in-person care.

DATA ANALYSES AND STATISTICS

For statistical analysis, all collected data were entered into STATA, version 17.0 (StataCorp. 2017. Stata Statistical Software: Release 15; StataCorp LLC, College Station, TX). Descriptive statistics were computed for sociodemographic variables, and overall access to telemedicine was recorded as a percentage of the total. For all analyses, alpha (α) was set at 0.05. A multiple regression model was fitted to explore the possible predictors of telemedicine usage.

ETHICS STATEMENT

The study was approved by the institutional review boards of Dubai Health Authority, Dubai (Approval # DSREC-06/2021_07).

Results

SOCIODEMOGRAPHIC CHARACTERISTICS OF THE SUBJECTS

Of 123,944 individuals who booked an appointment for the telemedicine service, 106,408 (86%) showed up. Most patients were 19–59 years old, UAE nationals, female, and having government insurance (Table 1).

Table 1. Descriptive Demographic and Clinical Characteristics of Patients Who Used the Telemedicine Service in Dubai Health Authority (n = 123,944)
VARIABLE n (%)
Age (years)
 Minimum = 2 days
 Maximum = 119 years
 Median = 36 years
Age groups
 Newborn 471 (0.4)
 Infant 1,450 (1.2)
 Child 9,368 (7.6)
 Adolescent 5,677 (4.6)
 Adult 91,438 (73.8)
 Senior 15,540 (12.5)
Gender
 Female 71,822 (58)
 Male 52,109 (42)
Nationality
 UAE 79,493 (64)
 Non-UAE 44,449 (36)
People with special needs
 Yes 806 (0.7)
 No 123,138 (99.3)
Payer
 Government insurance 82,682 (89.2)
 Private insurance 1,085 (1.2)
 Self-pay 65 (0.1)
 Charity 13 (0.0)
 Free COVID-19 test/vaccine 8,891 (9.6)

TRENDS OF USING TELEMEDICINE SERVICES AMONG PATIENTS

The most common medical consultations were general health counseling (GHC), followed by COVID-19 tests or vaccination (Fig. 1). The trend of telemedicine consultation during the COVID-19 pandemic is presented in Figure 2. The telemedicine care volume grew from 188 visits in January 2020 to 11,757 in April 2020.

Fig. 1.

Fig. 1. Medical consultation categories for telemedicine usage from January 2020 to July 2021.

Fig. 2.

Fig. 2. Trends of telemedicine consultation from January 2020 to July 2021.

The most common diagnosis was general health consultation (55,672; 52%), followed by COVID-19-related consultation (18,523; 17%) and laboratory test requests (11,064; 10%). Around 4,997 (5%) telemedicine consultations were for medication refills. Patients were able to ask for medication delivery, with telemedicine physicians filling in his/her delivery details. The other option for getting the medication at home was registering in the DAWAEE service and receiving the medicine at home within 3 days.

LINEAR REGRESSION MODEL PREDICTING CLINICAL NEEDS BY AGE AND THE INTERACTION OF GENDER AND NATIONALITY FOR TELEMEDICINE

A multiple linear regression model predicting COVID-19-related needs by age and the interaction of gender and nationality for telemedicine use was statistically significant (p = 0.0000) (Fig. 3). In addition, a multiple linear regression model predicting the types of diagnosis-related telemedicine needs by age and the interaction of gender and nationality was statistically significant for dermatology (p = 0.0000), respiratory (p = 0.0000), cardiovascular (p = 0.0000), endocrine (p = 0.0000), obstetrics and gynecology (OB&GYN) (p = 0.0000), urology (p = 0.0000), and gastrointestinal (GI) (p = 0.0000) diseases (Fig. 4).

Fig. 3.

Fig. 3. Adjusted predictions of COVID-19-related consultations using telemedicine in all nationality, gender, and age groups. CIs, confidence intervals; COVID-19, coronavirus disease 2019; UAE, United Arab Emirates.

Fig. 4.

Fig. 4. Adjusted predictions of telemedicine consultations for different symptoms in all nationality, gender, and age groups. GI, gastrointestinal; OB&GYN, obstetrics and gynecology.

UAE nationals, both males and females, had a significantly higher probability of telemedicine visits for GHC, dermatology, cardiology, urology, OB&GYN, endocrine, and GI symptoms compared with non-UAE nationals (Fig. 4).

Discussion

The COVID-19 pandemic has affected health sectors worldwide, and UAE was no exception. We in the UAE were dealing with this pandemic using all our health care providers’ services and capacities.12,13 However, the health care system was facing a lack of human resources during this health crisis. With mass mobilization of health care providers onto COVID-19 service-providing facilities, a tremendous need for telemedicine has emerged. This was the fundamental purpose of accelerating the use of telemedicine in our services.

With virtual care in PHC, we were able to meet the community’s needs for nonurgent COVID-19 and non-COVID-19-related cases during the pandemic. In the nonurgent care setting, this transition to video visits has demonstrated its feasibility and value in promoting social distancing. We adopted a guideline that guarantees the provision of care utilizing several methods (remote consultations through telephone and videoconferencing).

Our objective was to protect staff and vulnerable patients by minimizing the number of patients in our health care facilities. The fact that some of our family medicine physicians had chronic diseases, preventing them from directly interacting with patients, facilitated the early uptake of virtual consultations.

Mass migration to telemedicine occurred during the period April–June 2020, co-occurring with the peak of COVID-19 crises (Fig. 2). Telemedicine visits for COVID-19 care were spread across age strata, with the most significant use in the age group of 19 to 59 years (Fig. 3). We found more COVID-19 and respiratory disease-related consultations in non-UAE nationals than UAE nationals and in males compared with females (Fig. 4).

This is in line with a recent study showing the spread of COVID-19 in the UAE between different nationalities and capacities.12,13 Both male and female non-UAE nationals had a significantly higher probability (p < 0.001) of telemedicine visits for COVID-19-related issues compared with UAE nationals.

Among both UAE and non-UAE nationals, a significantly higher probability (p < 0.001) of having COVID-19 telemedicine needs was observed among those older than 13 years, with an increase in the adult group and then a decrease in the senior group. This was in line with our previous article showing a higher rate of COVID infection in non-UAE individuals, especially men.13 However, consultations for other diseases were more frequent among UAE national patients because consultations for UAE nationals were free. The ratios of respiratory telemedicine needs, by gender and nationality, were maintained throughout the life span.

However, the need was not linear between age groups. The lowest use of respiratory telemedicine was observed for newborns, while the highest use was for infants between 1 and 12 months of age. In the child and adolescent groups, there was a decline in the use of respiratory telemedicine service, which stabilized with a mild nonsignificant increase among patients in the adult group, followed by a mild nonsignificant decrease in senior citizens (Fig. 4). Among all nationalities, newborns had the greatest need for GHC (p = 0.0000), dermatology (p < 0.001), and GI (p < 0.001) telemedicine consultations compared with older age groups, which was significant.

UAE females had a higher probability of using the dermatology telemedicine service compared with UAE males (p < 0.001), while UAE males had a higher probability of using the cardiovascular telemedicine service compared with UAE females (p < 0.001). An extreme increase in the use of cardiovascular and endocrine telemedicine services was observed among patients older than the age of 59 years (p < 0.001 and p < 0.001, respectively) for all nationalities (Fig. 4). This is in line with recent research presenting higher use of telemedicine by senior patients.14 Since seniors in the UAE community are not that acquainted with the use of new technology, the younger family members assisted them in using telemedicine to avoid physical attendance at the PHC clinic at the time of the pandemic.

The highest use of OB&GYN telemedicine services was observed among UAE national females, which was significantly greater than for non-UAE national females (p < 0.001). The use of OB&GYN telemedicine visits showed a peak in the adolescent group with a significant (p < 0.001) increase of use in the adult group, followed by a decline of use that was significant (p < 0.001) in the senior group. This trend was seen in both UAE and non-UAE national females (Fig. 4).

Furthermore, the highest use of urology telemedicine services was observed among UAE national males and females, which was significantly greater than for non-UAE national male and female patients (p < 0.001). The use of these services was stable from age 12 to 18 years, with a statistically significant increase of use in the adult group (p < 0.001) and a steep significant increase in the senior group (p < 0.001) (Fig. 4). The highest use of GI telemedicine services was observed among UAE national males and females, which was significantly greater than for non-UAE national males and females (p < 0.001). The more frequent use of telemedicine services by UAE nationals over non-UAE nationals might be due to the payment factor as telemedicine was entirely free for UAE nationals and those using the service for COVID-19-related symptoms.

Looking at the present results, we can see that telemedicine has allowed for continued patient care while ensuring the safety of patients and health care workers during the COVID-19 pandemic. Telemedicine was used in Dubai by both government and private health sectors.

At the beginning of this pandemic, DHA required no license for adding telemedicine services in private sectors. This decision was made to further support the health sector in providing consultations for patients without physical interaction. However, these relaxed telemedicine regulations did not continue for long as DHA required all telemedicine providers in private sectors to get proper licenses from the Dubai Health Regulation Sector. This action was taken to have improved regulation of this service.

We believe the experience of telemedicine during the COVID-19 pandemic has added a lot to the service. When this crisis is over, telemedicine will add another dimension to providing efficient and cost-effective health care for patients and health care systems. This will be especially helpful in providing health care in chronic conditions that require repeated visits to the health care system, leading to increased costs of care, missed appointments, and nonadherence to treatment plans.

The expansion of telemedicine will accelerate technology-based solutions for telemedicine, including remote monitoring of vital signs and acquisition of other health data in real time, thus enabling timely diagnosis and prompt initiation of treatment. We believe that the designation of new services enhanced by AI might support an integrated transition between virtual and in-person care. However, privacy issues, data disclosure, interoperability of electronic health records, and data security will need continued scrutiny and updating as the telemedicine service expands.

Nevertheless, the rapid increase and wide adaptation of telemedicine into health care systems should be well adjusted for perception bias in some patients and providers regarding its safety and worth compared with in-person care. A concern exists that telemedicine may be viewed by both the physician and the patient as a loss of the empathic physician–patient relationship, resulting in the depersonalization of care. Hence, it is vital to identify and categorize medical conditions, the acuteness of the case, and sequential relationships to health care (e.g., initial or follow-up visits) that could be efficiently served by telemedicine.

Although virtual health care services during the COVID-19 pandemic improved access to medical care, reduced costs for patients (e.g., less travel and time away from work), and increased outreach to underserved populations (e.g., senior citizens and those in rural areas), continuity of efficient virtual care will require reliable communication infrastructure. In addition, cost-effective and readily accessible broadband connectivity along with good telecommunication use and awareness is required in our community.

We believe telemedicine provides an excellent opportunity to continue and improve virtual clinic visits in ways that will be more satisfactory to patients. For health care systems, telemedicine will become a force multiplier, considering its ability to support the upsurge in care; improve the efficiency of workflows; and expand health provider reach to senior patients who have difficulty attending the health visit in person. This report demonstrates the transformational impact of COVID-19 on telemedicine-driven health care at the time of the pandemic.

Considering the DHA’s existing implementation and efforts during the COVID-19 pandemic, reflected in the data presented here, we need to specifically focus on the type of expansion in telemedicine in providing health services. The results reflect that telemedicine may become a new norm in future health care, particularly during infectious disease epidemics.

LIMITATIONS OF THE STUDY

This study presents several limitations that need to be mentioned. One fundamental limitation of our study is that different health care providers might be using variant telemedicine systems. Nevertheless, applying and studying the DHA telemedicine framework in different health systems might help to validate the framework.

In addition, patients in our study presented with a wide range of symptoms and pathologies; nevertheless, it reflects a typical composition of PHC cases. In addition, complications may have been missed due to patients’ failure to physically present to the PHC clinic during the peak of the COVID-19 pandemic restrictions. However, because this was a study exploring a vital service tool minimally explored in both the UAE and regional populations, we believe that the results obtained are valid.

Conclusions

Virtual care services in PHC clinics have been highly successful in meeting the needs of patients during the COVID-19 pandemic. Patients widely accept virtual visits that represent a key component of providing timely and safe health care during this pandemic. Telemedicine has enabled clinicians to continue providing care to their patients while maintaining the necessary public health measures adopted in the fight against COVID-19.

However, the rapid transformation of inpatient care has created increased uncertainty over the future of PHC practice. Will the switch to telemedicine be sustainable in the long term and what will be the level and degree of telemedicine adoption beyond COVID-19? This requires more studies to explore how PHC organizations will provide further support and guidance on the suitability of telemedicine in various circumstances and clinical conditions and how it will affect medical practice and care. Many questions remain unanswered.

Authors’ Contributions

M.A. and A.M.R.A. designed the study and prepared the process evaluation framework. A.M.R.A., F.A., and M.K.A. contributed to data collection and coding. F.R.C. and M.A. analyzed the data and prepared the first draft of the manuscript. M.A. and F.R.C. contributed to data interpretation. All authors critically reviewed the manuscript, contributed to interpretation, and approved the submitted version.

Ethics Approval and Consent to Participate

The study was approved by the Human Research Ethics Committee of the Dubai Health Authority. Written consent for publication of data collected in this study was obtained from all participants. All methods were carried out in accordance with relevant guidelines and regulations.

Availability of Data and Material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Acknowledgments

The authors would like to express their appreciation to all the participants.

Disclosure Statement

No competing financial interests exist.

Funding Information

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

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