How telenursing, video visits and nursing informatics have benefited patient care in KSA and UAE

Solving the global workforce crisis in healthcare – Sponsored by KPMG  

Dr Mark Britnell, Global Healthcare Expert, KPMG International, highlighted that by 2030, we face a future with too much work, with too few workers. He said: “We will be 18 million health workers short by 2030 and this represents a gap to care.”

Related: How Saudi Arabia is approaching value-based healthcare

In the UK, he shared, nearly 10 per cent of all NHS posts are vacant. In the U.S., 1 million nurses and 120,000 doctors are needed by 2030; India needs 3.9 million doctors and nurses, while China needs 180,000 obstetricians by 2022.

In KSA, a changing demographic will see the need for 30,000 more doctors and 82,000 more nurses by 2030. Keeping this in mind, the country has started to prioritise nursing, and there has been growth in medical education from five medical to schools to 37, of which 28 are public and 9 are private. Also, the growing medical workforce ratio of doctors in the population rose from 2 per 1000 to 2.8 to 1000.

Dr Britnell suggests 10 changes to tackle the global health workforce crisis:

1. Productivity. Health is wealth.
2. Entrepreneurial government
3. New models of care
4. Patients as partners
5. Communities as carers
6. Professionals. Top of their game.
7. A new cadre of care workers
8. Digital dividend
9. Agile learning organisations
10. Manage and motivate the workforce

Digitalising the nursing profession

Dr Mohammed G Alghamdi, General Director of Nursing Affairs at the Ministry of Health, commenced an engaging session on digitalising nursing (sponsored by Vocera) by raising the issue of nurse shortages, and how this was addressed through approaches that included:

• Adapting new flexible temporary contracts and workforce restoration plan
• A new staffing model to provide safe nursing care to ICU patients that was published on its website.
• Publishing clinical guidance for nursing and protocol for quarantine facilities

Competency training is critical during the pandemic, and this is something that nursing leaders need to provide. But there was also a recognised need to minimise physical gatherings, and therefore an alternate solution was sought. One solution was a COVID-19 crash course that was completed by almost 20,000 nurses. It included topics such as hand hygiene compliance and burnout ("familiar to everyone").

Furthermore, nurses and nursing directors provide Excel sheets every day, which he believed to be impractical, showing numbers for nurse infections that reported to the national emergency operating centre. This method was automated or digitalised, resulting in the ability to track any rise in infections. The outcome was a decrease in the number of confirmed coronavirus cases in nurses from 19.2% to 6.1%.

Steven Matarelli, Senior Clinical Executive at Vocera, suggested that technology can also have a part to play in cognifive overload. It all becomes a blur. Nursing leaders we need to stop and think about how to end the technology burden, and become more unified.

He recommended thinking about communication as a strategic decision in hospital, and importantly for nursing leaders to be present at the table with tech partners to determine whether or not a product hinders or helps the nurse. He offered five key points to consider:

• Information needs to be ‘contextualised’ – with patient name and date-of-birth;
• All ‘noise’ must be deflected. This means technology turned off if administering a medication;
• A single source of information is necessary – a health record needs to works for the nurse, rather than the reverse;
• Information needs to be retrieved as a mobile healthcare giver (he asked how many have written vital signs on scrub pants);
• finally, extraneous information must be left out

Matarelli said furthermore that if technology does not contribute towards creating a safe, working environment then “we must go back to old school”. Every technology purchase must therefore pass a Failure Modes and Effects Analysis (FMEA).

Dr Elham Alateeq, Chief Nursing Officer at Makkah Healthcare Cluster, highlighted how Makkah Healthcare Cluster integrated nursing informatics, which has been a very positive experience, while there is a long way to go. She agreed with Matarelli in that nursing “should be part of IT” as solutions affect nurses at the bedside and frontline. She added that her organisation is looking into offering a certification in nursing informatics.

Dr Elham emphasised the need to consider how to make it easier for nurses when sharing “masses” of information through digital solutions, as they are usually the end users of information at the core of sending it.  

Benefits of tech in nursing

Aysha Al Mahri, Group CNO at Seha, began by saying that 2020 was the year of the nurse and midwife. She drew attention to the benefits of technology in nursing, saying that it helped her organisation identify opportunities for its utilisation from bedside to desktop. In the case of the former, it was embedded in care for patients.

Examples of its utilisation included an advanced communication system and patient monitoring – including telemedicine in the form of telenursing. Seha furthermore introduced e-learning platforms for nurses to train nurses, while a dashboard enabled staff to see where they were today and predict where they will be moving forward.

Dr Elham agreed that there were many ways technology could benefit nursing. In a clinical context, smart communications allow Makkah Healthcare Cluster to program medications, meaning that the nurse needn’t return to the room, taking care of infusion and flushing.

Recognising that nurses are unable to pick up a phone from their pockets for reasons of infection control, there are now voice-activated devices to enable calls. In addition, AI can send an alert when a physician writes an order that may result in a contraindication. All of these help to coordinate care safely. Finally, she agreed that nurses must have a key role in choosing technology -they must be involved in buying equipment from smart beds to monitors.

Lab session: COVID-19: Current issues and challenges 

This session focussed on sampling and laboratory testing for COVID-19 and what is being diagnosed and what will be done with the result? Keynote speaker Prof Mike Barer, Professor of Clinical Microbiology and Honorary Consultant Microbiologist, University of Leicester, UK, said that if these questions are not answered at the onset, it is a waste of time and efforts.

He also highlighted several challenges his team experienced in developing the capacity to provide tests. “It has been a dramatic experience as we are not used to operating at this scale. The training of the staff has been important for tasks such as labelling and sample registration. Handling reagents and consumables has also been a very challenging experience. We also sometimes had to order so much material that we didn’t have space to store it, and integration of new IT systems was also essential to operate effectively,” he shared.

Prof Barer also shared the example of “Face mask sampling”, an innovative sampling method where strips are fitted in face masks and a sample is taken over 30 minutes of wearing. Developed by Dr Alaa Al-Tae, the system has been effective in detecting TB and the process has been adapted for SARS-COV-2.

Understanding co-infection

While Dr Bandar Alosaimy, Assistant Professor, Viral Oncology and Cancer Sciences, King Fahad Medical City, discussed his study titled, ‘Influenza co-infection associated with severity and mortality in COVID-19 patients’.

According to the research, during pandemics, the detection of the novel virus may lead to underreporting of other pathogens that could be the etiological agent and contribute to the disease severity. Reportedly, during the 2009 influenza H1NI, 44.3 per cent of patients had unreported respiratory viruses.

“The study highlights the importance of screening when patients are hospitalized and during their stay. From our sample, 2/3^rds of patients who died had a co-infection. Also, diabetes was associated significantly with higher mortality.

“Given the high prevalence of influenza co-infection in the study, increased coverage of flu vaccination is warranted to mitigate the transmission of the ongoing pandemic and to reduce the hospitalization and associated mortality. Vaccination will reportedly prevent 4.4 million flu illnesses,” he highlighted.

The rise of telemedicine during COVID-19: Case studies from KSA

This session provided an in-depth look at the use and adaption of telemedicine within government, public and private hospitals in KSA.

First, Mouhamad Ghyath Jamil, Consultant Pulmonary, Critical Care and Sleep Medicine and Director Tele-ICU Program, Director Transplant ICU, King Faisal Hospital and Research Centre, KSA, shared that Saudi Arabia faces several challenges such as a shortage of ICU physicians (out of 300 hospitals, only 15 have certified intensivists), unequal distribution of health professionals, unorganised referral system, and distance between facilities.

“The government is committed to providing basic health to all KSA citizens as a fundamental right,” he said. “King Faisal Hospital started a program called ‘Same Care. Everywhere’ to provide care all over the country. The goal is to improve access, reduce the cost of travel, reduce professional isolation for rural doctors, improve quality of care, and enhance decision making between patients and specialised doctors.”

Moreover, the tele-ICU programme at King Faisal Hospital was launched in 2008. The programme is now in 45 cities around the Kingdom. The number of cases reportedly increased from 478 in 2013 to 583 in 2017. Jamil stressed that to practice telehealth effectively, hospitals need to follow country related regulatory requirements and train physicians to translate their work through the camera and ensure they feel comfortable.

Discussing John Hopkins Aramco’s telehealth programme was Dr Tamara Sunbul, Medical Director, Clinical Informatics. She said that the hospital used several innovations to manage patients during COVID-19. These included telemedicine video visits, nurse care line, telephone visits, COVID-19 care line, emotional helpline, drive-thru swab and home monitoring, medication pick-up and delivery and in-patient virtual visit.

She said: “The monitor me @ home – COVID-19 programme can be accessed on a smartphone and gives questionnaires to patients every day, and the caregiver will review those, and send escalation emails if needed. To ensure optimal performance, we had a patient satisfaction survey, a chart review and return to the clinic or EMS visit for related complaint within one week of video visit, and monthly reviews of quality.

“In fact, according to our in-house survey, 85 per cent of our patients found that their medical concern was resolved by the video visit, while 87 per cent would use video visits again.”

According to Weam Qattan, Pharmacist Informatics, National Guard – Health Affairs, KSA, telemedicine pharmacy services were quite effective during COVID-19. She said that at National Guard, pharmacists would participate in meetings virtually as well as receive online training through Microsoft Teams. This also allowed to maximise the use of technology to enhance the patient experience through the patient portal, and interactive voice response and web-based applications.

However, she said that some of the challenges included breaking staff into teams to avoid cross-infection, which led to staff shortages. There was also heightened anxiety and stress levels among pharmacists and issues in delivering medications to patients.

To conclude, Maissa Almagati, Director, Saudi Telehealth Network (STN) at the National Health Information Center (NHIC), said that the network is mandated to provide a telehealth network and create governing rules for telehealth practice. STN will be official launched in 2021.

She explained: “STN’s goal is to create a national telehealth network, which will be a centralised authority bringing multiple partners under one governance structure. It will provide standards, coordination and advocacy. It will standardise practice and provide education and training and support research and evidence-based practices. Its benefits include equality of access, increased quality and increase in non-petroleum revenues.”

STN's objectives include:

• Foundations to allow the growth of telehealth in Saudi Arabia
• Give a set of common rules applicable to everyone
• Ensure safety and quality of practices for the patients
• Create the proper approach to support telehealth activities

Radiology payment model and pricing 

Dr Yoshimi Anzai, Professor of Radiology, University of Utah, U.S., spoke at this session and gave an overview of the healthcare payment models in the U.S. and the recent pressure toward the price transparency of ambulatory services, including radiology. She further discussed how consumers (patients) balance price (cost) and quality of healthcare services.

Anzai explained: “Payment is based on volume. That needs to be changed to focus more on the value and outcomes for patients. There has been a continuous decrease in reimbursements in imaging. The rising cost of healthcare has led to double-digit growth in the insurance premium. Small employers have stopped offering health insurance or redesigned the plans with cost-sharing to employees.”

In the U.S., within the High Deductible Health Plan (HDHP), a patient has to spend over US$5000 dollars before getting any benefit from the insurance companies. Also, there is a wide price variation for imaging studies. Therefore, this year, the CMS Price Transparency Rule highlighted that hospitals must disclose standard prices of 300 “shoppable” services. These are non-urgent services that include imaging or ambulatory surgery.

The value of imaging can be demonstrated through quality and service such as accurate and timely diagnosis, high quality of imaging. “For healthcare, it is not just about price or cost, but about ensuring good quality and providing value,” she said. “Also, radiology is one of the most mentally demanding physician specialities with workload likely contributing to burnout, and this is where Artificial Intelligence/Machine Learning can play a crucial role in assisting with day-to-day operations.”