The Essential Role of Technology in the Public Health Battle Against COVID-19

Abstract

Technology has played an important role in responding to the novel coronavirus (SARS-CoV-2) and subsequent COVID-19 pandemic. The virus's blend of lethality and transmissibility have challenged officials and exposed critical limitations of the traditional public health apparatus. However, throughout this pandemic, technology has answered the call for a new form of public health that illustrates opportunities for enhanced agility, scale, and responsiveness. The authors share the Microsoft perspective and illustrate how technology has helped transform the public health landscape with new and refined capabilities – the efficacy and impact of which will be determined by history. Technologies like chatbot and virtualized patient care offer a mechanism to triage and distribute care at scale. Artificial intelligence and high-performance computing have accelerated research into understanding the virus and developing targeted therapeutics to treat infection and prevent transmission. New mobile contact tracing protocols that preserve patient privacy and civil liberties were developed in response to public concerns, creating new opportunities for privacy-sensitive technologies that aid efforts to prevent and control outbreaks. While much progress is still needed, the COVID-19 pandemic has highlighted technology's importance to public health security and pandemic preparedness. Future multi-stakeholder collaborations, including those with technology organizations, are needed to facilitate progress in overcoming the current pandemic, setting the stage for improved pandemic preparedness in the future. As lessons are assessed from the current pandemic, public officials should consider technology's role and continue to seek opportunities to supplement and improve on traditional approaches.

Setting the Stage

“To me, baseball has always been a reflection of life. Like life, it adjusts. It survives everything.” – Willie Stargell

In American baseball, each team has a chance to score and defend. This process alternates back-and-forth until a winner emerges. Similarly, in public health the game is performed as a series of “cat and mouse” sequences. A string of unexpected events and responses, and just when the disease is believed to be contained, new occurrences put the response on the defensive.

The world is faced with the most significant public health battle in modern day history. COVID-19 and the virus that causes it, SARS-CoV-2, have ravaged the world's population, leading the World Health Organization to declare COVID-19 to be a pandemic on March 11, 2020. Since its discovery, COVID-19 has affected more than 16.5 million people, killing more than 650,000 (as of July 28, 2020).¹

The perspective presented here is from a strange – but what has turned out to be an important – seat: technology. In this case, the authors specifically share the Microsoft perspective. Microsoft is a global enterprise company whose cloud-based technologies provide the underlying data platform for health care organizations and government agencies across the globe. As such, Microsoft has been engaged early in the course of the pandemic to provide technology assistance for those battling COVID-19. Though technology is an unconventional participant in the traditional public health sphere, it has turned out to be one of the star players, if there are any, for “Team Humanity.”

A Whole New Playing Field

“It's unbelievable how much you don't know about the game you've been playing your whole life.” – Mickey Mantle

In December of 2019, a cluster of cases of severe pneumonia of “unknown” etiology were reported in Wuhan, Hubei Province, China. The cause was later identified as a novel coronavirus labeled “severe acute respiratory syndrome coronavirus-2” (SARS-CoV-2).² The novel virus was discovered to possess a unique blend of attributes that continue to surprise and confound researchers and public health officials. Research into its transmissibility (median R₀ = 2.79; interquartile range 1.16) has suggested that it is more contagious than previous novel coronaviruses such as SARS-CoV-1.^1,3

Although small studies and case reports have shown that the viral load peaks near the onset of symptoms, levels from a patient described as “asymptomatic” were noted to be comparable to those exhibiting symptoms.^4,5 Rothe and colleagues have described these concerns as the basis for a reassessment of how SARS-CoV-2 is transmitted.⁵ Practically speaking, this meant that it was plausible – unlike with previous generations of coronaviruses – that asymptomatic human to human transmission was readily occurring, making public health guidance even more difficult to shape.^3,6

The Early Innings

“The great thing about baseball is there's a crisis every day.” – Gabe Paul

By mid-January 2020, the virus had made progress on a new front, arriving in the United States near Seattle, Washington (King County).⁷ This area would later become the epicenter for the nation's first outbreak. By the end of the month, the US Department of Health and Human Services declared the outbreak of SARS-CoV-2 to be a “public health emergency” and instituted mandatory quarantine measures for individuals who recently visited Hubei Province, China.^8,9

It was clear that growing awareness of the virus had fueled considerable public angst and uncertainty.^8,10 In the Seattle area, hospitals and call centers were inundated with patients experiencing subjective symptoms, questions, and concerns. These conditions created a paradoxical problem for patients who could not receive timely responses as many found their way to local facilities for assessment – increasing public exposure by comingling with infected patients.

An Unusual Partner: Triage Bots and Social Distancing

“Baseball is not a sport you can achieve individually.” – Curt Schilling

The impact of heightened public concern along with a readily transmissible respiratory pathogen necessitated that health systems adjust their underlying processes for screening and triage. Providence, a large multistate, multihospital health system with a significant presence in the Greater Seattle, Portland, and Los Angeles/Southern California regions, applied an artificial intelligence (AI)-based “chatbot” technology developed by Microsoft to address rising patient concerns about the virus.¹¹ The chatbot used it's natural language processing capabilities to screen patients for COVID-19 symptoms and/or exposures by asking a series of questions based on the latest Centers for Disease Control & Prevention (CDC) guidelines. Patients with symptoms and/or exposures were subsequently directed to Providence's telehealth portal for clinical evaluation and possible testing. The bot was facilitating successful and efficient population-level care coordination. This enabled high-risk and/or symptomatic patients to receive a timely remote clinical evaluation, without increasing the risk of virus transmission to other patients or extending the wait times for those with symptoms.

Anecdotally, users reported overwhelmingly positive and immediate results. One health system reported up to a 40% reduction in call volumes following introduction of the bot and triage system. This framework was successfully replicated at other health systems and government agencies including the CDC – each with differing criteria and variations of handoff mechanisms to fit unique infrastructure needs. As of mid-July 2020, there are more than 2100 COVID-19 health care bots using this framework, reaching more than 43.5 million users across 26 countries.

Surviving the Onslaught: Preserving Resources and Protecting Frontline Workers

“One of the beautiful things about baseball is that every once in a while you come into a situation where you want to, and where you have to, reach down and prove something.” – Nolan Ryan

Despite community efforts to control the spread of the infection and “flatten the curve,” the widespread nature and aggressiveness of the virus began to stretch the limits of what hospitals alone could handle. Intensive care unit (ICU) bed capacity, personal protective equipment (PPE), ventilators, and clinicians with expertise in critical care were all in high demand and limited supply. Early data showed that between 4.9%-11.5% of US hospitalized COVID-19 patients required critical care escalation.¹² Hospitals were faced with the urgent need to manage more patients with fewer resources, while not sacrificing patient or provider safety.

To address these limitations and to extend ICU capabilities to underserved areas, Oregon Health & Sciences University, a large academic tertiary care medical system, implemented a virtual ICU. The platform, based on the GE Healthcare Mural technology, integrated several disparate critical care data sources (eg, electronic medical record, telemetry, ventilator, infusion management) into a single platform, allowing for the remote management of critical care patients at scale.¹³ In practice, this platform provided the ability to safely monitor a multisite hundred-bed ICU infrastructure with a handful of intensivists and nurses (2 and 3, respectively). The platform provided a mechanism to disseminate not only technology, but also critical care expertise to areas where such capabilities were necessary and lacking.

In a further distributive concept, parts of the National Health Service in the United Kingdom have employed the use of Microsoft's HoloLens 2 mixed-reality headset with “Remote Assist.” Rather than several clinicians entering the room of a SARS-CoV-2 positive patient at different times, only one would enter, equipped with a HoloLens headset. The broader clinical team would join virtually, through other (non-HoloLens) computer devices. This approach reduced the number of touch points between SARS-CoV-2 positive patients and providers, and delivered information to many providers simultaneously, while exposing only one.^14,15

Managing the Effort: Sustainable Virtual Clinics

“Baseball is almost the only orderly thing in a very unorderly world. If you get three strikes, even the best lawyer in the world can't get you off.” – Bill Veeck

While patient influx kept key hospital resources at or near capacity, clinics and ambulatory practices were shuttered. Patients were discouraged from attending clinic visits and many hospitals and health systems closed outpatient clinics and ambulatory practices altogether (some voluntarily, others by mandate). Paradoxically, as hospital capacity was at its highest, systems were laying off and reducing pay for staff.¹⁶ This exposed yet another critical weakness in our health care infrastructure and underscored the reality that hospitals and health systems are often large regional economic drivers.¹⁷

It was clear that hospitals and payment systems needed to rapidly adapt to a new model of care, one that could be delivered virtually. Telemedicine became the primary mechanism for patients to continue to see their health care providers for non-emergent concerns. This acceleration toward telemedicine was facilitated by federal action and subsidization through the Coronavirus Aid Relief and Economic Security Act (CARES Act), which provided funds through the Federal Communications Commission's telehealth grants program.¹⁸ Additional federal actions to lift technology and reimbursement restrictions previously placed on virtual interventions further paved the path toward sustainability.¹⁹ These reimbursement and regulatory changes provided hospital systems the impetus to establish and implement virtual care programs at scale.

St. Luke's University Health Network (SLUHN) provided a prime example of how hospitals were dramatically shifting their ambulatory practices toward a “virtual care” model. SLUHN, a large regional health system encompassing multiple counties across 2 states, introduced and adopted virtual care using Microsoft Teams as its virtual care platform. The platform enabled the scheduling and evaluation of thousands of patients daily.^20,21 In a matter of days, the health system trained thousands of staff and providers to conduct, document, and schedule virtual visits – fundamentally altering its health care delivery apparatus.

Attempting to Mount a Comeback: AI-Based Innovations

“Baseball is ninety percent mental and the other half is physical.” – Yogi Berra

As hospitals directed sustainability efforts toward virtual care, researchers continued to investigate avenues for therapeutics and potential vaccine targets. The clinical experience from patients with severe COVID-19 demonstrated that immune-mediated inflammatory mechanisms were causing collateral damage to the body.^22
–24 To better understand this process, Adaptive Biotechnologies Corp., in collaboration with Microsoft, began applying AI to map T cell receptors to SARS-CoV-2 viral antigens to create a clear picture of how the immune system responds to COVID-19. This work led to the ImmuneRACE Study (Immune Response Action to COVID-19 Events), a population-level investigation with the objective of developing T cell-based COVID-19 diagnostics to address unmet needs in testing.²⁵

On a separate front, research has started to evaluate the clinical benefit of convalescent plasma (CP). CP is a treatment approach that involves infusing patients with plasma from those who have recovered from COVID-19. It has been shown to be safe and effective for patients with SARS-CoV-1, MERS, and H1N1 Influenza, and early evidence has suggested that CP may be effective for severe SARS-CoV-2 infection by inhibiting the viral infection while downregulating proinflammatory responses.^26

–29

Although early results in using CP for COVID-19 have showed promise, randomized controlled trials are needed to prove its efficacy.²⁶ The rate-limiting step has been the availability of plasma from surviving patients. To address the need for more CP donors, a large-scale coalition between academic medical institutions, plasma centers, national blood organizations, and several other participants launched The Fight Is in Us campaign.³⁰ This coalition has employed the use of Microsoft's AI-based bot framework to serve as a front-end screening tool for plasma donation.

While efforts directed at treatment mechanisms required extensive engagement, endeavors to uncover the virus's structure required another technological tool: high-performance computing. Following efforts to uncover the structure of the SARS-CoV-2 trimeric spike glycoprotein by Wrapp et al, investigators attempted the progressive step of understanding the protein's molecular dynamics – hoping to elucidate the viral spike-receptor interaction at the atomic level.^31,32 To accomplish this analysis in days rather than months required 24 petaflops of graphics processing units dedicated to performing complex simulations.³² The result was a better understanding of how SARS-CoV-2 binds to the angiotensin-converting enzyme 2 receptor and the atomic and molecular forces that drive that interaction. The analysis, while still underway, may hold valuable information for therapeutic and vaccine development.

Technology's Role in Returning to Work

“If the people don't wanna come out to the ballpark, nobody's gonna stop 'em.” – Yogi Berra

As the rate of infections began to slow, government officials shifted their focus toward reopening the economy. Officials' challenge would be relaxing restrictions, while not simultaneously increasing the possibility of a “second-wave” of infections. Coordinated efforts between municipalities, employers, public health officials, health care organizations, and the private sector would be essential to meet this task.

An initiative was undertaken by United Health Group (UHG), in collaboration with Microsoft and major lab testing sites, to help facilitate a safer return to the workplace with reasonable safeguards to reduce the risk of COVID-19 transmission and infection.³³ As part of this program, employers can have employees log in daily to a software application, ProtectWell, to answer a series of COVID-19 screening questions based on the latest CDC guidelines. Symptomatic individuals can subsequently be directed to a clinical resource for further evaluation and/or testing, at an employer's discretion. However, it should be noted that since proactive symptom screening does not identify asymptomatic and presymptomatic individuals, this program should not be implemented in isolation. Rather, it was designed to be supplemented with other interventions, such as policies to promote/mandate social distancing, handwashing, and mask wearing, protocols for disinfecting surfaces, facility adjustments to address ventilation, and processes to activate contact tracing.

To help close gaps left by self-attestation solutions, Microsoft developed an end-to-end Return to the Workplace tool on its Power Platform.³⁴ The solution encompasses “location readiness” and “management” in addition to daily employee safety screens. The tool offers enhanced readiness dashboards that provide managers with oversight over key metrics such as local infection rates and governmental policies that could affect their business.³⁴ Because this knowledge would be incomplete without supervision over local facilities, the workflow also provides dashboard visualizations for occupancy metrics, safety supply levels, and procedural best practices.

Promoting Teamwork and Camaraderie

“The way a team plays as a whole determines its success. You may have the greatest bunch of individual stars in the world, but if they don't play together, the club won't be worth a dime.” – Babe Ruth

Unfortunately, efforts to reopen have slowed because of the recent resurgence of viral infections. Issues faced early in the pandemic relating to shortages of test kits, PPE, bed capacity, and ventilators have resurfaced, leading to a renewed focus on resource allocation, prioritization, and effective supply-chain processes.

The COVID-19 Healthcare Coalition, founded by The MITRE Corporation, included health care organizations, nonprofits, and technology companies. The coalition utilized its unique collection of expertise to create and compile resources to be used and shared throughout the nation. Organizations established peer-to-peer exchanges by using and promoting established interoperability standards, dashboards for information sharing, knowledge management, and predictive models that forecasted demand for scarce resources.³⁵ The coalition has effectively developed a foundation with which to address market inefficiencies – highlighting the value of technology platforms in allowing for voluntary cooperation and better teamwork between organizations.

Because of the variable risk of COVID-19 mortality associated with age and comorbid conditions, approaches to data sharing and interoperability have become essential.^36
–38 Population-based models such as those described by Morden et al highlight mortality differences across US regions (based on comorbidities and age) in a manner able to inform policy decisions at a refined level.³⁹ When used in combination with information/resource platforms (such as those developed by MITRE) these models can facilitate better preparations for disease outbreaks. The shift from using case numbers to using “risk” – as determined by the specific pathogen in question – is necessary to guide disease mitigation and resource allocation decisions prior to disease outbreak, rather than in the midst of one.

An Ol’ Dog, with a Few New Tricks: Contact Tracing with Privacy Sensitive Protocols

“We've got to use every piece of data and piece of information, and hopefully that will help us be accurate with our player evaluation. For us, that's our lifeblood.” – Billy Beane

Planning and preparation are immensely important, but mitigation tools and strategies also are required to contain infection spread. Two important public health tools that can potentially contain outbreaks are exposure notifications and contact tracing. Exposure notifications can let you know if you've been in close proximity to someone infected with COVID-19, and contact tracing helps identify and locate individuals who have been in close contact with an infected person and who now may potentially be infected as well. The term contact tracing has come to encompass a broad range of solutions, from manual contact tracing performed by public health departments and trained professionals to automated systems that involve proximity awareness.

Researchers have developed and published “privacy-sensitive protocols and mechanisms for mobile contact tracing” that strives to balance the need to protect civil liberties, while still retaining the ability to contact trace. The group has protocolized a third-party free approach that excludes trusted third parties (TTPs) from the process of aggregating data.⁴⁰ Their approach allows users to retain privacy through the generation of hashed IDs (pseudonyms) that are broadcast and rotated frequently and stored locally. If a user tests positive, he/she can voluntarily choose to publish that information on a public server, which allows for the reconstruction of those broadcast signals and allows other users to cross-reference their exposures.⁴⁰

Using this protocol, researchers from the University of Washington along with a set of volunteers developed CovidSafe, an application that performs user-controlled contact tracing without a TTP. The application allows for symptom tracking functionality that prepares users for a case management interview with a public health official (contact tracer) and improves the accuracy of their responses through local aggregation on their device.⁴¹ This “opt-in” approach bridges the traditional public health apparatus with a technology that improves accuracy and efficiency of reporting, while not forgoing the rights of users to their own data.⁴⁰

Major mobile operating systems, iOS and Android, jointly announced in April 2020 that they would release a set of application programing interfaces (APIs) that utilize Bluetooth signals to perform mobile contact tracing.⁴² The “Exposure Notification” APIs allow for proximity-based contact tracing while preserving the privacy of end users. The APIs contain safeguards to ensure that location data are not collected, and identities are not shared with users or technology companies. This serious effort toward maintaining privacy provides a thoughtful and sustainable opt-in approach that could prove to be impactful on the public health response to COVID-19.

Far from the Final Score

“Every day is a new opportunity. You can build on yesterday's success or put its failures behind and start over again. That's the way life is, with a new game every day, and that's the way baseball is.” – Bullet Bob Feller

As lessons from the current pandemic are assessed to both enhance current actions and inform future pandemic preparedness, it is important that public health officials consider the following technologies as part of a comprehensive response:

Chatbot Framework: Early in the pandemic, hospital systems became overwhelmed with capacity and inquiries. Screening and triage bots became an important tool to perform these activities at scale. Ultimately, the technology freed hospital capacity, reduced call center wait times, and provided an easily accessible way for patients to receive actionable recommendations. In a similar capacity, chatbot technology provided an effective and efficient means to recruit subjects for COVID-19 research studies and donation efforts.

Virtualized Patient Care: During the pandemic, ambulatory care was delivered virtually, for the most part. This was predominantly in the form of telehealth visits. Looking forward, it is likely that virtual care will be adopted in other forms such as active and passive remote patient monitoring, virtual rounding, and virtual ICU care.

AI and Performance Computing: Technology, and in particular AI and machine learning, performed on large supercomputers, has the potential to greatly accelerate the pace of drug and vaccine discovery.

Data Platforms: Central to the ability to manage this and future pandemics is the development of open, secure, and scalable data platforms. These platforms should enable peer-to-peer exchange of information related to the virus and its impact on clinical parameters, resource availability, utilization, and access to other relevant data sets. Platforms should apply commonly agreed-upon interoperability standards and be available to researchers and clinicians around the world.

Contact Tracing and Associated Tools: Manual contact tracing is a well-established method for managing outbreaks. Technologies can help facilitate the management of data, coordination with other contact tracers, and help infected individuals recall who and when they met others. Proximity-awareness technologies (eg, Bluetooth low energy, global positioning system software) also can be helpful for mobile contact tracing, but require that safeguards be firmly applied to protect privacy and civil liberties.

The virus's unique blend of lethality and transmissibility have made containment efforts challenging and public health measures difficult to shape. Until a vaccine is developed, the battle will persist. Technology organizations and public health agencies should continue to seek opportunities to supplement traditional approaches, improve tools and workflows, and enhance interoperability. The result will be a more thoughtful and coordinated response to current and future public health emergencies.

Technology can be helpful in addressing emerging needs that arise from a pandemic. However, its proper use requires careful governance with a focus on finding the balance between public health, social needs, economic recovery, and individual rights. While public health officials continue to adapt their responses to address evolving challenges posed by COVID-19, technology, and all the resources it brings to bear, stands ready to meet the challenge.

Footnotes

Author Disclosure Statement

Drs. Rhew, Uohara, and Weinstein are employed by the Microsoft Corporation.

Funding Information

No funding was received for this article.

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