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As a result of the COVID-19 pandemic, providing health care while maintaining social distancing has resulted in the need to provide care remotely, support quarantined or isolated individuals, monitor infected individuals and their close contacts, as well as disseminate accurate information regarding COVID-19 to the public. This has led to an unprecedented rapid expansion of digital tools to provide digitized virtual care globally, especially mobile phone–facilitated health interventions, called mHealth. To help keep abreast of different mHealth and virtual care technologies being used internationally to facilitate patient care and public health during the COVID-19 pandemic, we carried out a rapid investigation of solutions being deployed and considered in 4 countries.
The aim of this paper was to describe mHealth and the digital and contact tracing technologies being used in the health care management of the COVID-19 pandemic among 2 high-income and 2 low-middle income countries.
We compared virtual care interventions used for COVID-19 management among 2 high-income countries (the United Kingdom and Canada) and 2 low-middle income (Kenya and Rwanda) countries. We focused on interventions used to facilitate patient care and public health. Information regarding specific virtual care technologies was procured from a variety of resources including gray literature, government and health organization websites, and coauthors’ personal experiences as implementers of COVID-19 virtual care strategies. Search engine queries were performed to find health information that would be easily accessible to the general public, with keywords including “COVID-19,” “contact-tracing,” “tool-kit,” “telehealth,” and “virtual care,” in conjunction with corresponding national health authorities.
We identified a variety of technologies in Canada, the United Kingdom, Rwanda, and Kenya being used for patient care and public health. These countries are using both video and text message–based platforms to facilitate communication with health care providers (eg, WelTel and Zoom). Nationally developed contact tracing apps are provided free to the public, with most of them using Bluetooth-based technology. We identified that often multiple complimentary technologies are being utilized for different aspects of patient care and public health with the common purpose to disseminate information safely. There was a negligible difference among the types of technologies used in both high-income and low-middle income countries, although the latter implemented virtual care interventions earlier during the pandemic’s first wave, which may account for their effective response.
Virtual care and mHealth technologies have evolved rapidly as a tool for health care support for both patient care and public health. It is evident that, on an international level, a variety of mHealth and virtual care interventions, often in combination, are required to be able to address patient care and public health concerns during the COVID-19 pandemic, independent of a country’s economic standing.
Pandemics pose a considerable threat to global health security and place an enormous strain on health care systems. The current COVID-19 pandemic has already claimed over 2.5 million lives, with over 112 million reported cases as of February 26, 2020 [
In this landscape review—discussing the technology developed and used for COVID-19 management in Canada, the United Kingdom, Rwanda, and Kenya—we define virtual care as the remote delivery of health care using technology. This includes technology that facilitates video communication and text messaging between patients and their health care providers (HCPs). This broad category encompasses eHealth, telehealth, and clinical decision support tools in the field. Virtual care tools may provide care for patients from the time that they decide to access the health care system up until the end of their care experience, facilitating HCP-patient interactions and care throughout the entirety of the patient journey with minimal in-person interactions. Thus, virtual care strategies may improve access to care and quality of care, reduce health care costs, and empower patients to care for themselves while providing a medium through which they can comfortably request reliable information or advice [
mHealth has been defined by the World Health Organization as “the use of mobile and wireless technologies to support the achievement of health objectives” [
In this paper, we explore the current virtual care strategies for both patient care and case contact tracing in 4 focus countries: Canada, the United Kingdom, Rwanda, and Kenya. These countries were selected because our research group received an urgent Canadian federal research funding to deploy and study an mHealth intervention associated with our research group and established partners in those countries related to other pandemics (HIV and tuberculosis).
The purpose of this review was to outline and summarize the landscape of mHealth and virtual care in 4 countries (2 low-middle income and 2 high income) that have been purported to be used or enhanced specifically due to the COVID-19 pandemic and to serve as examples from diverse regions: Canada, the United Kingdom, Rwanda, and Kenya.
The information for this landscape review was procured by accessing a variety of resources including peer-reviewed literature, gray literature (such as press releases), government and health organization websites, and firsthand experiences of this article’s authors and collaborators in Canada, the United Kingdom, Rwanda, and Kenya. We evaluated 2 high-income countries, classified by the World Bank as having a gross national income of more than US $12,535 per capita (Canada and the United Kingdom), and 2 lower-middle income countries, classified as having a gross national income of less than US $4045 per capita (Rwanda and Kenya) [
In Canada, several virtual care platforms with videoconferencing capabilities have existed and new ones emerged to assist physicians seeing patients remotely with some platforms that are offering their technology for free to assist with patient care during the COVID-19 pandemic. In Canadian provinces such as Nova Scotia and Prince Edward Island, health care websites highly recommend using Zoom for health care while other provincial health care sites do not specify a platform. The list of virtual care technologies is updated regularly with new platforms and features being developed as the COVID-19 situation evolves. In each province, virtual care “toolkits” have been developed to assist physicians when providing care for patients remotely (
The federal government developed a nationwide contact tracing app called COVID Alert. It was developed in partnership with Shopify, Blackberry, and the Canadian Digital Service and was launched on July 31, 2020 [
The Government of Canada has also provided a variety COVID-19 resources to assist in evidence-based decision-making on the Canadian Institutes of Health Research website [
In the United Kingdom, many common in-person medical communications have transitioned into virtual communications. For example, testing centers are booking COVID-19 tests online, and care homes are arranging all their regular resident and staff testing virtually. For those who are self-isolating, the national health service (NHS) has provided information to local authority helplines if self-isolating individuals require practical or social support, support for someone a patient cares for, and financial support. The NHS is also supporting a virtual clinic service powered by medio.link, which is video link–based [
With regards to other tracking options, the United Kingdom is also working on an app to track COVID-19 patients, which has completed trials on the Isle of Wight. Initially, the release of the app saw low download rates, with The Guardian reporting only 10% of the population in both England and Wales [
Rwanda utilizes several existing virtual and mHealth solutions in its ecosystem. To assist in monitoring and supporting patients (cases and contacts) directly under home-based isolation and quarantine, they rapidly deployed the WelTel mHealth platform, which they had previously been using to support patients attending HIV clinics for adherence support. WelTel is an integrated virtual care and 2-way patient engagement digital health intervention that acts as a hub for HCPs to communicate with their patients. As it is primarily used for SMS-based text messaging, patients do not need a smartphone or internet access in order to communicate with their HCPs. WelTel was launched in the Rwanda national emergency operations center for the COVID-19 response in mid-March, within a week of identifying the opportunity of using SMS to reach patients, as previous technologies to reach out to Ebola contacts that were online had limited uptake due to accessibility of the internet. Currently, the WelTel platform is being used for virtual home-based care of COVID-19 patients who are asymptomatic. Above 80% of people who tested COVID-19 positive in Rwanda are asymptomatic. This platform enables the daily follow-up of patients at their home as well as their contacts. The program was rolled out, and Rwandan COVID-19 response teams were trained. The WelTel platform offers several options to interact with the patient through SMS chatting, email, or video call. In addition, at the beginning of the outbreak, WelTel was used to communicate COVID-19 testing results, mainly with those who tested negative. Furthermore, Rwanda uses the DHIS2 (District Health Information Software 2) tracker to record everyone having a COVID-19 test, and it is linked to laboratory systems that push results to the patient’s mobile number and email. The data gathered through Weltel are stored at the Rwanda National Data Center. Rwanda has implemented an additional mHealth technology to help its citizens access HCPs. For example, robots have been implemented in health care centers to collect important patient information including temperature screenings and vital readings, to deliver video messages, and to instruct people to put on a mask. Most importantly, robots play a key role in reducing the exposure time of health care professionals with COVID-19 patients [
Kenya has a few different resources for virtual care using mHealth technology. mDaktari is providing virtual access to primary care via teleconsulting. Patients can access virtual care either through the app or web account, choose an available physician from a directory, or consult an expert using online video or voice calling [
There is a national mobile technology–focused group, called mHealth Kenya, which has developed a National Emergency System meant to capture, report, and view emerging epidemics. During COVID-19, the app Jitenge was developed, which allows registered users, either through self-registration or by Ministry of Health officials, to receive daily reminders and prompts to report their health status. The Jitenge system (
With regards to contact tracing COVID-19 patients, an app is available called KoviTrace. It was developed at Mount Kenya University, and it uses a geo-sensing technology to track a patient’s location over a 14-day period when they test positive for COVID-19. If an individual is in close proximity to a COVID-19–positive patient, SMS messages are sent with instructions, and it contacts a COVID-19 response team, depending on the contact’s location [
Schematic of the basic functionality of Jitenge on how it works with individuals in quarantine. Image used with permission provided by mHealth Kenya.
With an urgent, international emphasis on minimizing in-person communication, the development and implementation of mHealth technologies has undoubtedly increased in response to the current COVID-19 pandemic. It is evident that a wide variety of mHealth and virtual care tools with parallel functionality are being used in different sectors of health care throughout North America, Europe, and Africa. The key advantage that these technologies have is that they facilitate both the dissemination and collection of important health information while maintaining safe physical distancing. The most consistently used method of patient care involves teleconferencing and videoconferencing where patients are able to directly communicate with their health care practitioner. A few major players being used internationally include WelTel and Babylon Health, both emphasizing the importance of expedient and accurate delivery of health information and care.
Virtual care tools that facilitate direct communication with HCPs provide a secure way to disseminate or renew prescriptions and provide referrals, common patient needs that are easily addressed without the need for an in-person visit. There is also the added advantage of conversations between patients and HCPs being accessible by either party, especially in text message–based interactions where having access to prior conversations can help with care by verifying details. Traditionally, access to a patient’s health information is held by their HCP; however, being able to refer to conversations is not only useful for the patients, but also for other HCPs to understand what was discussed with the patient. This feature is especially useful for patients communicating with a clinic where different staff are responsible for monitoring a patient’s care.
Public health is also of primary concern, and all the countries discussed in this review are investing resources into national case contact tracing technologies to be able to track COVID-19 infections among their populations. A combination of locally developed smartphone apps and government-implemented technology is being used in order to understand, and hopefully mitigate, the spread of COVID-19. Although a variety of different technologies is being used, there is an emphasis to ensure that those within the vicinity of potentially COVID-19–positive patients are notified and asked to self-isolate. Encouraging self-isolation is occurring at an international level, although regular contact with those in self-isolation varies among the countries we looked at. In general, contact tracing apps can provide more information than just COVID-19–proximity notifications. Data are generated whenever a COVID-19 notification is presented on an individual’s phone, including how many individuals are in the proximity of a positive case as well as when the notification occurred. This information can be useful in figuring out trends of when higher instances of potential exposures are happening most often. Due to the nature of most apps, this information is available immediately and can be used to provide useful information for health authorities to inform decision-makers about how best to mitigate transmission. Moreover, depending on the location privacy of contact-tracing apps, it could be possible to identify zones where transmissions frequently occur. This information can also be stored for future reference.
The type of technology used to manage COVID-19 between the high-income and low-middle income countries was similar; however, Kenya and Rwanda had a more comprehensive approach when using novel technology. Studies evaluating the technical efficiency and overall performance of national COVID-19 management have consistently criticized the United Kingdom and Canada as underperforming despite having access to exceptional resources [
The implementation and utilization of mHealth and virtual care interventions have grown rapidly during the COVID-19 pandemic as a result of maintaining social distancing measures while providing much needed health care. Although it is not yet known which interventions are the most effective, it is evident that there is consistency with direct virtual health care provider and patient interactions as well as with case contact tracing to notify individuals in efforts to prevent the spread of COVID-19. Studies evaluating patients’ satisfaction with virtual care and mHealth technologies, both before and during COVID-19, have been overwhelmingly positive, strengthening the likelihood that these interventions will become integrated as a regular component of patient care [
Summary of online resources available to the public to access virtual care and public health resources in Canada, the United Kingdom, Rwanda, and Kenya, during the initial wave of COVID-19.
District Health Information Software
health care provider
mobile health
national health service
We would like to thank Charles Kamau from mHealth Kenya and Martin Thuranira from Samburu County Director of Health. This project was funded by the Canadian Institute of Health Research, Grand Challenges Canada.
RL has a financial and professional interest in WelTel Incorporated, a company for which he is chief scientific officer. WelTel Incorporated is subcontracted to provide the SMS software platform and maintenance for the project. WelTel Incorporated is a company founded by RL’s wife. The company develops software and related technologies to support mHealth through SMS-based, patient engagement platforms. WelTel Incorporated has been contracted by this research project to provide the software and the implementation service. As chief scientific officer of WelTel Incorporated, RL advises on the research and development aspects of WelTel and communicates with the scientific and customer communities concerning the support and utility of the software.