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In this Q&A, we pick the brain of Jarone Lee, MD, MPH and Shuhan He, MD, regarding their latest case study published in the New England Journal of Medicine Catalyst, Rapid Deployment of Telehealth in a Conflict Zone: Supporting the Humanitarian Needs in Ukraine.

Dr. Lee is an attending physician in Critical Care and Emergency Medicine and Dr. He is an attending physician in Emergency Medicine and works in the Laboratory of Computer Science.

What motivated you and your team to write this perspective article?

At the start of the Ukraine-Russian War of 2022, our team anticipated a need for large-scale, medical support above and beyond what the local health system, and also humanitarian aid groups will be able to deliver. COVID showed that telemedicine works and the technology exists so that access to healthcare should not be an issue in our day and age. Health Tech Without Borders (HTWB), in collaboration with the Mass General Hospital Center for Global Health, we decided to bring the global digital health and medical communities together to support the people affected by the conflict.

Our collective networks brought the full continuum of expertise in disaster telemedicine from the technology side to the medical side. This case report shows that digital delivery of healthcare through telemedicine into a conflict and disaster zone delivers high-quality and needed medical care in conflict-stricken areas, even when deployed extremely rapidly. We hope that our case study offers valuable lessons and a potential roadmap to support other humanitarian relief efforts.

What is the main goal of Health Tech Without Borders (HTWB)? 

HTWB is a global, non-profit, organization that aims to improve access to healthcare and health technology in underserved and low-resource communities globally. We bridge the gap between available health technologies and the communities that need them most, by promoting the development and deployment of innovative health technologies and increasing access to essential health services.

HTWB works to support health systems and communities to become more resilient and sustainable, particularly in times of crisis or disaster, by using technology to improve health outcomes and strengthen health systems. We remain agnostic to the technology deployed, apolitical, and non-sectarian. 

Can you expand on the execution your team followed to implement the initiative?

We implemented a telehealth support program in response to the conflict in Ukraine in three phases: Call to Action, Preparation, and Launch. We received an immense number of volunteer clinicians, as well as digital health companies wanting to support. While we wrote about distinct phases, much of the work was done in parallel. For example, meetings with the Ukrainian officials and technology companies were overlapping. It was not a clean, straightforward path and plan, but instead, messy and chaotic with a feeling of great urgency. Please take a close look at our timeline and you will see how all the steps overlapped. Ultimately, we went live with three of the companies and supported 62,806 tele-consultations by September 14. 

Did you come across any challenges while implementing telehealth solutions?

We faced severe challenges implementing telehealth in war conditions. First, we felt a time pressure with the acute and worsening need in Ukraine. Second, we looked for solutions that will work in both isolated, rural areas and urban centers. This included looking at low-bandwidth telehealth solutions that allowed for text, audio, and video consults.

Third, we collaborated with the Ministry of Health’s office to ensure compliance with local laws and credentialing. Fourth, we needed clinical volunteers that spoke Ukrainian or Russian. Fourth, security and safety were crucial concerns, as the telehealth solution had to be secure and safe for both providers and patients and be prepared to withstand military-grade cyberattacks and power outages. Lastly, we found that the most successful solution was a locally-based, ukrainian-built, telemedicine platform called Doctor Online.

Since Doctor Online was already in Ukraine and used, we had the most success with working with them as they already had local buy-in and trust of the Ukrainians already. At one point, RADA, the Parliament of Ukraine recommended Doctor Online to Ukrainians. 

Can you walk us through the process of recruiting the interdisciplinary teams that collaborated on this initiative? 

The telehealth support program was looking to recruit Ukrainian- and Russian-speaking clinicians and telehealth platform companies. A global call to action was issued and those interested were directed to an automated registration form on the website. Within two days, there was an overwhelming response with 240 clinicians registering as volunteers. This number increased to 577 clinical volunteers from 20 countries by May 11, 2022, with 54.6% of them speaking either Ukrainian or Russian. The call to action was successful with additional support from Doximity, which sent 276 U.S.-based clinicians to our roster. 

We evaluated the different technology companies to find the best fit and then paired them with volunteers. Overall, it was amazing to see the global response of volunteers and companies that came together around this crisis.  For Shuhan and I personally, this work would not have been possible without the support of Lindsey Martin and Dr. Louise Ivers and the Massachusetts General Hospital, Center for Global Health.  

What were two key variables to keep in mind when implementing telehealth solutions?

From our experience, the two critical key items to keep in mind include the following:

First, do not forget the need for a strong, local partner that understands and is integrated in the local community. They will understand the cultural nuances of how the local community adapts and uses technology.

Second, technology also remember that in 2023, technology should not be the barrier to accessing health services. We have it, know how to use it, and with the right processes, geopolitical policies, and structures, we should be able to offer healthcare to all across the globe, including here in the U.S.

How can this initiative be replicated to help other communities needing coordinated medical response? 

We hope that our publication can act as a roadmap for other teams wanting to support humanitarian disasters with telemedicine. A high level framework includes the following:

Identifying the need: Assess the communities in need of coordinated medical response, particularly those facing humanitarian crises and war conditions.

Building partnerships: Establish partnerships with local health agencies, Ministry of Health, and telehealth companies to ensure compliance with local laws and regulations.

Recruitment of volunteers: Develop an effective digital outreach plan to recruit a diverse pool of clinical volunteers, including those speaking different languages and cultures, to provide telehealth services.

Technology selection: Choose telehealth solutions that meet the high-priority requirements, such as fast deployment, compliance with privacy laws, language localization, user-friendly interfaces, multiple modalities, scalability, and strong cybersecurity measures.

Implementation: Deploy the telehealth solution rapidly, ensuring its usability and adaptability to the changing needs of the crisis and the local health care workforce.

Monitoring and evaluation: Continuously monitor and evaluate the telehealth initiative to identify areas for improvement and measure its impact on the communities in need.

Could you tell us what the next steps are in your efforts to provide Telehealth support? 

We will continue to support the crisis in Ukraine for as long as needed. The telehealth response detailed in this publication is only one of our active projects. We are agnostic to the technology and continue to look for new partners to deploy innovative solutions to humanitarian disasters not just in Ukraine, but also globally. For example, we will soon deploy a chatbot that can help teach the use of applying tourniquets in warzones. Similarly, we work with all of our partners to deliver educational content through webinars to pre-recorded videos on topics ranging from treating patients affected by chemical weapons to safe water practices after a flood.

Lastly, we talk about technology; however, some of the best solutions turn out to be lower tech. Interestingly for our telemedicine efforts in Ukraine, majority of the consults were completed via texting only within the protected platform.

Stay tuned with Jarone Lee, MD, MPH, and Shuhan He, MD, on Twitter