POLICY BRIEF

published: 02 November 2020

doi: 10.3389/fpubh.2020.556789

Designing Futuristic Telemedicine

Using Artificial Intelligence and
Robotics in the COVID-19 Era
Sonu Bhaskar 1,2*, Sian Bradley 1,3 , Sateesh Sakhamuri 1,4 , Sebastian Moguilner 1,5 ,
Vijay Kumar Chattu 1,6 , Shawna Pandya 1,7 , Starr Schroeder 1,8 , Daniel Ray 1,9 and
Maciej Banach 1,10,11
1
Pandemic Health System REsilience PROGRAM (REPROGRAM) Consortium, REPROGRAM Telemedicine Study Group,
Sydney, NSW, Australia, 2 Neurovascular Imaging Laboratory & NSW Brain Clot Bank, Department of Neurology, Liverpool
Hospital and South Western Sydney Local Health District, Ingham Institute for Applied Medical Research, The University of
New South Wales, Sydney, NSW, Australia, 3 The University of New South Wales (UNSW) Medicine Sydney, South West
Sydney Clinical School, Sydney, NSW, Australia, 4 The University of the West Indies, St. Augustine, Trinidad and Tobago,
5
Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland, 6 Department of Medicine, St. Michael’s Hospital,
University of Toronto, Toronto, ON, Canada, 7 Alberta Health Services and Project PoSSUM, University of Alberta, Edmonton,
AB, Canada, 8 Penn Medicine Lancaster General Hospital and Project PoSSUM, Lancaster, PA, United States, 9 Farr Institute
of Health Informatics, University College London (UCL) & NHS Foundation Trust, Birmingham, United Kingdom, 10 Polish
Mother’s Memorial Hospital Research Institute (PMMHRI) in Lodz, Cardiovascular Research Centre, University of Zielona
Gora, Zielona Gora, Poland, 11 Department of Hypertension, Medical University of Lodz, Łódź, Poland

Edited by:
Technological innovations such as artificial intelligence and robotics may be of potential
Alberto Eugenio Tozzi, use in telemedicine and in building capacity to respond to future pandemics beyond
Bambino Gesù Children Hospital the current COVID-19 era. Our international consortium of interdisciplinary experts in
(IRCCS), Italy
clinical medicine, health policy, and telemedicine have identified gaps in uptake and
Reviewed by:
Rukhsana Ahmed, implementation of telemedicine or telehealth across geographics and medical specialties.
University at Albany, United States This paper discusses various artificial intelligence and robotics-assisted telemedicine or
Charles Doarn,
University of Cincinnati, United States
telehealth applications during COVID-19 and presents an alternative artificial intelligence
*Correspondence:
assisted telemedicine framework to accelerate the rapid deployment of telemedicine and
Sonu Bhaskar improve access to quality and cost-effective healthcare. We postulate that the artificial
Sonu.Bhaskar@health.nsw.gov.au intelligence assisted telemedicine framework would be indispensable in creating futuristic
and resilient health systems that can support communities amidst pandemics.
Specialty section:
This article was submitted to Keywords: telehealth, digital medicine, pandemic (COVID-19), robotics, telemedicine, artificial intelligence,
Digital Public Health, coronavirus disease 2019 (COVID-19)
a section of the journal
Frontiers in Public Health

Received: 30 April 2020 INTRODUCTION

Accepted: 07 October 2020
Published: 02 November 2020 Telemedicine or telehealth is the use of medical information to improve patient’s health (1, 2).
Citation: Reorganization in healthcare delivery, financing, and advancement in electronic health records and
Bhaskar S, Bradley S, Sakhamuri S, clinical decision support systems can accelerate the telehealth adoption into healthcare delivery (2).
Moguilner S, Chattu VK, Pandya S, In this context, artificial intelligence (AI) and robotic technologies can play an important role in the
Schroeder S, Ray D and Banach M
use and delivery of telemedicine during coronavirus disease (COVID-19) and the post-pandemic
(2020) Designing Futuristic
Telemedicine Using Artificial
world (3–10). Our previous two reports have identified gaps in telemedicine across geographics
Intelligence and Robotics in the and medical specialties (11, 12). The current paper is a call for the integration of AI, robotics, and
COVID-19 Era. telemedicine with an organizational framework powered by AI to accelerate healthcare delivery
Front. Public Health 8:556789. and improve access to healthcare in the context of public health preparedness and response during
doi: 10.3389/fpubh.2020.556789 outbreaks or public health emergencies such as COVID-19.

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Bhaskar et al. AI and Robotics in COVID-19

ARTIFICIAL INTELLIGENCE ASSISTED processes that occur in the subconscious, such as intuition,
TELEMEDICINE insight, subjective evaluation, and the analyzation of ambiguous
or qualitative data (30). Jarrahi illustrates the benefit of the
Diagnosis is a multidisciplinary process that may involve symbiotic use of AI combined with a human in the loop by
multimodal testing such as clinical, imaging, blood, and showing the statistically significant reduction of error (85%) in
genetic markers. Moreover, discipline-specific testing such as detecting cancer in images of lymph nodes when compared to AI
neuropsychological tests may be needed, for example, to obtain or human interpretation alone (30).
comprehensive mental health assessments (13). In a telemedicine Telemedicine has provided a critical patient continuity
framework, some of these testing may be unavailable, while pathway in times of disruption in health service during COVID-
others may be cost-prohibitive. To address this complex 19 (10–12). This also helps protect healthcare facilities and
multivariate problem in finding an optimal diagnostic protocol, minimize risks to health workers during pandemics, which/who
innovative data-driven artificial intelligence (AI) algorithms are increasingly under pressure (31–33). Telemedicine has the
may offer a solution by applying machine learning to large potential to minimize the economic impact on society and
datasets of disease populations (14, 15). These models can healthcare services. Quarantined doctors can provide these
learn directly from the data without any prior statistical services in medical institutions with remote access or care
modeling, thus producing more objective results while focusing via telecommunications directly to the consumer, freeing other
on prediction generalizability for diagnostic purposes on diverse doctors to provide immediate assistance to more needy patients.
populations. Since the COVID-19 outbreak, international efforts Teleconsultations allow doctors to evaluate patients, detect signs
toward COVID-19 forecasting, prevention and treatment are of infection, and quickly and easily document patients who might
underway using data-driven tools and pooled datasets (16). be at higher risk of illness (34). Telemedicine solutions work
Moreover, the ML model features an important analysis that promptly, filling out insurance documents, which allows doctors
enables the search for more cost-effective protocols (17). to devote more time to treating patients. Clinics are expanding
Unlike traditional statistical hypothesis testing, data-driven their telehealth services to screen patients for COVID-19, which
computational approaches can test for synergistic variable is critical to identifying patients and speeding up medical
combinations and redundant feature elimination enabling care, as well as limiting public exposure (11, 32). Bundling
more effective diagnosis under the specific constraints of of various specialties such as teleradiology, tele-oncology, and
telemedicine (18). telepathology is another area of crucial consideration to facilitate
Analysis by Collier et al. found that the use of AI applications comprehensive management (35).
could result in ∼$150 billion in saved healthcare costs annually Further upstream in the telemedical framework, it is
by 2026 in the United States (19). According to Wahl et al., important to consider the integration of educational models for
the ubiquitous use of smartphones, combined with growing physicians and trainees, and particularly how these technologies
investments in supporting technologies (e.g., mHealth, electronic may address the issues of connecting distributed learners
medical record (EMR), and cloud computing), provide ample (particularly in the era of a pandemic) (36), and providing high-
opportunities to use AI applications to improve public health quality educating, training, and just-in-time training, in a way
outcomes in low-income country settings (20). Rapidly increased that is trusted, safe, and replicates the quality of “in-person”
usage of electronic gadgets accelerates digital shifts in healthcare training, particularly when it comes to surgical procedures
that appear to become essential in sharing information between (37, 38). Immersive technologies such as virtual reality and
and within medical workers and patients (21). augmented reality could enhance capabilities for collaboration,
AI exhibits clear advantages over humans in analytical both amongst learners and physicians in practice (39). Lastly,
reasoning and problem solving (especially when large amounts as has been mentioned elsewhere in this paper, immersive
of data are involved) and can effectively address the limitations of and telemedical technologies, whether used for consultations,
human function (22). However, the use of AI in healthcare must treatments, and diagnostics, or education, must be resilient and
consider or mitigate the potential loss of vital physician skills if capable of maintaining at least some degree of functionality even
AI is over-utilized (17). Furthermore, rigid algorithm protocols in the absence of internet or network connectivity (40). This is
and decision-making trees are subject to the consequences of relevant to areas where broadband internet access is poor which
the inability of AI to fully take in and interpret contextual limits the effective implementation of these technologies (41).
information or delineate between relevant vs. non-relevant
informational input even when employing deep machine
learning (23). Contingencies are the norm in healthcare, and ROBOTICS ASSISTED TELEMEDICINE
the human skill required to navigate and manage this off-
nominal, or unpredictable situations must be carefully weighed Robotics is a promising cutting-edge tool in telemedicine that
against the advantages of using AI technology (23–28). User has potential applications in transforming physical exam and
interface and data input methods are critical as voice recognition clinical care, as well as monitoring patients in remote conditions
and interpretation is a major challenge of AI utilization (29). (42, 43). Such experience with the Ebola outbreak and with
Generalized challenges to utilizing AI in healthcare are created the COVID-19 pandemic has revealed a wide range of robotic
by the fact that many cares and treatment decisions, especially in uses and telemedicine options (43, 44). Robotics can be used in
emergent and time-restricted scenarios hinge on human thought outbreaks of infections to minimize further exposure (45, 46):

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Bhaskar et al. AI and Robotics in COVID-19

FIGURE 1 | Traditional organizational frameworks such as (A) Decentralized, (B) Centralized, (C) Hub-and-spoke, (D) Dandelion, and (E) Holistic are shown.

for disinfection, delivery of drugs and food, measuring vital patient and operator, network issues, and communication issues
signs, facilitating border control, and automatic disinfection (49). Robot-assisted surgery has the potential to reduce COVID-
(43). Telepresence robots allow for two-way communication 19 exposure risk to medical professionals (51).
and can be remotely controlled to provide support to those
in isolation by connecting patients with family and physicians
(35). Exposure to COVID-19 may stimulate further robotics TELEMEDICINE ORGANIZATIONAL
research to address the risk of infectious diseases (42). Facilitating FRAMEWORKS
the integration of engineering, video technology, and infectious
diseases specialists with government funding can have a notable Various traditional organizational frameworks are illustrated in
impact on preventing future pandemics. A Smart Field Hospital Figure 1. One example of a traditional organization is the hub-
trial in Wuhan, China, used robots to minimize COVID-19 and-spoke framework for stroke reperfusion therapy delivery
exposure to patients and healthcare workers as robots and (52), which is based on a framework of conventional and
internet of things (IoT) devices provided medical services in hierarchical positioning. It involves a centralized hub, which
the facility (47). The adoption of robots could be explored in serves as a point of contact and instruction to several spoke sites
infectious disease and crisis settings as a means to potentially that deliver care (53). This structure is suitable for the set-up and
improve health systems capacity and preparedness (47). integration of telehealth networks but ultimately slows decision-
The Society of European Robotic Gynecological Surgery making, depresses innovation, makes it difficult for spokes to
has released guidelines for robot-assisted surgery (RAS) and communicate, and not everybody in the spoke has the capability
promoted the use of RAS over conventional laparoscopic and of the hub (54). Due to cost-benefit and infrastructural reasons,
open surgery in managing infection risk (48). Where RAS as well as a shortage of neuro-interventionalists, not every
is not possible, conventional laparoscopic is preferred over spoke will have endovascular therapy capabilities. Additionally,
open surgery due to the reduced amount of physicians and barriers in access to health systems, applicable to culturally
PPE required, aerosol and bodily fluid risk, and shortened and linguistically diverse communities (CALD) as well as those
hospital stay (48, 49). The European Association of Urology from marginalized backgrounds or low resourced settings, merit
similarly released COVID-19 guidelines, in which they pressed special consideration (55, 56).
the need to manage smoke dispersion in robotic or laparoscopic Centralized systems require strong leadership, otherwise,
surgery through the use of lowest intra-abdominal pressure and issues such as lack of efficiency, productivity, and physician well-
management of flow systems (50). being may develop (57). Decentralized systems can slow down
Potential issues associated with robotics-assisted telemedicine, the speed of uptake and pose inefficiency. Multiple hub-and-
include precision and interaction issues due to distance between spokes are another framework that can be leveraged (58), e.g.,

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Bhaskar et al. AI and Robotics in COVID-19

FIGURE 2 | The proposed artificial intelligence assisted framework for telemedicine. This system centers around artificial intelligence (AI) engine that looks within the
network to find the optimal resources within the geographical constraints and route incoming calls to the appropriate node (affiliated healthcare provider/facility). This
self-evolving and innovative approach processing system would potentially allow increased telemedicine penetration while reducing the inefficiencies of the top-down
or conventional organizational frameworks.

in Africa, a capital city can have a hub overseeing the local state structures (Figure 2). Hub-and-spoke can be used as a
governments, which could further branch out. There also exists a foundational set-up to trigger the quick adoption of technology
holistic model, in which there is no hierarchy (59). Each element initially. However, after an initial period, once such a structure
in the holistic structure is guided by the overarching vision of begins to stagnate and is no longer effective in skilling-up, a new
the organization. organizational framework will replace the foundational model.
The replacing model will consider leadership, technological,
DISCUSSION and organizational structure competence (61). This will involve
a move toward performance and competency-based systems
Telemedicine offers a new modality of delivering medical & (62). For example, when an acute stroke call is made, an AI
allied health services and communicating with patients (11). system will automatically find the best site of care depending on
The current COVID-19 pandemic has catalyzed the uptake of several variables, distance, availability of resources, clinicians’
telemedicine (12, 60). However, there are challenges concerning availability, and time constraints. This will focus on linking the
its geographical penetration, organizational structures, and patient to the best provider, thereby removing any elements of
infrastructure-related issues (12, 41). The consortium has bureaucracy. An independent governance and ethical framework
outlined gaps in current telehealth approaches (11), including are necessary for oversight over the AI performance and any
challenges to telemedicine implementation across geographics ethical issues (63, 64). An AI-powered system should prioritize
(12) and reliance on outdated organizational frameworks or the collective good and performance of the organization based on
operational structures discussed in the current report. evidence-based management principles (65). It will be utilized to
We propose a novel AI-powered staged-wise telemedicine form linkages between providers. For instance, in the event of a
organizational framework (61), which can potentially overcome cardiac emergency, the system could use the existing information
the challenges associated with traditional organizational on the patient to find the best teams to manage the patient.

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Bhaskar et al. AI and Robotics in COVID-19

Links between a cardiologist and cardiac surgeon will be made telemedicine framework proposed by the current consortium
so that they can communicate quickly. This involves role-based could be an enabler in improving telemedicine access and spread
linkage based on questions such as who is available quickly, who across medical specialties and geography. An international
is available in the region, and whether the practitioner agrees collaborative effort led by WHO, the current consortium, or
to treat such patients, rather than subjective person-to-person similar organizations could pave a way to greater telemedicine
linkage. Ultimately, however, such an autonomous framework penetration, especially to benefit the underprivileged and those
must also be able to assign responsibility in case of oversights. living in the low-resourced settings (12).
Hub-and-spoke systems allow teams to compete with each
other and to curry favor from management. The proposed AUTHOR’S NOTE
AI-assisted telemedicine organizational framework is focused
on role-competence and linkages, rather than individuals or The COVID-19 pandemic is causing an unprecedented public
teams. We anticipate this would foster regular and continuous health crisis impacting healthcare systems, healthcare workers,
collaboration. Powered by big data and advanced data analytics and communities. The COVID-19 Pandemic Health System
dashboard, AI-powered systems can be insightful because they REsilience PROGRAM (REPROGRAM) consortium is formed to
generate information about resource utilization in different champion the safety of healthcare workers, policy development,
regions, providing recommendations on system reorganization and advocacy for global pandemic preparedness and action.
and clinician mobilization in a COVID-19 pandemic situation.
This involves scoping the landscape and realigning across AUTHOR CONTRIBUTIONS
multiple levels to embed that particular intervention within the
health systems, thereby promoting rapid research and innovation SBh devised the project, the main conceptual ideas, including
translation as well as integrating contributions based on local the proposal for a new AI-powered telemedicine workflow, the
needs. Such a framework would imbibe resilience, innovation- proof outline, coordinated the writing, editing of the manuscript,
driven technology, and scaled intelligence to enable systems to and wrote the first draft of the manuscript. All authors
evolve and be responsive to local and emergent needs such as discussed the results and recommendations and contributed to
during an outbreak. COVID-19 has led to a sharp increase in the the final manuscript.
demand for telemedicine services (5, 34). It also has an impact
on telemedicine providers, a sector that is facing unprecedented ACKNOWLEDGMENTS
demand, which by some estimates has grown by 150% or
more (66). For telemedicine to expand across geographics, it is We would like to acknowledge the REPROGRAM consortium
necessary to account for geographical variations, cultural factors, members who have worked tirelessly over the last days in
and involvement of local stakeholders (12). contributing to various guidelines, recommendations, policy
briefs, and ongoing discussions during these unprecedented
CONCLUSION and challenging times despite the incredibly short timeframe.
We would like to dedicate this work to our healthcare
To summarize, AI and robotics could play an important workers who have died due to COVID-19 while serving
role in providing telemedicine services during an outbreak or the patients at the frontline and to those who continue to
public health emergency while limiting exposure to healthcare serve during these challenging times despite lack of personal
workers and health systems (14, 42, 43). The AI-assisted protective equipment.

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