JMIR PUBLIC HEALTH AND SURVEILLANCE Echeverría et al Original Paper COVIDApp as an Innovative Strategy for the Management and Follow-Up of COVID-19 Cases in Long-Term Care Facilities in Catalonia: Implementation Study Patricia Echeverría1,2*, MD, PhD‡; Miquel Angel Mas Bergas3*, MD, PhD; Jordi Puig1,2, MSc; Mar Isnard3, MSc; Mireia Massot4, BSN; Cristina Vedia5, PhD; Ricardo Peiró5, MD; Yolanda Ordorica6, BSN; Sara Pablo7, BSN; María Ulldemolins5, BSN; Mercé Iruela6, MSc; Dolors Balart7, BP; José María Ruiz8, BScB; Jordi Herms8, BCS; Bonaventura Clotet Sala1,2,9,10, MD, PhD; Eugenia Negredo1,2,10*, MD, PhD 1 Infectious Diseases Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain 2 Lluita contra la Sida Foundation, Hospital Universitari Germans Trias i Pujol, Badalona, Spain 3 Direcció Clínica Territorial Metropolitana Nord, Institut Català de la Salut, Barcelona, Spain 4 Servei d'Atenció Primària Vallès Occidental, Direcció Atenció Primària Metropolitana Nord, Institut Català de la Salut, Barcelona, Spain 5 Servei d'Atenció Primària Barcelonès Nord Maresme, Direcció Atenció Primària Metropolitana Nord, Institut Català de la Salut, Barcelona, Spain 6 Servei d'Atenció Primària Vallès Oriental, Direcció Atenció Primària Metropolitana Nord, Institut Català de la Salut, Barcelona, Spain 7 Direcció Atenció Primària Metropolitana Nord, Institut Català de la Salut, Barcelona, Spain 8 Lluita contra la Sida Foundation, Digital Health Department, Doole Health S.L., Badalona, Spain 9 AIDS Research Institute-IRSICAIXA, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain 10 Centre for Health and Social Care Research (CESS), Faculty of Medicine, University of Vic - Central University of Catalonia, Barcelona, Spain ‡ COVIDApp Group * these authors contributed equally Corresponding Author: Patricia Echeverría, MD, PhD Infectious Diseases Department Hospital Universitari Germans Trias i Pujol Carretera de Canyet s/n Badalona Spain Phone: 34 934978887 ext 3417 Email: pecheverria@flsida.org Abstract Background: The coronavirus disease (COVID-19) pandemic has caused an unprecedented worldwide public health crisis that requires new management approaches. COVIDApp is a mobile app that was adapted for the management of institutionalized individuals in long-term care facilities. Objective: The aim of this paper is to report the implementation of this innovative tool for the management of long-term care facility residents as a high-risk population, specifically for early identification and self-isolation of suspected cases, remote monitoring of mild cases, and real-time monitoring of the progression of the infection. Methods: COVIDApp was implemented in 196 care centers in collaboration with 64 primary care teams. The following parameters of COVID-19 were reported daily: signs/symptoms; diagnosis by reverse transcriptase–polymerase chain reaction; absence of symptoms for ≥14 days; total deaths; and number of health care workers isolated with suspected COVID-19. The number of at-risk centers was also described. Results: Data were recorded from 10,347 institutionalized individuals and up to 4000 health care workers between April 1 and 30, 2020. A rapid increase in suspected cases was seen until day 6 but decreased during the last two weeks (from 1084 to 282 cases). The number of confirmed cases increased from 419 (day 6) to 1293 (day 22) and remained stable during the last week. Of the 10,347 institutionalized individuals, 5,090 (49,2%) remained asymptomatic for ≥14 days. A total of 854/10,347 deaths (8.3%) were reported; 383 of these deaths (44.8%) were suspected/confirmed cases. The number of isolated health care workers http://publichealth.jmir.org/2020/3/e21163/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 3 | e21163 | p. 1 (page number not for citation purposes) XSL• FO RenderX JMIR PUBLIC HEALTH AND SURVEILLANCE Echeverría et al remained high over the 30 days, while the number of suspected cases decreased during the last 2 weeks. The number of high-risk long-term care facilities decreased from 19/196 (9.5%) to 3/196 (1.5%). Conclusions: COVIDApp can help clinicians rapidly detect and remotely monitor suspected and confirmed cases of COVID-19 among institutionalized individuals, thus limiting the risk of spreading the virus. The platform shows the progression of infection in real time and can aid in designing new monitoring strategies. (JMIR Public Health Surveill 2020;6(3):e21163) doi: 10.2196/21163 KEYWORDS COVID-19; mobile health; app; COVIDApp; long-term care facilities; institutionalized individuals; mHealth; elderly; long-term; care; public health; management; surveillance the use of this innovative tool for the management of long-term Introduction care facility residents as a high-risk population, specifically for The disease caused by severe acute respiratory syndrome early identification and self-isolation of suspected cases, remote coronavirus 2 (SARS-CoV-2), called coronavirus disease monitoring of mild cases, and real-time monitoring of the (COVID-19), was initially identified in December 2019 as a progression of the infection. case of pneumonia in Wuhan, China [1,2]. COVID-19 has since become a global pandemic that is affecting more than 200 Methods countries worldwide, with more than 3.5 million people infected globally and more than 240,000 related deaths as of April 30, Study Design, Objectives, and Population 2020 [3]. The World Health Organization declared COVID-19 We describe the implementation of a mobile app (COVIDApp) a pandemic on March 11, 2020, and called for coordinated for the management of COVID-19 in institutionalized persons mechanisms to provide a response to the infection across various in long-term care facilities (older residents and individuals with health sectors [4]. On March 14, the Spanish authorities declared physical and mental disabilities). This innovative strategy the pandemic to be a national emergency [5]. addresses the COVID-19 pandemic by intervening in prevention, care, and epidemiology. The rapid spread of the infection and its severity in a considerable percentage of patients has necessitated The COVIDApp tool was optimized to meet the following unprecedented public health measures. Health systems objectives: early identification and self-isolation of persons worldwide are working against the clock and taking exceptional suspected of having COVID-19 for rapid diagnosis of positive measures to address the crisis. Health professionals require cases by real-time reverse transcriptase–polymerase chain methods to detect, treat, and monitor patients with COVID-19 reaction (RT-PCR), thus minimizing the risk of transmission effectively and efficiently and to prevent further transmission in long-term care facilities; remote treatment and monitoring of the disease. of mild cases of COVID-19 self-isolating at nursing homes when indicated; and real-time monitoring of the progression of The health crisis generated by COVID-19 requires new the infection and its consequences in these at-risk facilities. approaches to disease management, especially in the case of older individuals, as this population is especially vulnerable to A total of 196 care centers (169 nursing homes and 27 severe illnesses and early data point to higher mortality from institutions for people with physical and mental disabilities) COVID-19 in this population than in young and middle-aged participated in collaboration with 64 primary care teams from patients [6,7]. In addition, the high risk of transmission of the northern area of Barcelona, Catalonia (Barcelonès Nord, COVID-19 in long-term care facilities (nursing homes and other Maresme, Vallès Oriental, and Vallès Occidental Valles), which institutions) with vulnerable populations and the resulting has a reference population of 1,986,032 inhabitants. In challenge of controlling the epidemic in these settings have Catalonia, the entire population is covered by publicly financed necessitated innovative responses [8,9]. In this sense, expert health services, and universal care is provided by primary care recommendations indicate that medical decisions should include teams and hospitals. Regarding long-term care facilities, rapid screening to identify suspected cases early and to facilitate although some of these facilities are private, all citizens are on-site management or transfer to hospital, as applicable [10]. covered by public health services. For that reason, each long-term care facility has a primary care team of reference. Given this scenario, we adapted a mobile health app that was designed in 2015 [11] and that has since been used for the We began using COVIDApp as a support tool for the clinical clinical management of HIV-infected persons in our HIV Unit response of primary care teams to the epidemiological crisis on (+Approp). For the last two years, the app has been used in April 1, 2020. The data reported in this paper were registered additional scenarios, such as clinical management of the general on the platform between April 1 and 30, 2020. population and of patients with chronic conditions (Doole Endpoints Health). COVIDApp is an adapted version of this app that aims to address the current COVID-19 crisis by closely monitoring The parameters reported by health care staff at each institution institutionalized subjects and their contacts through providing with respect to all residents and caregivers were the number of remote medical attention. The objective of this paper is to report persons with signs and/or symptoms of COVID-19 http://publichealth.jmir.org/2020/3/e21163/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 3 | e21163 | p. 2 (page number not for citation purposes) XSL• FO RenderX JMIR PUBLIC HEALTH AND SURVEILLANCE Echeverría et al (suspected/symptomatic cases), number of persons with a results. Fourth, suspected cases are isolated until the RT-PCR diagnosis of SARS-CoV-2 by RT-PCR, number of residents test result is available (within 24 hours), and cases who test remaining asymptomatic for more than 14 days, total number positive for SARS-CoV-2 remain isolated and quarantined, of deaths and deaths in suspected cases, number of suspected receive appropriate treatment, and are monitored twice daily. cases in health care workers, and number of isolated health care Fifth, clinical progress (vital signs, symptoms, and clinical workers (confirmed cases, suspected cases, or contacts). opinion) is reported daily by the long-term care facility staff via the app. Finally, clinical treatment is provided based on an The number of high-risk facilities was also described. We individualized care plan: mild cases receive acute and supportive categorized a long-term care facility as a high-risk center if it treatment, severe cases are transferred to hospital, and more presented one or more of the following risk factors for two or severe cases may receive end-of-life palliative care. All patients more consecutive days: reporting by long-term care facility remain in the center, except for severe cases, who are transferred managers of difficulties managing the crisis (requiring action to hospital. from local or regional authorities), reduced number of available health care professionals due to suspected or confirmed infection, lack of personal protective equipment (PPE) or need Results to disinfect the area, and situations where primary care teams During 30 days of follow-up using the platform, we managed detected that long-term care facility staff experienced difficulties data from more than 10,000 institutionalized individuals and complying with clinical recommendations or understanding up to 4000 health care workers. These data are a key element epidemiological recommendations for prevention of new of the project and are shown in Table 1. The table shows the infections. number of residents along with the percentages of centers that COVIDApp Functions reported data on the platform each week. Because the numbers varied over the 30 days depending on the mobility of some COVIDApp is an easily accessible mobile health app that is residents, the number of deaths, and the number of centers available in the Google Play Store for the Android platform and reporting data daily on the platform, we present the data in the Apple Store in iOS format; the app facilitates direct available at the end of each week throughout the 30-day period. communication between long-term care facilities and primary The percentage of the 196 institutions that reported data was care teams. Health personnel can access the app from any very high and increased over time, from 174 (88.8%) at day 9 computer through a webpage. However, only authorized to 190 (96.9%) at day 30. personnel can access the back office of the app to upload patients’ information. Figure 1 shows the information provided by long-term care facility staff on suspected/symptomatic and confirmed COVIDApp provides information on facility residents in real COVID-19 cases over time. A rapid increase in the number of time, including vital signs (eg, temperature, heart and respiratory suspected cases was seen until day 6; this number remained rate, blood pressure, and oxygen saturation rate) and symptoms stable until day 14 and decreased during the last 2 weeks. (eg, cough, expectoration, dyspnea, vomiting, diarrhea, or confusion). The platform provides a daily report of the numbers In contrast, the number of confirmed COVID-19 individuals of suspected or confirmed COVID-19 cases, isolated cases, increased progressively until day 22 and remained stable during people remaining asymptomatic for more than 14 days, and the last week. Over the 30 days, the number of residents deaths. COVIDApp also enables communication via chat or asymptomatic for more than 14 days was stable (5,090 of 10,347 video between the health care team and the patient’s family and (49.2%), Figure 2). can be used to send different types of messages (eg, Long-term care facilities reported a total of 854/10,347 (8.3%) recommendations or treatment protocols), although this tool institutionalized deaths during the 30 days; of these, 383 (44.8%) has not yet been activated. The app is implemented using were suspected/confirmed cases. Figure 3 shows the progress redundant servers, periodic and encrypted backups, information of the deaths over the 30 days; increases were observed in both encrypted via transport layer security (TLS) and HTTPS, and the total number of deaths and the deaths among an Amazon Web Services global cloud infrastructure. suspected/confirmed cases during the first 2 weeks, followed COVIDApp functions in various stages. First, vital signs and by a progressive decrease. This decrease was more marked from symptoms from all suspected cases are monitored daily at an the third week onward. individualized frequency (1 to 3 times per day) by health Figure 4 shows the progress of suspected cases and isolated personnel at the institutions and are collected in the platform in cases by center among health care staff working in long-term real time. An immediate alert is sent to the primary care team care facilities. The number of isolated health care workers through activation of an alarm via the app when people develop (suspected or confirmed cases or contact with a confirmed case) signs or symptoms related to COVID-19. Second, following an remained high over the 30 days, although the number of alarm, a clinical assessment by the primary care team is planned suspected cases decreased during the last 2 weeks; this decrease within 12 to 24 hours. Third, after the initial assessment, several became more apparent during the last week. measures are recommended, as follows: preventive epidemiological recommendations such as compartmentalization The number of long-term care facilities considered to be of specific areas and isolation of suspected cases and contacts; high-risk for COVID-19 decreased progressively from 19/196 measures for staff to prevent infection, including PPE; RT-PCR (9.7%) to 3/196 (1.5%). testing; and reassessment of isolation measures based on test http://publichealth.jmir.org/2020/3/e21163/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 3 | e21163 | p. 3 (page number not for citation purposes) XSL• FO RenderX JMIR PUBLIC HEALTH AND SURVEILLANCE Echeverría et al Table 1. Weekly data on the number of institutionalized residents, percentages of centers that reported data on the COVIDApp platform, and number of facilities considered to be high-risk. Week (2020) Residents, n Centers that reported data, n (%) High-risk centers, n (%) April 9 10,347 174 (88.8) 19 (9.7) April 16 10,089 177 (90.3) 8 (4.0) April 23 9909 187 (95.4) 5 (2.5) April 30 9785 190 (96.9) 3 (1.5) Figure 1. Numbers of suspected/symptomatic cases and confirmed cases of coronavirus disease among residents as reported by long-term care facility health care staff through COVIDApp over 30 days. Figure 2. Numbers of residents who were asymptomatic for coronavirus disease for more than 14 days as reported by long-term care facility health care staff through COVIDApp over 30 days. http://publichealth.jmir.org/2020/3/e21163/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 3 | e21163 | p. 4 (page number not for citation purposes) XSL• FO RenderX JMIR PUBLIC HEALTH AND SURVEILLANCE Echeverría et al Figure 3. Total number of deaths and deaths in suspected/confirmed cases among residents, as reported by LTCF health care staff over 30 days. Figure 4. Number of suspected cases in health care workers and number of isolated health care workers, as reported by LTCF healthcare staff over 30 days. second, remote management of mild COVID-19 cases treated Discussion in institutions; and third, knowledge of progression of the Principal Findings infection in long-term care facilities (progress of confirmed cases, isolated and asymptomatic residents, number of isolated Our app helped institutional staff from long-term care facilities health care workers, and management of risk of spreading the and primary care clinicians address the COVID-19 pandemic infection in LTCF with a high number of risk factors for by providing a new channel for real-time communication. The negative outcomes). strategy was focused on 3 actions: first, early detection of suspected COVID-19 cases and rapid development of With data and guidelines still in development, health care epidemiological actions such as self-isolation of suspected cases professionals are fighting the COVID-19 pandemic on multiple and contacts and relocation after positive or negative results; fronts, and support tools are needed to manage the situation due http://publichealth.jmir.org/2020/3/e21163/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 3 | e21163 | p. 5 (page number not for citation purposes) XSL• FO RenderX JMIR PUBLIC HEALTH AND SURVEILLANCE Echeverría et al to the complete saturation of national health systems (both Our strategy was based on detection and monitoring of suspected primary and hospital care). In this context, telemedicine could cases but also has a double epidemiological objective: to reduce be promoted for early diagnosis, patient isolation, and contact transmission in a vulnerable population (residents and long-term tracing. However, few data have been reported to date with care facility health care workers) and to monitor the progress respect to the use of technological platforms in the management of the infection in these centers [8,10,19]. Several authors have of the COVID-19 pandemic [12-16]. Preliminary data indicates suggested that the consequences of insufficient response to that telemedicine technologies, particularly video consultations, epidemics in long-term care facilities could be severe in older have been enhanced and scaled up to reduce the risk of persons, who are by definition frail and immunologically naïve transmission by monitoring symptomatic individuals in the to the virus [9,20]. United Kingdom [13] and the United States [14,15]. In France, Rolland et al [17] described the use of telemedicine to advise Limitations and support older people in nursing homes through a website Our tool was implemented in the midst of a pandemic, which that enables direct contact between a senior geriatrician and necessarily implies a series of limitations. First, data must be centers for older people. Much like our system, this approach interpreted with caution because they are reported and registered enables diagnosis and monitoring of cases with COVID-19 in by long-term care facility staff for use in clinical care planning, a care setting by mobile teams. However, no epidemiological although the data were validated by the primary care teams. data have yet become available from these studies. Second, despite our conviction of the usefulness of the tool, implementation was difficult to consolidate due to the Despite the limitations imposed by the COVID-19 pandemic, complexity of reporting the clinical status of individuals, we were able to monitor the progress of the infection over 4 especially in long-term care facilities experiencing multiple weeks of the pandemic in our area. We observed an initial difficulties managing the crisis. In the near future, it will be gradual increase in the number of suspected and confirmed cases necessary to work more closely with the staff of these facilities of COVID-19 with subsequent stabilization, together with a to improve individual reporting of signs, symptoms, and other decrease in the number of deaths and an increase in the number clinical information as well as to introduce additional of residents without symptoms for more than 14 days. Among functionalities of the app. The need for rapid implementation health care workers, the number of suspected cases decreased of the app resulting from the urgency of the situation enabled during the last weeks of the study. COVIDApp enabled us to us to manage COVID-19 in these centers; however, continuous intervene proactively by isolating residents with suspected changes in the platform have been necessary to ensure universal infection early and by monitoring contacts, not only among implementation and to optimize clinical data (monitoring of residents but also among health care workers, who are at high symptoms and vital signs and inclusion of additional clinical risk of COVID-19 infection. In this sense, the app proved to be and epidemiological data). In addition, other aspects (eg, a powerful tool for monitoring individuals living in health care laboratory data, adherence to treatment, and adverse events) institutions and the status of long-term care facilities and their must be tested in future analyses under conditions of clinical health care workers during the COVID-19 pandemic. practice. Consequently, the number of high-risk centers decreased during the study period. Monitoring centers at high risk of infection Conclusion by detecting key risk factors appears to be essential if we are The COVID-19 pandemic has highlighted the need to optimize to minimize the spread of COVID-19 in long-term care facilities. existing resources to prevent the collapse of health systems. The factors contributing to the vulnerability of these facilities COVIDApp is an innovative tool that can help clinicians rapidly were summarized by McMichael et al [18] as follows: working detect and remotely monitor suspected and confirmed cases of while symptomatic or working in more than one facility; COVID-19 in institutions, thus limiting the risk of spreading inadequate familiarity with and adherence to standard, droplet, the virus. In addition, the platform shows the characteristics and contact precautions and eye protection recommendations; and progression of the situation in real time, thus facilitating difficulty implementing infection control practices, including the design of strategies tailored to a specific setting. Cost-benefit inadequate supplies of PPE and other items (eg, alcohol-based studies are necessary to measure the real benefits of such hand sanitizer); delayed recognition of cases because of a low strategies. index of suspicion, limited testing availability, and difficulty identifying persons with COVID-19 based on signs and symptoms alone. Acknowledgments This work was supported by the Lluita contra la Sida Foundation, Barcelona, Spain. Authors' Contributions PE, MAM, JP, BC, and EN participated in the conception and design of the study; MI, MM, MV, RP, YO, SP, UMP, IM, and BD participated in the acquisition of data; and all authors participated in the drafting and critical review of the submitted manuscript. All authors read and approved the final manuscript. 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[doi: 10.1111/jgs.16464] [Medline: 32243567] 20. Garnier-Crussard A, Forestier E, Gilbert T, Krolak-Salmon P. Novel Coronavirus (COVID-19) Epidemic: What Are the Risks for Older Patients? J Am Geriatr Soc 2020 May 12;68(5):939-940 [FREE Full text] [doi: 10.1111/jgs.16407] [Medline: 32162679] Abbreviations COVID-19: coronavirus disease PPE: personal protective equipment RT-PCR: reverse transcriptase–polymerase chain reaction SARS-CoV-2: severe acute respiratory syndrome coronavirus 2 http://publichealth.jmir.org/2020/3/e21163/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 3 | e21163 | p. 7 (page number not for citation purposes) XSL• FO RenderX JMIR PUBLIC HEALTH AND SURVEILLANCE Echeverría et al TLS: transport layer security Edited by T Sanchez; submitted 07.06.20; peer-reviewed by J Portnoy, F López Seguí; comments to author 15.06.20; revised version received 26.06.20; accepted 06.07.20; published 17.07.20 Please cite as: Echeverría P, Mas Bergas MA, Puig J, Isnard M, Massot M, Vedia C, Peiró R, Ordorica Y, Pablo S, Ulldemolins M, Iruela M, Balart D, Ruiz JM, Herms J, Clotet Sala B, Negredo E COVIDApp as an Innovative Strategy for the Management and Follow-Up of COVID-19 Cases in Long-Term Care Facilities in Catalonia: Implementation Study JMIR Public Health Surveill 2020;6(3):e21163 URL: http://publichealth.jmir.org/2020/3/e21163/ doi: 10.2196/21163 PMID: 32629425 ©Patricia Echeverría, Miquel Angel Mas Bergas, Jordi Puig, Mar Isnard, Mireia Massot, Cristina Vedia, Ricardo Peiró, Yolanda Ordorica, Sara Pablo, María Ulldemolins, Mercé Iruela, Dolors Balart, José María Ruiz, Jordi Herms, Bonaventura Clotet Sala, Eugenia Negredo. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 17.07.2020. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete bibliographic information, a link to the original publication on http://publichealth.jmir.org, as well as this copyright and license information must be included. http://publichealth.jmir.org/2020/3/e21163/ JMIR Public Health Surveill 2020 | vol. 6 | iss. 3 | e21163 | p. 8 (page number not for citation purposes) XSL• FO RenderX