Pandemic

Symposium (XIII)

THINKING THE “NEW NORMAL” OF GASTROENTEROLOGY PRACTICE AFTER COVID PANDEMIC

APPLYING BIG DATA FOR GI PRACTICE – WHAT WE HAVE LEARNED FROM COVID-19 PANDEMIC?

Ming-Shiang Wu Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Superintendent, National Taiwan University Hospital, Taipei, Taiwan President, the Gastroenterological Society of Taiwan Secretary General, Taiwan Society of Internal Medicine

The outbreak of coronavirus disease 2019 (COVID-19) is a serious health crisis and has a great impact on healthcare system. The rapid spread of this pandemic has led to a scarcity of equipments, consumables and staffs for hospitals. They are requested to provide timely and high-quality patient care while simultaneously protecting the staffs who are at risk for contracting this contiguous disease. Just as the saying goes” every crisis has an opportunity “, the COVID-19 also provides an unprecedented opportunity for digital transformation of healthcare systems and progress of telemedicine. Application of communication and information technologies such as smartphones, internet of things and 4G/5G transmission technology enables direct interactions among healthcare workers or patients across distance, minimizing the risk of SARSCoV-2 infection and improving access to patient care. Implementing telemedicine platform thus could provide healthcare services without barriers of time and space and is ideal for addressing challenges poised by the global infectious disease. In addition, patient-generated health data including physical activity level, heart rate and blood pressure, can be combined with data from social networks to depict a more complete view of person’s lifestyle and health behavior. Together with advance of genomic medicine and artificial intelligence, we are for the first-time to collect, analyze and store the high volume, high velocity and high variety health data (Big Data). Big data may improve precision in study of pathogenesis, treatment intervention, risk prediction/prevention and surveillance. Collectively, digital health, data science and precision medicine are converging in health care and will result in a paradigm shift of GI practice as well as medicine.

Symposium (XIII)

THINKING THE “NEW NORMAL” OF GASTROENTEROLOGY PRACTICE AFTER COVID PANDEMIC

FUTURE ENDOSCOPY PRACTICE – RIGHT-SIZING, TEAM REBUILDING AND NEW TECHNOLOGIES

Ming-Chih Hou School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan Division of Gastroenterology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan President, The Digestive Endoscopy Society of Taiwan

COVID has changed our practice. Universal lock down to mitigate the crisis, we observed a variable decline of endoscopy volume as much as 75% and 100% at the height of the pandemic around the world. The restricting endoscopic procedures reduce in the absolute number of new cancer diagnoses and also associate with cancer progression to a more advanced stage by the time they are diagnosed and for some patients the time window for a curative treatment may have been missed. Studies also found a dramatic increase in clinically relevant findings per endoscopic procedure. It implicates that a high proportion of endoscopic procedures may be done unnecessarily, with questionable clinical benefit, exposing patients to increased risk, incurring greater cost, and requiring more resources. Facing this challenge, some are working hard and swiftly to combat the virus transmission as well as hoping for subsidence of the pandemic that we can return to the “old normal.” But the “new normal” after COVID will not be the same. This crisis – as with any crisis – is also an opportunity to learn and to improve. Rightsizing is the process of restructuring or reorganizing our organization (such as Endoscopy center) network by reducing its workforce, costcutting, rearranging its upper management and adding new technologies (such as AI and virtual telehealth) in an attempt to get the maximum value from endoscopy services. Technically, the term means adapting the endoscopy practice more efficient and appropriate. Actually, after the lockdown was lifted, the endoscopy volume did not surge above the pre-lockdown volume to accommodate the waiting lists. It reflects not only the adjustments to practice safely during the ongoing pandemic (e. g. need for PPE and screening of patients) and also that indications were viewed more critically and scrutinized for true relevance and appropriateness. The pandemic has forced us to do so to some extent. It gives us an opportunity to critically assess our current practice of open access scheduling and to build a foundation of how best to receive, review, and schedule endoscopy referrals, so that we perform endoscopies with high quality for those patients who may truly benefit from the procedure. We are not at the end of the COVID-19 crisis, and maybe not even at the end of the beginning. But it is not too soon to build the strategies that will foster broad-based growth. In today’s fastchanging environment of “the new normal or next normal”, the ability to adapt and respond rapidly is always crucial for survival.

Symposium (XIII)

THINKING THE “NEW NORMAL” OF GASTROENTEROLOGY PRACTICE AFTER COVID PANDEMIC

CAN TELEMEDICINE HELP GI PRACTICE?

Chun-Ying Wu College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan Division of Translational Research, Taipei Veterans General Hospital, Taipei, Taiwan

Importance of the topic:

1. Telemedicine will be widely applied in daily practice in these years. 2. Telemedicine will significantly change physician-patient relationship.

Innovations in recent years:

1. The rapid progress of 5G communication technology has made telemedicine not only useful to diagnose diseases and prescribe medicine, but also feasible to do operation remotely. 2. The pandemic of COVID-19 has made telemedicine technology widely accepted by patients, doctors and governments as an alternative physician-patient interaction

platform. 3. Taiwan’ Ministry of Health and Welfare has increased the ranges of insurance-paid telemedicine and has begun constructing nationwide telemedicine healthcare networks since 2021. 4. In GI practice, telemedicine can help in disease diagnosis, drug prescriptions, laboratory data interpretation, and doing procedures, such as ultrasonography and endoscopy, etc.

Impact on clinical practice:

1. Telemedicine will become a common physician-patient interaction norm. 2. GI doctors will be expected to be familiar with common telemedicine skills.

Symposium (XIII)

THINKING THE “NEW NORMAL” OF GASTROENTEROLOGY PRACTICE AFTER COVID PANDEMIC

CONSTRUCTING AN EFFECTIVE AND HIGH-PERFORMING GI REFERRAL NETWORK

Tun-Jen Hsiao Hsiao’s Clinic, Taoyuan, Taiwan

Hierarchical medical system is a major policy made by officer of Taiwan NHI which wants to build accessible and consistent medical services. The whole referral system is more complex because It includes upward and downward referral. In this speech, I just want to talk about upward referral because there are some limits in primary care setting including personal ability limit and facilities limitation.

There are 2288 specialists in our society. Among them, 660 (29%) work in primary care clinics. Among these 660 primary care GI specialists, 82% are internal medicine Drs and 18% are Pediatricians, and male to female ratio is 91:9.

In order to understand the GI primary are condition and unmet need of referral system, we organize a structural questionnaire. We send the questionnaire to the line group including 249 primary care GI specialists. Finally, there are 180 (72%) members replied the questionnaire. The mean age is 53.7 y/o and male to female ratio is 95:5. Among the repliers, 140 are clinic holders and the other 40 are employees. The majority of them worked in primary care setting for 10-20 years. Among all the repliers, 96% provide PES service, nearly 100% provide ultrasound examination, but only 69% provide colonoscopy examination. The number referred to hospital is diverse. The majority number of referrals is between 1-20 patients per month. 41% GI men refer to internal medicine Drs (IM) is more than surgeons, 15% surgeon > IM and 44% are IM = surgery. 64% repliers have no selection torment in referring, 29% have a little bit, and 7% have frequent torment. And what are the major considerations when they referred patients? First is the medical skills of the doctors, and the 2nd is the distance between patient and hospital, 3rd is the hospital level, and the 4th is the distance between clinic and the hospital. The other considerations are the request of the patients, what disease of the patients, long-term assessment of the hospital, and the hospital where the GI man to be trained.

The primary care committee of our society hold a conference every 6 months before our directors’ board council. In a committee held in 2018, Dr Wang raised a proposal hoping our society to give a suggested referral list for primary care GI man to use. This proposal was adapted after some discussion. After the committee, I raised a related proposal in our directors’ board council and listed a request of 11 diseases. The diagnosis and management of these diseases are more skillful and need more facilities. So primary care GI men have some torment when referring these diseases because we don’t know who are the really experts of these diseases in hospitals. Finally, our council adapted this proposal.

Our society asked the 35 teaching hospitals for educating GI specialist in Taiwan to give the

suggested list for these diseases. The first edition of the list is not useful, because all the GI men in hospital are listed in all diseases. Are they all really experts? We need a precision referral. Just like Secretary General Chiu said “can do is not equal to do it well”. Finally, a rule was made that no more than 3 experts in each disease can be given from each hospital. The suggested referral list was given to primary GI committee in 2020 and we sent it to all our primary care members. In this study, up to 97% of the repliers regard the list is helpful.

Thank for all the specialists in hospitals worked for hard GI and liver diseases. And thank for president Wu and secretary general Chiu of our society for generating the list of the specialists for referring. Thank for the 180 primary care GI men replied the questionnaire. We hope the referral list let “precision referral system” works.