Questions/Answers

Trace COVID-19 is a digital platform that is in operation nationwide since March 2020. This platform not only provides a consolidated view of public health to clinical staff, health authorities and decision-makers, but at the same time, supports the remote monitoring and follow-up of suspected and / or infected patients with COVID-19, as well as of their contacts. In order to guarantee the participation of citizens in this process, the data registered by them is now integrated into this solution itself − Autoreport COVID19 −, allowing for efficient monitoring in telehealth. The Autoreport COVID-19 allows patients to self-report their symptoms in accordance with the quality and safety criteria defined by the Norm n.⁰ 004/2020 issued by Directorate-General Health (DGS). Patients are then observed by the physician responsible for their remote surveillance / monitoring. By being made available online (web responsive, allowing its use on different devices), this solution offers to citizens the possibility, without losing proximity to health teams, to choose the means through which they feel more capable, and this Autoreport can be performed through an authenticated service on a web page (COVID-19 microsite or on the SNS 24 Portal – Personal Area). This initiative main objectives are: • ensure the delivery of quality and excellent health care while mitigating the need for physical presence of citizens who are suspected or confirmed with COVID-19 in clinical and hospital environments; • enhance citizen and community security through an integrated service; • empower citizens with means for their own reporting regarding data and information on their COVID-19 evolution; • provide a consolidated vision to the National Health Service (SNS) and its decision-makers to support and monitor the surveillance cycle of suspected and confirmed cases of COVID-19 infection, allowing the triggering of preventive and coordinated responses not only the national level, but also at the global level towards the fight against the pandemic

The initiative falls under the special category − Institutional Resilience and Innovative Response to the COVID19 Pandemic. This technology provides a new approach for the provision of services by Health Units and Professionals, providing them with greater levels of efficiency, since it is based on a data-centric decision-making approach. Thus, it allows remote, continuous, and large-scale monitoring of users suspected or diagnosed with COVID-19 who are under active surveillance or self-care at home, constituting a truly innovative telemonitoring / telesurveillance solution, implemented in a record time during a Public Health Emergency.

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Social – the contacts made by health professionals for the surveillance of cases were carried out using old technology, but accessible to all citizens – the telephone. The management of isolation by indication of public health and the management of cases of illness were, in this way, carried out at a distance, without charging additional fees to citizens. Moreover, to guarantee the response to citizens who were absent from their work, it was also possible to issue the Declaration of prophylactic isolation or Certificate of temporary incapacity (dematerialized, paperless). Economic − The centralized development of the platform made it possible to generate clear and transversal indications for the entire system, in addition to the concentration of resources in its development. The management of citizens in their homes allowed to reduce the use of Emergency Services and specialized technicians and infrastructures. Environments − The citizens’ trips to health institutions, using their own means or using emergency means of transport, was avoided. The dematerialization of the process contributed to reducing the use of paper.

COVID-19 disease is a highly infectious disease that can lead to severe respiratory complications. The spread of COVID-19 disease created an unprecedented pressure on healthcare infrastructures around the world, due to the high number of visits to healthcare facilities for assessment, testing, treatment and follow-up, bringing institutions to the breaking or near breaking point. To face the pandemic, countries reacted with tight measures to ensure the defence and resilience of public health. In this context, and given the devastating effects caused by this disease, it was needed to adopt innovative measures for the National Health System. This project was fundamental to support i) the approach of people with suspected and confirmed SARS-CoV-2 infection and their respective risk contacts, ii) the daily provision of healthcare within the scope of the COVID-19 pandemic management, and iii) the intervention of health authorities and teams of public health. This solution allows the National Health System to optimize the monitoring of all citizens who are at home and under surveillance, as well as improving the process of monitoring COVID-19 signs and symptoms via call and data recording and monitoring platform. Consequently, it facilitates and enables the early intervention of health professionals when identifying symptoms. The main focus of the proposed solution is based on the following principles: • Centralization of information relevant to the decision process; • Ensuring the consistency of information: a single view of reality; • Streamlining of the user follow-up process; • Optimization of resources, allowing health professionals to focus on more priority cases; • Focus on the citizen; • Improved service level.

No apparent impact in this area.

Given the progressive expansion of the geographical expression of the COVID-19 pandemic in Portugal, it was urgent to plan measures to ensure an adequate, timely and articulated response for the entire health system. Thus, the model for approaching patients with suspected SARS-CoV-2 infection in the National health System is applicable to all units throughout the health system. To address the monitoring of citizens infected or suspected with SARS-CoV-2, DGS issued the Norm n.⁰ 04/2020, in which is stated that suspected or infected patients with an indication for self-care at home, will be follow-up by health teams, supported by the Trace COVID-19 platform, through a set of tasks generated by the system. These are applicable, as a rule, to patients with lower associated risk, either because of their age or because of their comorbidities. It is, therefore, a telehealth system, which prioritizes patient safety and seeks to avoid overloading the health system. Trace COVID-19 is a platform that is already implemented and in use at the national level. This platform allows a consolidated vision and supports the monitoring and follow-up of the surveillance cycle of citizens suspected or infected with SARS-CoV-2 by health professionals. Primary Health Care and Hospital Care professionals conduct timely updated case information records, large-scale COVID-19 contact management tracking and clinical follow-up. The platform also intends to alleviate the National Health System, avoiding visits of non-critical cases to health institutions, and guaranteeing high levels of public safety in Portugal. Trace COVID-19 includes integration with various health systems, such as i) the National Epidemiological Surveillance System (SINAVE) with mandatory notification of the contacts made through the SNS 24 Line , ii) with the citizen's area of the Electronic Health Record (EHR), and iii) with the Electronic Certificates (CIT) area, among others. As mentioned, the solution is available in several channels and it is possible to easily follow-up all users, giving the citizen the possibility to choose what channels they are most comfortable with, which is especially important considering the elderly population that does not have the skills, access or literacy necessary to perform digital reporting. In this way, the clinical teams are able to monitor their patients, without the need to compulsorily travel to different locations, having only to do so when the clinical situation so requires. For the clinical teams, since there is a single base for monitoring patients within the COVID-19 scope (Trace COVID-19), it allows for a better allocation of time and resources for the clinical assessment of patients, especially in risk groups, such as seniors.

The platform's development began on March 12, 2020, with the first release of base features made available on March 26, 2020. Since that date until now, regular and frequent production entries have been made. The main areas available in the operational component are: • People: Person Detail Page and its entire route • Clusters: Summary list of clusters • Transmission Chains: List of cases Index of Transmission Chains • Prophylactic Isolation Statements (DIPs) Pre-issuance: possibility of DIPs being filled by citizens’ profiles other than health authorities, and later validated and issued by a health authority • Issuance of DIPs in Batch: Possibility of issuing DIPs in Batch • Case Manager (SP) – New confirmed: Possibility of associating a case manager with each person • Sending messages to users: Emails, SMSs • Self-Report: possibility for the User to register his / her own information • Support in the generation of Digital Recovery Certificates The developments made available are tested and approved by DGS and aligned to comply with published standards and norms.

The main obstacles: • Access to end users to clarify doubts and the process • Treatment of local data with different criteria that leads to additional questions, distrust in the system and loss of efficiency, as it is necessary to look for the reasons of the difference between things that are not comparable • Lack of information quality (e.g., laboratory tests without user identification, users without defined addresses, duplicate loading of information by users) How was it overcome: • Alert messages on the Portal; Release Notes of all new features made available • Conducting specific webinars for each set of features and per user access profile • Provision of detailed data analysis that allows confirmation of the values presented • Creation of an intermediate layer for information processing, implementation of security mechanisms that prevent the introduction of incorrect data; crossing of information with other systems for information verification (ex: National Register of Users [RNU])

When Portugal's response to COVID-19 is analysed in comparison with the response of other countries, it is immediately recognized that, unlike other States that have resorted to traditional means in the fight against COVID-19, Portugal, through the model implemented by the Norm n.⁰ 004/2020 issued by DGS and the tools developed by SPMS (Autoreport & Trace COVID-19), was able to trigger a proactive, high-quality and safe response, 100% digital. This was simultaneously based on the best available scientific evidence and good practices in ICT and Telehealth, in a real commitment towards the digital transition of health systems.

The initiative's success was based on the fact that the features were made available step by step, but right from the beginning of the pandemic. The release date was March 26, 2020. Having the functional support of elements that knew the processes very well, made the entire analysis and testing process more agile. Basic principles: • Existence of a centralized system for recording and monitoring patients • Need to track information • Support health professionals in task management • Provision of pandemic monitoring indicators at various levels: o Strategic o Operational • Task automation

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No knowledge about using a platform inspired by or based on this solution.

It consists of an information system that provides a solution to management of mandatory notification diseases for potential use elsewhere, but especially in other public health problems, when the transmission vector is difficult to control.

In terms of human resources from DGS, the following were involved in the initiative: • 1 Director of Services: for higher articulation and coordination; • 1 Head of Division: for internal articulation; • 1 Consultant (Hospital Administrator): to support and monitor developments, and interface with SPMS; • 2 doctors; • 2 nurses; • 1 jurist: for support and legal framework. From SPMS: • 1 Area Director: for higher articulation of the measure, considering its relevance • 2 Area Coordinators: for internal articulation of the areas of healthcare systems and citizen services • 2 Project Managers: for articulation and planning tasks in two systems integration points; Definition of requirements with the customer; Execution assurance; Monitoring of developments; Quality assurance and compliance with requirements. • 1 Systems Architect: for designing and delineating the technical implementation of the measure • 6 Programmers: for development and implementation of the measure • 2 Functional Analysts: for functional measurement design • 2 Testers: for testing integration between systems • 2 Support technicians: to support healthcare professionals and citizens • Jurists : The team that validates that the solution is in legal conformity.

This platform is: • A central platform • User referencing • Surveillance Management and Disease Status • Task generation for health professionals • Monitoring the evolution of users and their contacts • Contact Tracing • Identification of transmission chains and clusters • Sending messages to users In this way, it is currently focused on monitoring the COVID-19 pandemic, but the impact of transforming it into a tool for public health teams to monitor other types of diseases should be analysed and studied, so that the country is better prepared for future pandemics, enabling quicker responses.

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The solution is used every day by thousands of users. Whenever there is a problem, an answer is available through a technical support centre for professionals, who everyday report suggestions that would make it possible to improve the platform. The solution was implemented with an indicator reporting system, which allows for constant evaluation of the initiative.

The assessment is made daily, making the information available to the national Public Health Authority. Indicators can be found in the Impact Report – summarized, see annexed

The volume of usage and generated information allow for clinical and political decisions in the management of the pandemic.

This solution was developed by a public company in the sphere of the Ministry of Health of the Portuguese Republic, on the recommendation of the Portuguese Directorate-General Health.

As part of the response to the current COVID-19 pandemic, an innovative model of clinical and public health approach, based on telemedicine, was developed by the Directorate-General for Health (DGS), in collaboration with SPMS, which allowed for the provision of quality and safe healthcare to all persons suspected and confirmed with SARS-CoV-2 infection, as well as to their contacts. This was essential to maintain the sustainability of the National Health Service. This model was implemented based on the Norm n.⁰ 004/2020 issued by DGS.

Autoreport & Trace COVID-19 constitute an integrated response that, despite being designed for the unexpected advent of the current global SARS-CoV-2 pandemic, presents valences that are not exhausted in this timeframe, and may contribute to future debates about the interaction between the community, health professionals and citizens, including in the context of other high-impact diseases, namely communicable diseases. Thus, we believe that this response not only fulfilled its initial intentions, supporting the national response to COVID-19, but could also serve as a starting point for the discussion of other opportunities that positively impact the constant need for adaptation on the part of the health sector, on the path of continuously centralizing its priorities on the needs of the citizens. On the other hand, this model established a good policy of joint, concerted, and exemplary action by two institutions of the Ministry of Health, in favour of Public Health.