Key words : Digital, Health services, Organ procurement, Telemedicine

Introduction
Clinical transplant has proved to be lifesaving, even though presently less than 10% of the needed transplants are performed and only 0.05% of the worldwide deceased population serves as organ donors. Donor characteristics may condition transplant outcomes, because inclusion criteria differ according to cause of death, donor management, infections, malignancies, age, and pathologies, among other factors. A meticulous control of the clinical donation process and adequate training of health care professionals are necessary to best facilitate proper graft function.¹

Moreover, in December 2019, coronavirus disease emerged (subsequently designated as COVID-19). Since then, COVID-19 has dramatically affected our regular way of life, mainly the global economy and above all the health care system, including organ donation and transplant (ODT) activities, among other aspects. Social distancing, mobility restrictions, reduced budgets, and adjusted criteria for elective cases in those countries where the transplant community remained active have resulted in a substantial decrease in transplant performance and an increase in mortality rates due to infection in transplant recipients.²

According to the International Registry on Organ Donation and Transplantation (IRODAT), Spain, which is a world leader for organ donation, experienced a decrease from 49.61 to 37.91 donations per million population in 2020 (Figure 1). Other countries with high rates of donation, such as the United States and Croatia, followed the downward trend caused by the outbreak.³ Although measures of social distancing and face coverings were implemented in an effort to return to normal activities, there emerged a clear and present need for innovative tools to increase efficiency and quality of care and to add communication support to the ODT health care system.

Telehealth proved, once again, to be a great choice to help cover the gaps in the health care system. It became a key point in health care delivery during the pandemic period, allowing health care services to reach patients in their homes and keep others safe by social distancing and self-quarantine. Furthermore, telemedicine can supplement or replace in-person visits, improving access to medical care and allowing cost and time savings for patients. Previously, telehealth was mainly used for primary care needs; however, presently, specialists and clinicians are expanding knowledge, and urgent care health is now being achieved via telehealth more than ever before, optimizing engagement of patients and outcomes.^4,5

The Donation and Transplantation Institute (DTI Foundation), a nonprofit organization located in Barcelona (Spain) whose mission is to advise and support international entities from the public and private health sector in the development and strengthening of networks, programs, services, and research mainly in the donation and transplantation of organs, tissues, and human cells, has maintained close contact with a global community of experts in the field of ODT. The DTI Foundation has repeatedly referred to the need to cover the lack of specialized health care professionals in a large number of developing countries with limited human resources.⁶

Consequently, given the need to enlarge the number of available specialists, our aim was to bring scientific knowledge closer to the physicians in charge of potential donors and transplanted patients through an online medical platform specialized in ODT addressed to health care professionals. The platform would provide second opinion and instant messaging services, offering a second opinion/consultancy approach based on international practices.

Methods and Results
To develop a second-opinion ODT platform, DTI collaborated with beHIT,⁶ a technology solutions provider operating in over 20 countries across Europe, Asia, Latin America, Africa, and the Middle East and the original developer of the Medxat7 engine, an operative health communication platform. The clinical contents were created by the DTI Foundation medical team and international experts in the field of ODT to implement and adjust the functionality of the platform. As a result, the Innovative-DTI platform (I-DTI), a second opinion platform for health care professionals specialized in ODT, was launched in its beta version in 2020 (www.i-dti.com).

The I-DTI platform ensures data protection by using a database server encrypted with RAS along with cloud technologies. All communications are registered and sent through secure channels (ie, the HTTPS protocol, which is the SSL/TLS-secured extension of HTTP) to comply with international data protection laws.

The I-DTI work circuit starts when the health care professional, facing an adverse scenario, shares a case by using the original survey forms developed for the following topics: organ donation, organ transplant, follow-up transplant, and tissue donation. Media files can be attached to complete the consultation, and communications are available through the customized messaging service. The application form, completed with basic information, is managed by the I-DTI medical team to identify the relevant aspects and direct the inquiry to the most appropriate experts. Response is elaborated and validated in less than 24 hours, or up to 48 hours depending on the urgency and depth of study. Even so, the final decision remains with the consulting professional, who takes full responsibility of the case.

Along with the instant messaging service, other social media features such as profile customization and a contact search feature are available to facilitate usage.

To validate the platform, a pilot phase was performed in the following participating centers: the Institute of Medical Sciences in Kerala, India; the Southern Philippines Medical Center, Davao, Philippines; and the National Organ Transplant Unit, in Trinidad and Tobago.

More than 60 professionals, including physicians, transplant coordinators, nurses, and other health providers, were involved. They were asked to use the I-DTI application as a work communication tool and the second-opinion service in case they had a clinical scenario to consult. During the 6-month period of the pilot phase, consultations were received at an average frequency of 2 per week; significantly, more than half of these consultations were related to COVID-19. Following the work circuit, the experts’ opinions were delivered in 24 hours or less in most of the cases.

Studied parameters during this pilot period included the quality of the contents, user interface adherence, acceptance, feasibility, response time, and networking between users. Later, a survey was delivered to each participant to score the parameters previously mentioned. The average score received was of 9.3 out of a possible best score of 10. Feedback received was analyzed to solve possible problems and apply platform improvements (Figure 2).

Currently, I-DTI is constantly updated to enhance the user experience and to adapt new contents. Today, more than 700 health care professionals from more than 20 countries have signed up to the I-DTI platform (Figure 3).

Discussion
In 2020, the challenges hospitals faced, including restrictions, flight reductions, and border closures, affected national transplant programs worldwide. Nevertheless, the effects of the COVID-19 pandemic on ODT have created a paradigm shift for clinical management of patients and in-hospital policy decisions. Despite these facts, tremendous progress has been made to maintain ODT performance in terms of safety and security optimally during the COVID era, and new technologies have emerged to lead us into the next generation of telemedicine.

I-DTI platform has proved to be a feasible tool to assist health care professionals, for knowledge exchange and communication, ensuring access to international best practices. Likewise, its second-opinion service works as support in the decision making for clinical practitioners, especially in low-income countries with no defined ODT programs.

The nature of I-DTI goes hand-in-hand with development of new technologies such as e-health, big data, blockchain, and artificial intelligence. Synergies between these solutions are the turning point to reach more professionals and consequently saving more lives. Nevertheless, it is imperative that medical providers rely on these tools and actively encourage the use of innovative solutions currently available.

References:

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