Hi, welcome to our talk on global health in the post-COVID world. Dr. Shapiro is going to start off. Hi, this is Lauren Shapiro. I'm an Associate Professor in the Department of Physical Medicine and Rehabilitation at the University of Miami, and currently serve as the Medical Director of the Stroke Rehabilitation Service at the Christina E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, which is a collaboration between UHealth and Jackson Memorial Hospital. Today I'll be talking about discharging international patients during disasters. The objectives for today's talk will include to review challenges one should anticipate in returning newly disabled patients to their home countries during tumultuous times. I'll also discuss the impact of the COVID-19 pandemic on international discharge processes and provide best practices and some helpful resources to make these difficult discharges go as smoothly as possible. I will be discussing some real cases encountered at my institution during the pandemic. It's my hope that this will illustrate some of the challenges one may need to confront during the pandemic. Non-essential details have been changed to protect the patient's privacy. First a little bit about our program at Jackson Memorial Hospital. We serve as the referral center for major traumatic injuries and severe neurological conditions for the Caribbean basin, including the US Virgin Islands as well as several Caribbean island states. We also receive frequent admissions from Central and South America, and we receive ill and injured travelers and employees from cruise ships. Our international patient population is often middle class or low income. The majority return home via commercial flight, and many will be returning to islands with limited rehabilitation and specialty care. Here's a picture I took in one of our gyms of our practice airline seats. We were fortunate that these were donated from American Airlines so we could practice airplane transfers. Even under the best circumstances, international discharges are rarely easy. We often confront limited flights back home for our patients, and many of them need to leave very early in the morning, making the discharge process complicated for both our nurses and doctors. Some of our patients will need to take a boat for part of the trip, and unfortunately many of these Caribbean ferry boats are not the most accessible to those who are physically disabled. It is also usually quite difficult to coordinate follow-up care and the delivery of durable medical equipment. We often have to assist caregivers who may need some help getting stateside. We very frequently write embassy and or consulate letters. We also have faced a number of situations in which the country of origin may attempt to repatriate their citizen very quickly. This has been particularly problematic for Canadian cruise ship patients who are often very abruptly repatriated, and we have to coordinate their transfer back to Canada. Even prior to the pandemic, we often face some interesting challenges to discharging patients back home. Being located in South Florida and frequently discharging back to Caribbean nations, we very frequently have had hurricanes result in some significant discharge delays. Hurricane Isaias, of course, occurred during peak pandemic time in 2020, which further complicated some of our international discharges during that time. In years past, we've also had difficulty discharging patients, particularly back to Haiti, during times of political unrest and during times of doctor strikes, which would have complicated follow-up care. Moving on to the pandemic. Very early in the pandemic, we confronted a number of stranded international patients at our facility. Borders were closed, airports and ports closed, there were quarantines imposed. Some individuals traveled to our region to undergo elective procedures, which were then canceled, to maintain capacity for a surge, and those who were staying locally for outpatient therapy services faced limited availability. One such patient who became stranded was patient number one, who was a 29-year-old man transferred to Jackson Memorial Hospital in late February 2020 from a hospital in the Bahamas with an acute intracerebral hemorrhage, secondary to a ruptured aneurysm. He underwent embolization of the aneurysm and was transferred to rehab on March 20. To put this in perspective, the U.S. Defense Production Act was invoked just two days prior, and the Bahamas closed its border to incoming air and sea travel four days later. This gentleman progressed very nicely. He rather quickly achieved a supervision level with functional mobility and self-care, which was our goal for this patient. But unfortunately, we had no viable discharge plan as we could not return him back to the Bahamas at that time. Ultimately, we were able to discharge him approximately one month following his admission, and we did so by assisting his accompanying parent in obtaining a local short-term apartment. This was still very early in the pandemic. We had very limited outpatient therapy services, but he was prioritized and did receive all three disciplines as an outpatient. Unfortunately, most of his family who were going to be involved in his care were unable to travel to the United States during that time, so we provided them with appropriate updates and training remotely. Another stranded patient was a 32-year-old man from a Caribbean island nation that I will not share here just for privacy's sake, who sustained multiple gunshot wounds in late February 2020. He had a resulting severe traumatic brain injury as well as a left MCA stroke from an ICA injury. He underwent decompressive craniotomy and subsequent cranioplasty, PEG, and trach. During a very long and complicated hospital stay, he was ultimately medically stabilized and eventually discharged to our inpatient rehab facility in June of 2020. At that time, he fluctuated but required anywhere from moderate to total assist with mobility and basic self-care and had very significant cognitive impairment. His home country initially announced a 21-day border closure beginning March 24. Unfortunately, flight service to and from the United States did not resume until July 22 of 2020. He progressed nicely, but we anticipated that he would continue to require minimum assistance, at least with his transfers and locomotion. We very much believed that his family members needed some hands-on training before he could safely be discharged home. Ultimately, when flight service resumed, his significant other was able to travel to the United States and complete hands-on training. But then, of course, right before he was supposed to discharge home, Hurricane Isaias struck his island overnight, July 30-31, and that further delayed his discharge. Fortunately, we worked very closely with his insurance company and were able to get authorization for a few more days so that we were able to safely get him back to his home country. We then moved into a phase where there was this gradual reopening through the Caribbean. At this point, there were very different rules from one country to the next. They seemed to be constantly in flux, and we faced a number of challenges with our family caregivers. Many were forced to quarantine when they arrived in the United States, limiting their ability to participate in hands-on training. Some were possibly exposed to the virus during travel. Typically, our international patients will very often have a family member stay in their room overnight, but many of them couldn't stay at that time because they were quarantined and we were limiting visitors. Unfortunately, in one case, which I'll review in a minute, the caregiver became sick with COVID-19 while she was here. And of course, it's not just the patient that needs to be tested before returning home. Their family members who were participating in their caregiver training also needed to be tested before getting back on a flight. And unfortunately, while we were able to test our patients, the family members were not registered patients of ours, so we were not able to do their testing at our facility. Patient 3 is a 54-year-old man who was transferred to Jackson Memorial Hospital from Aruba with an acute subarachnoid hemorrhage. He was accompanied by his wife. He had very severe cognitive linguistic impairments, and he was newly blind, secondary to Tersen syndrome. His wife began family training with our rehab team, but a few days into his rehab stay, she developed symptoms of COVID-19, and she subsequently tested positive. Fortunately, he did not, but she had to be hospitalized as well. He was very much unable to travel home independently, so his discharge was delayed two weeks for her recovery. Ultimately, they both did very well, and they were able to return home safely. But here, again, flexibility was very much necessary given the situation, and we had to work very closely with our international case managers as well as his insurance company. We then moved into the vaccination era, which brought some other challenges as international patients began to request vaccination in the hospital, and unfortunately, our state policies at that time did not allow us to vaccinate them. We did have a patient who had dual citizenship, and he came to the United States for a planned meningioma resection in early 2021. He requested vaccination on discharge, and he did meet criteria at that time. We were able to coordinate this for him, not in our facility itself, but on our medical campus. His partner had accompanied him, but was not a U.S. citizen and was quite a bit younger. She did not meet criteria at that time for vaccination. At the time, locally, a number of facilities had gotten in some hot water by giving vaccines to some South Americans who had flown to Miami solely for the purpose of vaccination before the population more generally was considered candidates for vaccination. She was quite offended that we were unable to coordinate vaccination for herself and felt it was a form of discrimination. I had to review with her the state policies at length, and ultimately, she understood where we were coming from, but it was definitely an awkward conversation. As the vaccination era moved on, not everyone needed testing prior to flight to reenter their home countries. If they were fully vaccinated, this has very much been in flux with the rise of dangerous variants as well as breakthrough infections. We became very used to just routinely testing patients before returning home, and I kind of ordered a test I didn't necessarily need to order, and fortunately, the patient caught that in time before she had that nice little swab up her nose. She was admitted to our facility in July following a resection of a brain tumor. She was fully vaccinated, I'm sorry, a large acoustic neuroma. She was fully vaccinated two months prior. And again, I ordered the test, the PCR, and then she whipped out an app on her phone and showed me that she no longer required it to return home to the Bahamas. So reflecting back on the pandemic thus far, I think it's been extraordinarily helpful to have the involvement of international case managers, which I highly recommend if you're doing a lot of international discharges. Our team has really learned to be very flexible with discharge dates and times for these patients. We are always extremely aware of any approaching inclement weather that may preclude travel, particularly during the Atlantic hurricane season, which runs from June to November. We found it very helpful to have lists of testing and vaccination sites available for our patients' family members who may be traveling with them. We have long written fit-to-fly letters whenever discharging patients directly from our facility to the airport. We have continued to do so. We have also provided hard copies of their COVID results. Increasingly, a lot of our patients just prefer to log on to our EMR portal and show their test results on that, but there have been problems with that where they've had to resort to the hard copies. So we recommend continuing to do that. We have held a number of remote family training sessions and educational meetings, which I think the families have found hugely helpful when they've been unable to travel here. We've kept lists of local hotels, assisted living facilities, and short-term apartments with some availability. And we've had to really think ahead about the need for follow-up care and how that may be impacted by any quarantine when they return home. You may want to consider having some patients stay locally if they're able to, especially if there's a prolonged need to quarantine upon reentry, but they have an urgent need for close follow-up care. Moreover, if they're having additional procedures in the near future at your institution or in the region, it may make sense for them to stay rather than go back and forth, as they may have done pre-pandemic. And also, if a patient is severely immunocompromised, they may benefit from staying locally as opposed to traveling. I just wanted to share two additional really helpful resources. The International Air Travel Association has a COVID-19 travel regulations map. They keep very detailed lists of restrictions by country and they keep it regularly updated. And I have the website here for you. Travel Off Path is a travel blog that's also kept an updated list of countries that accept the rapid antigen testing for reentry. This has been very helpful for patients whose caregivers are returning home with them. And with that, thank you very much for your attention. I'm happy to answer any questions. You can reach me at the email address above. Thank you. Hello, everyone. I'm Matt Bartels. I'm the Professor and Chairman of Rehabilitation Medicine at Montefiore Health System and Albert Einstein College of Medicine. And I'm going to talk a little bit about facilitating rehabilitation of patients from revolving nations with some lessons from our experience in Jamaica, China and beyond. In the era of COVID, obviously, this has presented a lot of challenges. So I'll also be talking a little bit about what we do and what we see in disability in general in the world. These are my disclosures. So why is it so important to start to look at rehab in this post-COVID world? There's a very high incidence of disability. Approximately 15% of everybody, of the patients or individuals worldwide are experiencing disability by the WHO estimates of 2020. And this is a big challenge for local health ministries because they're not set up to deal with this. In fact, in many developing nations, the focus has been on infectious disease, which of course COVID is. But the consequences such as musculoskeletal, neurologic, and cardiopulmonary are not what they're set up for. So these disabilities include the musculoskeletal, neurological, vision, hearing, and things that are all part of our long COVID syndrome. And the other thing is that in many of the developing parts of the world, half of individuals can't afford healthcare. And this means that they are often in a situation where having had a loss of their ability to care for themselves and or provide their living, they also now cannot afford the care that they need. And the UN has actually now made disability the top of their non communicable disease list. So this translates to a greater than a billion people living with disability and unfortunately with COVID spreading, and with long COVID being prevalent in 10 to 15% of people, this is going to increase the number of people who have some form of disability significantly. The COVID-19 also disproportionately affects the disabled. So if there are individuals who are disabled in these nations, they are probably more likely if they do get COVID to have a secondary effect. And the quality of healthcare that's available, as I said, was very, very limited with very limited rehabilitation interventions. So what are the big barriers to healthcare and disability and for those folks who have COVID? Well, there's prohibitive costs. Durable medical equipment, as we know, is expensive in the United States and in first world nations. But it's extremely expensive if you have to consider, for example, in some nations that they have 100% import duties on anything they import. So take whatever we spend and double it, and that in a country with very limited resources can be prohibitive. There's limited availability as well. And now take a look at what we see with our global shipping crisis. If you even attempt to ship the device or ship some durable medical equipment to somebody in one of these nations, they are also going to potentially have a long delay, even if it is available. And then there's physical barriers in most countries. The physical barriers exist in that curb cuts and many of the things that we assume in a lot of our urban environments don't exist in many of these countries. And then if you're in a rural environment, you don't even have paved surfaces. So you can imagine somebody with mobility limitations trying to go over those barriers. And there's also inadequately trained healthcare workers who don't know how to work with individuals who have disability. And think particularly of all the cognitive issues that we see with COVID and how that's actually going to be very problematic as it's difficult in our settings to be able to do this. You can imagine the challenges in a very urban or very rural third world setting. So basically, the post COVID care and the disability that we see in these third world areas need to be seen as a public health issue. Because this is really an issue that will affect not only directly their health, but also the ability to deliver healthcare in these countries. And you need commitments from the ministries of health so that you have access to effective services. You need protections during the health emergencies, such as during this COVID pandemic. You also need to have access to other public health services, sanitation, water, hygiene. And as you can imagine, in a situation where sanitation and water access are limited, if you now have a disability on top of this, how difficult it may be for you to actually maintain even just basic living conditions. And this often requires policy and legislation, which requires interacting with the governments in these countries. And you have to worry about finance and service delivery, and then also doing data collection and research. And unfortunately, the World Health Organization is committed significantly to this. In fact, in 2019, the UN Disability Inclusion Strategy, UNDIS, made a goal of promoting sustainable and transformative progress in disability inclusion. And this is very important because fortunately, with the onslaught of many people with COVID disability, there is a structure that came in one year before the pandemic to help us with managing and providing services for these people. And currently, the World Health Organization is preparing a comprehensive policy on disability and action. And I've had the fortune of working on the pulmonary disability portions, but they're doing this also for cardiac and everything else. And we did this during COVID and did include some specific language regarding COVID. But actually, the pulmonary policies for any individual with pulmonary disabilities probably covers most of the disabilities that we see with COVID. And I feel that for brain injury and for some of the other things as well, COVID can be included, but does not need to have its own special category, because it's complicated enough to get the disability services internationally. So this is actually the UNDIS Entity and Accountability. They talk about leadership, inclusiveness, programming, and organizational culture. And I won't spend a lot of time going over this. This is available on their website, and it's in the slide set. So for those of you with more interest, you can look at this. But the real big thing is that you need to have leadership. You need to include both the patients and the caregivers. You need to have programming that is at both professional level as well as at layperson level. And then you need to really look at organization of an entire culture for employment, capacity, and communication. So it's a comprehensive program to approach this. Now, these are just the indicators that I have from the World Health Organization from 2019 about leading causes of death globally. And this parallels the disability. And you can see that stroke and chronic obstructive pulmonary disease and lower respiratory disease are in the top four, along with ischemic heart disease. So major sequelae that we have been seeing with COVID are being increased or increasing some of these top four categories of disability. And this is a real challenge. And if you look at low-income countries, the respiratory infections are already a tremendous problem for disability. And the actual leading causes of death, you can see ischemic heart disease wins, but disability is from respiratory disease. And COVID is going to just increase this burden. In upper middle income countries, which is where we are in the United States, we're actually at a high income country, ischemic heart disease and stroke and Alzheimer's disease, the pulmonary diseases are not as common. So we don't have as great an appreciation in our own populations of the actual major burden that they are facing in these other countries. So this is actually a plot that's kind of interesting that shows that the numbers of daily accounted life years, DALY, from 1990 to present is continuing to be roughly the same. However, the actual standardized daily rate is down and that's because population has been increasing. So overall, for many patients, the amount of disability accumulated life years is decreased because there have been services provided, but it's still way too high. So for the number of disabilities that are happening, we still have to work hard to decrease the amount of life years that are affected. And this map just shows you the blue countries are countries that have very high number of disability in proportion to DALYs, meaning that there are very few individuals with disability who actually can survive long, whereas in the very red countries, the disability survival is very, very low. Now, I'm just using as a quick example, coronary artery disease, and the rates are very high. And the problem is that in many of the developing nations, this is actually increasing. And the problem I'm using this as a corollary is trying to establish cardiac rehab programs and pulmonary rehab programs face similar limitations, but most countries until now have not been interested in pulmonary, but you can translate a cardiac rehab program into pulmonary. And the reason that this has been a priority is because it's the highest incidence of death in most nations causing a significant morbidity as well. So it's the leading cause of death and the news for the world is mixed, but smoking is a big problem. And that also has a lot of pulmonary disease. And with our COVID, we're actually now overlapping with some of the smoking disease, although COVID presents with a restrictive lung disease and smoking generally has obstructive lung disease, but the rehabilitation principles are very similar. The need to deliver oxygen, the needs to actually provide these services are also similar challenges in most of these areas. So what is our role from academic rehabilitation? And I'll try to circle back to what we're trying to do. There's a real role for academic rehabilitation to try to improve services. And I think Dr. Shapiro's talk was a great example of how interacting within the Caribbean and in the local area or the region of the world, we're able to provide a lot of services that are not available locally, but ideally these patients wouldn't have to travel much and we could actually provide more services locally. And so what we should try to do is educate about rehabilitation for providers in the developing nations. It's not necessarily reasonable to expect rehabilitation trained physicians, but if we can find orthopedists or neurologists or internists who are willing to learn the basic principles, we can actually start providing these services locally. And our opportunities are to collaborate with established schools and programs in these countries in order to try to establish education that's self-sustaining. It's the idea of train the trainer and then they can actually train each other. And we have done a lot of missions and visits to do face-to-face education to provide services. And the services that we provide, it's great to be there for a week or two weeks, but then the rest of the year you're not there. But we use those as opportunities to do hands-on training and education with our colleagues and then establish telemedicine or tele-consultation so that we can actually support them. We support local institutions and groups as well, and that can be charitable organizations or institutions and create sister hospital relationships. We have a lot of equipment that, you know, we renovate a floor and there's all these hospital beds that get replaced and they are brand new in these other nations and we can actually transfer them there. Same thing with a lot of our rehabilitative equipment. So the challenges, staffing, facilities, education materials, and funding. Community engagement, most developing nation infrastructure, as I had mentioned, is not disability-friendly and it's not part of the legislative ethos of these nations. There is no ADA in most nations. And because of that, you have to actually try to educate not just your fellow healthcare workers, but you also need to work on trying to get some of the local authorities to also realize that some simple modifications can make access much better for their citizens. So you want to start. You need to get a relationship with an existing facility, ministry of health and providers. If you decide to go to a nation and try to help and you haven't got any contacts or just a tourist, you need to actually be involved with somebody who's on the inside. My advice is to try to find local religious or other organizations that have communication with the ministries of health and the other ministries. And that's where we've actually had a great deal of success, mostly in Jamaica, where we actually have contacts within the ministry of health and have memorandums of understanding to help develop and provide services, which makes it so much easier. If we're importing equipment, we don't pay taxes and duties because it's brought in as diplomatic. If we actually try to establish or do something educational, they help by providing resources and making sure that the facilities are available. And when we go on missions, they help to facilitate that our providers get temporary licensure and insurance to be able to go and provide the services and then work side by side with our colleagues. You also need to engage with agencies and schools. And we've actually done that with some of the educational institutions in Jamaica. And you need to help the providers to provide the services. So it's maybe actually providing equipment and things. And Dr. Rand will talk a little bit about some of those experiences. So with our Jamaican relationships, we have the Golden Rehab Hospital in Kingston, Jamaica, that we have a very tight relationship with. This is a rehabilitation hospital that does not have speech language pathology or occupational therapy. So it is one of the only rehab hospitals in the Caribbean, but has very limited capacity to provide very complex care. And we also need to train providers. So here are some photos of some of our staff, residents, students, and others going down to Jamaica. And we've actually had tremendous success with engaging with our colleagues there. And over here on the upper right, we were making bioelectric hands using 3D printing. And here's the 3D printer we delivered, which I think Dr. Rand will talk more about. Now in China, this is one where I was approached by in-country commercial and governmental representatives. And as far as COVID, because of COVID, I have not been back to the country in two years. And it will probably be another six months before that's going to be possible. I have been doing telehealth and teleconferences and teleteaching to help our providers that we work with over there to develop programs to help patients and help set their facilities up to work with patients who are having long COVID. They fortunately have not had as high an incidence of the disease, but they actually do have some problems with this and are very interested in working with us because it's an expansion of the cardiac and pulmonary rehabilitation we did before. One big bit of advice is anytime you go to a country like this and you do work with them, whether it's Jamaica or China or any other nation, go with humility. You don't have the answers. You go there, do a fact-finding mission, find out what they think they need, what they want, and then work within those boundaries. Because your solutions may work in our settings, but they may not work in their local settings, and you may not know what their resources are. And these are some photos from experiences in China, everything from the Great Wall to some other lectures and conferences. So conclusion, you know, it's the right time for rehabilitation worldwide. The WHO has this as a world goal. COVID is actually providing us an opportunity to leverage the fact that there are going to be so many survivors with long COVID, and what we provide and what we can do should be modified to be able to provide this and is possibly an opportunity to open the dialogue. The rehabilitation is also cost-effective, and you can actually help the patients do a lot of their own care if you actually work within local resources. And you can often find a lot of local resources that are inexpensive, particularly to manufacture DME and other things. So for example, find local providers with 3D printers that can make the DME. For patients and family members, you need to have primary prevention. And, you know, the vaccination limitation is that currently only about 3% of people living in developing nations actually have had complete vaccination. So this is a real challenge, and we want families to be vaccinated as well as the patients. And we've been using the cardiac rehabilitation as a springboard for other vascular rehabilitation as well as now COVID because there are so many overlaps between the two. Thank you very much, and unfortunately can't answer any questions because we're doing this in a telemedicine format. Okay, I'm Dr. Stephanie Brand. I am the Associate Program Director of our PM&R residency at Monty and have been very involved in our global health initiatives, both for the institution and the residency for several years. I have nothing to disclose. I do not work for or have any stock in Google, Zoom, or any of the other open source companies that have become a very large part of our mission work post-COVID. So for this talk, we're going to talk a little bit about the different technologies and platforms that are available for international collaboration. They are often the same as the ones that you have gotten used to for general distance learning, but there are some that are more available on an international platform than you may be used to. So we'll go a little more detail into those. I'm going to highlight this through the example of most of our slash my global health work with Dr. Bartels in Jamaica and with the Monty residence and 3D printing program there. And we'll hopefully figure out some of the challenges that need to be overcome and the opportunities that allow for a successful program. Before COVID, we started running medical missions to the Sir John Golding Rehab Hospital in Kingston, Jamaica in 2016 as a combination of service and education, as well as local pop-up clinics while we were there for service and to the nearby University of the West Indies in Kingston for education. At our first mission, we presented a bit on what we were doing locally in the Bronx with our 3D printing for underserved population, primarily at that time printing prosthetic hands for children whose insurance denied their claims or who didn't have insurance. And the local buy-in in Jamaica was immediate. And we continue to work with them both in person twice a year, as well as occasionally remotely, even pre-COVID. This culminated in the delivery and us delivering a 3D printer to them in 2018. And there's a picture of it being delivered. Our first 3D print is on the far right, and this little circle is a tracheostomy cap. One of the first patients that the team identified was a spinal cord injured gentleman with a tracheostomy ready to be weaned, but without any tracheostomy caps. This is not an uncommon experience, both in the U.S. and internationally. The caps come in the kit for when the trach is placed and are often lost. I've been told by our ENTs that they like to use CBC red top tubes. They fit perfectly. But even that is a limited resource in some parts of the world, particularly in this case in Jamaica. So they often weren't able to have any caps. So within 90 minutes of identifying this patient, we were able to find a CAD file for the cap, print it, and deliver it to the patient. Prior to this, our colleagues at Golding told us that they had not had any trach patients successfully decannulated during their rehab admission and owing to the caps being misplaced. So following being able to print caps, in the year that followed, they successfully capped seven patients and decannulated six of them. And we helped them to track this information with the resources that I'm going to discuss shortly. Similarly, the first two photos here are showing splints. The rehab hospital often often went without having resting hand splints available to their patients because the commonly fabricated thermoplastic splints were hard to come by. Our team converted the typical template into a 3D printable file and that is printed. And then similarly to the thermoplastic molded in after a hot water bath. And we similarly, although not as dramatically, can track these patients that received 3D printed splints. Not surprisingly, as the pandemic hit, our efforts to travel to Jamaica have halted, but our communication has not. So now we're going to talk about sort of the goals of international communication. I break it down into three main purposes. Real-time communication, real-time conversations, questions and answers, teaching and learning, which as Dr. Bartels mentioned, has always been a big part of our missions and the purpose of global health in general, and then data tracking. We use different open source platforms to achieve these three different goals. This is not a one-on-one slide. To the last slide, the breakdown of how these different resources are utilized for the different goals will be explained in future slides. Our platforms can be broken down into instant messaging apps, teleconferencing and shared drives. Instant messaging apps, the most famous of which are text messages and iMessages, but the most commonly used internationally is actually WhatsApp and maybe the most commonly used amongst your residents as well and the residents and students out there. There are more than 2 billion users in 180 countries that use WhatsApp. It is internet-based, not self-reception based, so you don't have to be paying a carrier to use it like one would with text messages or iMessages. In 2014, Facebook acquired WhatsApp for $19 billion. When they did so, it was speculated that they wanted data mining, although they've always denied it. In 2016 and then earlier this year, there have been some changes in the terms of service and privacy policy in WhatsApp that actually, particularly in the beginning of 2021, caused a massive exodus of WhatsApp so big that they postponed future changes and have been rewriting their user agreements to again focus on not reading people's conversations, not sharing information. Anything that is written in WhatsApp is not saved to the WhatsApp servers. After they're delivered, they are stored on your personal device and the device of the person that they were sent to. Teleconferencing is a combination of conference calls, which are voice-only, and video conferences like we're doing now with voice and video. The most popular of which we all kind of know internationally, often using Zoom, WebEx and GoToMeeting, very popular in the US, although Zoom really took off in the pandemic, as I'm sure I don't have to tell anybody. Skype is still bringing up the end. When making a Zoom, things to consider, privileges, who has the right to start the meeting or share. Breakout rooms, as I'm sure you will see during some of the live AAPMNR sessions, are an excellent way for smaller group collaborations. The recording function is an important one to consider whether you're going to use it or not when sending lectures internationally. Recording it obviously means that people can watch it later, which is great. It also means that it's kind of out there and a little more permanent. Polling is an excellent way for some real-time communication in the middle of your Zoom. Of course, it can be used both for collaboration or just dissemination of information. Shared drives provide a location for secure collaboration, and they're primarily considered file hosting services. Dropbox, Google Workspace, Microsoft 360, iCloud are all popular. We use primarily Google for international work. We use primarily personally Microsoft internally, but it's a little harder to have a non-Microsoft account interface with a Microsoft 360. Why do we use Google Workspace, which is the old Google Suite? It's because it's free. It's because it's user-friendly. And because when you're working on it, you auto-save, which is great. Sorry. The accessibility features are all available for you to look up if you would like, and you can actually collaborate on documents in Google anonymously. I'm not providing that information on how to, but again, it's pretty easy to follow their directions. How do we use it? So, for real-time, we can use drawing to collaborate on projects. For real-time or delayed communication or collaboration, we use Docs, Slides, which is the Google version of Excel. I mean, of PowerPoint and Sheets, which is the Google version of Excel. Drive, we use primarily for delayed communications. The main problem with Google is it's not HIPAA compliant. If you're looking for something more HIPAA compliant, which there technically isn't HIPAA in most of the countries we're dealing with, and when we are doing international data sharing, we have kept our patient identifiers out of it, so it hasn't mattered, but if that's something that's important for a project, there is a service called NextCloud Hub. It is a self-hosting server, so you have to have local servers for the storage, which if you're going to be doing like a large electronic medical record or large amounts of data, you need to be aware that you have to have the local space, but you can access it anywhere through the cloud. When you're using Google Workspace or Microsoft 360, you're accessing it anywhere, but it's locally, the storage is not local on your computer anymore, the storage is on Microsoft servers or Google servers somewhere around the country or world, right? In this case, you have access to the data, so it's on your server, but you can still share it anywhere in the country or around the world through the cloud. It is HIPAA compliant, also high-tech compliant, which is an EHR technology act, and general data protection regulation compliant, which is the legal framework from the EU for about collecting and processing personal information. It is a much longer setup time than setting up a shared drive, for example, but it is compliant. Oop, I went too far. That was pretty much it, though. How do we do it? So I said, WhatsApp, real-time Q&A, teleconferencing for international lectures or international meetings and shared drives. We've uploaded and shared training videos, a repository for our computer-assisted design files, the files that we need for 3D printing, and sheets to track splints, trait caps, and decannulations. Thank you. So thank you to my colleagues who have already given excellent presentations. I am Monica Berduzco Gutierrez. I am the Chair of the Department of Rehabilitation Medicine at UT Health San Antonio. My practice is mostly neurorehabilitation, spasticity management, and now COVID-19. I am also the Medical Director of Critical Illness Recovery and Neurorehabilitation at Warm Springs Hospital, and my disclosures are there at the bottom. So one thing that I would be focusing on in talking about international telerehabilitation is why and what we do this. So a lot of, previously, I did take care of a lot of international patients, especially when I was at TIER. We had a big international program. And then in San Antonio, we're very close, obviously, to Mexico. So we have a big population of patients that come who can travel and come to Mexico to get some of their healthcare here. But during COVID, you've already heard about a lot of the limitations that we had. Clinics were closed, borders were closed. Travel was severely limited. And so we rapidly, everyone rapidly adopted telemedicine, but it became really an excellent way for us to be able to treat patients internationally, especially ones with limitation of travel. So we rapidly adopted this, and we know telemedicine has a lot of benefits. There's improved access to care. It can reduce barriers. And especially persons with disability, which you heard about a lot of the limitations that they have internationally, this is a very vulnerable population. I didn't want them to be traveling to the U.S. during some of this time. And so we had availability of telemedicine for this population. I've had maybe about three articles at this point where we wrote about telemedicine and persons with disabilities, and also some of the intersection identities that these patients with disabilities have, including being sometimes from developing countries or from marginalized groups, even here in the United States, and how this can provide some more equal access to care. So what are some of the benefits of telemedicine? So again, lower cost of care. Someone internationally doesn't have to fly in. They don't have to get a hotel. They don't have to travel in, whatever it may be. Then also, if I can see them in their own setting, that's some of the best part that I like is that I can see them in their home, see what they have around them, see what their caregivers do for them. I am not exposing them to any communicable diseases if they have to come here. And then also, if there's questions like, what medications are you on? Show me their medications. What therapy are you doing? A lot of times, especially international patients, they have a lot of home-based therapy since there's not a lot of formalized rehabilitation centers and so they can have their therapist or the person that's doing their home exercise program with them and actually show me what they're doing and we can work on their goals based on what I can see. So I like to see them, especially in their exercise or therapy program setting. And then again, they may not need to pay someone to bring them over and those extra costs that come with that. So it's just definitely has been something that international patients have really enjoyed. Of course, I'm not able to do interventional management through telemedicine, but at least can direct their care. So I'm gonna go through just some cases and some examples of what I'm able to see and what I'm able to do. So this is a patient, again, like I said, neurorehabilitation, it's spasticity. And actually what's great is that I can see them in their home setting and I can ask them to do certain activities that are part of their goals, which we want for them to have functional goals. And so in the case of this patient, her goal was for self-feeding. So I can actually have her sit at her table, watch this, watch her with food that's really there and see her feed herself. And then I'm able to make an assessment. Again, I don't have to do modified ASHRAW scales on everyone. I can direct a family member to do it for a patient, but it's not as good as seeing actual functional movement and me able to make a determination on what someone's gonna need for their treatment after that. Here's a patient who, again, we use different technologies in this case. For the most part, we use Zoom through Epic. And this is a patient who, you know, they're at their home. So they can tell me, okay, those last sets of injections worked well and this is what we're working on. They can go grab their guitar or whatever it might be that they have that is pertinent to them. And they may not always be able to, you know, bring a guitar into clinic, though that would be kind of fun, but definitely on telemedicine, being able to be serenaded and see patients that way. For this patient, you know, someone that I've followed over time, someone that we have a good long-term relationship with, who also has communications with WhatsApp, just with, especially when international patients have intrathecal therapies that need to be managed from out of country. And so I make sure I have a very close relationship with those patients. So they can even send me messages, send me videos doing telemedicine visits and able to see patients again. You know, there he is. I can see how he's doing with his walking. I can see, you know, the caregiver is there with them and able to give, you know, very live updates on how things are going with the patient. So again, using whatever technologies that they may have and using several different technologies, it's gonna be great for patients who are international rehabilitation patients. And what is the point of doing all of this? So I think we heard a little bit about how wonderful telemedicine is, how wonderful the WHO is at, you know, bringing a lot of attention to disability and disability management. And so there is a huge renewed focus on health equity right now. And we've seen this through COVID-19 and there are now global initiatives to use digital health technology for new approaches to reach more patients. And so this is a time again where I said we have rapid digital transformation of our healthcare system. And so this transformation affords us the opportunity to address many core health equity challenges. And so we need to have digital health enabled tools and environments to augment this in-person care and to be able to provide it globally and to address the structural challenges that we had before for marginalized populations, including lowering access to barriers of time and of distance, and then providing tailored communication with language and literacy. And this is just something that, again, it's being pushed a lot by the World Health Organization. They've created a global strategy on digital health and, you know, they have goals through 2025 where they want to, again, promote healthy lives and wellbeing for everyone, no matter where you are in the world and using technologies to do that, including there was an article just a few days ago that was at JAMA about, you know, how do we focus on digital health equity? And we need to do it in an international setting as well. So when I talk about digital and telemedicine and international, one thing that we have to think about as well is social media and using social media for an extension of the doctor-patient relationship. So I think you see more and more that patients are using social media to find their information, and that information may not always be the best information, but especially here in the US, 75% Americans use social media to research their symptoms. 90% of 18 to 24-year-olds actually believe what's on there. And I think before that, people would be aghast with that, but I think now we really see that people believe what's on social media and on their social feeds. And then also they want to see that their providers have a social media presence or that their practice or the department has a social media presence. So again, that's something that what's on social media is international. People internationally can be reading this. They can look at the information that you're providing on social media sites, whether that be your personal one or one through your own department or your own practice. And so again, something to increase health access, to increase the extension of your doctor-patient relationship, and really be able to reach your patients both locally and internationally and impact their daily choices on things that they make. So again, the CDC is encouraging leaders in healthcare to use social media. They had a Millennial Healthcare Summit. They want for people to use social media in these ways. Again, working towards health equity because you can facilitate real-time conversation, educate communities that usually are not reached, and this includes communities globally. Also the World Health Organization, as I said, they also endorse the use of social media to spread information. They have their new initiative right now. And this can be a tool that's used to reach underserved populations. They of course have their own multiple, multiple sites, whether that be on YouTube, Instagram, et cetera. So a little bit about, you know, I love telemedicine. I love doing international telemedicine. I love to be able to see those patients, things that it's wonderful. And this is based on one of the papers that I had stated earlier that we wrote. And it's like wonderful that telemedicine improves this access and reduces barriers, especially during COVID-19, but there are still barriers and challenges for persons who have disabilities. And we have to make sure that we access those challenges, which is anything from infrastructure, operational, regulatory, communication, and legislative. Again, always the legislative doesn't count in other countries where some of, where we heard about their limitations and what they have. So first infrastructure and access, and, you know, broadband in some areas may be inaccessible and it depends on where you're doing your international telemedicine. So yes, a lot of the international, some of the international patients I get to see are very well off and have the means otherwise to travel to the U.S. and see a physician. And so it is definitely different if you're doing an underserved population in a global area. So they may not live in an area where broadband is accessible. And we kind of even see that in some of our own rural communities. And a lot of times there's no investment into these communities, especially globally, where if it's a developing nation, they may not have the infrastructure to have that broadband in a lot of places. And it may not be a legal requirement in their country or in their area, and nor is there a financial incentive to do it. And so that is just definitely something that can cause a barrier for patients who are doing international telemedicine or some of the international practices you may want to do. And then the other thing is we need to find a way to develop novel bioperipherals. So again, I cannot physically put my hands on someone, but is there a place where they could go, a facility that may be able to, you know, monitor them or give them something that they're being monitored at home for their steps or for, you know, whatever it else may be. And this needs to be worked on. Operational systems and challenges. So again, what are the costs that are associated with some of these telehealth platforms? Yes, a lot of it is on ourselves and what we have for our facilities, but what about, you know, on the other end? And do they have the right kind of phone, the right kind of operational system to use these telehealth platforms? Next is logistical challenges. So again, I can see someone all day and I can say, oh, this is what I think you have. This is what, you know, I'm doing my assessments and I still cannot, you know, go and do an injection through telemedicine. And if I need labs, if I need a diagnostic test, then a lot of times they're going to have to find a place to do that and then get the results of what that is to me. So that does cause a lot of logistical challenges that we have to work through. And so, you know, figuring out, okay, I can order this and I can put it in the computer system, but where do we send it? Where does the patient get it done, especially in an international setting? And then once it's done, do they have access to those results to get them back to me? The other logistical challenges, when that patient does need a procedure, what gets done? Do we then decide, okay, now you can transfer or can I talk to a physician that is local to their country who may be a physiatrist who does, or a neurologist, in my case, a lot of spasticity injections, then, you know, will I see someone and say, well, this is what she had last time. This is what I would plan to inject. Is there someone that you could see locally and I can give you the plan of what I think, which muscle should be injected with how much, and then have someone to do it locally if that's the case. And again, they'd have to have access to someone to be able to do that treatment, but another consideration. The thing is regulatory barriers. And as we heard before, there is no ADA in other countries, though, you know, we have it here. One thing that's interesting about the ADA is that the ADA was before the time when we had all of this online type of telecommunications. And so there is no standardized telehealth regulatory framework or also protections under the ADA for this, just because it was done after the ADA was created. And then there's communication barriers that we know that, again, patients, other than international, some cases you're gonna need a translator. And so making sure that in the telemedicine platform that you use, that there's a way to bring someone to translate in if you need a translator. And then also what about the patients who, because we are physicians that take care of persons with disabilities that have their cognitive deficits, blind, deaf, then how are we communicating with them? And do they have a way to communicate back to us, especially if they're international? And then also are the education materials like, oh, how to sign in to MyChart and create a MyChart account. That paperwork and the people that answer the phones here are explained in English, but what if someone speaks Spanish? What if they speak Portuguese? What if they speak Arabic? Then are those materials available in their language? And then we've talked about legislative barriers already and need more regulations here in the U.S. but there's of course lack of regulations outside the U.S. What are some of the unique barriers? Just again, if patients have intellectual disability, how are you going to effectively communicate with them? Patients, if they're trying to use a phone because maybe they don't have a laptop and they just have to use what access they have with their phone, then do they have the manual dexterity handle their phone? And then again, if someone has autism spectrum or mental illness is a visual interface maybe not appropriate for them. So in closing, you know, tale of two outcomes. I always am very passionate about talking about health equity and making sure access to care is so, so important and that is both locally and internationally. And we know that healthcare disparities have been rampant during the pandemic for marginalized groups, especially outside of the U.S. where they don't have as many resources or they don't have as much access to some of the treatments or even to vaccinations. And this has been really highlighted during the pandemic. Disabled Americans are less likely to use technology but probably even less likely for persons who are from international communities and are disabled as well, where they're definitely more marginalized and have less money in those countries as well. And so outcomes need, you know, how can we supplement and how can we make this better? And so I think, yes, telemedicine for international work is very important and hopefully this just gets your mind thinking and there will be more to do for the future. Thank you very much. You're free to send me an email or if you have any questions on this. Thank you for joining us today or whatever day you actually watched this. Our information to chat more can absolutely be made available through the AAPNNR. I hope that you feel inspired to extend your reaches globally and have a great rest of the conference.

telemedicine

international settings

access to healthcare

patients with disabilities

COVID-19 pandemic

remote assessment

treatment

challenges

underserved populations

health equity