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How to Practice High-Quality Telemedicine in the Era of COVID-19

By ANISH MEHTA, MD

My practice received its first question about coronavirus from a patient on January 28, 2020. Though there were over 200 deaths reported in China by that time, no one could have imagined how drastically this would come to disrupt our lives at home.

Thankfully, I had a head start.

As a doctor at an integrated telemedicine and primary care practice in New York City, nearly two out of every three of my medical encounters that month was already virtual.

I spent much of January caring for patients who had contracted seasonal viruses, like influenza or norovirus (i.e. the stomach flu). My patients reached out nearly every day with bouts of fevers, fatigue, diarrhea, and vomiting. Our team did all we could to encourage each of these patients to stay home and avoid spreading their highly contagious virus throughout the community (sound familiar?).

We are now guiding our patients through the COVID-19 outbreak using the same tools we use to guide them through any healthcare need – real-time monitoring, proactive outreach, and team-based care.

After our first COVID-19 question, our team started compiling information about every patient who reached out with symptoms that even slightly resembled COVID-19. This soon turned into a comprehensive patient registry containing the epidemiologic risk factors, clinical risk factors, symptoms, and a follow-up plan for each patient. Based on their total risk level, we follow up with these patients every 24 to 120 hours.

Every day, one provider on the team texts or schedules a video visit with each follow-up patient, reassesses their symptoms, and re-stratifies their risk. Most patients respond with a text message letting us know that their symptoms are the same or slowly improving. But for patients at higher risk, we want more information. We help these patients acquire a thermometer or pulse oximeter to follow up on their respiratory vitals. With this data, our team can provide patients and their families with thresholds on when to seek out a higher level of care.

Our job for these patients is clear: provide treatment at home and only recommend the hospital if there is no other option. By centralizing data and establishing clear triggers for a new plan of care, a single provider can follow up with over 30 COVID-19 patients in a single day.

Of all the patients with COVID-19-like symptoms, so far not one has required hospitalization.

The other providers at our practice spend their days talking with patients via text, phone, or video. They have mastered one of the most valuable diagnostic tools in medicine: taking a history. But no matter how skillful they are at asking the right questions, a solo provider in the current outbreak can be cognitively and emotionally overwhelmed by the information coming in from patients.

Back when our brick-and-mortar medical offices were open, our team used to hold a daily huddle to discuss complex patients on the schedule that day. With the offices closed, this ritual still stands. Instead of discussing whose hypertension is poorly controlled or who is overdue for a Pap smear, now we focus on issues inevitably impacted by COVID-19. We discussed whether to prescribe steroids to a patient with an asthma flare likely due to COVID-19, or how to keep a patient feeling isolated and suicidal safe at home. This routine serves as an important reminder that we are not only providing COVID-19-care. Patients continue to have medical and mental health problems that are amplified by this pandemic.

During my medical residency, a senior doctor once told me that when it comes to sick patients, never worry alone. Our entire clinical team worries about COVID-19 and how the pandemic impacts our patients’ health. More than anything, the frequent huddles create space to share those concerns in the open. Even if there’s not an immediate solution, we can rest a bit more assured knowing that no one is worrying alone. We tackle these challenges as a team.

As the number of confirmed cases of COVID-19 in the US has skyrocketed to over a million, medical providers have a clear mandate: treat patients at home and keep them out of the hospital.

But to be effective, this will require more than simply swapping an office visit for FaceTime or Zoom. A coordinated, proactive, and team-based system can help patients get the care they need and keep communities safe. These elements are essential for an effective telemedicine response to COVID-19. And after the crisis has passed, I hope we continue to use telemedicine as the foundation for a new model of care, not simply as a shallow replacement for the doctor’s office.

Anish Mehta is a practicing physician and the Director of Clinical Affairs at Eden Health.

A Vigilante in Statistical Badlands

By ANISH KOKA, MD

Something didn’t seem right to epidemiologist Eric Weinhandl when he glanced at an article published in the venerated Journal of the American Medical Association (JAMA) on a crisp fall evening in Minnesota. Eric is a smart guy – a native Minnesotan and a math major who fell in love with clinical quantitative database-driven research because he happened to work with a nephrologist early in his training. After finishing his doctorate in epidemiology, he cut his teeth working with the Chronic Disease Research Group, a division of the Hennepin Healthcare Research Institute that has held The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) contract for the United States Renal Data System Coordinating Center.  The research group Eric worked for from 2004-2015 essentially organized the data generated from almost every dialysis patient in the United States.  He didn’t just work with the data as an end-user, he helped maintain the largest, and most important database on chronic kidney disease in the United States. 

For all these reasons this particular study published in JAMA that sought to examine the association between dialysis facility ownership and access to kidney transplantation piqued Eric’s interest.  The provocative hypothesis is that for-profit dialysis centers are financially motivated to keep patients hooked to dialysis machines rather than refer them for kidney transplantation.  A number of observational trials have tracked better outcomes in not-for-profit settings, so the theory wasn’t implausible, but mulling over the results more carefully, Eric noticed how large the effect sizes reported in the paper were. Specifically,  the hazard ratios for for-profit vs. non-profit were 0.36 for being put on a waiting list, 0.5 for receiving a living donor kidney transplant, 0.44 for receiving a deceased donor kidney transplant.  This roughly translates to patients being one-half to one-third as likely to get referred for and ultimately receiving a transplant.  These are incredible numbers when you consider it can be major news when a study reports a hazard ratio of 0.9.  Part of the reason one doesn’t usually see hazard ratios that are this large is because that signals an effect size that’s so obvious to the naked eye that it doesn’t require a trial. There’s a reason there are no trials on the utility of cauterizing an artery to stop bleeding during surgery. 

But it really wasn’t the hazard ratios that first struck his eye.  What stuck out were the reported event rates in the study. 1.9 million incident end-stage kidney disease patients in 17 years made sense. The exclusion of 90,000 patients who were wait-listed or received a kidney transplant before ever getting on dialysis, and 250,000 patients for not having any dialysis facility information left ~1.5 million patients for the primary analysis.  The original paper listed 121,000 first wait-list events, 23,000 living donor transplants and ~50,000 deceased donor transplants.  But the United Network for Organ Sharing (UNOS), an organization that manages the US organ transplantation system, reported 280,000 transplants during the same period. 

The paper somehow was missing almost 210,000 transplants.

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The New Normal is Still Unknown, on Earth as it is in Healthcare

By HANS DUVEFELT, MD

From the vantage point of our self-quarantined shrunken universes, we cannot see even the immediate future, let alone what our personal and professional lives will look like some years from now.

Factories are closed, luxury department stores are in bankruptcy, hospitals have stopped performing elective procedures and patients are having their heart attacks at home, unattended by medical professionals. New York office workers may continue to work from home while skyscrapers stand empty and city tax revenues evaporate.

Quarantined and furloughed families are planting gardens and cooking at home. Affluent families are doing their own house cleaning and older retirees are turning their future planning away from aggregated senior housing and assisted living facilities.

In healthcare, procedure performing providers who were at the pinnacle of the pecking order sit idle while previously less-valued cognitive clinicians are continuing to serve their patients remotely, bringing in revenues that prop up hospitals and group practices.

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Post-Pandemic Solutions: A Public Option for Universal Healthcare

By ROSEMARIE DAY

As the coronavirus pandemic overtook the tail end of the Democratic primary season, attention rapidly shifted from examining the nuances of the differences between the candidates’ healthcare platforms to simply demanding a response to the pandemic. Beyond addressing the immediate crisis, however, lie many questions about the weaknesses of our current healthcare system, and how we will address them in the long run.  These questions should be at the forefront of voters’ minds as we head into the election this fall. 

One of the major weaknesses in our system is that we do not have universal healthcare. Importantly, virtually all of the Democratic candidates called for making healthcare a right in the U.S. This is a key first step toward universal healthcare.  Their approaches to achieving this varied, however. Bernie Sanders and Elizabeth Warren called for “Medicare for All,” but most of the other candidates, including Joe Biden, have pushed for some kind of public option. The public option has faced criticism that it will simply maintain the status quo. This criticism inspired me to write this blog, because a large-scale public option program could actually help to reshape the US healthcare system and result in improvements in access to care in this country, ultimately getting us to universal healthcare.

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THCB Gang, Episode 10 LIVE 1PM PT/4 PM ET 5/21

Episode 10 of “The THCB Gang” was live-streamed on Thursday, May 21th

Joining me were regulars: writer Kim Bellard (@kimbbellard), policy expert Vince Kuraitis (@VinceKuraitis), patient advocate Grace Cordovano (@GraceCordovano), radiologist Saurabh Jha (@RogueRad), employer consultant Brian Klepper (@bklepper1), Deven McGraw (@healthprivacy) and a guest, former ONC Consumer head Lygeia Riccardi, now at Carium Health (@Lygeia)! The conversation moved onto the new normal of telehealth, how much things would change in the future, and what the story with testing and opening up would look like. You can see the video below

If you’d rather listen, the “audio only” version is preserved as a weekly podcast available on our iTunes & Spotify channels — Matthew Holt

Health in 2 Point 00, Episode 124 | Omada Health, Meru, Noom, and Alike

Today on Health in 2 Point 00, Jess asks me about Omada Health raising $57 million and then spending $30 million acquiring Physera, Holmusk raising $21.5 million, digital mental health company Meru raising $8.1 million, Noom partnering with LifeScan for digital diabetes care and Alike raising $5 million.—Matthew Holt

Home, Sweet Work

By KIM BELLARD

If you’re lucky, you’ve been working from home these past couple months.  That is, you’re lucky you’re not one of the 30+ million people who have lost their jobs due to the pandemic.  That is, you’re lucky you’re not an essential worker whose job has required you to risk exposure to COVID-19 by continuing to go into your workplace.  

What’s interesting is that many of the stay-at-home workers, and the companies they work for, are finding it a surprisingly suitable arrangement.  And that has potentially major implications for our society, and, not coincidentally, for our healthcare system.

Twitter was one of the first to announce that it wouldn’t care if workers continued to work from home.  “Opening offices will be our decision, when and if our employees come back, will be theirs,” a company spokesperson wrote in a blog post.  “So if our employees are in a role and situation that enables them to work from home and they want to continue to do so forever, we will make that happen.”

Other tech companies are also letting the work-from-home experiment continue.  According to The Washington Post, Amazon and Microsoft have told such workers they can keep working from home until at least October, while Facebook and Google say at least until 2021.   Microsoft president Brad Smith observed: “We found that we can sustain productivity to a very high degree with people working from home.”  

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The End of the Game

By IAN MORRISON

Back in the early 2000s I was on the board of the California Health Care Foundation and one day the German Minister of Health paid CHCF a visit as part of a learning tour of American healthcare. Mark Smith MD CHCF’s CEO invited me to join the meeting with the minister. She was a delightful person who didn’t speak much English, but because she was accompanied by her handler/translator we managed to communicate just fine. Mark and I tried to explain to the Minister how the American healthcare system worked, and we got to the point in the conversation about the money. The essence of the “game” we described was that commercial insurers (particularly self-insured employers) paid a significant multiple of cost (sometimes in excess of 300% of costs) in order to make the math work for providers. We explained that the game works only if these purchasers paid much higher prices. I don’t speak German, but I think she said: “What The F**k?!”. Exactly.

As we enter the Post COVID world, a key question is: Will healthcare simply restart this game? Or make it even more extreme, in fact, by providers turning to those commercial insurers and self-insured employers to make up the difference for the COVID “Elective Collapse Recession” that has so traumatized provider’s finances including hospitals, specialists, primary care, and dentists leading to job cuts, furloughs, salary reductions and bankruptcies of providers.

A number of recent articles have pointed to how the game works. In particular, the always superb New York Time’s columnist Sarah Kliff’s review of the Mayo Clinic and the other highflying institutions whose excellence is rewarded not by value based reimbursement but by high prices for commercial activity under a relatively benign payor mix (industry code for “don’t see a lot of poor people, uninsured or on Medicaid”).

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Testing Won’t Get Us Where We Need to Go

By ANISH KOKA, MD

The great pandemic is wreaking havoc, we are told, because the nation is not testing enough.  The consensus from a diverse group that includes public health experts, economists, and silicon valley investors is that more testing will allow the country to restart the economy and do it safely. 

The White House has been a mini laboratory for this testing strategy.  Everyone who comes into contact with the President and Vice President is tested daily.  This is supposedly what allows everyone to sit in meetings together and generally carry out the essential business of the country.  But over this Mother’s Day weekend members of the White House spent their time scrambling to track down contacts of Katie Miller, the press secretary of the Vice president who tested positive.  And contacts were left unclear about what exactly to do.  One official started self-quarantining, while another did not. 

If the White House has trouble with a mass testing, and contact tracing strategy, one wonders how this may work nationwide with thousands of new cases per day.  While it would be tempting to blame administrative incompetence for the difficulties in the most important household in the land, the real difficulties lies with inherent limitations to tests that need to be understood before getting on the testing bandwagon.

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RWJF Challenge: Health Care Emergency Tech

SPONSORED POST

By CATALYST @ HEALTH 2.0

Catalyst @ Health 2.0, in collaboration with the Robert Wood Johnson Foundation, is seeking health technology solutions that can support the needs of the health care system (e.g. providers, government, public health and community organizations, and more) by addressing several obstacles during an emergency such as:

  • Resource Management: Shortages of equipment, staff, and cash flow
  • Health Data Exchange: Limited information and access available on patients’ health histories
  • Training and Communication: Limited training and cumbersome communication between responders and clinicians
  • Capacity: Limited beds, equipment, and resources and a need to maximize patient flow/throughput

Innovators must submit their tech-enabled solution by June 12th, 2020 at 11:59 PM ET.

Can you create a digital tool that supports the health care system during a large-scale health crisis? Apply today!

Catalyst @ Health 2.0 (“Catalyst”) is the industry leader in digital health strategic partnering, hosting competitive innovation “challenge” events, as well as developing and implementing programs for piloting and commercializing novel healthcare technologies.

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