By MATTHEW HOLT
Smart Quarantine as the next step to combat COVID-19
As the nation and the world grapple with the impact of the COVID-19 pandemic, there is growing consensus among experts that we need a sustainable system of specific lockdowns, social distancing, and extreme resource provision in terms of labor, ventilators and PPE to arm hospitals and health providers as they deal with the onslaught of patients. Even while some American states start to slowly open up, we need a system that can manage COVID-19 over the coming months and years–especially if this Fall brings a second wave.
Writing in the NY Times on April 7, Harvey Fineberg and colleagues summarized an as yet overlooked issue. There are many patients who may or do have COVID-19, but are not sick enough to need hospital care, or who have been discharged from hospitals. We need to keep these patients away from hospitals but if they shelter in place in their household there is a high risk they will infect their families or housemates. This likelihood is even higher if they are homeless, incarcerated, or living in other group arrangements.
Instead of sheltering in place at home Fineberg and colleagues suggest those patients enter “smart quarantine” in temporary isolated accommodation, such as hotels or college dormitories, where they can be looked after by medical teams and tested semi-regularly. But whether they are at home or in temporary accommodation, leaving those patients with minimal support to be tested at the end of 14 days is not enough. A significant proportion of them will develop COVID-19 and some of those are going to be admitted to hospital. In addition several patients have been discharged from hospital, but still need to be monitored. We are going to need to be able to closely monitor a significant number of people even while the majority of them will need relatively limited amounts of care.
The good news is that we have had a couple of decades of development of the technologies and services required to both care for and monitor these patients, while keeping the main resources such as ventilators for those in hospitals. Pulling together available technologies and services, we will be able to quickly and accurately manage these patients, ensure their best outcomes, and spare scarce hospital resources. There are seven main components of this process, which I am calling “smart care in quarantine.”
Upon either a positive test for COVID-19 or a suspicion of those symptoms awaiting testing, patients can be admitted to isolation at home or in, say, empty hotels.
1. Monitoring equipment. Patients can be given FDA regulated monitoring devices which will work using bluetooth and WiFi (or 4G cellular). The main monitoring tools required are:
- Pulse Oximeters
- Stethoscopes (with acoustic recording)
- Weight Scales
- Video & audio via iPad, phone or computer
Their correct use can be instructed remotely or if necessary by on-site staff. All of these devices are now Internet-connected delivering data to anywhere in the world.
2. Asynchronous and synchronous communication. Using smart phones, tablets, computers and high definition video cameras, patients can be given education, connect with information online via chat bots, and use apps for asynchronous communication. In addition using modern telehealth systems patients can have immediate access to a full range of clinical professionals. Since the relaxation by CMS of restrictions on telehealth a whole range of checking and communications is instantly available to patients and any clinical staff who are in physical contact with the patient. This can include specialty consults, mental health, translation services, and a full range of drug and lab test ordering.
3. Monitoring Services: Underlying the monitoring devices and the communications/telehealth, these patients require an always-on team using a combination of technology, smart alerts and human surveillance to manage their care. Variants of this are already commonplace across the US health system. Currently several companies and provider organizations run virtual ICUs where patients in several ICUs in different locations are managed from a “control room”. Similarly nurses and techs in call centers or working from their own homes are managing the care of chronically ill patients at home. There are now hundreds of thousands of patients with diabetes, congestive heart failure or other conditions, who are equipped with smart glucometers, scales and other devices at home, and most have remote monitoring as part of that package. Essentially we need to take that process and replicate it for these COVID-19 patients. This “care traffic control” function (as John Halamka dubbed it) could be performed by nurses, techs and others from their own homes, or in hospitals or other centers. This function would be responsible for the 24/7 care of these patients for the 14 day (or more) quarantine period, including calling in telehealth services and physical staff when appropriate.
4. Staffing. There would be at least 4 main kinds of staff required to manage these patients. Staff on the ground would include non-medical staff doing food preparation & delivery, tech set up, laundry/housekeeping, transportation. Many of these staff usually service hotel and many of whom are currently on furlough. Also on the ground would be LVNs, RNs, pharmacists, phlebotomists, EMTs, etc under the management of (likely remote) MDs. Meanwhile, the “care traffic control” function could be performed by nurses, techs and others, while the telehealth function would be delivered by MDs including anesthesiologists, pulmonologists, infectious disease specialists, etc. Almost all of these latter two groups could be organized remotely.
5. Technology Stack & Data Integration: All these different data and services would be brought together in an open technology stack. While traditionally the data from monitoring and other devices have not easily been integrated into surveillance systems, there are now both easily available open standards and an acceptance from device manufacturers that they need to freely share this data to enable it to be used in workflow tools by clinicians and patients.The organization managing this process could integrate this data itself or use an off the shelf tool to link all these services together.
6. AI and analytics. Once data starts flowing through the system from enough patients, the latest wave of AI and analytics tools will be able to run simulations and suggest which patients are most likely to get sick enough to need hospital care. This will enhance the current rules and workflow-based monitoring function from care traffic control and also enable better projection of near-term hospital capacity requirements
7. Payment and administration. Finally, figuring out who gets paid for what in this process will be a challenge. The same organization that is managing the whole process can work with states, CMS, private insurers, employers and patients to figure out how the components and services being delivered get paid for. This will remove from the end-payers the typical dog’s breakfast of “after the fact” uncoordinated billing.
The “General Contractor” Organization
One organization can manage the entire process and all these components better than leaving it to the individual actors who each supply various services or components. In essence this will be the “general contractor” function that is typically lacking in healthcare but is common in manufacturing, construction and other industries. It’s possible that health insurers, remote monitoring companies, or even hospital systems could perform this function, but in all likelihood a new type of organization will need to take on that role.
This type of organization will require strong partnerships with different device suppliers, staffing and physician organizations, telehealth vendors, and technology vendors, as well as a clear understanding of the clinical workflow required for these patients as they move between smart quarantine, home and hospital.
Health care faces immediate challenges. We need new organizations to manage these new challenges.
Matthew Holt is the Publisher of THCB
Brilliant, Matthew. It seems so slick and expensive…but probably very useful.
I’m more in the dirt:
What I’m hoping for is an antiviral drug or chemistry correction that is possibly soon, that maybe only makes the disease much less lethal, that is cheap and oral, and that converts our worry of croaking into a typical flu season worry. Like maybe vitamin D? How do we find this miracle?
We need to exhaustively study those people who have been unequivocally exposed, some of whom have tested positive and some who have tested negative, and who have gone on to be healthy and relatively unaffected and thriving….about 80% of cases. And then we match their findings with the severely sick Covid 19 patients.
We should do every test in the book on these people including all the microbiology and clinical chemistry and immunology and hematology and precision medicine tests including total genomes and exons and epigenetic tags.
The answer to this occasional lethality has got to be right in front of us. That is all we are worried about: occasional lethality. Just think: this total unbelievable disruption of the world’s human cultures because we are worried about the death of 1-2% of the 1-2% who catch this disease: .01x.01 =.0001. This is too much cataclysm for too little insult. It is too simple a problem for too smart a society.
We need to do these tests in about a week and then have a group of smart people get in a quiet room and think for a few days. We don’t need desultory frenzy. We need thinking.
We’d all love a cure or at least a treatment. But that’s a totally different thread. What I am proposing here is a new system for managing patients in their homes or in other quarantine, that works both for COVID-19 and other chronic illnesses