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False Negative: Testing’s Catch-22

By SAURABH JHA, MD

In a physician WhatsApp group, a doctor posted he had fever of 101° F and muscle ache, gently confessing that it felt like his typical “man flu” which heals with rest and scotch. Nevertheless, he worried that he had coronavirus. When the reverse transcription polymerase chain reaction (RT-PCR) for the virus on his nasal swab came back negative, he jubilantly announced his relief. 

Like Twitter, in WhatsApp emotions quickly outstrip facts. After he received a flurry of cheerful emojis, I ruined the party, advising that despite the negative test he assume he’s infected and quarantine for two weeks, with a bottle of scotch. 

It’s conventional wisdom that the secret sauce to fighting the pandemic is testing for the virus. To gauge the breadth of the response against the pandemic we must know who and how many are infected. The depth of the response will be different if 25% of the population is infected than 1%. Testing is the third way, rejecting the false choice between death and economic depression. Without testing, strategy is faith-based. 

Our reliance on testing has clinical precedence – scarcely any decision in medicine is made without laboratory tests or imaging. Testing is as ingrained in medicine as the GPS is in driving. We use it even when we know our way home. But tests impose a question – what’ll you do differently if the test is negative? 

That depends on the test’s performance and the consequences of being wrong. Though coronavirus damages the lungs with reckless abandon, it’s oddly a shy virus. In many patients, it takes three to four swabs to get a positive RT-PCR. The Chinese ophthalmologist, Li Wenliang, who originally sounded the alarm about coronavirus, had several negative tests. He died from the infection.

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Covid-19 & Digital Health in Italy: “10 Years of Evolution in 10 Days” | WTF Health

By JESSICA DaMASSA, WTF HEALTH

“It’s fair to say that, in Italy, we are doing 10 years of digital health evolution in 10 days.”

Our “man-on-the-street” in Italy (well, man-sheltered-in-place in Italy) Roberto Ascione, CEO of Healthware, reports in on the Covid-19 outbreak and what’s happening with digital health startups, health system partners, and hospitals as Italians continue battling at the forefront of the coronavirus outbreak.

A few weeks ahead of the U.S., there are many things to learn about Covid-19 testing, treatment, outcomes, and timing from the experience in Italy, including some foresight on how pathways for telehealth and digital health continue to evolve as conditions become more serious and the outbreak progresses. (For all you Gretzky fans, this is “skating to where the puck will be” kind of stuff…)

Some navigational guidance on this chat which took place March 26, 2020:

  • Update on Italian Covid-19 outbreak from health industry insider
  • 10:25 minute mark: Digital Health startup case study, Paginemediche, self-triage chatbot data from 70K Italians, data sharing with Italian government & WHO, telehealth model flipping to give overwhelmed physicians opportunity to triage and “invite” patients based on needs
  • 19:10 mark: How to work with Italian digital health startups to advance Covid-19 work

Health in 2 Point 00, Episode 114 | COVID-19 Stimulus Package & Startup Responses

Today on Health in 2 Point 00, we have a viewer question! For our friends who are wondering what will happen to all the IPOs that were supposed to happen this year, I weigh in on how this crisis will impact IPOs and startup funding. On Episode 114, Jess asks me about the stimulus package granting $117 billion to hospitals and for my thoughts on all the startups coming up with ways to address COVID-19. A few startups that come to mind include Conversa with its virtual care conversation, Coronavirus Health Chats, Biofourmis which is looking for ways to track infected people earlier through its AI-powered arm sensor, and Surveyor Health leveraging its data analytics platform as well. For more on this, check out covid19healthtech.com where my colleagues at Catalyst have put together a resource hub for health tech solutions. —Matthew Holt

Infection Control for COVID-19 Imaging

By STEPHEN BORSTELMANN, MD

Occasionally, you get handed a question you know little about, but it’s clear you need to know more.  Like most of us these days, I was chatting with my colleagues about the novel coronavirus. It goes by several names: SARS-CoV-2, 2019-nCoV or COVID-19 but I’ll just call it COVID.  Declared a pandemic on March 12, 2020 by the World Health Organization (WHO), COVID is diagnosed by laboratory test – PCR.  The early PCR test used in Wuhan was apparently low sensitivity (30-60%), lengthy to run (days), and in short supply.  As CT scanning was relatively available, it became an important diagnostic tool for suspected COVID cases in Wuhan.

The prospect of scanning thousands of contagious patients was daunting, with many radiologists arguing back and forth about its appropriateness.  As the pandemic has evolved, we now have better and faster PCR tests and most radiologists do not believe that CT scanning has a role for diagnosis of COVID, but rather should be reserved for its complications. Part of the reason is the concern of transmission of COVID to other patients or healthcare workers via the radiology department.

But then someone asked: “After you have scanned a patient for COVID, how long will the room be down?” And nobody really could answer – I certainly couldn’t.  A recent white paper put forth by radiology leaders suggested anywhere from 30 minutes to three hours. A general review of infection control information for the radiologist and radiologic technologist can be found in Radiographics.

So, let’s go down the rabbit hole of infection control in the radiology department. While I’m a radiologist, and will speak about radiology-specific concerns, the fundamental rationale behind it is applicable to other ancillary treatment rooms in the hospital or outpatient arena, provided the appropriate specifics about THAT environment is obtained from references held by the CDC.

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Telehealth Startup CEO On How Covid-19 Is Changing Telemedicine Use In Hospitals | WTF Health

By JESSICA DaMASSA, WTF HEALTH

Jamey Edwards, CEO of one of the larger in-hospital B2B telehealth startups in the US, Cloudbreak Health, is already seeing changes in the way hospitals are using his company’s telemedicine services in the wake of COVID-19.

From a noted rise in the rate of infectious disease consults, to “quarantine rooms” where telemedicine equipment is cleverly deployed to practice “clinical distancing” to minimize risk to front-line healthcare workers (and also preserve PPE), Jamey talks about what he’s seeing among hospital clinicians and what they seem to need most right now from telehealth providers amid the COVID-19 outbreak.

With changes to licensing regulations, HIPAA policies, and reimbursement changing the very infrastructure around telehealth, will we finally see virtual care become a true part of the healthcare system at-scale?

“One of the hardest things to do in our healthcare system is match cost to acuity,” says Jamey. “I’m not going to say we’ve overvalued the in-person encounter, but we certainly have been very hesitant to step away from it.”

“The fact of the matter is that that’s a bias. And so it’s up to us to look at these biases and say, ‘Well, no. What is the right way to do this?’”

Can AI diagnose COVID-19 on CT scans? Can humans?

Vidur Mahajan
Vasanth Venugopal

By VASANTH VENUGOPAL MD and VIDUR MAHAJAN MBBS, MBA

What can Artificial Intelligence (AI) do?

AI can, simply put, do two things – one, it can do what humans can do. These are tasks like looking at CCTV cameras, detecting faces of people, or in this case, read CT scans and identify ‘findings’ of pneumonia that radiologists can otherwise also find – just that this happens automatically and fast. Two, AI can do things that humans can’t do – like telling you the exact time it would take you to go from point A to point B (i.e. Google maps), or like in this case, diagnose COVID-19 pneumonia on a CT scan.

Pneumonia on CT scans?

Pneumonia, an infection of the lungs, is a killer disease. According to WHO statistics from 2015, Community Acquired Pneumonia (CAP) is the deadliest communicable disease and third leading cause of mortality worldwide leading to 3.2 million deaths every year.

Pneumonias can be classified in many ways, including the type of infectious agent (etiology), source of infection and pattern of lung involvement. From an etiological classification perspective, the most common causative agents of pneumonia are bacteria (typical like Pneumococcus, H.Influenza and atypical like Legionella, Mycoplasma), viral (Influenza, Respiratory Syncytial Virus, Parainfluenza, and adenoviruses) and fungi (Histoplasma & Pneumocystis Carinii).

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Livongo Health’s Jenny Schneider on Covid-19 & Helping Patients with Chronic Conditions | WTF Health

By JESSICA DaMASSA, WTF HEALTH

“What’s happening in COVID is those of us living with these chronic conditions are at highest risk — not to contract the disease, but highest risk for outcomes. Our unique ability to be able to see what’s happening in that population and deliver that care remotely is incredibly valuable always, but, particularly, in this strained time.”

Livongo Health has always been committed to helping its members (people with diabetes, heart disease, and other chronic conditions) manage their health “where they are.” Collecting loads of patient data along the way. As the traditional health system grapples with caring for those infected with COVID-19, what changes? What role will digital health companies like Livongo play as they continue to provide front-line, day-to-day care to their members and customers amidst the challenging environment of this pandemic?

Dr. Jennifer Schneider, Livongo’s President, stops by to chat about what’s happening at Livongo now as the country looks to virtual care solutions to help shore up capacity for the traditional health system. As the spotlight is turned to digital health, we get Jenny’s perspective on what it will take for health tech companies like hers to continue to prove their value to healthcare incumbents and to patients who have a growing need for their help managing their everyday health.

COVID-19 Update: A Message From Concerned Physicians

By HOWARD LUKS MD, JOEL TOPF MD, FACP, ETHAN WEISS MD, CARRIE DIULUS MD, NANCY YEN SHIPLEY MD, ERIC LEVI MBBS, FRACS, BRYAN VARTABEDIAN MD

“EVERYTHING WE DO BEFORE A PANDEMIC WILL SEEM ALARMIST. EVERYTHING WE DO AFTER WILL SEEM INADEQUATE”

—Michael Leavitt

Last updated 3/18/2020.

Why are we writing this? 

The COVID-19 pandemic has reached a point where containment is no longer possible. The COVID-19 threat is real, and rapidly getting worse. Many of you are very nervous, some are unsure of the validity of the information you are reading. As physician leaders, we felt it was important to craft a resource you can rely on as being scientifically accurate and one which contains as much actionable information and guidance as possible. 

Accurate, actionable information during an epidemic can save lives. Physicians are on the front line of this epidemic. Not only are we treating the sick, but we are also cringing at the misinformation spread through both traditional broadcast and social media. Evidence matters. Unfortunately, evidence is often slow, methodical, and boring and has a tough time against clicky headlines and exaggeration. We believe that an accurate representation of the current COVID-19 pandemic followed by a set of actionable steps you, your loved ones, politicians and local officials can utilize is of paramount importance and ultimately could save tens of thousands of lives. 

COVID-19 isn’t just the flu? 

COVID-19 has been described by some as “just a cold”, or just like the common flu. COVID-19 is not the common flu. COVID-19 is an order of magnitude worse than the flu. The fatality rate is approximately 10 times worse than the flu.

The flu spreads from September through April in the US, and June through August in the Southern Hemisphere. Yes, it does cause severe illness in many, but it does so over a longer time course. Time is a variable that is working against us during this COVID-19 outbreak. COVID-19 victims will be presenting to a hospital in need of critical care at a rate that is far higher than occurs with the flu.

In addition, these patients will be requiring hospital treatment over the course of a few weeks rather than the 3-4 months of a typical flu season. The healthcare system in the USA is not ready to handle tens of thousands or hundreds of thousands of people over a short time frame. In Italy, the healthcare system buckled under the strain and the healthcare teams are now forced to make horrible life and death decisions. 

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Bruce Greenstein to Health Tech: “This is The Make-or-Break Time” | WTF Health on Covid-19

By JESSICA DAMASSA, WTF HEALTH

“Health tech providers — this is the make-or-break time. If you can’t prove your value in the next, say, eleven weeks, then you should NOT be in the health care game. It’s time to get serious.”

Bruce Greenstein, former CTO at HHS and current Chief Strategy and Innovation Officer at LHC Group, one of the country’s largest home health care providers, stops by to share what he’s learned about the federal government’s response to the COVID-19 pandemic.

Bruce represented the home health industry during last Friday’s (3/13/20) White House meeting, which culminated in a Rose Garden press conference starring the ‘who’s who’ of American health care, retail, and pharma leadership. (Bruce was the guy who elbow bumped Trump.)

Lots of attention on virtual care and telehealth during that presser, and Bruce weighs-in for our health tech and digital health audience about how they can get involved and what big health care companies like his are looking for in digital solutions right now (LHC Group works with 350 hospitals caring for 100K patients.) And how about those HHS Interoperability Rules that have been basically lost in this news cycle? We get Bruce’s feedback on how HHS did, plus his insider info on the HHS “hack.”

Some guidance to help you navigate this chat. Hot Tip: Open up the transcript in YouTube and navigate to these different breaks in the conversation.

  • The ‘Trump Bump’ & Gossip from the Rose Garden Press Conference & White House Meetings
  • 8:40 mark — Advice for health tech startups (must-watch)
  • 15:25 mark — Find out what startups can do that would lead Bruce to “put them in Health IT Hell for the rest of their existence”
  • 16.45 mark – HHS “Hack”
  • 18.14 mark – HHS Interoperability Rules

A Healthcare System, If We Can Keep It

By KIM BELLARD

We are in strange days, and they are only going to get stranger as COVID-19 works its way further through our society.  It makes me think of Benjamin Franklin’s response when asked what kind of nation the U.S. was going to be:  “A Republic, if you can keep it.” 

SAUL LOEB / AFP VIA GETTY IMAGES

The versions of that response that COVID-19 have me wondering about are: “A federal system, if we can keep it,” and, more specifically, “a healthcare system, if we can keep it.”  I’ll talk about each of those in the context of the pandemic.

In times of national emergencies — think 9/11, think World Wars — we usually look to the federal government to lead.  The COVID-19 pandemic has been declared a national emergency, but we’re still looking for strong federal leadership.  We have the Centers for Disease Control, infectious disease experts like Dr. Anthony Fauci, and a White House coronavirus task force.  But real national leadership is lacking. 

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