One harsh Chicago winter, I remember calling a patient to cancel his appointment because we had deemed it too risky for patients to come in for routine visits—a major snowstorm made us rethink all non-essential appointments. Mr. Z was scheduled for his 3-month follow-up for an aggressive brain lymphoma that was diagnosed the prior year, during which he endured several rounds of intense chemotherapy. His discontent in hearing that his appointment was canceled was palpable; he confessed that he was very much looking forward to the visit so that he could greet the nurses, front-desk staff, and ask me how I was doing. My carefully crafted script explaining that his visit was “non-essential” and “postponable” fell on deaf ears. I was unprepared to hear Mr. Z question: if this is his care, shouldn’t he be the one to decide what’s essential and what’s not?
This is a question we are all grappling with in the face of the COVID-19 pandemic. The healthcare industry is struggling to decide how to handle patient visits to doctor’s offices, hospitals, and imaging centers, among others. Elective surgeries are being canceled and advocates are arguing that non-essential outpatient and ER visits should be stopped. Ideas are flying left and right on how best to triage patients in need. Everyone has an opinion, including those who ironically consider themselves non-opinionated.
an oncologist, these various views, sentiments, tweets, and posts give me
pause. I understand the rationale to minimize patients’ exposure and thus prevent
transmission. However, reconsidering what we should deem “essential” has made
me reflect broadly on our method of providing care. Suddenly, physicians are
becoming less concerned about (and constrained by) guidelines and requirements.
Learning how to practice “essential oncology” may leave lasting changes in our
Practices cannot survive the COVID-19 cash flow crisis
By JEFF LIVINGSTON, MD
Will doctors be able to keep their practices open during the worst pandemic in our lifetime? Our country needs every available doctor in the country to fight the challenges of Covid-19. Doctors working in independent practices face an immediate cash flow crisis threatening their ability to continue services.
The CARES Act was signed into law on Friday, March 27, 2020. The law offers much-needed help to the acute needs of hospitals and the medical supply chain. This aid will facilitate the production of critical supplies such as ventilators and PPE. The law failed to consider the needs of the doctors who will run the ventilators and wear the masks.
Cash flow crisis
Private-practice physician groups experienced an unprecedented reduction in in-office visits as they moved to provide a safe and secure environment for patients and staff. In compliance with CDC guidelines, practices suspended preventative care, nonurgent visits, nonemergent surgery, and office procedures.
These necessary practice changes help keep patients safe and slow the spread of Covid-19. The unintended consequence is an unreported and unrecognized cash flow crisis threatening the viability of physician practices.
If, as they say, necessity is the mother of invention, then you’d have to say that the COVID-19 pandemic is proving to be the mother of invention and innovation. And, like Isaac Hayes sang about Shaft, it is a “bad mother…(shut your mouth).”
Many believe that the Allies won WWII in large part because of how industry in the U.S. geared up to produce fantastic amounts of weapons and other war materials. It took some time for businesses to retool and get production lines flowing, during which the Axis powers made frightening advances, but once they did it was only a matter of time until the Allies would prevail.
Similarly, COVID-19 is
making scary inroads around the world, while businesses are still gearing up to
produce the number of ventilators, personal protective equipment (PPE), tests,
and other badly needed supplies. COVID-19 is currently outnumbering
these efforts, but eventually we’ll get the necessary equipment in the needed
By CHITRA CHHABRA KOHLI MD, AJAY KOHLI MD, and VINAY KOHLI MD, MBA
With a doubling time of cases estimated between 3 days within the U.S. and about 6 days globally (at the time of this writing) COVID-19 is demonstrating its terrifying virulence as it spreads across the world.
What’s perhaps equally terrifying, if not more, is the absence of a known cure or treatment plan for COVID-19. While there has been a lot of attention focused on Hydroxychloroquine and Azithromycin, there has been debate on the scientific validity of these treatment options, either as therapy or as prophylaxis. The impact of a solution certainly has far reaching potential, the scope of the challenge is overwhelmingly large. The editor-in-chief of Science recently wrote that the efforts to find a cure are not just ”fixing a plane while it’s flying — it’s fixing a plane that’s flying while its blueprints are still being drawn.”
There is a promising therapy that may help us weather the COVID-19 storm and, perhaps, flatten the curve. It’s based around science that defines immunology and has already been used in many different diseases, going as far back as the 1918 flu pandemic. This potential treatment is convalescent plasma therapy — using antibodies from patients who have recovered from COVID-19 and then transfusing them into patients who are currently mounting an immune response against the rapidly rising viral loads of COVID-19.
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.
“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
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
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 importantdiagnostic 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.
By VASANTH VENUGOPAL MD and VIDUR MAHAJAN MBBS, MBA
What can Artificial
Intelligence (AI) do?
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.
on CT scans?
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
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).
“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.