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What’s a diagnosis about? COVID-19 and beyond

By MICHEL ACCAD

Last month marked the 400th anniversary of the birth of John Graunt, commonly regarded as the father of epidemiology.  His major published work, Natural and Political Observations Made upon the Bills of Mortality, called attention to the death statistics published weekly in London beginning in the late 16th century.  Graunt was skeptical of how causes of death were ascribed, especially in times of plagues.  Evidently, 400 years of scientific advances have done little to lessen his doubts! 

A few days ago, Fox News reported that Colorado governor Jared Polis had “pushed back against recent coronavirus death counts, including those conducted by the Centers for Disease Control and Prevention.”  The Centennial State had previously reported a COVID death count of 1,150 but then revised that number down to 878.  That is but one of many reports raising questions about what counts as a COVID case or a COVID death.  Beyond the raw numbers, many controversies also rage about derivative statistics such as “case fatality rates” and “infection fatality rates,” not just among the general public but between academics as well.  

Of course, a large part of the wrangling is due not only to our unfamiliarity with this new disease but also to profound disagreements about how epidemics should be confronted.  I don’t want to get into the weeds of those disputes here.  Instead, I’d like to call attention to another problem, namely, the somewhat confused way in which we think about medical diagnosis in general, not just COVID diagnoses.

The way I see it, there are two concepts at play in how physicians view diagnoses and think about them in relation to medical practice.  These two concepts—one more in line with the traditional role of the physician, the other adapted to modern healthcare demands—are at odds with one another even though they both shape the cognitive framework of doctors.  

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The 2020 COVID Election

By KIM BELLARD

Many believe that the 2020 Presidential election will be a referendum on how President Trump has handled the coronavirus pandemic.  Some believe that is why the President is pushing so hard to reopen the economy, so that he can reclaim it as the focal point instead.  I fear that the pandemic will, indeed, play a major role in the election, but not quite in the way we’re openly talking about.  

It’s about there being fewer Democrats.

Now, let me say right from the start that I am not a conspiracy believer.  I don’t believe that COVID-19 came from a Chinese lab, or that China deliberately wanted it to spread.  I don’t even believe that the Administration’s various delays and bungles in dealing with the pandemic are strategic or even deliberate.  

I do believe, though, that people in the Administration and in the Republican party more generally may be seeing how the pandemic is playing out, and feel less incentive to combat it to the fullest extent of their powers.  Let’s start with who is dying, where.

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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.

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How Will COVID-19 Change the Health Care Balance of Power?

By KEN TERRY

In any economic disaster, the largest, best-financed organizations have a natural advantage over smaller, cash-strapped organizations. The bigger entities have a greater ability to withstand economic downturns, while the small ones can quickly go out of business because they lack the financial reserves needed to tide them over.

In the roughly 2 ½ months since the COVID-19 pandemic began sinking its hooks into America, the pertinence of this business axiom has been amply illustrated. Small companies across the country are desperate to reopen so they can survive, while many large corporations are seeing their stock prices soar. Most healthcare systems are not for profit, so they don’t issue stock; yet bigger hospitals are not suffering as much financially as smaller and rural hospitals are. Even though the large hospitals’ losses from elective surgery bans have been higher, they have much deeper reserves and greater access to bank lines of credit.

Physician practices have been hit disproportionately by the pandemic. Most practices have switched to telemedicine visits as patients have shunned in-person encounters and the offices have tried to protect their staffs. But the revenue from virtual encounters has not come close to making up for the loss of revenues from office visits that, in many cases, include lab tests and/or minor procedures.

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We Need to Fix COVID-Damaged Care Sites and Give the Country Better Care and Universal Coverage in the Process

By GEORGE HALVORSON

The COVID crisis has shown us clearly that major portions of the American care system are extremely dysfunctional and some are now badly broken. We need to put in place a cash flow for American health care that can help our care sites survive and ultimately thrive, and we need to put that approach to save the sites in place now because a vast majority of hospitals and medical practices are badly damaged and some are financially crippled and even destroyed by their response to the crisis.

We have learned a lot in the COVID crisis that we need to use now in building our next steps and our collective response to the crisis.

The COVID crisis has shown us all that our care sites do not have good patient data, do not have good patient linkages, usually do not have team care of any kind in place, and most are so dependent on current piecework fee volumes from patients that they quickly collapse financially when that volume is interrupted.

We should be on the cusp of a golden age of care delivery that uses all of the best patient support tools to deliver continuously improved care — and we now know that the piecework way we buy almost all of our care today will keep that golden age from happening for the vast majority of American patients for the foreseeable future until we change the way we buy care.

We need to buy care in a way that both requires the use of those tools and rewards caregivers and care teams when they use them.

We need a dependable cash flow for care to anchor that process.

We are unlike most of the rest of the industrialized world in not having a dependable cash flow now to buy care. We rely on a hodgepodge and mishmash of unlinked, unaligned and uncoordinated payment sources now and that lack of coordination in payment creates a vast and damaging lack of coordination in the delivery of care.

We can make a huge improvement in that entire process and we can give our health care system a stable and functionally useful future cash flow by becoming a much more highly skilled purchaser of coverage and care. We need a flow of money to make that happen.

We actually can create that flow relatively quickly and fairly easily by imposing a payroll tax on every employee that exactly copies the approach we use now for our Social Security payroll tax process and then using that money in a health care purchasing pool to buy health coverage for every person who is not on Medicaid.

The numbers work.

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After COVID-19, What Next? A Recovery Blueprint for Health System Leaders

By JAMES GARDNER

Is the beginning of the end in sight? Perhaps. After much stress and strain, many experts believe we’re seeing early signs of a COVID-19 plateau in some states and cities. Everything could change tomorrow, but healthcare leaders should be preparing now to reopen their shuttered operating rooms and get back to business. 

When restrictions loosen, lost days and weeks could have dire implications for health systems already weakened by months of deferred and canceled elective procedures. These surgeries — joint replacements, tumor biopsies, gallbladder removals, and cosmetic procedures, for instance — underpin the economics of hospitals and physician groups. Delay some of these surgeries for too long and patient care can also suffer. Essential? Absolutely.

Unfortunately, healthcare leaders will be reopening their doors to a world unlike anything they’ve seen before. Aren’t we all seeing our personal health through a new lens?

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Is Covid-19 the Argument Health Data Interoperability Needed? | WTF Health

By JESSICA DAMASSA, WTF HEALTH

“This pandemic highlights why we need that free flow of healthcare data. So that we can make better decisions sooner.”

In the way that Covid-19 has proven the utility of telehealth as a means for health systems to reach their patients, has the pandemic also become the final argument for healthcare data interoperability? Has this pandemic been the worst case scenario we needed to make our best ‘case-in-point’ for why U.S. healthcare needs a national health data infrastructure that makes it possible for hospitals to share information with one another and government health organizations?

Interoperability advocates have been clamoring for this for years, but Dan Burton, CEO of data-and-analytics health tech company, Health Catalyst, says this public health crisis has likely created an inflection point in the interoperability argument.

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Can AI and radiographs help in resource-poor areas for the fight against COVID-19?

Pooja Rao
Tarun Raj
Manoj TLD
Preetham Srinivas
Bhagarva Reddy

By POOJA RAO, TARUN RAJ, BHARGAVA REDDY, MANOJ TLD, and PREETHAM SRINIVAS

In March 2020, we re-purposed our chest X-ray AI tool, qXR, to detect signs of COVID-19. We validated it on a test set of 11479 CXRs with 515 PCR-confirmed COVID-19 positives. The algorithm performs at an AUC of 0.9 (95% CI : 0.88 – 0.92) on this test set. At our most common operating threshold for this version, sensitivity is 0.912 (95% CI : 0.88 – 0.93) and specificity is 0.775 (95% CI : 0.77 – 0.78). qXR for COVID-19 is used at over 28 sites across the world to triage suspected patients with COVID-19 and to monitor the progress of infection in patients admitted to hospital

The emergence of the COVID-19 pandemic has already caused a great deal of disruption around the world. Healthcare systems are overwhelmed as we speak, in the face of WHO guidance to ‘test, test, test’ [1]. Many countries are facing a severe shortage of Reverse Transcription Polymerase Chain Reaction (RT-PCR) tests. There has been a lot of debate around the role of radiology — both chest X-rays (CXRs) and chest CT scans — as an alternative or supplement to RT-PCR in triage and diagnosis. Opinions on the subject range from ‘Radiology is fundamental in this process’ [2] to ‘framing CT as pivotal for COVID-19 diagnosis is a distraction during a pandemic, and possibly dangerous’ [3].

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The Problem With “Herd Immunity” as a COVID-19 Strategy

By e-PATIENT DAVE DEBRONKART

Caution: This post is not a prediction. It’s just a tutorial about the concept of herd immunity, with an eye to why it’s probably not an approach the US wants to take in solving the complex problems we’ve gotten ourselves into with COVID-19.

Click this graphic to go see a six second animation of these images, created in 2017 by Reddit user TheOtherEdmund. You many need to watch a few times. Get a feel for the differences in what happens in the different blocks, and come back to discuss:

This weekend I’ve labored to understand this concept, which first came to my ears regarding coronavirus in March, when British prime minister Boris Johnson proposed it as a possible approach for Britain to take: let the virus take its course, and they’d end up with “herd immunity,” and that would be the end of that.

In my unsophisticated knowledge “herd immunity” meant “you let the weak cows die, and the rest of the herd will be fine.” And in fact in April a Tennessee protestor held up a sign saying “Sacrifice the Weak – Reopen TN.” (It’s not clear whether the sign was mocking or real (Snopes), but it illustrates the point.)

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Deep-Dive on GuideWell’s Covid19 Innovation Collaborative for Health Tech Startups | WTF Health

By JESSICA DaMASSA, WTF HEALTH

“I think that the baseline platform of telehealth adoption created a whole springboard opportunity for the plethora of digital health companies that are out there eager to get into the space and grow their businesses. I think the industry as a whole now is a whole lot more receptive to looking at things like that then they were eight weeks ago.”

Among those in the industry very open to digital health, digital therapeutics, precision medicine, and virtual care solutions in this time of covid19 is GuideWell, which counts Florida Blue and four other healthcare businesses among its subsidiaries.

The national healthcare company is looking to bring together health tech startups around five different kinds of healthcare challenges created by the coronavirus pandemic via its Covid-19 Innovation Collaborative. With the application deadline set for Friday, May 8, we caught up with GuideWell Innovation’s Executive Director, Kirstie McCool, about the details behind the unique model for the Collaborative, its non-dilutive funding awards, and what happens to the startups that are selected to participate. (Hello, other Blues plans!)

If the Collaborative’s areas of focus aren’t enough to clue you in on where the healthcare giant is interested in rounding out its own array of services as a payer, provider, and innovator, we asked Kirstie point-blank to tell us what she thinks is next in terms of supporting the traditional healthcare system with outside-in innovation. Tune in around the 15:20 mark for that part of the conversation, and a final word-to-the-wise for any startup looking to work with a large healthcare enterprise.