Consulo Indicium - 5/26/20

Information for your Consideration… 

Coronavirus Tracking App Shows Promise – The New York Times recently reported on the difficulty that public health officials are having when it comes to tracking the spread of the coronavirus real time. The article cited a study published in Nature Medicine that revealed that the use of an symptom checker app was quite effective in predicting coronavirus infections among the 2.5 million people who were part of the test case. It’s important to note that the results were for “symptomatic” COVID-19 patients. Picking up on asymptomatic patients – of which there seems to be a very large number – has not been resolved. Regardless, through the use of machine learning and artificial intelligence (= the physician’s next stethoscope) the researchers were able to predict which people were most likely to have COVID-19 based on their age, sex and a combination of four symptoms with almost an 80% accuracy. We are going to see more of this type of tool and intelligence in the future. 

The Transmission Problem – The riddle of why the COVID-19 virus seems to affect gatherings more prominently may have been resolved.  In a report from researchers at the National Institutes of Health and the University of Pennsylvania published in the Proceedings of the National Academy of Sciences, the results of study on small group gatherings were assessed.  In the experiment the researchers used a laser light to assess the respiratory droplets created as a result of human speech in an enclosed environment. The study revealed that the small respiratory droplets emitted through ordinary speech lingered in the air for about eight minutes. The lingering effect of the droplets explains why the clustering of COVID-19 cases in nursing homes (which represent approximately 1/3 of all US cases to date), cruise ships, and other confined spaces with a limited air circulation seems to be such a prominent origin for outbreaks.  This is the primary reason that places where there is lots of speechifying (e.g. Republican and Democratic Conventions) or singing (e.g. churches and concerts) have been dissuaded from opening up until Phase IV.  One of the researchers - Andrew Noymer, an epidemiologist from the University of California at Irvine noted in a wry comment that: “Speech creates droplets that breathing alone does not. That much is clear. Big mouths of the world, beware. You’re putting the rest of us at risk.” Hmmm…

Furthermore, the US Centers for Disease Control (CDC) in the latest guidelines (May 20, 2020) noted that the virus “does not spread easily” by touching contaminated objects or surfaces but then noted that such passing of the virus “may be possible”. Long story short, keep up the hand washing, social distancing and cleaning of your environment. Also, the report importantly noted that animal-to-human contact is unlikely (I let my dog, Toto, and cat, Willie Nelson, know that they are safe – actually I figured that was the case since they have both been with us since the outbreak started – all with no ill effect.)

The Loses Are Mounting – It’s not only the loss of human live that is a tragedy that could have been prevented from more forward leaning action by the government, but also health care organizations of all stripes.  As an example, Harvard Medical School announced losses for FY20 ranging from $39 – 65 million. I’m confident that this is not the only medical school that has been affected.  A health care system in the neighborhood has been noting losses of more than $1.5 billion due to a combination of the number of severe COVID-19 and loss of revenue from traditional services that have been deferred.  Individual practices for primary care and specialists have also been markedly affected from either closure, marked reduction in utilization or referring of services. But, more importantly at this point, is the loss of human life.  I don’t have to argue about whether the US has effectively responded.  I simply look at the data.  The data speaks for itself and is very powerful.  You be the judge.  Here it is…


And, if you don’t like the preceding data – try this data on:


By the way – thanks to Dr. Eric Topol who tweeted both of these graphs on Twitter. To paraphrase or parafrays, “America, we’ve got a problem!”  And, now we are engaged on “re-entry” which on the one hand is an understandable desire but on the other hand, is happening by using a disjointed, each-state-on-its-own approach that runs the risk of increasing rather than helping over the coming months.  I guess we’ll have to wait-and-see what the data shows.  I’m not optimistic… 

For the interim, you may want to consider the suggestions of Atul Gwande who wrote a piece for the public in The New Yorker magazine on a suggested approach to re-entry… It is the topic du jour for many organizations as they grapple with the “how to’s” of bringing their organizations and businesses back to life.  Meanwhile, except for the meat market (which has an increasingly spartan supply), the grocery store, the pharmacy and the post office – all with a mask on and hands washed immediately upon returning home – life remains a pretty much hunkered down. I haven’t become paranoid yet just diligently obsessed.  So, stay well…be safe…keep your distance.  And, watch for good data to give you advice on where we are headed!! 

And, Now – The Really Bad News – It seems that almost half of the messages coming at us from the social media platform on COVID-19 since January have been information disseminated by “bots”!  Yes, computerized robotic information – not people with opinions.  The study was noted on NPR from researchers at Carnegie Mellon University who reviewed over 200 million tweets about the virus since January.  They discovered that about 45% exhibited “bot” like behavior.  In fact, they are engaged in further research to determine if people were behind the process or if the information was simply coming out from computer driven protocols.  The researchers identified more than 100 pieces of false information coming over the wires on Twitter. Dr, Kathleen Carley, one of the researchers on the project, commented: "We do know that it looks like it's a propaganda machine, and it definitely matches the Russian and Chinese playbooks, but it would take a tremendous amount of resources to substantiate that [fact]”.  I guess I’m not really surprised.  I don’t find a lot of useful information on Twitter except from experts in the field that I know are reliable – like Dr. Topol. The bigger issue that the COVID-19 mis-information bot finding is what this portends about the future of information sharing and information as we move more and more toward virtual data sources coming at us like a torrent.  It’s troubling to say the least… 

Unemployment Up, Health Insurance Down – Over 40 million Americans are at risk of losing their current health insurance as unemployment goes up during the pandemic according to a new study by the Urban Institute Health Policy Center. The report noted that, “Near-term forecasts suggest the unemployment rate will likely be between 15 to 20% by June.” It further estimated that a large percent of the uninsured (i.e. about one-quarter) would “not be able to access Medicaid or enroll in insurance through the ACA.” This explains the major losses being experienced by the hospital and health care organizations across the country.

The Exploding Telehealth Phenomenon – Telehealth, in general, and telemedicine, specifically, have exploded over the last month!! Health care providers of all stripes are moving to the virtual platform as a way of managing care for their patients.  In fact, I was taken aback recently when a gastroenterologist shared with me that he had never done a telemedicine visit until about a month ago. However, he’s already decided that about 80% of he once did through office visits can be done through the use of telemedicine.  And, this does not take into the account what can be done once providers adopt “telecare” – or, the actually delivery of care services using digital resources. Use of telehealth has grown at a rapid pace over the last several years with a doubling of use since 2010. But, I believe we’ve only seen the tip of the iceberg – especially when we see the impact that analytic and machine learning will have on the future of care delivery using telehealth techniques.

The experts such as Joe Kvedar, MD (Partners Healthcare Center for Connected Health) and Judd Hollander (Jefferson Health Center for Healthcare Innovation) are finally being heard. The media widely report on their presentations at the recent Massachusetts Health and Hospital Association webinar on telemedicine and COVID-19. Kvedar noted that application of telehealth capabilities allows patients to be seen with an average wait time of only 6 – 7 minutes and, more importantly, by addressing the needs of the patient about 80% of the time. Hollander described the fiscal side of the equation noting that the return was positive. He observed that the “left without being seen” rate alone can essentially pay for the implementation of a telehealth program.

Historically, the challenge has been physician acceptance.  But, in the face of the pandemic – the opposition to telehealth implementation is melting away. Several physicians who are on the front lines of care delivery have noted for me that once the pandemic passes, care delivery will NOT return to “same old, same old”. The change in care delivery is permanent and the efficiencies and effectiveness are becoming apparent even to the most ardent skeptics. It’s about time…  The major impediment has been the reimbursement by health insurance providers for telemedicine services.  However, with the advent of Centers for Medicare and Medicaid Services (CMS) changes in virtual care delivery coverage for Medicare patients the shift moved into the fast lane. In fact, I have been predicting for many years that once Medicare gets on board, the rest of the insurers will quickly follow – and, that is what we are now seeing. So, it seems to me that we will only see an acceleration of telemedicine – quickly followed by telemonitoring and telecare, the more “proactive” use of technologies for delivery quality care. We have seen the future and it is upon us!

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