Consulo Indicium - 6/2/21

Information for your Consideration…

Practicing Physicians See Continuation of Telehealth as a Practice Norm – An article recently appeared in the May 2021 issue of the Journal of Medical Internet Research where the authors conducted a survey of practicing physicians to gain a perspective on the short- and long-term implications of the shift to telemedicine during the early COVID-19 pandemic. They assessed their attitudes toward telehealth training and care provision during the early pandemic to determine the potential implications for quality, access, and mode of U.S. healthcare delivery. The sample was small with only 148 physicians. On average, the use of telehealth visits increased from 13.1% immediately before the pandemic to 59.7% - on average – during the early months of the pandemic. In essence, the physicians felt that telehealth patient-visits and face-to-face patient-visits were comparable in quality and, that telehealth care should continue to play a larger role (44.9% of visits) in U.S. healthcare post-pandemic. The study is comparable to the informal results I hear from colleagues across the country. The pandemic has precipitated a massive change in how we will be interacting with patients and providing care into the future. 

Breakthrough Investigations Stopped by CDC – According to a recent report the CDC released on April 30th, there have been 10,262 breakthrough infections among the approximately 101 million people in the U.S. who had been fully vaccinated or, a 1% chance. As a result, the CDC will stop investigating breakthrough infections unless people are hospitalized or die. According to CDC’s Morbidity and Mortality Weekly Report “of the 555 cases available for sequencing, the B.1.1.7 (UK) variant represented half (56%) of cases; followed by the B.1.429 (Pango) variant first identified in California at 25%; the B.1.427, another California variant, at 8%; and the P.1 (Brazilian) variant at 8%.

Expanding Global Supply – One of the issues we are facing globally is the insufficient supply of coronavirus vaccines across all of the nations. It seems that everyone agrees that the supply of vaccine must be greatly expanded not only for caring, humanistic reasons but also for practical reasons in managing the spread of the pandemic. But, the problem is that the political and science leaders cannot agree on how to accomplish the task! A stark statistic is that only 0.3% of the vaccine doses administered on a global basis have been given in the 29 poorest countries. This is a tragedy in the making. Some solutions are coming to the forefront in the last couple of weeks such as: stepping up vaccine production by the manufacturers, waiving patent protections for a period of time, and donating vaccine stock from the wealthy nations. Advocacy from all of us would no doubt help…

The Topic of the Week – Beyond the vaccine production problems is the growing debate on vaccine credentials. Personally, I carry my handwritten CDC vaccination record that I received from my local hospital when I received both of the Moderna vaccinations. Also, the software developers were quick to the party as well. They rushed to build technologies and one where there is a high degree of competition is apps for tracking if you’ve been near someone with covid. These so called “vaccine passports” are designed as apps for your smartphone.

It is important to note at this point; however, that there is a big difference between vaccine credentials and exposure notification apps. The exposure notification apps usually work on an anonymous, non-visible basis where the signaling capability of Bluetooth between mobile phones is used as the connector. Vaccine passports – on the other hand – use digital identifiers that are tied to the individual. These identifiers can be sent to or shown to others who are near you as evidence of your status relative to a Covid-19 infection. 

In the UK, the National Health Service recently announced a new digital credential for crossing borders. At the present time, it’s only used for people going out of the UK from England (Scotland, Wales, and Northern Ireland) although it has also been suggested for monitoring people’s exposure around town (e.g. the “pub”) as well.

Beyond the UK, the EU itself is pursuing the development of a proposed a digital “green certificate. Also, the French TousAntiCovid contact tracing app has been recently updated to show a vaccination certificate or a negative test result and they are working on getting other countries to accept it. Italy is in the same position with its Immuni app. And, the Germans intend to rollout their option by the end of June.  Beyond Europe, Israel has an early version of its Green Pass  and Singapore has released TraceTogether which holds an individual’s vaccination record. To date, few countries are accepting proof of vaccination as an alternative to quarantining or showing a negative covid test. So, the “app solution” will take time and probably need some type of credentialling process to be fully accepted.

The idea surrounding the use of these apps is controversial at best. Can you imagine the privacy debates we’ll have here in the U.S.? So far, US, officials have indicated that they do not intend to develop a federal app. As a result, various states and private companies are creating a patchwork of approaches to be deployed in the coming months many of which are attached to the travel industry (e.g. CLEAR and others). Stay tuned. We’re only at the beginning… 

The Other Problem – I grew up in North Dakota. Owning guns was a natural part of life. My Dad owned guns as did my brothers. I did not. Why? Because my uncle took me out one day when I was about 10 years old to learn the basics of using a gun. We went to a local pond and there were lots of frogs hanging out at the pond enjoying a summer day. So, they became our target. However, after hitting a couple of frogs with bullets, I found is entirely distasteful to see these little guys blown to pieces by my shots. I never picked up a gun again. My brothers – on the other hand – were avid hunters and brought home ducks, geese and even deer. So, while I fully appreciate the need for having access to guns for hunting, I find it absolutely incredible that we do not have licensing of guns for all of the other uses including defense. The statement that it is a guaranteed right is accurate just like the right to free speech – which does not include shouting fire in a theater; or, the right to assemble which does not include the ability to storm the capital; or, the right to protection against excessive bail which is set by the states. The constitution provides guidance on a number of issues, but it does not provide specifics. The specifics are set by our legislators and policy makers. In the case of guns, does it make sense to allow for the purchase of guns whose sole purpose is to “kill”? I don’t think that Washington, Jefferson, and the other framers of the Constitution had that in mind. In fact, gun control has been a continuing concern for the Republic since 1791 when the ten amendments to the Constitution (= The Bill of Rights) were first approved.

 firearms

Laws that provide for reasonable oversight would seem to be a prudent course otherwise we will continue to have uncalled for mass shootings and other forms of violence foisted upon us in an unmitigated fashion. It seems to me that reasonable gun control can be formulated that protects everyone on all sides of the political debate.

What is particularly troubling are statistics like the information released by the CDC in 2019 showing that firearm deaths are now the leading cause of death for children and teens, ahead of motor vehicle, cancer, suffocation, and poisoning deaths. The situation represents a major public health crisis! When is the health care community going to stand up and say something – not just the pediatricians but all of us?!  The situation – in general – is a sad commentary and preventable. And, it’s just one element of the ongoing gun control debate that deserves dialogue and discussion rather than simple obstruction.

Medicare Telehealth Usage on a Major Uptick – In 2020 at the outset of the pandemic, Medicare expanded coverage for telehealth visits enabling enrollees to maintain their care while also minimizing their risk of exposure to the coronavirus. When the benefits were expanded, the stipulation was that they would continue as long as the COVID-19 public health emergency remained in effect. In April, the emergency was extended in April but with this Executive Order no expiration date was set. This is good news across the entire care delivery spectrum. People residing in rural areas or in situations where it is difficult to get to a physician’s office either due to travel or disabilities AND physicians who have found the use of telehealth not only popular but effective – are all cheering the news. In fact, 1 in 4 Medicare beneficiaries have seen their medical provider on remote basis – including me!! The nonpartisan Kaiser Family Foundation recently released a report on the outcomes related to the expansion of telehealth benefits.

benefits

The report noted that people with disabilities who are low income and among communities of color were some of the greatest beneficiaries. The study noted that, “the temporary expansion of telehealth coverage may be helping some of Medicare's more disadvantaged populations continue to access needed care." The inflection point has occurred. Telehealth is here to stay and will only expand as the technology, bandwidth and public expectations grow.

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