How the coronavirus has changed health care … for good
The COVID-19 pandemic is forcing the health care industry to rethink how medical care is delivered.
From the pages of In Business magazine.
Throughout history, health-related catastrophes have had a way of bringing drastic change. The “Black Death” that devastated 14th century Medieval Europe is said to have contributed to the demise of feudalism because it so shrunk the population, particularly the farmers who basically toiled as serfs for feudal lords, that suddenly peasants who worked for crumbs could command better compensation from others willing to pay them more. Eventually, a mercantile system developed to replace what is now derided as the “futile system.”
Not every pandemic generates rapid change but change eventually comes. Following the devasting Spanish Flu, which spread in several waves from 1918–1920, and infected an estimated 500 million people worldwide — killing a mind-boggling 50 million — it took 25 years to license a flu vaccine for use in humans. Before that pandemic hit, the only control efforts, beyond the preventive aspects of good personal hygiene, were isolation and quarantine, but a treatment eventually produced to combat that scourge has real potential to fight the coronavirus [COVID-19].
It’s still a bit early to predict all the ways the COVID-19 pandemic has or will change American society, global relations, or even the globalization of the economy, but there is little doubt it will affect the delivery of health care in profound ways. The mad medical scramble to slow down the spread of COVID-19 either has ushered in profound changes or intensified certain medical trends already underway but taking their sweet time.
To learn more, we contacted the following local health care industry executives: Michael Barbouche, founder and CEO, Forward Health Group; Dr. Frank Byrne, president emeritus of SSM Health St. Mary’s Hospital–Madison and chief clinical officer of Forward Health Group; Cheryl DeMars, CEO of The Alliance; Dr. Mark Huth, president and CEO of Group Health Cooperative-South Central Wisconsin; and Mike Hamerlik, president and CEO of WPS Health Solutions. We also present a message from Epic about the role data is playing and will play going forward.
DeMars best summed it up by noting the pandemic is forcing the industry to rethink and reengineer how health care is delivered. “I think it is accelerating the pace at which the public is embracing alternative modes of care delivery,” she says.
One of those alternative modes of care delivery is telehealth, aka telemedicine. The federal government tried to mitigate the impact of COVID-19 through the expanded use of telehealth in which providers engage with patients virtually, either through video visits or other remote means. President Trump’s March 13 emergency declaration allowed the Centers for Medicare & Medicaid Services to provide waivers for a number of federal rules and other red tape that get in the way of providers using these technologies.
In an interview on CNBC, Seema Verma, CMS administrator and a member of the White House Coronavirus Task Force, says the decision to relax regulations boosted telemedicine, especially for vulnerable senior citizens who can communicate with their doctors via Skype, FaceTime, or another video conference platform. “Essentially what that means is that America’s 62 million seniors that benefit from the Medicare program can communicate and have a full visit with their doctor,” she notes. “This is really important because even our seniors that aren’t experiencing coronavirus symptoms — maybe they are a diabetic or somebody with heart disease that needs to check in with their doctor — they can do that from the safety of their home. They don’t have to travel. They don’t have to sit in a waiting room.”
The latter point is important, especially during flu season, because it reduces the incidence of sick people infecting others simply by sitting in a waiting room. “So,
it is a game-changer,” Verma stated.
Use of telehealth such as remote monitoring, especially in rural areas, had been growing but at a pretty slow rate, and really had not been deployed as broadly and effectively as it could have been. Now, thanks to caregiver shortages, especially professionals such as critical care physicians, nurses, and behavioral health caregivers, these virtual tools are seen as a way to stretch resources.
Relaxed rules also meant that emergency rooms could set up alternative emergency test sites, use providers across state lines, and otherwise offer more flexibility within hospitals so they can move patients around, Verma added, noting that public health officials hear from front-line providers every day asking for more flexibility.
The question that remains is will those rules remain relaxed so that they can offer the same advantages in a conventional flu season? DeMars believes they will, especially if patients have had a good experience with telehealth during the pandemic. “If people get comfortable with a different way to receive health care services, particularly if their experience is positive, this won’t be just a change that’s limited to the current crisis,” she says.
Huth, who continues to see patients as a family physician, believes the crisis has cemented the need for accessing patients in variety of different ways. That has been driven by the fact that the medical community realized that face-to-face visits, while important and something that must continue in some fashion, are not only way care can be delivered. “I’ve heard it said from other partners here in town that they have done more to set up virtual visits in the last 10 days than they have in the last 10 years,” he stated in a March 25 interview.
Locally, Epic plays a role in virtual care, as many virtual appointments are made using its telehealth infrastructure software, including live-video appointments through a patient’s MyChart account. Novant Health, based in Winston-Salem, North Carolina, is one of more than 200 customers Epic has helped with telehealth setup, expansion, and training. Novant Health recently went from 200 video visits a year to more than 12,000 a week, according to Dr. Keith Griffin, its chief medical informatics officer.
The coronavirus also pushed more mental health counseling online, as people needed help coping with the psychological effects of social distancing. Whether it was anger, anxiety, boredom, or another consequence of remote living, getting mental health services in this environment required a form of virtual counseling known at teletherapy. While there is no substitute for face-to-face counseling, there is a role for the remote version, particular if a visual image of the patient is possible. Teletherapy was already helping people deal with the stigma of mental illness, but during the coronavirus outbreak, when such services were expanded under Medicare (at least temporarily), virtual counseling proved its value to a wider audience.
Indeed, medical professionals might just be scratching the surface in the way technology can improve the delivery of care, and the pandemic will be an accelerator. “People are learning about it in terms of volume and learning what kinds of services can be done through telemedicine — things that are being done that before we were reluctant to do,” Hamerlik says. “Mental health is one of those.”
Even though he concedes the occasional necessity of face-to-face visits, and he wonders how such encounters will be reimbursed under what he considers to be an archaic financial model for health care, Barbouche is even more bullish on telehealth. “This will have been the moment where they [patients] opened the box, and they will never be able to close the box,” he states. “Once patients experience care in this manner, off they go.”
Testing public-private partnerships
Americans cannot blame their government for a highly contagious respiratory virus that originated in China, and that the Chinese government kept hidden for weeks, especially when Chinese Community Party officials initially claimed it could not be transmitted from human to human. However, they can ask why domestic work on a more robust testing system didn’t begin much earlier.
According to a report in the Wall Street Journal, the first test kits were sent to state and local government labs, but the only people who were tested were those who had symptoms of the virus who recently had traveled to China. Only about 100 people a day were being tested in the U.S., and by then the pathogen had already spread to Europe, where most of the newly infected Americans had traveled.
While the virus quietly spread within the U.S., officials at the Centers for Disease Control in Washington were telling state and local officials that testing capacity was more than adequate to meet the demand. President Trump downplayed the possibility of a wide outbreak in the U.S., and Health and Human Services Secretary Alex Azar defended the testing program by citing a low number of confirmed cases when few diagnostic tests were available.
Private labs remained on the sidelines, as did manufacturers that could have ramped up production of test kit supplies such as swabs and chemical reagents. In addition, an initial test kit developed in a government agency lab failed, and many flawed tests were taken out of circulation.
Contrast the initial U.S. response with that of South Korea, which was testing upwards of 20,000 patients per day, and countries such as Taiwan, which established a far-reaching diagnostic program after its experience with the 2003 SARS epidemic, and it’s clear that some soul searching is in order for U.S. federal health agencies and elected officials.
From this point forward, expect crisis plans to factor in the role that public-private partnerships can play in responding to a pandemic, including the production of tests and ventilators, and the stockpiling of supplies for future use.
Barbouche laments that screening has never really been a big-ticket item for American health care, even after the Spanish Flu pandemic of 1918. “Whether it’s having sufficient capacity to provide enough mammograms to women for screening or other examples, we have not really closed the measurement gap that would be possible for a country of our means,” he states. “I want to believe that coming out of this great screening and testing fiasco, which creates the most exposure and risk for all of us, we will demand an understanding of how to measure a population and how to screen a population in groups.”
In coming out of this with a far stronger capability, Barbouche envisions leading roles for local companies such as Exact Sciences, which is creating new tools for cancer screening and, at the request of Gov. Tony Evers, was one of several local companies — along with Promega Corp. and UW Health — that helped scale up Wisconsin’s COVID-19 testing capabilities. Barbouche also sees more respect for a group of health care workers who in the past have been undervalued. “The deeper heroes of all this will be clinical lab people that were always shunted to the basement and impacted by budget cuts,” he states.
As was the case on U.S.-bound flights after recent travel bans went into effect, some basic testing or screening may become more routine in the U.S. before people depart from airplanes, a procedure Hamerlik is well acquainted with. During one stretch of his career, which coincided with the 2009 H1N1 swine flu outbreak, he frequently traveled to China. “I remember getting into either Japan or China, and our temperature was taken before we even got off the airplane,” he recalls. “When that was happening back then, there was a delay in getting off the airplane, but it wasn’t onerous, and it was something you just sort of tolerated. It wasn’t that big of a deal. It was just part of a process.”
Byrne indicated that the American health care system, and various consultants advising it, are partly to blame because in the name of efficiency, surge capacity was engineered out of the system over the past two decades, but more intensively in the last 5–10 years. By surge capacity, he not only means physical facilities, equipment, and supplies, but staffing, as well. One of the greatest surge capacity tools a health system can have is highly qualified people who, for a variety of personal and professional reasons, prefer to work part-time but are prepared to ramp up their time commitment during peak flu season, weather emergencies, or national disasters.
“At one time, I was grateful that we had a significant percentage of part-time employees in our health care delivery system, and that’s your surge capacity,” Byrne explains. “We had significant health care employees and efficiency consultants swarm us and say, ‘Well, it’s more expensive and you’re giving benefits down to half-time FTEs, including health insurance, and so you really need more full-time employees. That’s one of the things that eliminated our surge capacity, and we need to rethink that.”
Drive-through coronavirus testing labs began to spring up when it became clear the U.S. didn’t have enough diagnostic tests to detect the coronavirus and measure the scope of the unfolding crisis. Will these impromptu labs become a fixture during cold and flu season, or will history view them as just a situational solution that the medical community would prefer not to rely on again?
In general, the service was provided to patients based on their symptoms and exposure, and typically they had to be referred for testing by a health care provider. For safety reasons, patients remained in their car while a physician or an advanced practice provider — outfitted in protective gown, goggles, mask, and gloves — swabbed the inside the nose for a sample.
In addition, with that one swab, drive-through patients also can be tested for more common respiratory pathogens that cause the flu or related conditions.
It was a relatively quick and easy way — each appointment took just a few minutes — for the medical community to play catch up with a test developed by Stanford Medicine researchers and approved by the Food and Drug Administration.
Given those advantages, are we on to something that becomes a permanent best practice? In Barbouche’s view, there is no reason not to explore such new ways of doing things. “Why don’t we, after establishing all these mobile testing centers for coronavirus, continue to sustain them and say that you can come here and get your flu shot next year? You can come here and get access, through one of the hospitals, to your mammogram. We can help you here with nutrition support and nutrition counseling. We can help you here with behavioral health. I don’t know why we wouldn’t look at the build out of this infrastructure.”
This wasn’t the only example of crisis-induced innovation for testing. In late March, medical-device manufacturer Abbott Laboratories unveiled a molecular test that can tell if someone is infected with the coronavirus in as little as five minutes and is so small and portable that it can be used in almost any health care setting.
Dusting off old treatments
New medical innovation to deal with the coronavirus will be evident to all as the scientific community develops solutions, but it was old technology pulled from the shelf that offered short-term hope. While scientists worked to develop vaccines or antiviral drugs, researchers at Johns Hopkins University in Baltimore suggested convalescent serum as something that could be deployed in the interim. The term refers to a century-old, but somewhat forgotten method of harvesting virus-fighting antibodies from the blood of previously infected patients.
In essence, they take the blood of former patients who have developed immunity and use it to treat those who became ill, according to Dr. Arturo Casadevall, chair of the molecular microbiology and immunology department at the Johns Hopkins Bloomberg School of Public Health.
Convalescent serum was used during another historic health scare, the Spanish flu epidemic of 1918. Scientists found that transfusions of blood plasma taken from survivors led to a 50 percent drop in deaths among severely ill patients. Later on, it also was used to treat and stop the spread of polio and measles outbreaks, but eventually it was replaced with advances in vaccines and antiviral drugs.
With time of the essence during the COVID-19 outbreak, convalescent serum has been revived and could be used until a coronavirus vaccine is developed and tested for efficacy and safety in ongoing clinical trials, an accelerated process that still could take 18 months or more. The treatment took on local significance in early April, when UW Hospital joined the National COVID-19 Convalescent Plasma Project, and later announced it would treat patients with convalescent serum as part of a Johns Hopkins clinical trial.
The same kind of hope was generated by hydroxychloroquine, a drug first developed in the 1940s for the treatment of malaria and granted FDA approval in October 1949. After it was studied in a recent open-label trial in Marseille, France, it was put to work on patients with advanced COVID-19 symptoms in New York, the hottest of all COVID-19 hotspots, in combination with another drug called azithromycin, with encouraging results.
Stephen Hahn, commissioner of food and drugs, indicated that some of the near-term COVID-19 answers could be made available through the concept of “compassionate use,” where the usual FDA rules are waived if physicians deem it appropriate for a particular condition. The compassionate use concept is established law in states such as California, which have applied it in the case of medical marijuana.
No matter how such treatments are put to use in the short-term, they should still be thoroughly studied using established scientific standards in clinical trials, notes Byrne. Anecdotal evidence is fine, but it behooves the health care system to make certain these drugs are safe and effective in the COVID-19 context, rather than continuing to use them on an ad hoc basis.
“We have an obligation as a health care delivery system to ensure that if these medications are being used, they are being used just as we’ve done with other therapies, other interventions, other medications,” Byrne states. “We must ensure that they are used in a formal trial with results reported and aggregated so that we can tell, when the dust settles, whether it helps or not.”
The same applies to the eventual vaccine, he adds. “If we don’t do that, if we just start ad hoc subscribing these medications, we won’t know anymore when this situation is stabilized than we do now. We won’t know for the next time, and there will be a next time, by the way.”
Lessons from a SARS whacking
Depending on your source, President Trump either disbanded his pandemic preparedness team, hampering the administration’s response to the pandemic, or he simply reorganized it. Either way, the lack of initial tests and alleged cuts in global health staff funding were the two main sources of criticism being leveled at him
as the pandemic unfolded.
The nation’s handling of the crisis will be investigated, and world leaders will have an opportunity to push back on such allegations, but the U.S. review likely will center on the 2018 disbanding of a National Security Council unit focused on pandemic preparedness.
Thus far, Trump has dismissed the criticism, but it’s bound to come up as the presidential election unfolds. Architects of the NSC makeover responded by asserting they merely streamlined a bloated outfit, putting pandemic and bioweapons experts in the same room.
They contend the new arrangement can work if given enough warning, placing the blame on Chinese government foot-dragging, and they point to the now suppressed upsurge in cases of Ebola hemorrhagic fever in the Democratic Republic of the Congo as proof of the revamped unit’s capabilities.
Multiple reports say the U.S. government, despite repeated warnings to do so, never replenished its stockpile of N95 masks after they were exhausted during the H1N1 outbreak. That particular viral experience killed 1,200 Americans, but it did not cause the national trauma that COVID-19 has. Which begs the question: Does it really take a traumatic event for America to get serious?
It did for Taiwan, which given its proximity to China, figured to suffer as much as any nation from the highly contagious COVID-19. However, it really hasn’t, and the reason is that Taiwan was fully prepared to act, and sooner than most, thanks to its devastating experience with severe acute respiratory syndrome (SARS) in 2003. In Taiwan, the International Journal of Infectious Diseases studied the five-month period from March 14 to July 30, 2003 and found that of the 668 cases of SARS reported in the country during that period, 181 or 27 percent resulted in fatalities.
In 2020, the results were significantly better. As of March 18, only 100 COVID-19 cases were reported in Taiwan, even with one dozen weekly round-trips between Wuhan, China and the Taiwanese capital of Taipei before flight restrictions were imposed. They attribute that to big data, transparency, and an epidemic control unit (a national health command center) that is focused on responding to large outbreaks.
In an article published in the Journal of the American Medical Association, Jason Wang, an associate professor of pediatrics at Stanford Medicine and a native of Taiwan, credited that nation with quickly implementing a list of 124 action items to protect public health. As early as Dec. 31, Taiwan began inspecting airline passengers for fever or pneumonia symptoms on direct flights from Wuhan, a sprawling city in Central China with more than 11 million people (by comparison, New York City’s population is 8.6 million).
By Jan. 20, the first travel alert was issued, and a central epidemic command center was activated. Two days later, the Taiwanese government began to promote efforts to quarantine and allocate masks to retailers (it had more than enough in stock), and by Jan. 24, testing for COVID-19 began at designated hospitals.
The inevitable review of the U.S. government’s response to COVID-19 will no doubt recommend a few things from successful models elsewhere.
Breaking the China chain
To the public’s astonishment, many of the life-saving drugs we depend on each day are manufactured in China. That point was brought home during the early stages of the COVID-19 crisis, as an article in Xinhua, which is China’s state-run media agency, claimed that China could impose pharmaceutical export controls that would hamstring our efforts to fight COVID-19.
China’s grip on the on the global supply chain, especially for drug therapies, is strong and needs to be unwound. Efforts already are underway to diversify the global manufacturing base, disconnect at least some pharmaceutical manufacturing from China, and bring more of it home, but that won’t happen overnight.
Perhaps more importantly, are local health care providers willing to collaborate and share rather than always compete for market share? “We need a more global, community wide, and regional approach to managing this,” Byrne says. “I’ve talked with several other health care leaders, both clinical and administrative in this region, and they have concerns about the ability to coordinate resources if they might be overwhelmed at their institutions, and vice versa. We’re cheating those in need if others are overwhelmed in putting a system in place. I think that we could do better with that.”
In early March and througout Madison’s experience with the pandemic, there was heartening local news with the sharing of supplies, information, and learnings, plus better communication and coordination of effort. “You see that happening already, that when the system is being strained, entities that competed six months ago are now working together to meet the needs of the community,” DeMars notes. “I hope that will be a lasting change.
“We’ve lapsed into competition for market share and revenue generation instead of what should be a collaborative effort to keep people healthy.”
No barriers to good health care
Dr. Alison Craig demonstrates her COVID-19 innovation — a desktop droplet barrier that protects caregivers and patients.
If necessity is the mother of invention, the need to compensate for a shortage of personal protective equipment — to fight a pandemic, no less — made an inventor out of Dr. Alison Craig, chief of staff at Group Health Cooperative of South-Central Wisconsin.
Craig, a practicing pediatrician, had several sleepless nights due to the shortage of PPE for health care workers. She had a lot of sleepless company among over-burdened health care organizations across the country, but since GHC-SCW has outpatient clinics, it is considered low-priority for receiving PPE.
She couldn’t just stand by and do nothing to protect herself and other caregivers during COVID-19 testing, especially with no idea of when and how many masks and gowns would come their way, so she got creative. With the help of team members, that creative spark led to some online research and the invention of a prototype desktop droplet barrier, which was made out of everyday items like plexiglass, light fixture rings, cast protector sleeves, and a utility cart.
Outside parties also weighed in, especially after Dr. Craig posted a video of the prototype on YouTube, which received thousands of comments, views, and shares to other social media platforms. She connected with others that could not only help build replicas but make improvements, including a new and improved sleeve option courtesy of Brownmed, a medical supply company from Iowa. In addition, a group of volunteers then built replicas of the barrier and delivered nine to GHC-SCW in short order.
The response to Craig’s innovation truly humbles her, but as she stated, “As health care providers, we have no choice but to rise and face the challenge together.”
Dr. Mark Huth, the organization’s CEO, marvels at how quickly it all came together in less than a week from the moment Craig approached him and asked a “what if” question about a glass shield that could be used to take a swab from a patient. “A facility guy went off and literally two hours later came back with a prototype he had built that worked perfectly,” Huth recalls, “and we got the specs out and a local assembler built nine more of them for us over the weekend.”
GHC-SCW has released all of the specifications as open source to anybody in the global medical community who wants to mass produce it. “That’s just to say that here’s an option to keep provider and patient safe,” Huth states. “When taking a nasal swab for a respiratory infection, it reduces the number of gowns and face shields that you have to use.”
Dr. Alison Craig demonstrates her COVID-19 innovation — a desktop droplet barrier that protects caregivers and patients.
Epic message on covid-19
By Drs. Jackie Gerhart and Chris Alban
Dr. Jackie Gerhart
Dr. Chris Alban
The world is learning a lot about how to respond to a pandemic.
We’re learning how important it is that health care workers have what they need. We need to keep them safe and make sure they’re protected with the equipment, tools, and information they need to do their job. In this case, that means knowing where the available beds and ventilators are and getting information to hospitals and public health departments so they can manage critical resources.
It also means that providers need information to both understand the health of their individual patients, as well as manage the health of their communities. Data will help us better understand what to do. For example, how are patients with the disease responding to a particular drug? How do things vary from one state or community to another? How will insight from those that have gone before impact how other communities prepare? How will what we learn in the beginning affect how we respond in the future?
Right now, physicians at Epic are working together to look at data from health systems to help answer questions about the virus and treatments, including whether certain drugs are working. Over 85 percent of the admissions in Wisconsin happen in Epic, and more than half of the patients in this country have a record in Epic, so we can be a helpful source of information.
Health systems are making big changes — and fast. Patients who would have gone into the office are now staying safer at home and interacting with their doctors online. Today, some of our customers are doing more than half of their visits virtually.
Working with health departments and hospitals has been meaningful. That’s been one of the most positive things — to see everyone pull together to slow the spread and care for patients.
– Physicians Jackie Gerhart and Chris Alban are members of Epic’s clinical-informatics team.
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