Telehealth and the Future

2020 witnessed amazing explosive growth in telehealth.  Although an infrastructure for telehealth developed in the prior five years by visionary entrepreneurs there was slow to non-existent adoption by providers, hospitals, and allied health providers.  Much of the reticence was due to poor reimbursement by health plans.  

During January 2020 to current times telehealth became an established and at times preferred method for outpatient visits.  This was due to an existing crisis fueled by a viral epidemic (pandemic) by a novel coronavirus (COVID-19). Social and physical distancing was mandated by public health officials globally.  This served to radically alter the health care setting. Physician office visits plummeted, even for the normal population. Elective surgical procedures were canceled and postponed. 

How COVID-19 is affecting internet performance

According to Fastly, to understand how the internet is performing with the changes in internet use brought on by the COVID-19 pandemic, we investigated two key metrics during February and March in some of the countries and states that were hit hardest by the virus: changes in the traffic volume served to those regions as a reflection of changes in internet use, and changes in download speed measured at our servers as a reflection of internet quality. In almost all regions, the largest increases in traffic volume occurred immediately after public policy announcements, such as school closures or stay-at-home orders. Similarly, the most dramatic decreases in download speed followed the official starts of those policies — presumably when populations made the shift to staying home.

Table 1 reveals the sharp uptick in internet traffic by country and state and the effect on broadband speed.  The findings reveal metropolitan areas suffered the least, most likely due to penetration and redundancy of the internet in cities.  Italy suffered the most increase in usage and the decrease in broadband speed. In the U.S.A. rural states such as Michigan saw a marked decrease in internet speed. Michigan is a rural state and the penetration and less redundancy in infrastructure caused network speeds to decrease by almost 40%.

Definition of High-speed internet

Perhaps the best modern measurement of whether an Internet connection is “high speed” is in what services are supported at that speed. Virtually any broadband, or non-dialup, connection can support a home user’s standard browsing habits. Streaming of standard-definition video, with a pixel width of 480, requires a minimum 1Mbps connection. Low-end high-definition video, with a pixel width of 720, requires at least 2.5Mbps. Streaming high-definition 1080p video needs at least a 9Mbps pipeline to avoid buffering delays. And these numbers only take into account a single device — if five users in your office network simultaneously stream separate 1080p videos, your 10Mbps will not seem “high speed.”   

If one lives in a rural area there may be severe limitations on live streaming used by telehealth.

The. Brookings Institute published a breakdown of what type of internet customers can access.  There are some surprising results

The lack of internet broadband access in the mid-south has created a need for cellular coverage.  While 4G/LTE is widely available there are some areas that only provide 3G. 4G/LTE may be adequate for video streaming when signal strength is strong. As 5G cell coverage becomes ubiquitous it becomes mainstream.   A recent test on T-mobile cell coverage in Southern California revealed a 60-75 MPs download and 40 MPs upload speed. That is adequate for live streaming as indicated by calls on Zoom and other video conferencing apps such as GoToMeeting, Google Meet, Webex, or Cisco.

Webinar: What is the future for telehealth?  REGISTER

There are some indications that some payor and Medicare are planning to re-institute restrictions on telehealth reimbursement once the acute pandemic ends.  However, that is a big contingency since the ongoing pandemic is still evolving.

Treatment with Hydroxychloroquine Cut Death Rate Significantly in COVID-19 Patients, Henry Ford Health System Study Shows | Henry Ford Health System - Detroit, MI

There have been conflicting comments and opinions on the efficacy of Hydroxychloroquine for the treatment of Covid-19 patients. Many have opined on the failure of HCQ to reduce morbidity and death in patients with Covid-19.

The patients studied at HFH Systems were treated early in their disease. 

In a large-scale retrospective analysis of 2,541 patients hospitalized between March 10 and May 2, 2020 across the system’s six hospitals, the study found 13% of those treated with hydroxychloroquine alone died compared to 26.4% not treated with hydroxychloroquine. None of the patients had documented serious heart abnormalities; however, patients were monitored for a heart condition routinely pointed to as a reason to avoid the drug as a treatment for COVID-19.

                                      


Patients treated with hydroxychloroquine at Henry Ford met specific protocol criteria as outlined by the hospital system’s Division of Infectious Diseases. The vast majority received the drug soon after admission; 82% within 24 hours and 91% within 48 hours of admission. All patients in the study were 18 or over with a median age of 64 years; 51% were men and 56% African American.

“The findings have been highly analyzed and peer-reviewed,” said Dr. Marcus Zervos, division head of Infectious Disease for Henry Ford Health System, who co-authored the study with Henry Ford epidemiologist Samia Arshad. “We attribute our findings that differ from other studies to early treatment, and part of a combination of interventions that were done in supportive care of patients, including careful cardiac monitoring. Our dosing also differed from other studies not showing the benefit of the drug. And other studies are either not peer-reviewed, have limited numbers of patients, different patient populations or other differences from our patients.”

Dr. Zervos also pointed out, as does the paper, that the study results should be interpreted with some caution, should not be applied to patients treated outside of hospital settings and require further confirmation in prospective, randomized controlled trials that rigorously evaluate the safety and efficacy of hydroxychloroquine therapy for COVID-19.

“Currently, the drug is "off label" and should be used only in hospitalized patients with appropriate monitoring, and as part of study protocols, in accordance with all relevant federal regulations,” Dr. Zervos said.

Treatment with Hydroxychloroquine Cut Death Rate Significantly in COVID-19 Patients, Henry Ford Health System Study Shows | Henry Ford Health System - Detroit, MI

FDA MedWatch - Hand Sanitizers with Methanol

In a rush to manufacture and distribute hand sanitizers some companies took shortcuts and had defective alcohol production methods resulting in the production of methanol.  This was also a problem during the era of prohibition in the 1920s.  Methanol is toxic to the optic nerve and will cause blindness.   A MedWatch Safety Alert was added to the FDA Drug Safety and Availability webpage.  TOPIC: Hand Sanitizers with Methanol: FDA Updates  AUDIENCE: Consumer, Health Professional  ISSUE: FDA is warning consumers and health care providers that the agency has seen a sharp increase in hand sanitizer products that are labeled to contain ethanol (also known as ethyl alcohol) but that have tested positive for methanol contamination. The agency is aware of adults and children ingesting hand sanitizer products contaminated with methanol that has led to recent adverse events including blindness, hospitalizations, and death. Methanol is not an acceptable active ingredient for hand sanitizers and must not be used due to its toxic effects. FDA’s investigation of methanol in certain hand sanitizers is ongoing. The agency will provide additional information as it becomes available. Recent recalls include:  All Clean Hand Sanitizer, Moisturizer and Disinfectant by ITECH 361 Mystic Shield Protection Topical Solution by Transliquid Technologies BACKGROUND: Substantial methanol exposure can result in nausea, vomiting, headache, blurred vision, permanent blindness, seizures, coma, permanent damage to the nervous system or death. Although all persons using these products on their hands are at risk, young children who accidently ingest these products and adolescents and adults who drink these products as an alcohol (ethanol) substitute, are most at risk for methanol poisoning.

RECOMMENDATION: FDA reminds consumers to wash their hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after coughing, sneezing, or blowing one’s nose. If soap and water are not readily available, the Centers for Disease Control and Prevention (CDC) recommend consumers use an alcohol-based hand sanitizer that contains at least 60 percent ethanol. This chart outlines the information on hand sanitizer labels for consumers to use to identify a product that has been tested by FDA and found to contain methanol, that is being recalled by the manufacturer or distributor, or that is purportedly made at the same facility as products that have been tested by FDA and found to contain methanol. FDA advises consumers not to use hand sanitizers from these companies, or products with these names or NDC numbers. Consumers and health professionals are encouraged to report adverse events or side effects related to the use of these products to the FDA's MedWatch Safety Information and Adverse Event Reporting Program: Complete and submit the report online. Download form or call 1-800-332-1088 to request a reporting form, then complete and return to the address on the form, or submit by fax to 1-800-FDA-0178.

FDA MedWatch - Hand Sanitizers with Methanol

How can the Coronavirus pandemic end?

As we struggle to re-open our economic and social fabric in the United States we wonder how will the pandemic end?

There are two ways it can end.

1. Herd Immunity (also called herd effect, community immunity, population immunity, or social immunity)



In our present setting, the coronavirus only affects a very small percentage of the world population.  Even so, it is causing major disruption to the economy and to social functions.

A mathematical model for the unrestricted spread of infectious diseases, such as smallpox,  pertussis, measles, or coronavirus has been developed.  The model has been tested and proven by previous pandemics.  The variables in the equation are R (the number of infections transmitted by a single host) and S ( the proportion of the population who are susceptible to infection and setting this product to be equal to 1.

Viral entity                                R0                                   HIT       

Measles Airborne                    12–18                              92–95%

Pertussis Airborne droplet 12–17[51]                      92–94%

Diphtheria Saliva                       6–7                              83–86%

Rubella Airborne droplet          6                                       83–86%

Smallpox                                       5–7                                       80–86%

Polio Fecal-oral route

Mumps Airborne droplet           4–7                                 75–86%

COVID-19

(COVID-19 pandemic)              2–6                                50–83%

SARS

(2002–2004 SARS outbreak)               2–5                    50–80%

Ebola

(Ebola virus epidemic Bodily fluids      1.5–2.5               33–60%

Influenza

(influenza pandemics) Airborne      1.5–1.8                    33-40%

These are the facts, numbers do not lie.  

Prevention at the moment (summer 2020) may reduce the numbers, or flatten the curve but has the disadvantage of population variables, such as political motivation, willingness to comply with distance, wearing PPE, following CDC and WHO guidelines.  As we have experienced as soon as PPE, social distancing are removed the infectious rate quickly returns to a high level since the vast majority of the population is naive to coronavirus.


2  An effective vaccine.

Belgian virologist Guido Vanham, the former head of virology at the Institute for Tropical Medicine in Antwerp, Belgium, and asked him: how will this pandemic end? And on which factors might that depend?

Guido Vanham (GV): It will probably never end, in the sense that this virus is clearly here to stay unless we eradicate it. And the only way to eradicate such a virus would be with a very effective vaccine that is delivered to every human being. We have done that with smallpox, but that's the only example - and that has taken many years.

So it will most probably stay. It belongs to a family of viruses that we know - the coronaviruses - and one of the questions now is whether it will behave like those other viruses.

It may reappear seasonally - more in the winter, spring and autumn and less in the early summer. So we will see whether that will have an impact.

But at some point in this epidemic - and certainly in the countries that are most affected, like Italy and Spain - there will be saturation, because according to predictions, up to 40% percent of the Spanish and 26% of the Italian population are or have been infected already. And, of course, when you go over 50% or so, even without doing anything else, the virus just has fewer people to infect - and so the epidemic will come down naturally. And that's what happened in all the previous epidemics when we didn't have any [treatments]. The rate of infection and the number of those susceptible will determine when that happens.

This natural course, prior to vaccines places a demand on health services, significant morbidity, and mortality.  The cost of a natural process would exceed the cost of quickly developing an effective vaccine. Despite media exaggerating the mortality rate coronavirus kills few that it effects, mainly older and the chronically ill. Examining the R0 and HIT covid-19 is far less infectious than Pertussis and Measles.

Measles have been a chronic illness of children and when a vaccine developed it was eliminated very quickly.

The charts above display the rapid diminution of viral epidemics once vaccination begins. Normally the development of a safe and effective vaccine may take several years using previous technology.  Vaccines are now manufactured using RNA technology rather than growing batches of viral particles to be injected.  If the proper RNA is developed it can be injected directly into humans and the normal biochemistry of cells will develop the protein segment of the virus to be used as a vaccine. This means an entire viral particle is not necessary to produce immunity.

Several other factors could take place.  Covid-19 has exhibited some mutations in serotype already which are minor thus far.  A mutation could evolve spontaneously that would alter it immunologically and also it's pathophysiology.

Today pharmacology allows a pipeline to be developed to manufacture like products without having to reinvent the entire process.

Antibody Research Q&A | Baseline COVID-19 Research Project

If you or a friend have had documented Covid-19 this important information will help others who are ill.  You may be able to donate your blood (plasma) for their treatment.  Studies have revealed it reduces mortality from Covid-19

Coronavirus vaccine will not be available until 2021.  However  Coronavirus serum antibodies are available now. The vaccine will induce immunity and is preventive, while the results of antibodies are immediate.

3 Wishes Project – Helping to make meaningful memories at end-of-life

End of life conundrum for families with parents in ICUs

As her mother lay dying in a Southern California hospital in early May, Elishia Breed was home in Oregon, 800 miles away, separated not only by the distance but also by the cruelty of the coronavirus.  Even at times when family members cannot attend the end of life activities for a loved one, there are means of addressing this challenge. As her mother lay dying in a Southern California hospital in early May, Elishia Breed was home in Oregon, 800 miles away, separated not only by the distance but also by the cruelty of the coronavirus.  Unlike many families of dying COVID patients, Breed and her family were able to find some comfort in her mother’s final hours because of the 3 Wishes Project, a UCLA Health end-of-life program repurposed to meet the demands of the coronavirus crisis. In the U.S., where more than 120,000 people have died of COVID, it’s part of a wider push for palliative care during the pandemic.

At 5 p.m. on May 10, Mother’s Day, before Breed-Rabitoy’s life support was removed, more than a dozen family members from multiple cities and states gathered on a Zoom call to say goodbye. John Denver’s “Rocky Mountain High,” one of her soft-rock ’70s favorites, played on speakers. Online, a chaplain prayed. 

  

The project was developed in Canada but co-launched at UCLA Health in 2017 by Dr. Thanh Neville, an intensive care physician who serves as 3 Wishes’ medical director. It aims to make the end of life more dignified and personalized by fulfilling small requests for dying patients and their families in the ICU.

“I would still say the majority of COVID patients die without families at their bedside,” Neville said. “There are a lot of reasons why they can’t come in. Some are sick or old or they have small kids. A lot of people don’t want to take that risk and bring it home.”

                                                      Overall Goal

To improve the quality of the dying experience for patients and their families

Start Up Guide

The 3 Wishes Project Start-Up Guide was developed as a tool to help clinicians to try to improve the quality of the dying experience in ICU and to assist those who are interested in starting the project or adapting it to their own site.

A study published by Neville and colleagues last year found that 3 Wishes is a “transferrable, affordable, sustainable program” that benefits patients, families, clinicians and their institutions. They calculated that the mean cost of a single wish, funded by grants and donations, was $5.19.

Email milo@mcmaster.ca for a free copy of the 3Wishes Project Start-Up Guide.

3 Wishes Project – Helping to make meaningful memories at end-of-life

COVID-19 Spawns an Important New MD Job Title

Author: Gary M. Levin M.D., Health Train Express

The coronavirus pandemic has caused a massive rewrite of the way we deliver healthcare in the United States. Perhaps most consequential among many changes has been the remarkably rapid pivot to telehealth.

Bernard Godley, MD, PhD

Regulators and payers have relaxed patient privacy and reimbursement policies that had inhibited the use of telehealth, dramatically altering the playing field. We can safely assume that the widespread use of telehealth will outlive the pandemic and become a fixture of patient/provider interactions.

As a result, it's critical to develop a new job title that will integrate telehealth into health system operations and maximize its still untapped potential. As the healthcare system moved away from the transactional model of care and toward the experiential model, a new title was created: Chief Experience Officer.

Another new title was created for leaders guiding their systems from volume- to value-based delivery: Chief Transformation Officer. The Chief Medical Information Officer role was created to drive integration of EMRs and other digital platforms in support of system transformation.

Now an additional title is likely to become common in the C-suites of many hospitals, health systems, and large medical groups post-COVID-19. This title is so new that there is as yet no name for it. Our proposal: Chief of Distance Care Delivery. It might more simply be called Chief of Telehealth, while CMO for Telehealth or Chief Digital Care Officer are other options.

Post-COVID-19, convenience, and lower cost will continue to drive the expanded use of telehealth. As the crisis subsides, regulatory and reimbursement organizations will require that policies be enacted to bring quality, safety, privacy, and other benchmark standards in line with those of traditional delivery methods.

An emerging leadership position will have to be assigned to oversee what could become the primary method of providing ambulatory care, along with artificial intelligence-driven interfaces and remote patient monitoring technology. What would be the duties of this role, and who would qualify?

Briefly stated, the Chief of Distance Care Delivery (CDCD) would conceptualize, implement, and maintain high-quality telehealth services across the hospital, health system, or group. In academic environments, the role also might entail an outcomes research component.

Key to the role would be developing and overseeing quality, patient experience, and safety care measurements and protocols. Similar to other dyad structures, the role may evolve to have an administrative and/or nursing partner as telehealth becomes a major source of revenue, potentially overwhelming traditional ambulatory care delivery in some settings.

Joseph Kvedar, MD, president of the American Telemedicine Association and professor of dermatology at Harvard Medical School, has personally observed how health systems, physicians, and patients have rapidly embraced telehealth. He notes that at the Brigham and Women's/Massachusetts General Hospital–affiliated Partners Healthcare System, a network of about 7000 physicians, there were only 1600 virtual patient encounters in February 2020. In April 2020, that number had jumped to 242,000.

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COVID-19 Spawns an Important New MD Job Title

We test a home antibody kit for tracking Covid-19 transmission

Easy-to-use postal tests may be important for monitoring community transmission.

Home testing kits will likely be an important part of monitoring Covid-19. Swab tests can tell whether a person is currently infected, while antibody tests look for signs of past infection. But before tests like these are rolled out, researchers need to make sure they're reliable and easy for people to use at home. We tried one of the home testing kits and spoke to researcher Christina Atchinson about the REACT (real-time assessment of community transmission) study being run by Imperial College London in the UK.

Information from Nature. doi: 10.1038/d41586-020-01677-y

Exploring the Role of Supply Chain Management in Healthcare

How many lessons have we learned from the Covid-19 pandemic?

1. Plans to deal with health emergencies alone are not enough to deal with crises. A written battle plan will not work until the proper and adequate support and training are part of the plan. This requires annual inventory and sufficient workers (in reserve) to meet the needs.  All manuals must be dated and reviewed annually.  Diagnostic testing and treatment protocols can change quickly with the new condensed development times for testing and treatments.

2. Expect routine supply chains (wholesale distribution, transportation, and trucking services to be disrupted, so that new supply chains must be readily available. Rather than using normal distribution channels, alternative delivery services can be utilized, such as USPS, UPS, FedEx, DHL, and Amazon Fulfillment Centers can be brought online quickly. The lack of PPE, sanitizing solutions is a critical product for controlling the spread of infection.

3. The workforce will be disrupted by public health measures such as distancing and a  possible lockdown to prevent further spread of infectious diseases.  Public services such as light rail, bus transportation, airlines may become unavailable.

New York Subway during Covid19 Lockdown

TSA at Airport

Artificial intelligence and machine learning must be developed to study this pandemic to model for inevitable future events.  Historical stories may not be applicable comparing 1919 (Spanish flu) with SARS, MERS, nor COVID-19.  Projections into the future may not be valid when shifts in technology occur. For instance, the changes in transportation (airline flight), medical technology (diagnostic testing, treatments, and the use of new forms of medication and vaccine development.)

The use of newer forms of vaccine manufacturing using RNA technology vs the use of introducing foreign proteins in the body to form an immune reaction.

     How can providers overcome common challenges in healthcare supply chain management?

Some healthcare organizations have found success with supply chain management through cost transparency. By harnessing price and utilization data, healthcare organizations can track and manage inventory more efficiently and construct more informed purchasing contracts with manufacturers.

“Due to vertical internal structures, supplies and supply data historically have been siloed and firewalled so that information important for efficient business operations is fragmented,” Steve Kiewiet, Vice President of Supply Chain Operations at BJC HealthCare, told RevCycleIntelligence.com in June 2015. “We end up spending billions of dollars of inventory within these various silos because we live in a world where you can never run out of anything ever, in the interest of what is best for the patient.”   

All of these factors operate during 'normal times: If a public health emergency occurs, all bets are off.  Typical laws of economics, supply and demand begin to operate, and costs soar as manufacturers seek to profit.

During the current Covid-19 pandemic prices soared for masks and sanitizers and all other     PPE. Hoarding and preferential sales to emergency workers, hospitals, and essential workers prevented almost everyone else from obtaining needed PPE.

Gowns up 2,000%

The largest reported price increases have been for isolation gowns (2,000%), N95 masks (1,513%), 3-ply masks (1,500%), and reusable face shields (900%). The most remarkable rise was for 3M N95 masks, which rose from $0.11 to $6.75 each (6,136% increase), though they are currently unavailable, according to SHOPP.

 

Present and Future Price Trends

Global Personal Protective Equipment Market 2020: Application, Revenue Status, Leading Player, Demand, Growth, Future Opportunity & Forecast to 2024

Wild Card Vendors/suppliers/manufacturers

The widespread use of online shopping has given visibility to many DIYers who manufacture small orders for masks. The potential for the small home-based business to manufacture face masks and protective eye shields.  This niche market is also driven by word of mouth at hospitals and is also available on Youtube

Exploring the Role of Supply Chain Management in Healthcare

WHY?

A new and dangerous public health threat has emerged in North America. As yet it is not known how the disease spreads.  Outbreaks have been rare, but in the more recent two decades it has taken close to 100 lives in the U.S alone.

It kills swiftly but is not uniformly fatal. It leaves a trail of heartbreak and never-ending questions? Those not killed by its outbreak ask could we have been immunized against it?  How can we find a cure or treatment?

What are we writing about here?  Mass murders in schools, and public places.

Among the questions asked are;

Can it be predicted and/or prevented?

Why has it become more prevalent?

What are the risk factors?

Is there something wrong with our mental health system?

Prediction of these events has been a total failure. Forensic psychologists and psychiatrists have elaborated on several personality traits in persons who commit these crimes.  They caution however that these traits do not necessarily point to violent behavior.

There may be an explanation (or several) for it's increase in prevalence.  

Questions 2 and 4 may be related.

The development of effective anti-psychotic and other psychotropic drugs to control unacceptable behavior, psychosis, anxiety and depression initiated a paradigm shift in the treatment of mental illness. Prior to 1980 severely and chronically emotionally disturbed people were admitted to either short term or long term psychiatric institutions.  Most hospitals had a mental health ward that was secure and locked down. Some were smaller private residential facilities, but the vast majority were large state and/or federally administered facilities.

The institutions were expensive to maintain, and in the new era of 'effective' drugs to control aberrant behavior, it was deemed possible to treat more emotionally disturbed people as outpatients once their acute symptoms were controlled.  The number of patients needing to be admitted both for short term or long term hospitalization decreased dramatically and gradually most of these in patient facilities closed or were downsized significantly. The ability to admit patients became more difficult.

The stigma of mental illness remains high. People are fearful of what they do not understand. While it is now better understood what causes emotional disturbance now neuroscience is able to study the metabolic activity of the brain using metabolic scans coupled with MRI imaging. 

Above: The evolution of police uniforms

The image of the policeman on the right does not engender a warm and fuzzy feeling.

The cover of a book is designed to give the reader a sense of what lies inside the covers. Redesigning the uniform of negotiators or mental health personnel would be a significant change.

Social Workers Co-responders

As a result of increasing violence, and criminals obtaining military-grade weapons police have resorted to increasing their own protective equipment and support equipment. Swat teams have evolved to heavily armored transportation devices coupled with entry battering rams. Police have developed an on, off response at one level. Swat teams are called in regularly when an armed criminal event takes place. It often occurs for a 'domestic violence' event. Common sense has devolved into brute force for relatively minor events. This markedly elevates the 'threat' component of an event.

Gun violence under the microscope

Recently a national reaction to episodes of police violence a movement has called police reform mandatory to detach racial profiling from enforcement. Several propositions proposed to 'defund the police' include disbanding present police departments and replace them with new entities. Others suggest integrating more mental health diagnosis and treatment integrated into the police force. Police have recently become much more 'enforcement' entities over 'protect and serve'. The gradual shift has taken place over several decades. It is apparent the current situation is non-sustainable.

Certainly swat teams are indicated for mass shootings at public or school events. The events initiate a heightened sense of awareness and anxiety.

Why is this appearing on a health blog? Statistics reveal this is a public health problem, just as Covid-19 has become. Public health experts who study the situation can make recommendations, but will officials and/or authorities follow their guidance. If Covid-19 sets precedence, it is doubtful. Economic concerns and 'reality' often override science as we observe the current Covid-19 return to normal.

WHY ?