Kurt Waltenbaugh and Won Gabriel Chung, MD, Carrot Health, Inc. [i]

[i] Carrot Health, Inc. is based in Minneapolis, Minnesota. The Carrot MarketView™ software platform incorporates social, behavioral, environmental, and economic barriers to health data to deliver a 360 degree view of the consumer, providing actionable insights to inform growth, health, and quality. Contact: https://carrothealth.com/contact/

Two Tool Kits When Disease Breaks Out: Medical Intervention and Data

Infectious disease outbreaks like the Coronavirus Disease 2019 (COVID-19) are frightening and disruptive. As a society, we have two major toolkits at our disposal to limit the spread of outbreaks, and to minimize their impact on health, life, and the economy.

Medical intervention: The first toolkit is direct medical intervention. Right now, public health officials, medical researchers and clinicians are working to quarantine people with the virus, discourage travel to impacted areas, and identify and treat carriers as quickly as possible. Testing kits are being distributed, and a vaccine is in development.

Data: The second toolkit is data. With the right data, public health personnel can turn panic and passivity into preparation and progress, directing intervention efforts and resources more effectively and appropriately.

In London in 1854, Dr. John Snow, an obstetrician, used data to trace incidents of cholera infection to its source: a contaminated well. With COVID-19, we already know the source of the SARS-CoV-2 virus, but we can use data to predict the vulnerability of a given community, should the outbreak arrive.

Carrot Health’s COVID-19 Risk Index

At Carrot Health, we use robust data analytics to predict and help manage the health risks of patients and members for our health plan and provider customers. We have developed a risk index that we believe can help providers, plans, communities, public health workers, and political leaders make more informed decisions around forecasting and managing the impact of COVID-19.

Our index predicts the populations and communities that are most susceptible to the negative impacts from an outbreak. In other words, we’re not predicting where and when a COVID-19 outbreak will occur – we’re identifying who is most vulnerable. This analysis can be used to help inform public health and intervention decisions at the national, regional and community levels.

As of March 11, 2020, scientific research on the SARS-CoV-2 virus is still limited. We based our initial index on research published in two recent studies published by the Journal of the American Medical Association[i] and the New England Journal of Medicine[ii]. These articles identified six factors that influence both the risk of the Coronavirus transmission and the severity of its impact, including: Smoking status; COPD status; high blood pressure status; diabetes status; age (increase in risk for those over 65); and gender (increase in risk for males).

As scientists and public health professionals learn more about COVID-19, our index will evolve. For example, current research suggests that approximately 2-4 percent of people with the virus die, depending on where in the world they live. So far, no children have died, and deaths are higher in males and much higher for those over age 65. New data and additional studies might change those assumptions. In addition, the actual infection rate may be higher than reported, which would mean that mortality rates could be lower than currently estimated.

With those caveats in mind, Figure 1 shows our predicted COVID-19 population risk index at the county level (red = high, green = low):

Figure 1. Forecasted COVID-19 Population Risk, County-Level

Examining the national map, we can see the age-related impact. Counties which skew older show up with higher risk levels. Older adults also show higher rates of chronic disease, specifically COPD, hypertension, and diabetes – which further increases their vulnerability.

We can learn a great deal by zooming in to the local ZIP code level. For example, Figure 2 shows forecasted risk levels in the Seattle metropolitan area (red = high, green = low):

Figure 2. Forecasted COVID-19 Population Risk, Seattle-Tacoma

As the map in Figure 2 shows, variations across a metro area can be significant. Identifying these more granular pockets of risk can help coordinate resources to protect those most vulnerable. With such insights, public health officials or and health providers can decide what kind of advance preparation is necessary. They can then determine where to divert scare resources like ventilators and test kits, should an outbreak occur. They can monitor specific populations or neighborhoods and move in more quickly when circumstances warrant.

Each year, 5 to 20 percent of the U.S. population gets the flu. If SARS-CoV-2 has a similar overall infection rate, the impacts will be enormous. Take Seattle as an example: in the scenario where an outbreak affects 10 percent of the at-risk population, we would expect 26,307 critical cases, and (assuming that resources are available for appropriate treatment of these critical cases) 5,266 deaths – and the relative risk to different sub-populations in different geographies is highly variable.

Looking Forward

These insights are not meant to inspire panic, but to promote thoughtful preparation. Data-driven insights will be critical in saving lives, deploying resources, and minimizing disruption, both for this public health crisis and for future ones. Ultimately, a vaccine will be produced and COVID-19 contagion may become a cyclical event similar to the current “cold & flu” season.

In the meantime, the United States remains less affected than some parts of the world — but we are more vulnerable. Our healthcare system does not promote prevention or early intervention. The combination of high cost deductibles and lack of sick days for employees discourages people from seeking or taking the care they need.

Fortunately, we also have powerful data tools at our disposal to better prepare and deploy resources, and a culture of helping those who are vulnerable. Carrot Health is making this research and analysis available to all of our customers to aid in their response to the communities they serve. We urge you to take good care of yourself, your loved ones, and your coworkers and community members during this time of uncertainty.

Please contact us if you are interested in learning more about your community.

Endnotes and References

[1] Carrot Health, Inc. is based in Minneapolis, Minnesota. The Carrot MarketView™ software platform incorporates social, behavioral, environmental, and economic barriers to health data to deliver a 360 degree view of the consumer, providing actionable insights to inform growth, health, and quality. Contact: https://carrothealth.com/contact/

[2] Dawei Wang, MD, Bo Hu, MD, Chang Hu, MD; et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China”. Journal of the American Medical Association, February 7, 2020. doi:10.1001/jama.2020.1585
https://jamanetwork.com/journals/jama/fullarticle/2761044utm_campaign=Carrot%20Health%20Insights&utm_source=hs_email&utm_medium=email&utm_content=84400289&_hsenc=p2ANqtz8H08DQVDgKLUjEHolzE_fRWXQvdt0lYwBBAxPGaNFrwpzILynzJ5tZKpkzg18V0QermOvdQ3mzphh4W7JoVkPzVhIYmwYmDJ_FdNUnGGaUxUgylk&_hsmi=84400289

[3] Wei-jie Guan, (et al.), for the China Medical Treatment Expert Group for Covid-19. Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine, February 28, 2020.  DOI: 10.1056/NEJMoa2002032.
https://www.nejm.org/doi/full/10.1056/NEJMoa2002032utm_campaign=Carrot+Health+Insights&utm_source=hs_email&utm_medium=email&utm_content=84400289&_hsenc=p2ANqtz8H08DQVDgKLUjEHolzE_fRWXQvdt0lYwBBAxPGaNFrwpzILynzJ5tZKpkzg18V0QermOvdQ3mzphh4W7JoVkPzVhIYmwYmDJ_FdNUnGGaUxUgylk&_hsmi=84400289

Mary Rochelle Phillips, MSN, RN, CCRN, Duke Regional Hospital- ICU Clinical Nurse II [i]

[i] The views and opinions expressed in this article are mine alone, and do not represent the opinions of my employer.

On the Front Lines in the ICU

Last week was one of the most frightening of my career as a frontline nurse in the ICU: after caring for a patient during one of my shifts, we were testing for COVID-19 the following night, after which the patient was placed in isolation. My heart raced and had many “what-ifs” going through my head. But then I realized I was giving in to the hysteria and needed to start thinking critically.

Luckily, I am a member of one of the top hospitals in the country that has extensive infection protocols and guidelines in place. My facility established real-time data and action plans that are easily accessible to staff, patients, and the surrounding community. I appreciate our leadership’s transparency and how our organization has been successful in coordination and constant communication in response to COVID-19.

It is reassuring to know that I have the full support of my organization throughout this time of uncertainty so I can continue to serve and care for our patients and our community. Yet, our health system needs to improve if we hope to address this challenge and the others that will inevitably follow.

As a world society, we have driven through past challenges such as SARS, MERS, and Ebola. But, despite extensive health advancements following these outbreaks, the world is still highly vulnerable to the spread of infectious diseases. In response to the most recent Ebola outbreak, Bill Gates said in a TED talk “the world needs to prepare for pandemics in the same serious way it prepares for war”. At the same time, he also predicted that “we are not ready” for the next outbreak. This was five years ago. He was correct then and, unfortunately, is still correct now.

As history is our great teacher, now is the time both to react to think strategically about the long-term implications of our reactive approaches. Unfortunate as it is, the coronavirus outbreak is forcing us to adapt and innovate in real time.

A Nurse’s Perspective on Proactive Opportunities for Change

My experience on the front lines suggests three actions involving crisis planning, telemedicine, and flexible use of skills that can build on existing expertise in the healthcare system in order to make a big difference.

Crisis Planning Teams: As former U.S. President Dwight D. Eisenhower once said, “Plans are useless – but planning is indispensable”. The simple act of proactive planning helps us to become better prepared and more successful at responding to chaos. All healthcare systems need to maintain Crisis Planning Teams. The mandate of a crisis planning team is to identify policies, practices, tools, and technologies that, when implemented, will enable frontline healthcare staff to better respond to future outbreaks. As part of this activity, the team needs to simulate mock codes to hospital staff. We need both planning and practice in implementing the plans – and in knowing how to adapt when the world works in ways that the plans do not expect.

As we think about planning for crisis management, let’s take to heart a recent internet meme: “Remember how it feels like working as a health care professional during the COVID-19 pandemic? Remember the band playing on the Titanic while the ship was sinking, and they just decided to continue to play? Yes, that’s us!”

This is the inconvenient truth: the healthcare system is being overwhelmed by the influx of new COVID-19 sufferers, but we are still playing the same tunes — operating at the same capacity and using the same mindsets — as before the outbreak. We need to reduce the need to bail out the ship so rapidly by flattening the curve.

Epidemiologists use “flatten the curve” as a strategy to reduce the number of people who are simultaneously getting sick and overwhelming the hospital system, so that the number of patients stays below capacity. Tactics such as social distancing and limiting the frequency and size of public gatherings, including schools and sporting events, are some recent examples of effective ways of flattening the curve.

We cannot simply try to flatten the curve by forcing frontline staff to work harder. Instead, we need planning for surges that allow us to respond more effectively. If not, then mandatory on-calls, overtime, and nursing shortages — all of which I have experienced — will result and compromise both patient and staff safety. Therefore, flattening the curve by getting ahead of the game is a must.

Telemedicine beyond and within the walls: Telemedicine has huge potential to increase both the scope and safety of our responses. Reaching patients in the community maintains the safety of the hospital and staff while increasing access to care. This practice allows the patient to receive care remotely while simultaneously limiting everyone’s exposure to their underlying illness. It also allows the hospital staff to make referrals as needed.

In addition, with increased patient needs and staffing issues, telemedicine within the walls of the hospital will be beneficial in the ICU, as Margaret Rouse recently discussed.[i] For instance, having a remote critical care nurse from the telemedicine side can be an extra set of eyes for the primary care nurse at the bedside. Additionally, if the bedside nurse needed help inside the isolation room, he/she needs the ability to communicate with the other primary team aside from the use of portable phones or call bell. Nurses are natural innovators, and temporary solutions we came up with at my current facility include walkie-talkies and baby monitors inside COVID-19 isolation rooms. There are many opportunities to add more ways of communicating, both in real time and asynchronously.

Flexible use of skills: To be most effective, we need to use all the skills of all the people in the health care system. This means having flexible licensures among MDs, APRNs, and RNs so they can serve patients in multiple states. For instance, travel nurses should be redeployed to the hardest hit areas of the country.

Unfortunately, under current regulations, many of the hardest-hit states in the U.S. are non-compact states (e.g., Washington, New York, Massachusetts), meaning that doctors and nurses will have to reapply for licensure in the state before they can begin their practice. As a result, states with low numbers of COVID-19 cases and staff surpluses cannot reinforce the hardest-hit, non-compact states. We need to relax this requirement now to set up the ability for people to adapt more flexibly in the future.

Looking Forward

Effective solutions to the COVID-19 pandemic and similar challenges in the future will require both technical and organizational responses. Leveraging technology and analytics to drive proactive change helps mitigate the risks of uncertainties. We have more resources than ever to stay connected, make informed decisions, and support each other. At the same time, we need to rethink regulations and organizational norms that get in the way of our ability to use our technical and personal skills.

Let’s use our resources in the way that they can have the most impact. And most importantly, don’t forget to wash your hands.

[1] The views and opinions expressed in this article are mine alone, and do not represent the opinions of my employer.

[2] https://searchhealthit.techtarget.com/definition/Electronic-Intensive-Care-Unit-eICU

Markus Saba, Kenan-Flagler Business School, University of North Carolina at Chapel Hill

Like every business school across the country, UNC Kenan-Flagler Business School’s normal operations have been turned upside down as all classes were flipped to online virtual courses. Fortunately, Kenan-Flagler has the top ranked online MBA program, MBA@UNC, with 800 students currently enrolled. As a result of this program, students, faculty, and staff are familiar with virtual learning, and the infrastructure is in place to deliver high-quality, immersive online education – a capability that all programs in the business school leverage.

Making Lemonade Out of Lemons

To understand the implications of COVID-19, UNC Kenan-Flagler relies on its Center for the Business of Health (CBOH), which has deep expertise, capabilities and networks in the healthcare industry. The CBOH has been convening thought leadership on COVID-19 since the crisis began.

On the weekend of March 13 – 15 the school planned to bring hundreds of online students together for a three-day, in-person Summit in Vancouver, British Columbia. This event was cancelled one week before as a result of the coronavirus. Many students were attending the summit to earn their final credit prior to graduation. By collaborating together, the CBOH and MBA@UNC were able to act swiftly to provide a compelling program.

Under the leadership of Dr. Brad Staats, Professor of Operations, Faculty Director UNC Center for the Business of Health, Associate Dean of MBA Programs the decision was taken to “make lemonade out of lemons.” The in-person course was converted to online with a day-long program focused on the coronavirus entitled ‘COVID-19 Exploration’.

The course included lectures, panels, interviews, and workshops. In addition, asynchronous content was quickly developed – a mix of newly recorded videos by Professor Staats, exploration of current events articles, and questions to reflect on the knowledge. This prepared students to come to the event ready to learn as much as possible.

The agenda for the day-long virtual event included top-level health professionals, professors, and industry executives with deep knowledge and expertise regarding the current crisis. Topics ranged from understanding the current situation from a medical and scientific perspective to looking into development of testing and vaccines to discussing the impact on financial markets and supply chains. Figure 1 reports the agenda.

Figure 1: Agenda

The event was a tremendous success. In a manner that ensured student and faculty safety, we were able to engage students in a meaningful way. Students held workshops in online breakout rooms, panel discussions created interesting debates, and presenters answered questions in real time. The program explored ways in which business executives can effectively lead, manage, and navigate in the current crisis.

Students learned first-hand how a large hospital system is preparing for the current situation, the difficulties and challenges the laboratory sector is having in developing tests as quickly as possible, how best to manage corporate communications during a crisis, what is being done in the industry to develop vaccines and antivirals in a safe and quick manner, and finally how to analyze and assess what is happening in the financial markets, supply chains and various services.

In addition, the course covered important themes such as the importance of public private partnerships; industry collaboration with regulators such as the FDA, CDC, HHS, and NIH; how one-time fierce competitors collaborate in consortia to share information and resources; the importance of transparent communications; and the challenges of managing risk/benefit concerns with regards to safety and speed.

Finally, a key lesson from across each presenter was the need for kindness as we work with those impacted by the coronavirus.

Students were put into breakout rooms, held workshops, and asked questions. Key lessons learned were shared. The program was timely, relevant, and impactful — and to our knowledge, was the first business school course for credit on the coronavirus. As a result of the partnership between the CBOH and the MBA@UNC program, the business school was able to leverage its healthcare expertise and existing digital solutions to effectively and efficiently provide 150 MBA students with a unique and valuable learning experience.

Looking Forward

The COVID-19 challenge forced us to test a model that can be applied well into the future. We now know how to make lemonade. We will use this model in the future when we face new sudden challenge. In addition, this is now part of our ongoing toolkit for “regular” teaching. We are stronger as a result.

Kevin Schulman, MD, MBA, Stanford University, and Will Mitchell, PhD, University of Toronto

How Can Hospitals Divide Tasks In Order To Conquer COVID-19?

Fortunately, during our careers, most hospital leaders have not faced a crisis like the current COVID-19 pandemic. This fortunate experience also means that leaders of healthcare organizations are now learning in real time about the gaps in their planning processes and reaction ability. For those grappling with this crisis, we have highlighted some lessons learned from strategy studies and from other organizations.

Divide and conquer: Four teams

While the initial response to COVID-19 in many organizations has been an all-hands-on-deck response, it’s critical that we divide management tasks across different teams to allow us to focus on immediate needs as well as issues that are lurking around the corner as this epidemic and similar challenges continue. At the same time as hospital leadership addresses current demands, we also need to anticipate a rapidly changing operational and strategic environment. To do this, we believe that each hospital needs to establish four related COVID-19 teams: for immediate challenges; remote services; external coordination; and scenario planning.

Each of these four teams needs to report directly to senior leadership of the hospital. Where appropriate, it is useful to have overlapping membership across teams, to help coordinate their activities. In turn, the senior leadership of the hospital needs to act as the conductor, shaping and orchestrating the overall set of activities.

Immediate challenge team(s)

First, each hospital needs to create one or more immediate challenge teams. The role of these teams is clear – addressing the hourly, daily, and weekly tasks at hand. A familiar but not exhaustive list of tasks is determining the care needs and staffing implications of COVID patients; developing and communicating situational information internally and externally; addressing staff training and personal protection; and dealing with supply chain and operational challenges that result.

One of us is at Stanford, where COVID cases are on a rapid rise. The hospital has set up a cross-functional team that meets daily to address situational needs. After sending out individual e-mails about this rapidly evolving situation to faculty and staff, the hospital began to publish a single daily e-mail with essential information for providers, vetted by the cross-functional challenge team. This notice includes information on evolving hospital policies; services changes in response to the outbreak such as establishing a new outdoor, drive-through virus testing service; and other information that needs to be communicated to faculty, fellows and resident physicians. This notice is also linked to the local intranet, which may contain more detailed information on specific topics and links to resources such as the CDC website.

Remote services team

Second, each hospital needs a remote services team. Many of the services that we now offer patients in hospitals could be accomplished externally, whether at patients’ homes or in out-patient facilities. Continuing to ask those patients to come to a hospital for services raises obvious risks of congestion and infection. While some elective services can be delayed until the crisis subsides, others need to be dealt with to ensure patient health during the crisis.

All modern hospitals now have access to telemedicine services in one form or another, whether as internal practices or via external partners. This crisis creates an opportunity to ramp up and extend our use of telemedicine to new in-home and out-patient services. Indeed, it is likely that many of these services can continue to be offered after the corona crisis subsides, as a way of shifting appropriate care out of expensive and sometimes risky in-patient venues to more effective out-patient settings. The need to extend nascent telemedicine services during the crisis can help overcome organizational barriers that have slowed their current expansion.

As important as the technology backbone is the staffing model for the telemedicine service. A switch from in-person to a telemedicine service includes the development of SOP’s, training of staff, and building provider schedules to staff the service. While this is a challenge, the COVID-19 pressure creates an opportunity to overcome traditional barriers to dealing with these issues.

One hospital we are familiar offers telemedicine services in which specialists provide consulting services to remote communities in its region while guiding local clinicians in those communities to provide sophisticated care that is beyond their normal practice. This same hospital now has an opportunity to provide the same services to referring clinicians in its local community – explaining the criteria for COVID screening as testing becomes available, and explaining treatment and referral options as those issues arise. Beyond COVID treatments, the telemedicine applications can be used for other patient services. Bringing telemedicine local will avoid burdening the hospital with patients who do not really need to be there and also risk infection at the hospital. As it ramps up to address the immediate COVID needs, the hospital is working with its referring clinicians and with relevant payers to adjust the financial structure of their services.

External coordination team

Third, each hospital needs an external coordination team. The idea that all health care is local is an old adage – COVID is again bringing this issue to the fore, while highlighting the organizational complexity of local health care environments. The external coordination team needs to work with external stakeholders to link their hospital’s activities with those of other organizations in the health system that are engaged with the COVID-19 challenge.

Relevant external organizations include other hospitals, out-patient facilities, local and national public health agencies, political bodies, and many others. Joint responses can include designating specific COVID care sites or, as importantly, non-COVID care settings; shared efforts to support population health; ensuring the availability of post-acute care services; and developing regional telemedicine programs. The external coordination team will need to gauge where it makes sense to be the leader in facilitating system-based activities and where it makes more sense to follow the lead of other actors.

One of us recently was involved with a panel discussion of initial steps toward addressing the COVID-19 crisis, involving experienced leaders from multiple relevant organizations. Reassuringly, each individual had a compelling message of how their own organization was responding. Much less comforting, though, was the fact that each person’s organization faced real struggles in coordinating their activities with others. The external coordination team can address this lack of integration.

Scenario planning team

Fourth, each hospital needs a scenario planning team. The current challenging state will be part of a marathon as well as the immediate sprint. The epidemiology underlying this infection is unclear, with a tremendous uncertainty about impact over time. Given this set of challenges, a separate team should be established to begin the difficult scenario planning that will support further decision-making at the organization level.

These scenario exercises need to consider contingency planning for alternative cases including staff shortages due to illness or the lack of child care; financial implications of cancelling profitable elective services to care for critically important but less financially valuable COVID patients; operational issues such a co-location of infected patients; and availability of local nursing home beds for patient transfers. In light of the tremendous uncertainty, these scenarios should consider a broad range of outcomes, ranging from a rapid decline in cases to an evolving pandemic with new incident cases over an extended period of multiple months or even years until reliable treatments and vaccines are available.

One of us brought their children to Disney a few years ago. When a toddler (not ours) jumped into the pool before their parent, the lifeguard blew their whistle and jumped in. But the amazing thing was that the whistle signaled other guards to shift and cover the vacant chair because there could have been another child in the water. Disney’s training developed a procedure to address the immediate needs and also deal with the contingency. It’s a lesson that can help those on the front lines of this uncertain crisis.

Looking forward

Individuals throughout the healthcare system in countries throughout the world are committed to meeting the challenge of COVID-19. But success requires far more than individual effort. Hospitals and other parts of the healthcare system need to take systematic approaches to split up the burden of response, while working internally and externally to coordinate the activities that we require for a robust response to this challenge.