David Brailer | May 4, 2020
When Hurricane Katrina slammed into New Orleans in 2005, I happened to be there, briefing southern governors on the nation’s health information technology strategy. I became a volunteer clinician at a shelter for a few days, and witnessed the outpouring of support from clinicians, volunteers, the Red Cross, Walmart, Humana, UnitedHealthcare, Walgreens, and many other people and companies. It seemed everyone was involved – except the health IT community. It never occurred to us back then that health IT was relevant to disaster management. But we did have a role to play and, thanks to the hard work of the Markle Foundation and many other people (as well as the patience of many federal lawyers who gave me running room), we created Katrina Health – a repository of claims and prescription data for people in the flood zone so they could continue their care and medications. Katrina Health was operational nine days after the hurricane came ashore and was later recognized by many as a lifesaver.
Here we are, 15 years later, in a crisis of vastly larger impact and harm. Yet again, and at a breadth and intensity never seen, all hands are responding to address the medical, social, economic, nutritional and other aspects of the pandemic. The tremendous response to COVID-19 from hospitals, clinicians, PPE makers, diagnostic companies, life sciences companies is breath-taking. It is the fullest display of America’s unique public-private collaboration, with governments, non-profits, private and public companies working in unison against a common enemy. The response and collaboration will become legend.
This time, the health IT community is right in the middle of the fight. A sweeping set of public-private partnerships and collaborations are being formed at astonishing speed. These companies, agencies and partnerships are working fast to advance diagnostics, improve care, protect clinicians, and help public health officials manage the crisis, as well as accelerate therapeutic and vaccine development. Here are a few examples that I am watching.
Testing. The challenges in being able to test front-line workers and symptomatic people, let alone perform screening and surveillance, are widely known. However, beneath the reagent, PPE and testing capacity issues is the interoperability challenge of getting data from a laboratory to a public health agency, along with relevant data about the positive case to support rapid isolation. The patchwork of testing tools, electronic records and public health agency systems makes this a very difficult challenge. The Office of the National Coordinator is doing a lot to advance this, and many private companies such as Change Healthcare are pushing interoperability as well.
Self-care. The COVID-19 crisis is a rare health event when people are being pushed away from hospitals and clinics, to free capacity and to lower contagion risks. Numerous new or repurposed online tools were rapidly built to help people assess their risks and prevent getting infected. Outstanding work in this area is being done by COVID Check, the public-private offshoot of the Rockefeller Foundation’s Commons Project. At the same time, with hundreds of millions of people asking questions about how to change many aspects of their lives, there has been an equally strong response by companies that help people care for themselves and their loved ones. A great example of this is the Quil COVID-19 Preparedness Tool. Also, Microsoft partnered with the CDC to deploy a chatbot that enables individuals to self-assess and connects at-risk patients with medical professionals. Providence Health customized its two-year-old chatbot Grace, developed with Microsoft, to remotely screen potential COVID-19 patients.
Forecasting. Through a series of political, surveillance and other failures, we were caught unprepared for the pandemic. Future investigations will scour every detail of what happened and assign blame, but that will not change the fact that we cannot safely reopen the economy without surveillance and the ability to forecast local outbreak risks. Optum is doing just that by adapting its flu forecast to predict the likelihood of a COVID-19 outbreak six weeks ahead for any zip code. Likewise, athenahealth and others have created interactive dashboards to support public health agencies with real-time information about risk and burden across the US, based on lab test orders and changes in high-risk patient populations.
Triage and risk assessment. In a fast-moving disease with so many unknowns like COVID-19, determining who is sick and who is at risk has always been a guessing game for front line clinicians, particularly in emergency rooms where speed and accuracy are often at odds. Each clinician is more-or-less learning alone and, despite specialized social media and pre-print publication that share research articles upon submission to rapidly share insights, group learning is slow and difficult. Data analytics and AI are changing that learning curve in a way never seen before. Just like autonomous vehicles aggregate the learning of millions of drivers, AI tools can aggregate learning about COVID. This is what Clarify is doing in New York and elsewhere through an AI-driven point-of-care patient risk evaluation that helps triage and care planning, while pooling insights from many clinicians to continually improve its assessments.
Telemedicine. Many executives, policymakers, technologists and others have been working to move telemedicine into the mainstream for years, but it took a pandemic to actually make the necessary sweeping reimbursement and state licensure policy changes, as well as relaxation of HIPAA. This rapid shift to online virtual care was driven by the need for capacity at hospitals and efforts to keep clinicians apart from patients. Telemedicine is the big HIT story in the pandemic, and dedicated telemedicine companies, such as Teladoc Health and AmWell are expanding rapidly, while long-established technology companies like Intel are throwing their muscle into telehealth and rapidly scaling capacity for telemonitoring ICUs.
Clinician support. Front-line clinicians are being put in harm’s way as they are called on to work harder and longer hours. Remote care tools can make their life-critical work safer by reducing exposure to patients or even enabling isolated employees to continue working. This is also critical for local hospitals that need access to expert radiologists and others to consult on complex cases. Siemens Healthineers is doing that with its syngo Virtual Cockpit and its teamplay Images solutions. Similarly, Nuance voicebots and chatbots help clinicians access telehealth services and cloud speech tools to simplify their work and keep them safer.
Contact tracing. We saw the collapse of traditional contact tracing in the United States as the case rate exploded and public health staff became overwhelmed. Despite hiring thousands of people, that can easily happen again if case rates surge a second time. This is why the Google and Apple collaboration on a common API for privacy-protecting digital contact tracing is so important. Covering 98% of smart devices, this will be a gamechanger in helping public health officials automate and accelerate contact identification. Also, the Samsung social distancing watch that buzzes when you are too close to a co-worker is a promising, if potentially irritating, way to keep us apart.
The rapid deployment of critical capabilities reveals the true power of modern health information technology. It also reveals the massive obsolescence and tech debt of our public health infrastructure. The very fact that these capabilities could be and yet had to be stood up during an emergency shows how profoundly we have underinvested in public health information technology. Our federal, state and local public health agencies are filled with talented and hard-working professionals who do their jobs out of commitment and passion, but they are as unsupported by missing information technology as our front-line clinicians are by missing PPE.
It didn’t have to be this way. In 2004, when I founded the Office of the National Coordinator for Health IT, we laid out a plan and budget for funding a nationwide Public Health Information Network (PHIN). It had three features. First, seamless data sharing, from local agencies to state agencies to federal agencies, using standardized case reports and related data. Second, integration of the PHIN directly into lab systems and electronic health records for direct reporting of case data. Third, analytic tools for automated tracking and projections so the data could be used to plan and direct resources in real time. Unfortunately, the PHIN was never funded and, to this day, very little of the vision has been realized.
The public-private HIT collaboration that underlies American health care will get us through this crisis. But we need to invest now to modernize our public health information technology capabilities, now and in the future. When we finally are able to assess how this virus was able to impact us so existentially, we can add obsolete public health information technology to a growing list of things to which we should say “Never Again!”