Sourcing Digital Health for COVID-19? Mount Sinai’s Medical Innovation Lead Has Advice | WTF Health

By JESSICA DaMASSA, WTF HEALTH

As hospitals, health systems, and physician practices look to quickly scale up their digital health, telehealth, and remote monitoring offerings to adjust their delivery systems to the COVID-19 pandemic, what questions should they be asking health tech companies in order to make the right decisions? And, how can these health tech businesses, many of them startups, meet these ready customers half-way?

Ashish Atreja, Chief Innovation Officer for Medicine at Mount Sinai Health System (and also founder of digital health credentialing organization, Node.Health, and platform-builder Rx.Health) leans in with some critical advice at a time when health system sourcing, vetting, and contracting for digital health has never moved so fast.

“This COVID-19 solution you’re gonna bet on can be a catalyst for your entire digital health strategy and platform,” says Atreja, speaking as a health system innovator giving advice to others in similar roles. “There’s no pressure to bet on the right horse, but I think this is a moment of opportunity where you can see what is gonna give you long-term benefit.”

Pop-in around these minute-marks for more specific insight on:
6:37 — Common hesitations clinicians/hospitals have about bringing in digital health solutions
8:06 — Is fast-track contracting and integration here to stay?
10:55 — Advice for hospitals/physicians practices trying to bring in digital health and other virtual care solutions (what questions they should be asking health tech companies)

This interview is part of a ‘WTF Health: What’s the Future, Health?’ special series on health tech’s response to COVID-19. To hear more about what health innovation’s ‘who’s who’ are saying about digital health, telehealth, remote monitoring, and more, visit http://www.youtube.com/WTFHealth.

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“Essential Oncology”: The COVID Challenge

By CHADI NABHAN MD, MBA, FACP

One harsh Chicago winter, I remember calling a patient to cancel his appointment because we had deemed it too risky for patients to come in for routine visits—a major snowstorm made us rethink all non-essential appointments. Mr. Z was scheduled for his 3-month follow-up for an aggressive brain lymphoma that was diagnosed the prior year, during which he endured several rounds of intense chemotherapy. His discontent in hearing that his appointment was canceled was palpable; he confessed that he was very much looking forward to the visit so that he could greet the nurses, front-desk staff, and ask me how I was doing. My carefully crafted script explaining that his visit was “non-essential” and “postponable” fell on deaf ears. I was unprepared to hear Mr. Z question: if this is his care, shouldn’t he be the one to decide what’s essential and what’s not?

This is a question we are all grappling with in the face of the COVID-19 pandemic. The healthcare industry is struggling to decide how to handle patient visits to doctor’s offices, hospitals, and imaging centers, among others. Elective surgeries are being canceled and advocates are arguing that non-essential outpatient and ER visits should be stopped. Ideas are flying left and right on how best to triage patients in need. Everyone has an opinion, including those who ironically consider themselves non-opinionated.

As
an oncologist, these various views, sentiments, tweets, and posts give me
pause. I understand the rationale to minimize patients’ exposure and thus prevent
transmission. However, reconsidering what we should deem “essential” has made
me reflect broadly on our method of providing care. Suddenly, physicians are
becoming less concerned about (and constrained by) guidelines and requirements.
Learning how to practice “essential oncology” may leave lasting changes in our
field.  

I
may not be an authority on deciding what’s an elective versus non-elective
surgery, but I will take a stand and offer some of my thoughts on the current
state and what might await us as oncologists in the post-COVID-19 era. Before I
offer my opinions on essential oncology, I thought I should ensure that my
definition of “essential” matches that of others. Assuming that some patients
might have already done so, I Googled the term and found that Oxford defines “essential” as “a thing that is
absolutely necessary,” while Merriam Webster’s definition of “essential” is “something necessary,
indispensable, or unavoidable.” Neither definition infers perspective, but we
can all agree that what’s deemed necessary is in the eyes of the beholder. As
such, in tackling this pandemic, oncologists are having to take a long, hard
look at what care is necessary to provide and which guidelines are necessary to
follow.

First off, some are questioning our current dosing schedules of chemotherapy, including the novel ones such as checkpoint inhibitors. Why not give that chemo drug every 4 weeks instead of every 2 weeks? Maybe we should give nivolumab every 6 weeks? Let’s lower the dose of pembrolizumab and skip a few days of venetoclax. Opinions vary, but the concept is the same: let’s give less chemo because suddenly COVID-19 is riskier than cancer. If our dose modification schemes change (most of which were not based on real basic science or pharmacology) this might throw all our regimens in shambles. If outcomes are not adversely affected, do we go back to our routine dosing and scheduling, or do we maintain the novel COVID-19 approach to chemotherapy? You tell me.

Next, my inbox has been flooded with invitations to attend webinars and virtual meetings on how best to manage patients during COVID-19 and how to balance risks and benefits, as if such balance should never exist outside of a pandemic. Never have I seen the oncology community engage in more debates about the risk/benefit ratio of chemotherapy in late-stage metastatic incurable malignancies. Suddenly, physicians who had been advocating 4th line chemotherapy for a metastatic cancer where data were marginal became loud voices encouraging stopping chemotherapy and offering only palliative care. It took the COVID-19 pandemic for the oncology community to look at itself in the mirror and ask whether chemotherapy should be given in end-stage disease. This may be the only real benefit of COVID-19.

Furthermore, it has been proposed that adjuvant therapies can sometimes be delayed and that some drugs should be avoided. Many have argued that stem cell transplantation should be deferred until we are over the COVID-19 hump. I am certain that there will be studies in the years to come (I even might do one if I’m not too busy tweeting) on whether delays in adjuvant therapies for some cancers had any detrimental effect on outcomes. How would that affect guidelines, recommendations, and future care? Stay tuned; there will be so many papers on this and little time for peer-reviews.

Fourth,
how we approach imaging in determining progression-free survival may entirely
change. Typically, scans are needed every 6-8 weeks to determine a response to
therapy and allow a decision on whether to continue or stop the treatment. I
don’t want to bore you with the RECIST criteria (and trust me, it’s boring),
but it’s what radiologists use when helping oncologists determine if
an anti-cancer therapy is working or not when treating solid tumors. Thanks to
COVID-19, oncologists now have to make these decisions based on how patients
feel and their perception of whether the drug is providing a clinical benefit.
It should have been this way before COVID-19, but it wasn’t. We were so blinded
by RECIST that we sometimes missed the larger picture. Could COVID-19 be the
death sentence to RECIST? Will we find out that we were overutilizing our
scanners? Could COVID-19 lead to saving future healthcare costs when some of
these guidelines change? Maybe.

Fifth,
follow-up visits for cured patients or those in remission have always been—and
should continue to be—considered an essential component of routine care. It
might be in the not-so-distant future when hospital administrators decide that some
kinds of patient visits need to be conducted virtually. However, the rapport
and bond established between a patient and his/her physician extends beyond the
duration of chemotherapy administration. Patients need the reassurance that
their disease remains at bay. The positive energy from these visits is also
welcomed by oncologists as a break from cases where patients are less fortunate
and a reminder that patients do get cured. Stripping oncologists and our
patients of this right to face-to-face routine visits seems cruel. For now, we
can all endure deferring these appointments or transitioning to telemedicine for
the greater good, but I fear that this might extend beyond COVID-19. While I
agree that virtual visits can save time and money, most would concur that
nothing replaces human-to-human interaction—especially now, when we’re all
feeling the effects of social distancing. Remembering how important Mr. Z’s
follow-up appointment was, I dread the day when hospitals consider converting these
routine visits to virtual ones so that new patients can be accommodated.

Finally, will COVID-19 teach us how to better conduct clinical trials? Every oncologist understands the value of clinical trials and how they advance science and help patients. But trials are strictly regulated. Labs have to be drawn within X and Y times, scans must be done within X-days from subsequent therapy, and face-to-face visits are a must. Dispensing an investigational drug requires several staff members present and a verification process that is critical, but sometimes unnecessarily complicated. Now that clinical trials have taken a hit, will this pandemic teach CROs that 700 signatures on an adverse event sheet might not be needed? Would potential changes give patients more sense of autonomy when they are participating in these studies? I predict that if we apply the lessons learned from COVID-19 on how we conduct studies, enrollment in oncology trials will increase. But this means that all of us, including CROs, need to do things differently.

It
has taken a pandemic and a relentless virus to get the medical community to
think critically about our own behavior and the care that we provide. We will
overcome this at some point, and although we will all remember the horror of
COVID-19, maybe we can find a silver lining in camaraderie and in adjusting
some of the ways we provide oncology care. Until then, please stay home.

Chadi Nabhan ( @chadinabhan) is
a hematologist and oncologist in Chicago whose interests include lymphomas,
healthcare delivery, strategy, and business of healthcare.

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The THCB Gang Episode 3, (LIVE Today at 1PM PT/4PM ET)

This episode of “The THCB Gang” Episode 3 will be streamed live here (below) and is also preserved as a weekly podcast and available on our Itunes & Spotify channels a day or so later. Each week 4-6 semi-regular guests drawn from THCB authors and other assorted old friends of mine will shoot the shit about health care business, politics, practice, and tech. It should be fun but serious and informative!

This week, joining me today are Deven McGraw (@healthprivacy), Kim Bellard (@kimbbellard), Vince Kuraitis (@VinceKuraitis), Michael Millenson (@MLMillenson), Brian Klepper (@bklepper1), & Daniel O’Neill (@dp_oneill). It should be a fun and argumentative discussion about the developments around COVID19 and what we should pay attention too — Matthew Holt

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India’s COVID Conundrum: To Lockdown or Not to Lockdown

By SOMALARAM VENKATESH, MD

 In “Asterix and the Roman Agent”, Julius Caesar deploys Tortuous Convolvulus to cause internal conflict among the Indomitable Gauls. Until then, the only fights the peaceful Gaulish village witnessed were between Unhygienix, the fishmonger and Fulliautomatix, the village smith. The Gauls always stood united against the Roman army and in spite of the occasional free-for-all, would always come together at the end for a boisterous feast. 

In the new millennium, India – like many other countries – has exhibited deep fault lines circumscribing hardened ideologies. It is that time in India’s history that Government’s economic and administrative actions are either inherently partisan, or projected to be divisive by its detractors. If SARS-Cov2 were to be an insidious single-stranded helical malware designed to sneakily break societal monoliths, there couldn’t have been a more opportune time than this. This pandemic has become an administrative nightmare. 

The first case of Corona Virus Disease (COVID-19) in India was detected on January 30th. After a lull for the next two weeks, stray reports of Covid-positive cases started from mid-February. A surreal calm descended across the country even as the COVID deaths climbed rapidly elsewhere in China, Italy & Iran. The nation went through a phase of wishful denial & unfounded bravado that tropical heat will protect Indians & that a younger, innately immune population will be somehow spared. 

That was until March 10th. And then the first COVID death happened. It quickly dawned upon Indians that the country will be catapulted on to the now-familiar exponential curve of COVID case numbers. WhatsApp groups launched into existential discussions; private citizens, inspired by twitter & other social media, populated hashtags on Social Distancing & took to hand-washing challenges. On 22nd March, Prime Minister Narendra Modi asked the country to observe a ‘voluntary’ 14-hour curfew on Mar 22nd preparing the public mood for the ominous times ahead. Following a substantial success of this curfew, and possibly getting wind of the looming avalanche of the pandemic, the Indian Government announced a lockdown in 75 of the 800-odd districts of the country. And on 24th March, the Prime Minister went on national television to announce a 21-day lockdown of the whole nation starting 4 hours from the beginning of his speech. 

By this time, many privileged Indians on social media – some doctors included – were keyed in on the contagiousness, the merciless paralysis of healthcare systems and the rapidly climbing death toll around the world. For them, the ineffectiveness of government’s messaging about Social Distancing, wilful violation of self-quarantine by Indians who had returned from China, Europe & the Middle-east (and by their contacts) were frustrating. This class of people lauded the Indian Government’s decision to lockdown the country. 

However, within hours of announcement of the lockdown, mainstream and social media were fired up about the possible impact on the poor. Survival of India’s migrant rural laborers working in the metros and daily wagers depends on an up-and-running economy. Shutting it down would jeopardise livelihoods exposing them to starvation. It is estimated that nearly 200 million people lack adequate food security. A lockdown will also limit movement of essential supplies and bring misery especially to these underprivileged. Visuals showing exodus of migrant workers, some setting out on foot with children on journeys of hundreds of 

kilometres went viral. Criticism that incumbent Central Government should have put a systematic plan in place – to address imminent needs of hungry millions – before announcing a hard lockdown, became widespread. The narrative that the lockdown is for the privileged at the cost of ignoring a sixth of population who will starve to death. Some even went on demand lifting of the lockdown with the theory that widespread COVID infection would lead to development of herd immunity in the community even if it comes at the cost of SOME Covid-related mortality. This, they argue, is preferable to the bigger tragedy of widespread starvation deaths. Even after the United Kingdom abandoned – after realising that it was based on a flawed statistical model – its famous strategy of No-lockdown and ‘Social Eugenics’ & shut the society down, this approach finds its proponents among some Indians. 

What is not understood is that the choice between Lockdown & Eugenics is not a binary. If cities and towns are not shut down, it is among poor, who live in overcrowded districts & use public transport, that COVID will spread like wildfire. Social distancing is the prerogative of the privileged in India: families that live in one room tenements and share toilets with several others can’t dream of self-isolation. In the absence of lockdown, India will ride on a dual time-scale of the pandemic: a steep early peak consisting of the poor and a gentler longer drawn curve consisting of the upper classes that can afford to practice social distancing. Of course, there will be an overlap, but the important point is that poorer patients will cluster around the time when Indian hospitals and healthcare professionals haven’t yet figured out the best Covid practices, PPE and ventilator production/imports have not yet been optimised and the vaccine has not yet been discovered. Therefore, case fatality rate among the poor will be disproportionately high, and as Saurabh Jha tweeted ‘India, particularly its slums, will be in corona flames’. The more affluent who will ride the flatter curve, will experience a lower case fatality, as long as there is enough surviving medical workforce from the first wave. 

Meanwhile, because the virus has wreaked havoc, the economy will be shut anyway & the migrant labourers & daily wagers will again be out of jobs & have their food security will be threatened. 

Asking to end the lockdown will thus subject the poor to a double whammy. 

Once this crisis settles, either with the country in ruins or having weathered the storm relatively unscathed, the Narendra Modi administration will stand to trial whether it should have ordered the lockdown earlier. Regardless of that, the path ahead seems to be clear: 

1. Strengthen the lock down & intensify humanitarian efforts: Many individual and groups have still not understood the magnitude of the disaster standing at their threshold. They continue to violate the lockdown. This has to be curbed by force if necessary. 

If not now, at the first sign of relaxation of restrictions, exodus of daily wagers seems inevitable. Testing this migratory population, quarantining the positive cases with dignity, rehabilitating the rest methodically in tranches so that the transport vehicles are not overcrowded after educating them about social distancing is the way to go. 

Hunger alleviation & prevention of starvation deaths among urban and rural poor will be a big challenge but needed urgently to avert a humanitarian disaster. The administrative machinery from the central, state and local government bodies should make war-like efforts in this direction. 

Dr Somalaram Venkatesh is Senior Interventional Cardiologist & Head of Cardiac Cath Lab at the Fortis Hospital, Bangalore, India and heads the Cardiology fellowship (DNB) program at his hospital. 

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Understanding Covid19: How Data From People’s Daily Lives, Flu Outbreak Models Can Help | WTF Health

By JESSICA DaMASSA, WTF HEALTH

In the face of Covid-19, health tech startup Evidation Health is leveraging their relationships with the 4-million people on their Achievement app, the “always on” stream of behavioral data these folks bring to the table via wearables, sensors, and surveys, and everything they’ve learned from years of studying and modeling flu outbreaks to examine the Covid-19 virus in the context of people’s everyday lives.

Evidation’s CEO, Deb Kilpatrick, and Sr. Data Scientist, Ernesto Ramirez, stop by to talk about their company’s efforts for large-scale, frequent symptom surveillance of Covid-19 to add new insights to our understanding of the pandemic and, possibly, even help with making predictions about its spread and severity.

The company is already publishing some of its findings in a weekly report called “Covid-19 Pulse” that is already gleaning insights from a 150,000+ person cohort asked to weigh-in specifically on what they’re doing and how their lives are changing as a result of the pandemic. What’s unique in Evidation’s spin is that they’re adding that critical data from “daily life” that is more or less missed by just looking at the data reported from those who’ve entered the hospital.

“Those folks that are presenting into the medical system — that’s not the full picture of what’s going on,” says Ramirez. “What we need to do is better understand, really, what’s going on at the community level to understand community spread, to understand surveillance efforts, to understand mitigation efforts that may or may not be having impact around the spread of Covid-19.”

Find Evidation’s Covid-19 Pulse Report here (https://evidation.com/news/covid-19-p…), or join the cohort via the Evidation Achievement App as found in your mobile app store.

To learn more about how healthcare technology companies in telehealth, remote monitoring, data science, and more are responding to the Covid-19 crisis, check out other interviews in this special ‘WTF Health – What’s the Future Health?’ series at http://www.youtube.com/wtfhealth.

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Health in 2 Point 00, Episode 115 | Olive, Bright.md and AristaMD

Today on Health in 2 Point 00, we have a no-nonsense April 1st episode—with deals this time! On Episode 115, Jess asks me about Olive raising $51 million for its AI-enabled revenue cycle management solution, Bright.md raising an $8 million Series C for its asynchronous telemedicine platform, and AristaMD raising $18 million for a different sort of telemedicine, eConsults, which allow primary care physicians to consult with specialists virtually. —Matthew Holt

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Trump Urges Insured COVID-19 Victims to Use For-Profit Medical Care

By MICHAEL MILLENSON

(Foxnoxious News) WASHINGTON, April 1 –  President Trump today urged all insured Americans infected by the coronavirus to seek care only at for-profit facilities.

“American capitalism is the world’s greatest job-creating engine,” said the president in a prepared statement. “That’s why I urge all Americans who have both good health insurance and COVID-19 to get their care at for-profit hospitals and other wonderful, for-profit health care facilities.

The president expressed his compassion “for all the great companies whose share prices are suffering.” Americans who fall sick “can help make your life savings great again,” he said, by using investor-owned firms. In addition to hospitals, these include for-profit nursing homes, rehab facilities, home care and hospice, as well as funeral homes.

“If one million Americans get  infected by COVID-19, that’s a terrific business opportunity,” the president declared.

At his daily press briefing, the president said that while he had nothing against non-profits, he wondered about their quality of care.

“Personally, I love nuns,” said Trump, “but what the hell does someone who takes a vow of poverty and chastity know about medicine?  It’s ridiculous.

“And hospitals run by universities? Who thought of that? A bunch of English professors running around in white coats. It’s crazy. Why would you get care from people like that?”

A White House spokesman emphasized that while President Trump felt those with good insurance should use for-profit facilities, he continued to believe that non-profits were best for those on Medicaid or without any health insurance at all.

Michael L. Millenson is president of Health Quality Advisors LLC and adjunct associate professor of medicine at Northwestern University Feinberg School of Medicine.

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