After the Flood

I keep thinking about the COVID-19 pandemic as a flood. 

You know the water is rising, you usually know how high it will get and even when, but there's just not much you can do about it.  You can put in levees or floodwalls, maybe throw up some sandbags, but for big floods the water is going to have its way.  It creeps up and subsumes everything in its path.  Inevitably, the waters do recede, but leave their mark.  Some things survive, some are badly damaged, some are simply swept away. 

Looking at the coronavirus statistics every day is like watching the water rise, and I wonder what our healthcare system will look like once the pandemic flood subsides.

Before the current pandemic the U.S. already had plenty to be unhappy with about its healthcare system.  It cost too much, it delivered care unevenly, its focus seemed too oriented to profit instead of to quality, and, most importantly, it didn't actually seem to be keeping us healthy.  No one seemed happy about it -- not patients, not clinicians, not even the army of administrators who have infiltrated it.  But, we assured ourselves, at least it would be there for me/us if I/we had a health crisis.

That seems like wishful thinking now.  As Dr. Siddhartha Mukherjee wrote in What the Coronavirus Crisis Reveals About America Medicine, in the wake of this pandemic "the medical infrastructure of one of the world’s wealthiest nations fell apart, like a slapdash house built by one of the three little pigs."  

Credit: CNN

We can't get enough essential personal protective equipment (PPE).  We can't accurately test sufficient numbers of people.  We're overwhelming the healthcare system in hot spots.  Our health care heroes -- doctors, nurses, first responders, and the myriad of workers who support them -- are working long hours, putting themselves at greater risk, and struggling to figure out how to best help patients.

The pandemic is wrecking havoc on our healthcare system.  Costs for PPE are skyrocketing.  We're having to reconfiguring health care facilities to reduce risks of exposure. The weaknesses of our supply chains have been exposed.  Many parts of our healthcare system are working past peak capacity, while others have been idled. Deferral of most "elective procedures" have made very clear how much our health system is dependent on them; even in a pandemic, many hospitals are being forced to cut staff as a result.

Already vulnerable hospitals have become even more vulnerable.    Nursing homes are struggling to absorb new costs to deal with COVID-19, and we're realizing that their very nature makes them petri dishes for such a pandemic.  Many primary care physician practices are floundering; less than half think they can stay open for another month.  Private equity firms that had bought up hospitals and specialty practices are rethinking their investments. 

People like to point to telehealth as one innovation that the pandemic has spurred.  Patients and physicians who had previously never tried it are now becoming fans.  Regulatory barriers and reimbursement limitations are being addressed.  Almost half of physicians now report using telehealth, drive largely due to COVID-19 concerns. 

Still, though, whether telehealth advances persist after the pandemic subsides remain to be seen.  We're still struggling with reimbursement, the inter-state licensing issues have not gone away, and the relief from HIPAA requirements is not permanent. 

People rebuild in flood plains even after being hit by a flood; we may be stupid enough to try to go back to the healthcare system we used to know once we lose our alarm about COVID-19.  That would be stupid.  As Dr. Mukherjee put it: "Medicine needs to do more than recover; it needs to get better."

Here are a few thoughts about how:

Telehealth:  It's the 21st century; time to bake telehealth fully and firmly into our healthcare ecosystem.  Just as retail and offices are unlikely to return to pre-pandemic norms, relying more on virtual options, healthcare must as well.  

Supply chain: We're still going to import some healthcare supplies from abroad.  But we do need to spread our dependencies over more options, including more domestic options, and ensure that they have the ability to scale up when needed.  

Nursing homes: Nursing homes/assisted living facilities weren't a great option for residents' health even before the pandemic, and the pandemic has exposed what a terrible option they are during such outbreaks.  We need 21st solutions for supporting people in staying safely at home.  

Unnecessary procedures: We've known for decades that too many of our health care services are unnecessary and sometimes inappropriate.  We've taken a meat-axe to them during the pandemic, chopping needed services as well as unnecessary ones.  The post-pandemic period should be the time to finally take a hard look at what we really should be doing to/for patients.

Infrastructure: We have too many buildings for what should be an increasingly virtual system.  The buildings we do have need to be more nimble, as the scramble for ICU beds has shown.  Our systems need to produce data that is more shareable, searchable, and real-time.  And we have too many layers of bureaucracy that add to costs but not to outcomes.   

Public Health: It is usually only visible during public health crises, but public health needs to be seen as an ongoing investment not just in managing such crises, not just in avoiding them, but also in improving our health.  It should be the base of our healthcare system, not an adjunct to it.

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Credit: MGMA

Right now, we're still watching the water, hoping it is no longer rising and waiting for it to recede.  Right now we know there is damage to our healthcare system, but not how bad it will be.  Right now, we're more focused on establishing the "new normal" for our daily lives, but not what the new normal for our healthcare system should be.  

As hard as it is to think past the pandemic, we must.  Returning to something that resembles "normal" is way too low a bar when it comes to health care.  Pandemics like this only come along perhaps once in a century, so we have a unique opportunity to, as Dr. Mukherjee says, make our healthcare system better.  We mustn't miss it.  

Hiding Our Heads in the Sand

There are so many stories about the coronavirus pandemic -- some inspiring, some tragic, and all-too-many frustrating.  In the world's supposedly most advanced economy, we've struggled to produce enough ventilators, tests, even swabs, for heaven's sake.

I can't stop thinking about infrastructure, especially unemployment systems.

We'd never purposely shut down our economy; no nation had.  Each state is trying to figure out the best course between limiting exposure to COVID-19 and keeping food on people's tables.  Those workers deemed "essential" still show up for work, others may be able to work from home, but many have suddenly become unemployed.

The U.S. is seeing unemployment levels not seen since the Great Depression, and occuring in a matter of a couple months, not several years.  As of this writing, there are over 22 million unemployed; no one believes that is a complete count (not everyone qualifies for unemployment), and few believe that will be the peak.

Many unemployment systems could not manage the flood of applications.

It's not surprising.  Any system might struggle to handle such sudden increases in volume.  Some seemed purposefully intended to fail (that'd be you, Florida!).  Not having robust enough systems might have seemed a viable political strategy when unemployment was low, but less so with such widespread unemployment.

The word that has been repeatedly used to describe unemployment systems is "antiquated."  Many are still mainframe systems based on COBOL, dating as far back as the 1960's.  COBOL was a very popular language in its day and is still in widespread use, but it is not the language of choice in modern systems.  It's hard to even find COBOL programmers anymore.

New Jersey Governor Phil Murphy lamented: “We have systems that are 40 years-plus old, and there’ll be lots of postmortems.  And one of them on our list will be how did we get here where we literally needed COBOL programmers?"  Cybersecurity expert Joseph Steinberg told CNN: "Governors should not have to think about computer systems during a pandemic, and we should have systems that if there are emergency situations, should not make the emergencies worse."

Amen to that.

And, let's be fair: it's not just state unemployment systems dependent on COBOL; many key federal systems are as well, including some used by the IRS, HHS, Treasury, and DoD, not to mention many banking systems.  The systems needed to produce those promised stimulus payments and small business loans are not easily adapted.  Former IRS Commissioner John Koskinen told The Washington Post: "The IRS systems are still hard-coded.  It’s not just a keystroke to go into the code and make the change and hope you’ve made it correctly."

There had been precious little money spent on upgrading the systems to more modern architectures, or even to retaining the programmers who could keep them running.  When making budget decisions, it often seems like there will always be time to modernize...until there isn't.  Like in a pandemic.

Michele Evermore of the National Employment Law Project told Vox: "It’s really not a sexy item to fund UI [unemployment insurance] administration.  The only times any improvements have ever happened with UI has been because a recession exposed holes in the coverage."  We've found the holes now, and they are big ones.

But we should not be surprised.  We're a nation that likes to push its problems into the future.  All that emergency COVID-19 spending?  Trillions of dollars of deficit spending, on top of existing annual trillion dollar deficits, deficits that some future generations will have to deal with.

We're a nation that tends to underfund public pensions, at the local, state, and federal levels.  We're a nation whose infrastructure -- e.g., roads, bridges, railroads, dams, water and sewer systems-- is rated D+ by the American Society of Civil Engineers.   And, as the COVID-19 pandemic is making so very evident, we're a nation that has been extremely shortsighted in funding public health.

A new report from the Trust for America's Health minces no words.  President and CEO John Auerbach charges:

COVID-19 has shined a harsh spotlight on the country’s lack of preparedness for dealing with threats to Americans’ well-being.  Years of cutting funding for public health and emergency preparedness programs has left the nation with a smaller-than-necessary public health workforce, limited testing capacity, an insufficient national stockpile, and archaic disease tracking systems – in summary, twentieth-century tools for dealing with twenty-first-century challenges.

Public health contact tracing.  Credit: The Daily Iowan

Similarly, Julie Bosman and Richard Faussett warned in March: "A widespread failure in the United States to invest in public health has left local and state health departments struggling to respond to the coronavirus outbreak and ill-prepared to face the swelling crisis ahead."  The Association of Schools and Programs in Public Health claims we have a shortage of 250,000 public health workers -- you know, the kind of people we need now to do hot spot analysis and contact tracing.

Tom Frieden, formerly of the CDC, warns: "We need an army of contact tracers in every community of the US to be ready to find every contact and warn them to care for themselves and stop spreading it to others."  Unfortunately, as Brian Castrucci of the de Beaumont Foundation told Time: "We waited until the house was on fire before we started interviewing firefighters."  

Oh, now we're seeing why we need to invest in public health.  Now we see why we need to invest in better UI systems.  Now we see why things like the federal emergency stockpile and the Defense Production Act are important.  It's not like we didn't know that pandemics could happen and how devastating they could be; we just chose to not be prepared.

We've been hiding our heads in the sand.

We'll get through this pandemic.  Not all of us, and not without too many of the rest us suffering in many ways.  We're told that we're probably not going back to "normal," at least not anytime soon, that we'll have to adjust to a "new normal."  I just hope that the new normal includes a more clear-eyed perspective on being prepared for when pandemics and other catastrophes do strike. 

We may never be fully prepared for when emergencies do hit, but we certainly can do better than we've done so far with this one.

Wait -- Robots Work But I Get Paid?

We're not through the COVID-19 pandemic.  We're probably not even near the end of the beginning yet.  That hasn't stopped many pundits to start speculating about how our society (and our healthcare system) are likely to be permanently changed as a result, such as continued reliance on telecommuting and telemedicine. 

OK, I'll play too: I believe we need to greatly expand the role of robots, and begin something that resembles Universal Basic Income (UBI).  They're not the only changes that may result, but they are two that should.

Robots
We've been seeing robots infiltrating the workforce for many decades, such as in manufacturing but also in many other industries.

Still, though, as our economy pares down to "essential businesses" during the pandemic, I've been alarmed at how many of the jobs remain done by humans.  Not just healthcare workers on the front lines but also all those people doing the cleaning for essential businesses, all those people in the supply chain of food and other vital materials, all those people making deliveries, all those first responders, all those people all those people keeping the power on, the water running, and the internet streaming, among others.  And so on.

We're already seeing reports of positive tests for COVID-19 in grocery workers, Amazon employees,  meatpacking workers, not to mention first responders and healthcare workers.  The trucking industry fears the impact.  Garbage collection was already a not very desirable job and carries the risk of COVID-19 infection as well.  At some point, we run the risk that we won't have enough essential workers.

Thus, robots.

An article last month in Science Robotics noted: "As epidemics escalate, the potential roles of robotics are becoming increasingly clear."  The authors cited four key areas where robots could make a key difference in a pandemic:

• clinical care (e.g., telemedicine and decontamination), 
• logistics (e.g., delivery and handling of contaminated waste),  
• reconnaissance (e.g., monitoring compliance with voluntary quarantines), 
• continuity of work and maintenance of socioeconomic functions  

Disinfecting robot.  Credit:UVD Robots

Indeed -- but I believe that even those areas do not go nearly far enough.  Professor Richard Pak, an automation expert, told The New York Times: "Pre-pandemic, people might have thought we were automating too much.  This event is going to push people to think what more should be automated."  AMP Robotics CEO Matanya Horowitz pointed out the obvious advantage of robots: "They can't get the virus."

If some jobs are truly "essential," the current pandemic highlights the risk that there may not be enough people to do them, at least not safely.  We should be making every effort to identify if/how more of them could be done by robots.  It'd be a big investment to make, but that investment would pale next to the costs of the current shutdown to our economy.

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Universal Basic Income
This idea has been floating around for several years, largely by tech futurists worried about what happens when robots do, in fact, take a significant number of our jobs.   It was the centerpiece of Andrew Yang's presidential campaign, and brought him more ridicule than respect. 

Illustration by Anna Parini for The New Yorker

Now this idea seems prescient, as job losses soar past the levels of the last Recession and could exceed the joblessness of the Great Depression.  No one knows how long the economy will persist in shutdown mode, nor even exactly how we'll emerge from it.  Many experts caution we may never go back to "normal," especially not until there is a proven vaccine.

State employment programs vary widely in terms of which workers are covered, how much benefits are, or for how long.  Those programs have been overwhelmed, both by the huge, sudden increase in volume and by the antiquated systems they use (let's put it this way: these are the salad days if you happen to know COBOL). 

Congress belatedly responded to the employment crisis by throwing money at the problem in three separate bills, each costing more than ten times the prior bill.   The bills tried to expand paid sick leave, give loans to businesses that do not lay off their workers, beef up state unemployment benefits, and make direct payments to most Americans (a very limited UBI program!), as well as, of course, providing subsidies to big businesses.

Despite all that, few believe the trillions of dollars are nearly enough, especially if the shutdown continues into or even past this summer.  For example, the small business loan program, designed to help small businesses keep their workers, has been beset with problems -- neither banks nor small businesses knew what to do -- yet is reportedly already running out of money. 

Other countries address unemployment by directly subsidizing the majority of workers' paychecks, thus limiting unemployment and making restarting the economy quicker.  It is an idea that has been argued even by some conservative Republicans here.  It is much simpler, and more direct, than the various programs Congress has enacted.

When people can't work, or we don't want them to work, we should have a uniform national income support system already in place, one that allows people to pay their bills, without them having to jump through a variety of hoops that will end up stymieing too many of them. 

Ours is a federal system, which specifically reserves rights to the states, but in times of a national or even regional emergency like a pandemic, it's crazy that we have to wait until the crises hits, then rely on the federal government to belatedly respond with (borrowed) largesse squeezed through a crazy-quilt of programs. 

Some believe the COVID-19 crisis could be the crisis that helps bring about MedicareForAll, but I think the economic crisis it is causing may prove to be an even more powerful impetus to create a federal income entitlement program.  We just have to decide if it this should be an true, always-on UBI program (remember those robots!), or one aimed solely at reducing lost employment income. 

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A year ago -- heck, six months ago -- each of these were issues that we knew might someday be important, but we thought we had time to think about.  We are out of time.  It is time for action.    

There Will Be Consequences

Crises -- like our current COVID-19 pandemic -- force people to come up with new solutions.  They slash red tape, they improvise, they innovate, they collaborate, they cut corners.  Some of these will prove inspired, others will only be temporary, and a few will turn out to be misguided.  We may not know which is which except in hindsight.

I covered some of these in a previous article, but let me highlight a few:

• Hospitals: we're building new hospitals, such as in convention centers, to address the expected shortage of beds.  Hospitals are also coordinating where to send which types of patients.
• Testing: we're creating drive-through testing centers in parking lots and elsewhere.
• Telehealth: we've loosened the restrictions on telehealth, improving reimbursement and rules about when it can be used.
• Coverage: we're trying to ensure that deductibles/copayments do not pose barriers to people getting tests and treatment, even for those without insurance.
• Clinicians: we're looking for clinicians everywhere we can -- allowing licensed ones from other states to practice, letting people who were health care professionals in other countries practice here, calling retired ones back into service even if their license had expired, even letting almost-graduated medical professionals start practicing.  
• FDA approvals: The FDA is using its "emergency use guidance" authorization to start allowing use of drugs and other treatments much quicker, and with much less evidence, such as for hydroxychloroquine, diagnostic testing, and ventilators. 

This is certainly not a complete list, and people are still developing new ones.  Kudos to all the people working long hours to try to do what is necessary, even if it means doing things that are unconventional.  We are not in conventional times.    

That being said, we should not ignore the fact that these solutions will have consequences, and some of those may not be good ones.  I'll quickly discuss a few of the things that could result in problems:

Networks

When I read about these new hospitals, I immediately think, hmm, I wonder whose networks they're in, and what the payment rates for them will be.  Same for hospitals cooperating about which hospitals do which patients, or for the new drive-through testing centers.

So is this field hospital in-network? Photo: AFP/Bryan R. Smith

I.e., I may want to go to an in-network hospital, but get sent to some other hospital, possibly one of the new, a jury-rigged ones.  Am I going to get billed out-of-network charges? 

Similarly, it's great that so many healthcare professionals are flowing to where the needs are, but I suspect that most of the "new" ones are not credentialed/considered in-network for most health plans,  What will they charge, and will those charges be considered out-of-network?

I think networks should be a thing of the past, but we can't ignore that they do still exist.

Licensure

Some of the health care professionals who are being recruited to start practicing in order to help out aren't licensed in that state.  Aside from the network problem discussed above, that means that patients may end up getting some portion of their care from clinicians who have not demonstrated to their state's licensing bodies that they are qualified to do so.  

Many will prove to be eminently qualified, but a few may not, especially as the surge of COVID-19 patients overwhelm parts of the health care system.  Mistakes will be made, some care will be substandard, and when this is all over some injured parties may seek remedies via medical malpractice or other lawsuits.  Those without current "proper" licensure would be an obvious target.

I personally do not think our current system of licensing for health care professionals is particularly effective, nor appropriate for today's connected world, but I am not enough of a libertarian to believe that there shouldn't be any kind of licensing.  

Coverage

It is understandable that during a pandemic we can't afford to let cost be a barrier to necessary testing, and it's only compassionate that we don't want treatment to be unaffordable for COVID-19 patients, but it creates inequities for patients with other conditions.

The health plans that are waiving deductibles and copayments for COVID-19s are essentially unilaterally revising their contracts during the contract year.  There are other patients with critical needs who may not think COVID-19 patients should get such preferential treatment, and it's hard to say they're wrong, especially since coronavirus coverage may increase everyone's premiums.

Moreover, since we have not had anything like universal testing, there are COVID-19 patients who have never actually tested positive for it.  When it comes to covering COVID-19 preferentially, how do we distinguish those patients from others who might have had similar symptoms and treatments?  We're not even counting deaths accurately.

Safety

Maybe hydroxychloroquine will be the solution some believe it will be.  Maybe GM, Ford, and others can make ventilators just as well as their usual manufacturers.  Maybe the new coronavirus tests will each prove equally accurate.  But, chances are, some of the shortcuts the FDA is allowing will result in some harm.  

The FDA has sometimes been criticized for taking longer to approve new drugs, treatments and devices than other countries, but, in this crisis, it is understandably taking actions at what is, for it, a breakneck pace.  But we should not be naive; the normal FDA review processes are in place for reasons.  Even if there are not always perfect, they serve as guardrails for patient safety -- and we're now removing some of those guardrails.  

There will be some patients who suffer, perhaps even die, as a result of some of these shortcuts.  Who will we blame?  

Privacy

Telehealth companies have spend many years trying to make their platforms HIPAA-compliant and, ideally, integrated with other health platforms.  Now, though, we're using FaceTime, Skype, Zoom, and other video platforms to do telehealth, even though some of these (I'm taking to you, Zoom!) have prioritized ease-of-use over privacy, much less adherence to HIPAA.   

This is a time for telehealth, but when this is all over we may wonder whether the cost to our privacy was worth it.

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There is nothing about the current pandemic that allows us to be business-as-usual.  It's natural in a crisis to focus on the short-term problems, especially when there are so many and they are so big.  Each of the solutions being developed is being done with good intentions to address immediate problems.  But it's not too early to be thinking about what the longer-term implications of these solutions might be.  

Crises demand action, but actions have consequences.  

Pandemics Are the Mother of Invention

If, as they say, necessity is the mother of invention, then you'd have to say that the COVID-19 pandemic is proving to be the mother of invention and innovation.  And, like Isaac Hayes sang about Shaft, it is a "bad mother...(shut your mouth)."

Many believe that the Allies won WWII in large part because of how industry in the U.S. geared up to produce fantastic amounts of weapons and other war materials.  It took some time for businesses to retool and get production lines flowing, during which the Axis powers made frightening advances, but once they did it was only a matter of time until the Allies would prevail.

Similarly, COVID-19 is making scary inroads around the world, while businesses are still gearing up to produce the number of ventilators, personal protective equipment (PPE), tests, and other badly needed supplies.  COVID-19 is currently outnumbering these efforts, but eventually we'll get the necessary equipment in the needed amounts. 

Eventually. 

What intrigues me, though, is how people are innovating, inventing new solutions to the shortages we face.  I want to highlight a few of these:

Hospitals: China received a lot of press when they built COVID-19 hospitals in a matter of days, and now that is starting to happen here. In New York City, the U.S. current epicenter, the Army Corps of Engineers has, within a matter of days, repurposed the Javits Convention Center into an overflow hospital with almost 3,000 beds, making it the largest hospital in the city.  It will serve primarily non-COVID-19 patients, allowing other hospitals to focus on COVID-19 patients.

Javits Center hospital

Governor Cuomo has set a goal of 1,000 bed overflow hospitals in each of the five boroughs, the other sites being Brooklyn Cruise Terminal, the Aqueduct Racetrack facility in Queens, CUNY Staten Island and the New York Expo Center in the Bronx.  

In addition, another field hospital is literally being set up in the field, in this case Central Park's East Meadow, across from Mt. Sinai Hospital.  It will have ICU capabilities.

Testing: When this is all over, there will be many analyses about how the U.S. botched coronavirus testing.  As of this writing, although testing has become vastly more available, it still is well below what is needed, and we do not have a good understanding of how widespread the virus has spread and who is currently spreading it.

Abbott Labs COVID-19 test.  Source: Abbott Labs

Part of the problem is that, even for those who can get tested, the results can take hours or even several days to get results.  During that time, they may be asymptomatic and further spread the virus.  All that may be changing. 

Abbott Labs has gotten approval for a point-of-care test that can give results in as few as five minutes.  FDA Commissioner Steve Hahn and former FDA Commissioner Scott Gottlieb both called it a "game changer."

Another game changer is the ability for individuals to self-administer diagnostic tests, alleviating the need to go to testing facilities, and risk exposure for health care workers.  A new study has found that such testing can be as accurate as physician-administered tests.  Such tests are awaiting FDA approval.

PPE: There similarly are not enough masks and other personal protective equipment.  Health care workers are being told to change them after each contact with infected patients, and, as a result, the numbers being used are skyrocketing.  President Trump might suspect that something nefarious is going on, but the need is real. 

Manufacturing of PPE is ramping up, but it will take time to catch up to need.  So Battelle Labs has developed a decontamination system that can allow masks to be reused up to twenty times.  It took intervention from Ohio Governor DeWine to persuade President Trump and FDA Commission Hahn to grant FDA approval in a matter of days, but now the system is quickly being ramped up to full capacity. 

Ventilators: Ventilators are one of the most troublesome bottlenecks in treating COVID-19 patients.  When such patients go into respiratory distress, as an alarming number do, it is quite severe and lasts for much longer than for other ICU patients.  As a result, the ventilator supply has been badly stretched.  Hospitals are having to make tough choices about who gets one and who doesn't. Governors are fighting over where additional ventilators get sent, and manufacturers are scrambling to increase production.

Some hospitals have innovated by using single respirators to serve several patients simultaneously, although the safety of this is unclear.  Others are using continuous positive airway pressure machines (CPAPs), more typically used to treat conditions like sleep apnea, although, again, the safety of this is in question.

Fortunately, the engineers are at it.  In Italy, some clever people started 3D printing badly needed respirator values, for free, when hospitals couldn't get them from the original manufacturers. 

Dyson CoVent ventilator

Never one to be outdone, James Dyson, of vacuum cleaner fame, developed an entirely new ventilator in an astonishing ten days, and is already producing them.  Virgin Orbit, which normally, you know, sends things into space, has developed its "mass producible bridge ventilators" and is hoping to begin production in early April, pending FDA approval. 

Not to be outdone, within two weeks an MIT team developed an "open source, low cost" ventilator design which it believes can be built for as little as $100 (a normal ventilator costs as much as $30,000).  They are waiting for, you guessed it, FDA approval, and warn that these "have to be manufactured according to FDA requirements, and should only be utilized under the supervision of a clinician."  In other words, don't try this at home.

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These are just a few examples.  I didn't discuss, for example, how new treatments and vaccines are being rushed through at a breakneck pace, or the countless innovations front line health care professionals are being forced to come up with every day as they face the crush of very sick, infectious COVID-19 patients.  

We are, indeed, at war with the coronavirus, and there are going to be casualties.  A lot of them.  The number of deaths will shock us.  But as shocked as we may become, as overwhelmed as we may feel, we're also going to be amazed at the creativity and innovation people are bringing to the fight.  In the end, though, that and the heroics of our health care workers are what is going to win the war.

The New Scarlet Letter

If you live in one of the jurisdictions that have imposed stay-at-home requirements, you're probably making your essential excursions -- grocery store, pharmacy, even walks -- with a wary eye towards anyone you come across.  Do they have COVID-19?  Have they been in contact with anyone who has?  Are they keeping at least the recommended six feet away from you?  In short, who is putting you at risk?   

Baidu coronavirus map app (Qilai Shen/Bloomberg News

Well, of course, this being the 21st century, we're turning to our smartphones to help us try to answer these questions.  What this may lead to remains to be seen.

We long ago seemed to shrug off the fact that our smartphones and our apps know where we are and where we have been.  No one should be surprised that location is of importance to tracking the spread of COVID-19.  No one should be surprised that it is already being used.  We may end up being surprised at how it will be used.

Last week Israel granted its domestic security agency emergency powers to track the mobile phone data of people who have (or may have) coronavirus.  The intent is for the health ministry to track whether such persons are adhering to quarantine rules, and possibly to alert others who had previously come in contact with them.    

China is using the AliPay Health Code to assign color codes to individuals based on their known health status -- green, yellow, red.  No one is admitting exactly what the codes mean or how they are determined, but The New York Times did an analysis that:

found that the system does more than decide in real time whether someone poses a contagion risk. It also appears to share information with the police, setting a template for new forms of automated social control that could persist long after the epidemic subsides.

Alipay Health Code 

The system is used in real time to determine, for example, who can board mass transit or use public housing.  It is being rolled out nationwide, despite the lack of transparency about how the codes are determined, used, or updated.  As one citizen told The Times: "Alipay already has all our data. So what are we afraid of? Seriously."

Seriously.  

Singapore has developed a tool -- TraceTogether -- that uses Bluetooth to track whose phones have been in close contact, and for how long.  If someone then tests positive for COVID-19, the health ministry can easily determine who has been in contact with them.  It supposedly does not collect name or even location, but the health ministry can identify individuals if deemed "necessary."  The government is making the technology freely available to developers worldwide.  

South Korea is using smartphone data to create a publicly available map of movements of known coronavirus patients, and aggressively message those who might have come in contact with them.  As The Times also reported:

South Koreans’ cellphones vibrate with emergency alerts whenever new cases are discovered in their districts. Websites and smartphone apps detail hour-by-hour, sometimes minute-by-minute, timelines of infected people’s travel — which buses they took, when and where they got on and off, even whether they were wearing masks.

Unfortunately, the information about their movements is having significant ripple effects, disclosing destinations users might have preferred not be public, or attaching a stigma to places they frequented. One person told The Guardian: "I thought I only had to protect my health, but now I think there are other things more scary than the coronavirus."

In the U.S., volunteers from several big tech companies built covidnearyou, which allows people to self-report such facts as any symptoms, travel history, or exposure to people who have tested positive.  Anyone can then use their map to determine if there are affected individuals near them. 

MIT's Media Lab has developed Private Kit: Safe Paths, "An app that tracks where you have been and who you have crossed paths with—and then shares this personal data with other users in a privacy-preserving way."  Unlike efforts in some other countries, the data is encrypted and does not go through a central authority.  MIT Technology Review says:

This lets users see if they may have come in contact with someone carrying the coronavirus—if that person has shared that information—without knowing who it might be. A person using the app who tests positive can also choose to share location data with health officials, who can then make it public.  

Oura smart ring.  Credit: San Francisco Chronicle

Going one step further, two San Francisco hospitals have developed a smart ring that is "able to detect body temperature and pulse."  It is aimed at health care professionals and workers, such as ER doctors, as an early indicator of COVID-19 exposure.  It's probably only a matter of time before laypersons demand a version.

One can easily imagine such a smart ring being connected to a smartphone app, perhaps even generating a color code, and broadcasting the individual's status and location to others worried about potential exposure.  I bet Alibaba would be happy to help.

Everything else being equal, it's good to know who represents a risk to us.  Typhoid Mary became Typhoid Mary because people around her didn't know she was a carrier.  It would be in the public benefit to ensure that people can get warning about other people who are most likely to be infectious with COVID-19.

That being said, everything else is not equal.  We don't have a good understanding of when people with COVID-19 are most infectious, how COVID-19 is most likely transmitted, or how exposure to such people increases risk of third-party transmission.  Tagging people and then broadcasting that tag, along with location and even identity, could put people at risk of discrimination (e.g., refused service or contact) and even attacks. 

As one privacy expert told The Times: "That could extend to anyone, to suddenly have the status of your health blasted out to thousands or potentially millions of people.  It’s a very strange thing to do because, in the alleged interest of public health, you are actually endangering people."

And we need to bear in mind that whatever technology we bring to bear on this public health problem could subsequently be used for other problems, public health or other.  We increasingly live in a surveillance society, and that can be to our benefit -- or to our detriment.  We don't always realize the slippery slope we're on until the slide has become irreversible. 

I'm all for using technology to address public health crises.  I'm just not clear what the ultimate price we're going to have to pay for that, and that makes me nervous. 

Not Another Twenty Years...

I know that everything is COVID-19 these days, but I don't know that I can read another article about it right now, and I certainly can't write one.  I need a break, and maybe you do too.  Instead, I'll talk about tech adoption and some lessons architecture -- yes, architecture -- might have for healthcare.  

Credit: Getty Images

The Wall Street Journal has an article Tech Disruption Can Take Decades -- Just Ask Architects.   Many of us knew that computer assisted design (CAD) had revolutionized the field of architecture, but until reading this article I did not realize that particular wave passed through the field in the latter  decades of the 20th century.  The wave that is currently passing through is something called building information modeling (BIM).  

BIM is 3D modeling on steroids.  AutoDesk, which I gather is to CAD and BIM as Epic is to EHRs, defines it as: "BIM is an intelligent model-based process that helps make design, engineering, project and operational information accurate, accessible and actionable for buildings and infrastructure." GRIFTISOFT, a competitor, says "BIM is the use of 3D virtual models of buildings, as well as a process of managing and collecting building data."  

In its BIM 101 article, engineering.com stresses that BIM is not just for architects and not just for design.  Instead, "BIM is all about the information. It doesn’t just create a visually appealing 3D model of your building—it creates numerous layers of metadata and renders them within a collaborative workflow."  

Keep that in mind for later.  

BIM didn't really start to take off until the last recession, when layoffs or fewer active projects gave architects more time to earn the software.  Not surprisingly, younger workers picked it up first, either then teaching other workers or assuming more duties and shunting older and/or less tech proficient workers to tasks less connected to design, "sometimes creating a complex generational dynamic."  

Phil Bernstein, a Yale architecture professor, told the WSJ this about BIM adoption:

I’m surprised by how slowly this is all happening.  When we first proposed the idea that Autodesk would shift from drafting platforms to modeling platforms, if you told me that almost 20 years later we’d finally be at the point where it was normal everyday practice, that’s a long time."

As one architect told the WSJ, "The promises of technology are oftentimes extremely exciting and encouraging when you hear the sales pitch.  The reality is that it’s a much longer and more complex process than originally envisioned."  

The article goes on to note:

The phenomenon holds lessons for other industries and trades, as digital tools offering more efficiency and precision replace older, more manual technologies. The barriers to adopting costly automation or technology can be significant, especially in fragmented fields with many small players.

Architecture has gone from a field marked by emphasis on drafting skills and reliance on reams of architectural drawings to one reliant on shared, dynamic, interactive 3D models infused with various types of relevant information.  In short, everything we should expect EHRs to be.

EHRs and telehealth are the two obvious parallels to CAD/BIM in healthcare.  Neither is a new technology.  Epic, for example, has been selling EHRs for forty years, and the VA's VistA has been in existence about as long.  EHRs have finally gained broad use, due in large part to the HITECH stimulus payments, but not deep satisfaction among clinicians.

Similarly, companies like Teladoc Health and American Well (Amwell) have been offering some form of telehealth for over fifteen years, and it is only with the COVID-19 crisis (darn -- I should have known I couldn't avoid it altogether!) that we are finally lifting some of the many barriers -- e.g., licensing, reimbursement -- that have kept telehealth from becoming mainstream.  

Of course, the fact that we have separate EHR solutions and telehealth solutions is an example of not fully embracing technological change (although some vendors are starting to integrate).  Similarly, the fact that we have telehealth solutions that are distinct from commonly used messaging/video services is another example that we're not fully maximizing available technology.

Healthcare has had many barriers to technological change.  Until fairly recently, most physicians worked in solo or other small practices.  Most hospitals were single location, nominally non-profit.  Home health agencies, nursing homes, dialysis centers, even drugstores were largely "mom-and-pop."  Most of that has changed to larger, more vertically/horizontally integrated models, but mindsets and technologies have not adopted as rapidly as business structures.   

And, of course, reimbursement has been a factor in healthcare technology adoption: there is a multiplicity of third-party payors using a byzantine medical coding system to pay an array of payment levels.  It can be tough to introduce new technology that doesn't fit existing molds and that may, in fact, slow processes during the learning curve.  

When you think about those older architects who struggled to learn CAD and then were forced to adopt to BIM, think about physicians spending hours trying to catch up on their EHR documentation.  A recent article in Harvard Business Review claims: "Estimates of physician productivity suggest that 20% to 30% or more of a physician’s available capacity is absorbed by clinical documentation, electronic medical record (EMR) inputs, and other compliance-related work."

Right now, you might say that healthcare is at the 2D CAD level.  Yes, we're moving away (ha!) from paper and more fully utilizing computers, but we're a long way from the 3D, interactive, information-embedded BIM that architecture uses.  

Imagine, for example, an EHR that:

• has a 3D model (digital twin!) of patients, annotated with pertinent images and information;
• is accessible and updateable by other clinicians as appropriate;
• is accessible and updateable by patients and patient devices;
• can be used as a communications vehicle with patients and clinicians

None of that technology is beyond our current reach, but I hate to think that it might take another couple of decades for such an approach to be in wide use.