Care Redesign For a Post-Peak COVID World

By Robbie Hughes, Founder and CEO, Lumeon | Article originally published at Healthcare IT Today

In this brave new world, of so called post-peak COVID, if we have no clear means of vouching whether a patient is ‘clean’, then the challenge we all have is how to bring them into an environment with other more vulnerable patients and avoid a ‘salt shaker’ moment.

We will face 2 problems before there is widespread immunity that will require us to substantially redesign the provision of care so it is less likely that patients will come into contact with one another, by directing them:

a) into protected ‘blue’ clean environments where the possibility of transmission should be eliminated.
b) or into restricted ‘red’ environments where the downstream risks of transmission are eliminated.

Arguably, in the healthcare setting, our ability to test, prevent, and ultimately manage the problem is substantially better, but to counter this, the vulnerability of patients is far greater.

So, what do these two scenarios look like in the context of a healthcare setting?

Care Design for Separation

If we were to use this crisis as an excuse to remove much of the regulatory and reimbursement limitations that have supported the current status quo, we might find that we start doing things very differently:

– the implementation of end-to-end processes for specific interventions and/or diseases, staffed by specialists, probably in outpatient centers, that keep well, low-risk patients away from sources of infection. Where this has been done around the globe, complication rates drop dramatically, outcomes improve and costs plummet.

– a substantial shift in outpatient visits towards telemedicine, to ensure improved efficiency but combined with robust protocols to ensure quality and appropriate follow up.

– the virtualization of the hospital more broadly, to create networks of care that work together in a coordinated fashion to deliver the right focus to the right patient at the right time.

While these ideas might be good for lower-risk patients what further things might we need to do for those more severely ill patients?:

– virtualization of care will allow for increased specialization and reach – rather than having to make do with the junior specialist on call, it’s possible that the global expert might be available, even if they’re on a different continent.

– the ‘proceduralization’ of lower-risk procedures will free up substantial capacity by reducing complications, enabling the well to stay well and the sick to get better care.

Screening “Front Door”

In a world where patients can be asymptomatic carriers and transmission nodes of COVID-19, the challenge will be how to ensure that a patient is ‘safe’ to come into contact with other patients? Or, if they’re not, how can we manage their care anyway?

Eventually, herd or vaccinated immunity will be achieved and we might then put it in the ‘problems we can probably ignore’ bucket like we do measles, but there will be a considerable amount of time between now and then.

In the event that we don’t go to the lengths of separation described above, we will need a way of testing patients prior to entry, then redirecting them to protected ‘blue’ sites where we know they are at low or no risk, or to ‘red’ sites where the inevitability of onward infection presents no additional harm.

This presents two immediate challenges:

1) designing processes that provide a near real-time test, showing the degree to which a patient is infected and hence their infectiousness to others.

2) having received the test results, what should we do to facilitate ongoing care?

Without getting into the specifics of serology testing, (the challenges of which are discussed in great length here), the issue at hand is the creation of a screening event, much like a new “front door” to the clinical process that determines whether the patient should turn left into the ‘blue zone’ for ‘safe’ patients or right into the ‘red zone’ for ‘unsafe’ ones.

Assuming the test can be commoditized, a screening “front door” should be a relatively simple thing to scale, but it will present interesting operational challenges:

  • testing will likely need to be done by the ‘owner’ of the care event themselves, whether a provider, health system, clinic, or hospital.
  • this will be necessary as they will need to assure themselves that, for this specific clinical event, they are not placing the patient or other patients in harm’s way. The asymptomatic spread means that a patient could be infected at any time, so once this patient has passed the threshold of this new front door, we can be assured that we know where we stand with them.
  • this also presents very real challenges all across the supply and personnel chains for clinical settings. There will be a need to guarantee and verify that there is no possibility of contamination risk in the blue zone and that nothing from the red zone leaves without decontamination.

I can imagine signposting physically separate sites on campus and hospitals being split in two. The balance between these two will also be interesting: does one allocate 50% of resources to the red zone or 10%? Is the ability to flex this resource share important? Should the orchestration of the patient’s care be flexed differently over time?

Should we even allow patients to leave a red or blue zone until their treatment is finished? Does this mean the creation of red and blue hotels on-site?

Looking in the Rear-View Mirror

Once there is a vaccine, all of this will become less relevant, but it will still be important. Guaranteeing that every patient has their vaccine and it is up to date will be the only way to ensure that this particular virus is eradicated in the wild.

For the future, however, the reality is that Pandora’s box has already been open for a long time and we’ve simply been lucky that the random mutations of past viruses haven’t crossed us in the way that this one has. It’s my view that designing a healthcare system that can function to eliminate the possibility of the spread of disease is what we will inevitability need to come to terms with.

Given the options laid out above, I don’t believe this is an either/or situation. We will need to implement care virtualization to limit access to red and blue zones to contain the spread. We will also need to thoroughly screen on entry, to ensure patients are appropriately signposted. Both will have to happen to enable healthcare to be effective in the future and both are already happening in hospitals globally.

The other key question is how the change is going to be funded.  Small hospitals won’t be able to make the investments to do this themselves, and either it is going to have to come from government or we will see a huge wave of consolidation from those with substantial balance sheets.

Coronavirus has presented very real economic challenges for health systems of every size and capital investment in the future is going to be hard for some years to come, but without material changes in how care is delivered, not only is today’s problem going to persist, but the next round will cripple them.

Feel free to send me your views or go to Lumeon’s Coronavirus webpage to see what we’re doing to help our customers address the challenges of COVID-19.

Keep safe everyone.