COVID-19 Insights from the Front Line
About this webinar:
How are physicians on the front lines of the pandemic using data to better understand comorbidities, break down language barriers and target underserved patient populations?
As COVID-19 rates continue to rise in the US, hear from pulmonary critical care and sleep physician, Sreelatha Naik, MD, on how the pandemic has impacted patient volumes, unlocked new opportunities in digital health, and unleashed new data-driven approaches that have the potential to revolutionize healthcare as we know it.
Check out our conversation between Dr. Naik and Komodo chief medical officer, Dr. Aswin Chandrakantan, on observations from the front lines of COVID-19, and the unique opportunity for patient journey data to support a more effective health system response.
(slide 1) 00:00 Aswin Chandrakantan: Thank you very much, today, everybody for joining us. My name is Dr. Aswin Chandrakantan and I am the Chief Medical Officer at Komodo Health. I have with me, Dr. Sreelatha Naik, who will be joining us to talk through the impact of COVID-19 on the front lines.
(slide 2) 00:20 AC: So, a little bit about my background, so I am an MD by training and went to medical school at the University of Medicine and Dentistry of New Jersey and New York. I then joined management consulting at McKinsey and then joined Google, and then was one of the early employees of Komodo Health. I am going to let Dr. Naik introduce herself.
00:43 Sree Naik: Hi! My name is Dr. Sreelatha Naik. I'm a pulmonary critical care and sleep physician at Geisinger Health System. I did go to medical school with Aswin here and it's now Rutgers. And so, a lot of changes, I guess, over the years. And then, I went on to internal medicine training and pulmonary and critical care fellowship as well as sleep fellowship. I now practice in Pennsylvania.
01:09 AC: Wonderful, thank you.
(slide 3) 01:12 AC: So, I wanted to introduce Komodo Health before we get into the discussion portion of our panel. So first I'm going to share a little bit about Komodo Health, share some analysis that we've done from a national data perspective and then sit down with Sree, who's been on the front lines of treating COVID-19 patients to understand some of the best practices, learnings, and challenges of containing the pandemic within the US.
01:39 AC: So Komodo’s mission is focused on reducing the global burden of disease. By burden of disease, we mean their morbidity and the mortality of disease. So, morbidity has to do with the activities of daily living that are impacted by living with the disease. And mortality is essentially the number of years lost having had a disease.
(slide 4) 02:05 AC: So our journey starts by, not being the comprehensive view of the entire US Healthcare system. And so Komodo we think of ourselves as breathing life into data. And data has been around the industry for over 30 years, but nobody has made that data intelligible, actionable, valuable – And so we think of our company as a company that is essentially stitching together a canonical view of 320 million patients, the providers and the institutions where they see care, the therapies and interventions they use to treat those conditions, and the outcomes that relate to that.
02:45 AC: We use that then to funnel that into software products that helps our life sciences customers, our provider customers, as well as payers to affect and impact and optimize disease burden and reduce it in a very, very actionable way.
(slide 5) 03:05 AC: Now, I wanted to talk to you a little bit around the work that Komodo Health has done to actually trace the impact of the pandemic across different care conditions. So, this is on the left side, a map of cholesterol testing and utilization rates, state by state, in you know, the week 14 of 2019. Fast forward a year where the pandemic has just broken loose in the US and you essentially see across the board, basically evaporation of cholesterol testing.
03:42 AC: And so, these are patients that are obviously looking to understand where they are and whether or not they're doing well on their medications, and whether or not they're hyperlipidemia is well controlled and hypercholesterolemia is well controlled. And now are essentially not undergoing any of those tests and preventing then providers and caretakers, and other healthcare stakeholders from making informed choices about how to optimize these patients with chronic conditions.
(slide 6) 04:12 AC: Secondly, we looked at childhood vaccination rates. And what's really interesting here is that you see in green 2019, and you see in green 2020 - and across the board, there's essentially a dip in the childhood vaccination rates across the United States. This dip starts in the pandemic, but then picks back up and starts to mirror 2020 rates. 2019 rates, a little bit later on into June, July. But the challenges is that you would have expected the dips in rates that are in the green to actually have been made up in latter months, which they're not. So that's actually telling you is, not only just care delayed but it's actually showing you that some of these patients may have not gotten these vaccinations and they never caught up with those vaccinations either, which creates a really strong thesis around the impact and the backlog of medical care, as well as important, you know, public health and safety interventions like childhood vaccinations.
(Slide 7) 05:23 AC: Mammography similarly. What I like about the mammography curve is when you do see the dip in the early parts of the pandemic, compared to 2019, you see the utilization rates start to go up in August. But the challenges is that oftentimes a stage one cancer that might have been caught in March is now essentially waited five months and now been caught in stage two or stage three. And so these are the some of the, you know, public health implications of delaying care in the context of acute conditions where the disease burden aggregates. And so, in chronic care okay you miss your hemoglobin A1C test, you miss your cholesterol test you miss your lipid test, and, you know, hopefully can get back on track barring any acute events. But in the history of, but in the case of mammography, other conditions that have more high mortality associated with them like breast cancer, you cannot, you know, essentially claw back that time. And you're looking at massive disease morbidity and mortality in the population associated with that delay in care.
(slide 8) 07:07 AC: The last piece that I wanted to highlight is that, the pandemic has created an uptick in adoption and education around telemedicine. And so, this has been really well documented in some of our previous webinars and the work that Komodo Health has done on our blog so I urge you to go in and take a look at that. But what we also did here is, to look at a county by county representation of telemedicine utilization. And so, what it shows us is that, unsurprisingly perhaps that the richest counties across the US have a far greater telemedicine utilization than the underprivileged populations. And so, what that highlights to us is that, disparities of care, although telemedicine is helping to overcome some of the challenges of COVID, the disparities of care are leaving our most underprivileged and most disadvantaged populations still at high risk. And this can be because of technology barriers on the patient side on the provider side, or both. But it's really important that we understand this in the context of, you know, public health policy and also across provider systems that have a lot of the nice or serve large geographical catchment areas that may have varying distributions, a very high income and high or low income populations and how you might serve them differently.
(slide 9) 08:10 AC: So with that said, it's actually a perfect transition to the conversation that I wanted to have with Sree, who works in the Geisinger System and helping us understand a little bit around some of the populations, the opportunities, the responses that she's had.
(slide 10) 08:30 AC: And so I'm actually going to go ahead and pause the screen share here just so that myself and Sree can have an organic conversation.
08:38 AC: So Sree, I know that we spent a lot of time together, you know, thinking through and talking through some of the implications of the pandemic and the response. Maybe you can just share a little bit around the anatomy of COVID-19 when the pandemic first started, and the response that you and your health care system immediately started mobilizing in order to drive education and understanding and best practices.
09:10 SN: So, I thank you Aswin. So, you know, even before we started to see local patients within our system, and I'm so lucky to work for a system that anticipated the need for testing and preparation for the events, and then as we started to see the east coast getting ahead there were those kind of a mobilization of critical care and inpatient resources first. The outpatient system took a little bit longer and trying to make sure, especially some of the things that you talked about, making sure our chronic care was not affected. I definitely have seen some of the things you were talking about in terms of delays in cancer care. Both because typical screening, for example like lung cancer screening CAT scans, that while they're available patients are afraid to come in.
10:03 SN: And so even kind of divulging patient's symptoms, they're worried about telling Geisinger because they were worried about coming in or worried that my doctor is going to ask me to come in. And so, both on the spectrum of cancer, on the spectrum of heart failure, as well as chronic lung diseases such as COPD, patients have been waiting until they've gotten really, really sick. Which then, you know, we're seeing the patient at a later point in their disease process and unfortunately prevents us from offering them the best treatments that we could have done at an earlier time point.
10:43 AC: Has that attitude amongst the patients shifted in the last few weeks or the last few months?
10:53 SN: I'm sorry, repeat that again?
10:55 AC: Has that attitude amongst patients around being reticent or seeking care, has that changed in the last few weeks or the last few months?
11:06 SN: To some degree. But there is such a polarization in our patients. Either there is, you know, complete, you know, lack of belief that this is a real problem or from a public health standpoint. And so, some patients are really kind of cavalier about being everywhere, not just in the healthcare setting. But there is a population of patients that are so scared that they don't even want to go outside the home. This idea that COVID is airborne, so I can't go out on my back porch, because I can get COVID that way. And so that attitude still exists. And these are patients that we're seeing like in a in a tele-med setting. And those are the words that they use.
11:47 AC: Can you tell me a little bit about when COVID hit, can you talk to me a little bit around how you essentially mobilized as a pulmonary critical care unit? There's both the acute setting, there's the chronic care, which we've been talking about, can you just give me a sense of like – In given the lack of information at that time back in March, what are the precautions and set of practices that were instituted? And then how is that evolved given, you know, the sort of research and understanding the disease over the last few months?
12:27 SN: So critical care was kind of a first department to kind of completely take a lead. One of my partners is a director for critical care in the northeast, part of where I work in Geisinger. He, and our entire team, our colleagues in nursing, as well as even physical therapy, and respiratory therapy, kind of had these like very frequent meetings in terms of how to deal with the changing picture. It's grown into this giant multi-disciplinary group of hematologist and infectious disease experts, within our system and really even outside, so that we can all stay… because the literature was lacking in the beginning, what little evidence we had of lower quality, perhaps we just wanted to make sure there was an agreement, a consensus in our treatment protocols and that treatment approach was updated on a fairly frequent basis and emailed out to everybody.
13:28 SN: I think what was really wonderful that we saw in the beginning was full transparency about all of these, at the amount of knowledge we had – and what we knew and what we didn't know. And how we were going to get to a point of knowing more. And it was just very impressive the way that was orchestrated. I, for one, you know, felt safe coming into work, which I think is not something a lot of people can say.
13:53 SN: As an example, there was the way the IV pumps were moved out of the exam room and placed right outside the patient's room. How to utilize the ventilator, so that the monitor of the ventilator is outside the room, whereas the pump mechanism is inside the room. And treatment protocols, we kind of already talked about, how to coordinate with between the critical care of emergency medicine and the hospitalist team and internal medicine. How do we support these various specialists that are perhaps like surgeons that are taking patients into an OR [operating room] because they have no choice. And there's co-morbid COVID at the same time. And so it was really well orchestrated machine which continues to evolve, even now.
14:42 AC: And you mentioned a little bit earlier on around some of the, you know, heterogeneity of the populations at Geisinger, can you talk to me about the disadvantaged populations and some of the, you know, outreach mechanisms you use in order to drive education and adoption around the best standards of care for those patients? and how you would work with them versus other population? Because I know there's a lot of heterogeneity. It sounds like you guys got a really good standard of care going acute setting, but now shifting back to the outpatient side, how is your outreach and how is it different?
15:51 SN: So yeah, so our systems spans about a two-hour radius from east and west, north to south and really we're one of the few medical entities in this area. And so that's what makes our population so heterogeneous is that it's so large, such a large geographic span. And, we are, it's between us and then there's one county in Florida that every year we shift, we're the largest Medicare population in the country. And so, we have this kind of elderly age group. And then we also have multiple colleges and universities in the, in our encatchment. And then also, there are areas/pockets that are, you know, a low SES and non-English speaking populations that we needed to capture. And so it's a very, very geographically, you know, and linguistically, any which way you can think of, very heterogeneous group.
16:19 SN: One of the things that we started to see, you know, early on was that our patients that were non-English speaking, of primarily Spanish speaking Nepalese, is the populations we see here, were disproportionately affected. You know, in my first two weeks of ICU in March, it was just a lot of my patients are just Spanish speaking. And so we needed to immediately, why was this happening when prior to COVID, that's not the population I was seeing in the ICU. And so, we were able to kind of reach out to, you know, of course the system I work in has a committee to address health disparities. And so I was able to reach out to them and say you know, health literacy steering committee and say, hey, like this, this population is being affected. And so, they were able to kind of get some data to see whether this is an objective observation or something that's just anecdotal on my part.
17:17 SN: And based on our data, we were able to target certain zip codes of where patients, perhaps need a greater degree of education. And so, for example with our Spanish speaking population and our geographic in one geographic location, they were able to reach out to employers to make sure the employers were better educated on infection prevention policies or recommendations. Having availability of testing to that population. Education by reaching out to the TV stations that were there in Spanish, as well as the newspapers there, it made a huge difference. We are still not sure whether or not we captured that population well because we have a population health team that then follows any COVID patients, for example, with contact tracing. And so, we're in the process of actually looking at whether or not those disparities are still present.
18:15 SN: So one of my residence, for example, is looking through the number of … evaluating our population to a greater degree in terms of, how many patients were with COVID disease that were non-English speaking versus English speaking and did they receive the appropriate care.
18:33 SN: In terms of vaccination, which was a big thing you brought up in vaccination, you're absolutely right, especially going into the flu season was a big concern we have. You know, the symptoms look similar, especially in the beginning, but you know, they can cause of your ARDS in a similar fashion. We don't need our ICUs to be filled with flu. So if patients are doing telemedicine, how are they getting their pneumonia shots? How are they getting their flu shots? So, some of the things that I think are really cool is partnering with things like EMS to set up flu drive through trucks. And so, you know, if you just Google Search it, you're able to find locations and different times of drive through flu shot locations. And so, these are some of the initiatives that you know are very innovative and utilizing what resources we have.
19:28 AC: That's wonderful. I mean, I feel like the drive by vaccination/primary care has been something that's been instituted very broadly and global public health in underserved or disadvantage countries, but to also recognize that it has value even for America where, you know, now there's a there's a risk between coming in for care versus trying to keep patients out and congregated and keep trying to, you know, divide the sick versus the non-sick population.
20:02 AC: Tipping the gears a little bit to the standards of care for COVID, So can you tell me like, I heard A) that you guys had a really strong centralized governance process around decision making. Secondly, I heard there was really like, you felt safe coming to work. I think you are like one of the only providers that I’ve ever talked to, especially in pulmonary critical care, so that's kudos to you guys at Geisinger for that. And so you talked about what the personal protective policy looked like and process looked like for care providers, can you talk a little bit about the evolution of the standard of care for these patients? Recently, we're starting to see drops in mortality for COVID-19 and it's being reported across the media quite broadly. Can you share is that like the evolution of the standard of care? Is it because you know this is a different segment of the population that's been getting sick? Just curious to understand what standards of care were developed early on and how it's evolved over time.
21:12 SN: So, I guess those standards of care may or may not be relevant to the current mortality. And so that's an analysis that needs to be done at some point. Because originally the testing, so the denominator of who we were testing relative to mortality being the numerator was different. Because we were reserving a lot of the testing for very sick patients that had to be admitted. Whereas now, the testing is a lot more widely available. Like you could get tested and have results within 24 hours in our system, we do entirely. And I think that's true for a lot of the country as well. So that's kind of that portion of it.
21:51 SN: But in terms of the evolution of standard of care, what's really great is that, we are not alone as a system or a single physician or even as a state. I just happened to be at the virtual conference for The American College of Chest Physicians this week. And you know there's a free flow of information between multiple institutions. Whether it be on these webinars that The American Colleges of Chest Physicians has been holding on a fairly frequent basis. In the beginning, there was even a point where they were doing it almost weekly. And then they have also been updating these various governing bodies like even, The American Thoracic Society, for example, even updating the resources on their website so that there's access to things like, you know, water infection control proven precautions water treatment recommendations. You know, at some point we were utilizing anticoagulation therapeutically, which I think you know some centers still advocate to a very high degree. But The American College of Chest Physicians really saying like, hey, like this is where the evidence lies. This is our kind of recommendation right now coming from up top is what's really helping us.
23:09 SN: In terms of what we've done to treat patients differently with COVID, we've essentially you know this is ARDS that we see from a critical care standpoint. And so, utilization of things like steroids, in our system at least that's been done from the very beginning, just because that's how you treat severe ARDS. So that's really been no different. There were certain medications like the IL-6 drugs that were evaluated in the interim, and we're not... no longer, you know, using them consistently because the evidence is lacking. And we were part of a clinical trial to evaluate them with Regeneron sarilumab.
23:54 SN: And now we're kind of another realm of evaluating , like with Regeneron again, with the spike protein for family members - spike protein antibodies. And so, there's this evolving level of evidence, as you say. But it's always important to keep in mind, why we do the science we do. Why we run clinical trials, the way we do. And in medicine as a whole and not just in my center, it's that you can always cause harm. Anecdotal evidence is not sufficient always. You can, you don't know the long-term sequelae of the medications that we're using either. And this is why, we've not been kind of utilizing therapies unless they're done in a controlled RCT, like randomized control trial fashion.
24:42 AC: Wonderful and actually take them right into our last, final question. So can you tell me a little bit around, you know, what data do you believe in the next year is going to be most helpful for you to make informed care choices for I would say the pulmonary critical care doctors around the country? How are they going to make these informed choices around patient treatments? What's lacking? What's there? What's not? It sounds like there's a lot of fluidity and accessibility. And so, is there a couple of data points that you feel the industry needs in order to make more informed choices? And if so, what are those?
25:31 SN: So that's a really interesting question. So, I think number one is that a lot of focus has been put in the acute setting and critical care. And you know, I specialize in pulmonary critical care and sleep. And that acute part, there still needs to be, we have yet to see therapies, aside from dexamethasone, that have made a real realistic impact. And even that study that was done in Europe, right, it's a bias population. And so there's more data that needs to be duplicated in that study. I'll leave it there. And so that acute setting, we definitely need to see what therapies can actually change the course of the disease. And that's what needs to be done in the acute setting.
26:13 SN: The second portion, what I've been spending a lot of my, this morning and the past few weeks thinking about is that, there are these chronic sequelae that are developing. There's this entity called post intensive care syndrome that we've seen for years in patients after critical illness. But now we're seeing it in COVID. But not just in the patients that are in the ICU, but also in the patients who've had milder disease. And so, what that is is, either physical, cognitive or psychological effects of the acute disease process.
26:53 SN: And so, thinking back to patients that are, you know, still having flashbacks to the hallucinations they had during their delirium, when they were in the hospital for COVID, even though they weren't in the ICU. So, and we're seeing a lot of attention to this and the media, with something called the long, the COVID long hauler syndrome and various other terms that are used. So, what resources does the country as a whole have to support something like that. We're great at recognizing the physical effects of, you know, any you know disease entity, right? So, lung function is measurable. It's quantifiable. You know your modified Rankin scale is quantifiable. But how is the psychiatric impact of this quantifiable? And do we have the physicians and the psychologists, the social workers, the providers there for that? That's something I'm actually working on actively because we don't have that. And I have the patient population for it, you know.
28:00 AC: First of all Sree. Thank you for your contributions on the front line of COVID. Secondly, thank you for joining our webinar today. Super valuable, didactic experience for myself as well as everybody else whose joined the conversation today. And to your point, you know, there's a lot that we know. There's a lot that we don't know. And very much appreciate scientific rigor and also the driving of education adoption around the standards of care. And appreciate your time today and joining us. So thank you so much. No problem.
28:39 SN: No problem. And thank you for having me here.