HealthBlawg

H1N1 Response Center - Microsoft launches interactive tool

Microsoft has just launched its H1N1 Response Center online, and I had the chance to speak this morning with David Cerino, General Manager of Microsoft Health Solutions Group (the man from HealthVault) and Arthur Kellermann, MD, Professor of Emergency Medicine and Associate Dean at Emory School of Medicine, about this new creation.

On the surface, it's a very simple H1N1 Q&A to take if you think you might have the flu.  It leads you through some questions and within a few screens tells you to go see your doctor or reassures you and suggests that you rest, push fluids, etc.  Since estimates of likely H1N1 infections in the US this season range from 20% to 40% of the population (i.e., 60-120 million people) any triage tool like this should be welcomed by health care providers and public health officials around the country.  In fact, they were involved in putting it together as a result of brainstorming sessions at a conference hosted by the Institute of Medicine on influenza-like illness in early September. 

Working with Microsoft, this tool was put together in about a month, and the algorithm can be tweaked easily over time as new information about the disease and the pandemic come to light.  (The current algorithm is adult-only.  The under-12 set will be picked up within a couple weeks; the American Academy of Pediatrics is working on it.) 

So far, so good: a questionnaire that you can review at home (i.e., without overwhelming waiting rooms and exposing yourself to sick people if you don't really need to see a medical professional) that gives you recommendations, links to resources, etc., related to your individual responses.

The next step: when you're done, the system prompts you to save your responses in your Health Vault PHR, or to set one up first if you don't have one yet.  You can then authorize your doc -- if he or she is on Health Vault -- to see your responses.  Sick people should get medical attention; the "worried well" should stay out of the way.

Coming soon: at the end of the questionnaire, you can have the option to upload data and consult with a doc via TelaDoc or American Well.  (This functionality should be there within a couple months.)

After that: the architecture can be put to use for other sorts of screenings.  Cerino says Microsoft would welcome hearing from other expert partners who want to help build tools for other diseases.

But here's the real power of this tool: It has the potential to provide "epidemic intelligence in real time," according to Kellermann, citing a recent Science editorial coauthored by IOM Director Harvey Fineberg, entitled Epidemic Science in Real Time.  By collecting a limited data set (including symptoms reported as well as zip code, age and gender), Microsoft would be able to map progress of any epidemic or public health event -- not just H1N1, but also a foodborne illness outbreak, a potential bioterror incident, etc., etc., replacing the shoe leather approach, says Kellermann, represented by the hole in sole of the shoe proudly displayed in the logo (above) of the CDC's Epidemic Intelligence Service.  If people opt in to share de-identified data, this tool has the potential to put Google Flu Trends to shame.

Look for more Microsoft partner links at the end of tools like this one; if you want to partner with Microsoft and have an idea for an online interactive questionnaire powered by a peer-reviewed algorithm that can appropriately direct people to your service, please get in touch and let's talk.

Kudos to David Cerino and his team for blending a contribution to the public health and the broadening of the Health Vault brand simultaneously -- and look for plenty of links to this new site on Bing, MSN, MSNBC and other Microsoft web properties.

So: What other tools would you like to see tied into this architecture?

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Dr. Ben Kruskal, Director of Infection Control at Harvard Vanguard Medical Associates: Conversation with David Harlow about H1N1

The kids are back in school and it's time to pick up the H1N1 conversation with Ben Kruskal, MD, PhD, Director of Infection Control at Harvard Vanguard Medical Associates.  In today's installment, we look ahead to the fall and winter, and discuss the planning that will see us through the season.  Dr. Kruskal touches on H1N1 crowding out seasonal flu in the southern hemisphere during its winter season, and on the likelihood that H1N1 vaccines will only require a single dose, and not two, as had been anticipated.

Our conversation runs about 15 minutes and is available for download/podcast.

Update 9/20/09: The transcript of my conversation with Dr. Ben Kruskal about H1N1 is available at the link and below.

Our earlier conversations are available here and here.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting 

Interview of Ben Kruskal, MD, PhD

Director of Infection Control of Harvard Vanguard Medical Associates

September 17, 2009

David Harlow:  This is David Harlow on HealthBlawg, and I’m speaking today with Dr.  Ben Kruskal, Director of Infection Control of Harvard Vanguard Medical Associates.  Hello Ben, how are you?  

Ben Kruskal:  I’m very well, David.  How are you?  

David Harlow:  Very well, thank you.  So, Ben, we last spoke in the spring as people were just trying to get a handle on swine flu, as the infection was spreading, and as various groups were trying to get ahead of swine flue.  So here we are 4, 5 months later and I’m interested to hear: From your perspective, have things gone as you might have expected 4, 5 months ago?

Ben Kruskal:  I would say they have.  We continued to see some H1N1 disease gradually winding down from the spring through the summer, things were quite quiet through the summer and are still relatively quiet, although we’re just beginning to get the intimation of maybe things ticking up again.

David Harlow:  OK.  I was looking at some Massachusetts Department of Public Health figures and it looked like there was a bit of a spike in late May/early June, does that track with anything that you saw?  

Ben Kruskal:  That’s exactly right.  What we saw was seasonal flu winding down through April and then at the end of April and beginning of May, a big spike well above the normal levels for that time, with a gradual trail coming down through May, June and trailing of back to sort of true in between season levels in the middle of July or so.  

David Harlow:  Okay, so as we look ahead to the following school year, here we are end of summer, college kids are back at school, school kids are back at school, have you seen any uptick in cases what with folks back into school and back in closed quarters with other young folks?  

Ben Kruskal:  We’re not seeing a whole lot of cases here yet but there are certainly reports from all over the country of some outbreaks, localized particularly in the college and the university world.  

David Harlow:  Do you attribute that to a dumb luck or has there something else been going on locally that may be helping in mitigating this spread?  

Ben Kruskal:  I don’t know that there is anything we can easily attribute it to. I know that there has been some earlier activity in the southeast which may have something to do with an earlier start to the school year for school age kids, they start a week or two at least before we do, so that may explain some of it.  

David Harlow:  Right, so we may see that on a rolling basis, just as school gets underway.  

Ben Kruskal:  Exactly.  

David Harlow:  So we’re looking forward to seeing a vaccine in the near future and I’m wondering whether you can tell us anything about the vaccine, and about whether there has been any change in characteristics of the virus overtime.  And also – again, back to the vaccine - there has been varying information about whether people will need one dose or two for the H1N1 vaccine.  

Ben Kruskal:  Well, let me speak first to the issue of the virus changing.  Buy and large, it seems to be fairly stable in its behavior through the flu season in the southern hemisphere. Most of the reports were that it was very similar to what we had seen here. There are a few locales where there has been a higher proportion of severe disease, just as it was in Mexico in the very beginning of the outbreak, and we really don’t understand why that is the case.  

David Harlow:  Have any theories been floated or any ideas about why some people are hit harder by this?  

Ben Kruskal:  There are a few theories out there.  One is that the areas that are harder hit may have populations with particular genetic susceptibility to the virus.  Another possibility is that in certain locales there are other microbial pathogens, other co-infections that could potentiate the H1N1 and cause it to become more severe.  Yet another theory is it relates to lower immune defense because of malnutrition.  I don’t think that theory flies quite so well as the others because it really doesn’t correlate terribly well.  The severity of disease doesn’t correlate terribly well with economic indicators.  

David Harlow:  So we’re looking forward now to the fall and winter and looking at H1N1 layered on top of the seasonal flu; would you expect there to be a more severe flu season because of the added ingredient to the H1N1?   Ben Kruskal:  Well that is certainly a big question mark.  The experience that we have to guide us from the southern hemisphere seems to be that by and large the typical flu seasonal flu strains were simply displaced by the novel H1N1.  And so rather than seeing the 2 or 3 circulating strains that we normally see in a typical flu season in the southern hemisphere, the vast majority of flu that they saw was the novel H1N1.  

David Harlow:  Interesting, so it’s sort of crowded out others?  

Ben Kruskal:  Right and that’s been a feature of previous pandemics as well, so it’s not entirely surprising.  So what we anticipate, most likely, is that we will have an H1N1 outbreak - it will last as long as it lasts.  It will quite likely occur earlier than typical flu season and hopefully after that’s over, it will be over and we won’t have any more flu for another year.  

David Harlow:  Right, but in the meantime, there has been a lot of contingency planning done both by health care providers, schools, employers even looking forward to what they can do to mitigate interruptions in operations in case there is greater incidence of this flu.  Are there any particular plans that you can point to that seem to be well thought out and executed on the health care front?  Thinking particularly about the issue of vaccinating health care workers, I remember reading in the past few weeks about some health care providers who have said that they don’t want to be inoculated and I’m wondering whether that is something that should be left to the individual provider?  

Ben Kruskal:  Well, you have to probably start with the trends in seasonal flu vaccination for health care workers.  Flu is a relatively unusual virus in that it’s serious enough to cause disease that’s quite a problem for many patients but it’s not serious enough that everybody who gets it won’t come to work.  So if you have dedicated health care workers who get sick and still get into work, so they don’t strand their coworkers and their patients, they are infecting their patients.  And so as a result there has been a strong move over the past 5 years or so to increase health care worker vaccination against seasonal flu and actually in many health care organizations that’s made a requirement of employment and that’s a trend that has been accelerating rapidly with the H1N1 outbreak.  For example, here in Massachusetts, the Commissioner of Public Health issued a public health order mandating that all health care organizations offer seasonal flu vaccination and pandemic flu vaccination when relevant to all of their staff and that staff who don’t want that vaccine have to actively decline.  

David Harlow:  That stops short of mandating it, so someone could still decline the inoculation and come to work.   Ben Kruskal:  That is true and there are certainly some health care organizations that have been experimenting with making it a firm condition of employment, allowing only medical exemptions.  

David Harlow:  Other than the Department of Public Health Commissioner’s order there has been a lot of activity at the Department of Public Health and I’m wondering if you could comment on some of the other actions taken there and whether those have been moving things forward in your estimation.  

Ben Kruskal:  I think so; I think Massachusetts is ahead of many states in terms of pandemic planning.  The Department of Public Health has been working on this for at least 8 or 9 years and as a result I think we have plans that are considerably more mature than in many other areas of the country.  That being said, you still want to be fully prepared but the Department I think has been coping very, very well and really is serving something of a model for other states.  

David Harlow:  Could you give us an example of one of the parameters along which the Department has done some good advanced planning or perhaps something from your experience at Harvard Vanguard?  

Ben Kruskal:  Well, I think the Department has done very well establishing communications channels both to healthcare providers and to the general public.  They set up the 211-information line.  They have made epidemiologists available to answer questions during the outbreak; they really staffed their communication center quite heavily so that people were available.  They were holding frequent conference calls with various constituencies to keep us up-to-date.  They worked very, very hard at communicating and I think they did a very successful job of it.   

David Harlow:  As you’re mentioning these various items I’m remembering that Dr.  Al DiMaria, the state epidemiologist, also put up a YouTube video on how to wash hands.  

Ben Kruskal:  Absolutely.  

David Harlow:  So they are really firing on all cylinders there.   

Ben Kruskal:  That’s right.  

David Harlow:  Are there other areas of concern that you see ahead of us?  We were talking about health care workers refusing inoculations, are there other potential areas of concern that we need to be thinking about?  

Ben Kruskal:  I think we need to be really focusing everyone’s attention - both health care’s attention and the public’s attention - on basic infection control measures.  And washing hands because, juvenile as it may seem, really is a major contributor to decreasing transmission of many respiratory illnesses.  And there have been several studies in the last few years that have really demonstrated a clear impact of improved hand hygiene on transmission, for example within a household.   

David Harlow:  Okay, and that’s something that’s easy to do and have a real impact.  

Ben Kruskal:  Exactly.  You don’t need a college degree.  

David Harlow:  Anything else that you would like to highlight as we continue this experience?  

Ben Kruskal:  You raised some questions earlier about the vaccine, which we really haven’t gotten to.  The vaccine in the early trials that have been reported performed much better than expected.  Given that it’s a relatively new strain that most young people have not had any prior exposure to this strain or related strains and that therefore there is little preexisting immunity, it was expected that we would need two doses of vaccine, one to sort of immunologically prime us and a second to give us a full boosting to get really good levels of antibody.  And surprisingly in all of the major vaccine trials that have been reported in the last few weeks, a single dose has been sufficient to generate very good levels of protection - better than many seasonal vaccines.  And so we’re feeling very hopeful that we’ll be able to get a lot more people vaccinated with the supply that we have.  

David Harlow:  And the supplies are coming in or when are they doing?  

Ben Kruskal:  They are nominally due in around the middle of October. Secretary of Health and Human Services Sebelius has said that they may be able to mobilize some doses even a week or two before that.  We expect that we will start with small shipments and gradually swelling shipments and then get a steady supply over a period of many weeks.  

David Harlow:  And do you see looming difficulty in getting folks in to have both the seasonal and H1N1 inoculation?  

Ben Kruskal:  My experience with seasonal flu has been that the vaccination rate in any given year depends very heavily on media attention.  And one or two well publicized cases or especially deaths can really spur vaccination quite a lot.  So I think it’s going to depend an awful lot on what the public perception is and what the media’s shaping of that public perception is.   

David Harlow:  Well, we’ve certainly been hearing a lot about H1N1 and I suppose people will be getting their seasonal flu vaccines as well as a result.

Ben Kruskal:  Right, it certainly has generated a larger than usual interest in seasonal flu vaccine so far this year.  

David Harlow:  Okay, well thank you very much.  I’ve been speaking with Dr.  Ben Kruskal, Director of Infection Control of Harvard Vanguard Medical Associates here in the Boston, Massachusetts area.  Thank you again.  

Ben Kruskal:  It’s a pleasure David.

Dr. Ben Kruskal, Director of Infection Control at Harvard Medical Associates: Conversation with David Harlow about Swine Flu / H1N1

My conversation with Ben Kruskal, MD, PhD, HVMA Director of Infection Control, about swine flu / H1N1 continues. 

In today's installment we discussed incidence of new cases, their concentration among children, chances for emergence of a more virulent strain of flu, and closer coordination between large ambulatory practices such as Harvard Vanguard Medical Associates (which has 400,000 patients) and the state Department of Public Health. 

The audio file of our conversation runs about 10 minutes and is available for download/podcast.

Update 5/15/09: Read the linked transcript or the copy below. 

Our earlier conversation is available here.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Interview of Ben Kruskal, MD, PhD, Director of Infection Control,
Harvard Vanguard Medical Associates, May 14, 2009

David Harlow:  Hi, this is David Harlow on HealthBlawg and I have with me today Dr. Ben Kruskal from Harvard Vanguard Medical Associates where he is Director of Infection Control.  We spoke a week or so ago about swine flu or the H1N1 virus, and I am eager to learn whether this week you see any change in the progression of this pandemic or epidemic and what sort of changes you see in its progression?  I looked at the numbers today, here in Massachusetts we’re up to about 133 confirmed cases as of this morning.  So, I'm curious to see if you see a progression or a trend in the past week or so?

Dr. Ben Kruskal:  Well it's pretty clear that the virus has, as predicted, started to spread pretty widely in the community and the number of confirmed cases being reported is clearly a pretty big underrepresentation of the real number of cases because we're not even attempting to test all cases.

David Harlow:  Okay, so these are just lab confirmed cases, is what you're saying?

Dr. Ben Kruskal:  Exactly.

David Harlow:  Okay and what was interesting to me in looking at the Department of Public Health's figures is that the majority of these cases are among school-aged children, and CDC said last week that it felt it was no longer necessary to close schools in the event of children being sick.  I am wondering if these numbers might cause us to reconsider that approach.

Dr. Ben Kruskal:  Well, I think what CDC said was not to not close the school at all, but rather not to close the school for a single case which is what the original advice was.  What they are now saying is that the school should only be closed if there is a significant cluster within the school, so I think they're still acting responsibly in the sense that if the school is clearly a focus of spread, that is the time to close things down.  If there are one or two cases that are well-contained, then the inconvenience to the large number of people would occur from closing the school isn’t worth it.

David Harlow:  Okay, fair enough.  And so I think it was in New York today or yesterday where a number of schools were closed.  There is a cluster of 50 cases in one of the schools, so that's consistent with what you are saying, and the CDC policy.

Dr. Ben Kruskal:  It is also very interesting to see that cases do seem to be concentrated among younger people and the explanation for that isn't clear.  I think the predominant speculation is that older people may have encountered strains that were related enough to afford them some immunity, whereas younger people have never seen a strain like this before.

David Harlow:  Interesting.  So you're referring to the swine flu that we had in the mid-70s?

Dr. Ben Kruskal:  Not necessarily that strain, but some other related strain at some point far enough back -- at least 20 years back -- so the young people who are the predominant population affected so far wouldn’t have had any exposure.

David Harlow:  And are those numbers in terms of age distribution consistent across other areas as far as you know, beyond Massachusetts?

Dr. Ben Kruskal:  It's a little hard to make good sense out of the numbers and areas that don’t have a lot of cases because the people who are being tested are very a skewed population, and probably not representative of all cases.  I think in the areas where many fewer cases are reported the predominance of adults is largely because they're looking at people with travel histories.

David Harlow:  Okay.  So how do you see this playing out over the next weeks and months as we get into the warmer weather, and how do you see this playing out next fall or next winter?

Dr. Ben Kruskal:  Well it's still very much up in the air.  The fact that there is as much transmission as there is, even in the relatively warm weather that we've been having in the last couple of weeks, is a little bit of a concerning sign to me that transmission may continue at a really, really high rate even through the summer.  So in terms of spread, it’s surprising that it’s still going on at the rate its going.  There is a concern based on some previous examples of novel strains that as the virus is transmitted from person to person, there may be selection for more virulent sub-strains and that the severity of disease may increase over time.  In some prior outbreaks, the virus has gone underground for the warm season and then re-emerged in a more virulent form in the fall, but I am somewhat concerned, seeing the level of the transmission we’re still sustaining now, that we may be possibly headed for more severe cases even sooner than the fall.

David Harlow:  So it likely will continue even through the warmer weather which will be unusual as I understand it.

Dr. Ben Kruskal:  Absolutely, but again the degree of spread that we're seeing now is pretty unusual as well.

David Harlow:  But thus far at least, it doesn't seem to be that virulent an illness?

Dr. Ben Kruskal:  No, thank goodness, it has been quite mild in the vast majority of cases.

David Harlow:  So, I’m interested to hear how you are dealing with this on behalf of your medical group in dealing with the large population [of 400,000 patients] that you are responsible for?  What are you and your team doing on a daily or weekly basis in order to help manage this?

Dr. Ben Kruskal:  Well, we started from the very beginning and we're fortunate enough to have a plan in place which we were able to adapt quickly to the current situation.  We focus on providing information for our patients that’s been crafted centrally but we’re not relying every on every individual doctor and nurse to create the message themselves.  We had the help of specialists in communications and we have also been working hard to get timely, consistent and accurate information out to our staff in order to equip them to deal with patients’ questions and concerns.  The patient anxiety clearly has been much, much bigger than the actual number of cases, so I think done a reasonably good job of giving people these tools and giving our patients information directly as well.  In addition, we focus very heavily on protecting our staff, knowing that it's hard to come to work if you think you’re going to be infected with something nasty and we’re taking precautions that may be excessive given the relatively mild nature of the illness, but again being conservative and making sure that our staff feel safe coming to work.

David Harlow:  I also understand there's has been a national stockpile of antiviral medication being distributed, has that been distributed to your group as well or is that going just to pharmacies?

Dr. Ben Kruskal:  It actually was initially meant to be distributed only to hospitals and we were active in lobbying the Department of Public Health to include the ambulatory health care organizations as well and succeeded in getting a significant chunk of the distribution for large practices such as Harvard Vanguard.

David Harlow:  So have you been coordinating with the State Department of Public Health along other lines as well?

Dr. Ben Kruskal:  Yes.  We’ve been talking to them for quite some time about the role of ambulatory care providers in provision of care in pandemics and other disasters and I think we’ve really pushed their attention in the direction of what ambulatory care can provide in a disaster like that, and we have extensive discussions which I think have helped to inform the way they are working with other ambulatory groups as well.

David Harlow:  That's encouraging and it makes a lot of sense, since so much care that was in the hospitals traditionally has really been pushed to the ambulatory setting.

Dr. Ben Kruskal:  Right, and enabling the primary care providers to continue to function during an outbreak has several advantages.  One is that by virtue of the existing relationship that we have with our patients we may be able to convince them of things that they might otherwise feel too nervous to hear from a provider they never met before,  so we can help them comply with public health directives in a way that's much harder for an unknown person to do.  In addition, we can take the load of the worried well and the mildly ill off of the hospital, so they can focus their attention on the things that only they can do, which is caring for the most severely ill.

David Harlow:  That makes a lot of sense.  Thank you for your time.  This is David Harlow on HealthBlawg.  I’ve been speaking with Dr. Ben Kruskal, the Director of Infection Control of Harvard Vanguard Medical Associates here in Boston, Massachusetts.  Thank you again.

Dr. Ben Kruskal:  Thanks David.

David Harlow speaks about swine flu with Harvard Vanguard Medical Associates Director of Infection Control Dr. Ben Kruskal

I've been following a lot of updates on swine flu (or, as we're now supposed to call it, H1N1), found everywhere from The Daily Kos to the swine flu feeds "blokcast" set up by Tom Stitt.

Update 5/4/09: There is also an excellent overview of pandemic preparedness and thoughts about the future on Health Affairs' blog. 

To get a handle on the situation, I spoke with Ben Kruskal, MD, PhD, Director of Infection Control for Harvard Vanguard Medical Associates, a Boston-area medical group with about 400,000 patients.  The audio file of our conversation runs about 6 minutes and is available for download/podcast.  I plan to check in with him periodically as this situation unfolds. 

Update 5/5/09: Read the linked transcript or the copy below.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Interview of Ben Kruskal, MD, PhD, Director of Infection Control, Harvard Vanguard Medical Associates, May 3, 2009

David Harlow:  This is David Harlow on HealthBlawg and I have with me today Dr. Ben Kruskal who is the Director of Infection Control for Harvard Vanguard Medical Associates -- that’s a large group practice in the Boston area with about 400,000 patients.  Thank you for being with us today.

Dr. Ben Kruskal:  It’s my pleasure, David.

David Harlow:  I am interested in your perspective on the H1N1 flu pandemic, and how that is affecting your patients, the patients of your group and the public at large.  What should we be concerned about at this stage?

Dr. Ben Kruskal:  Well, the good news is that the severity of illness seems to be very much on the low end of the spectrum as of now.  Unfortunately, I don’t think we can be entirely complacent because there certainly is potential, based on history, for things to become more severe over time.

David Harlow:  Is there some point in time where you think we’ll have a good sense whether this is a pandemic that’s going to blow over with a less severe illness or whether we’ll start to see a more severe illness?  Is there a point in time where that will be apparent?

Dr. Ben Kruskal:  I don’t think we’ll be able to say with great confidence until quite a while from now.  Again, by analogy with the previous outbreaks, sometimes a novel strain will appear very mild, will go underground for a period of some time, often months, and then reemerge in a more virulent form.

David Harlow:  Right.  Now, I’ve seen some graphs and depictions of the course of pandemic in the 1918 Spanish flu epidemic and the question that’s raised there is whether some stricter controls including, for example, closing schools might be beneficial.  I'm thinking in particular of a graph comparing the number of cases say in Philadelphia versus St. Louis where Philadelphia didn’t close any schools or other public areas and St. Louis didn’t, their experience was overall better.  Do you see a need at this point in time for sort of stricter approaches to closures of places like schools?

Dr. Ben Kruskal:  Well, no question that with a virulent strain and a strain with a very high attack rate, school closures and others so-called “social distancing measures” can be very helpful.  It’s not clear to me at this point how necessary, how stringent we need to be in terms of school closings.  Right now the CDC has taken a fairly conservative view and is recommending that schools consider closing with even one confirmed or likely case. Given how mild this disease is and the fact that spread doesn’t seem extremely high at this point that may not be quite necessary, but again, it’s early to say for sure.

David Harlow:  Okay.  So the way things look now, it doesn’t seem that that’s entirely necessary.  We’re talking about the CDC and some recommendations coming from there, and I understand that the Federal government had put a pandemic plan in place over the past year or so and that that’s being activated or put into play.  There’s a lot of discussion in recent weeks about the fact that a lot of top appointed positions in the administration have remained unfilled.  Do you see that that has been a problem in addressing the pandemic as it unfolds?

Dr. Ben Kruskal:  I don’t think so.  I think, again, fortunately, things have been relatively mild so far and the CDC’s response seems as if it’s been pretty well coordinated, no major issues or problems.

David Harlow:  There are these plans that are in place -- whether it’s the Federal level or say the local levels -- and I wonder if, as you’ve been saying, this seems so far to be a relatively mild pandemic or relatively mild strain of flu, is it entirely necessary to be activating these plans?

Dr. Ben Kruskal:  Well, I think everyone has been reasonably measured in the response so far, really with a strain as novel as this one.  The potential for rapid spread and for severe disease is there and I think both at the state and the Federal level it has been appropriately conservative initially and is being tempered over time based on what’s occurring, so I think things had been quite proportional.

David Harlow:  Okay.  Well, thank you very much.  Any thing else that you would like to add?

Dr. Ben Kruskal:  I'm not sure I would call this a pandemic at this point, pandemic generally refers to a large segment of the population being infected and we’re certainly not there yet.  I think there is still quite a lot of potential for spread although again I hope the severity of the illness will remain as mild as it is now.

David Harlow:  Okay.  Well, I certainly hope so too.  Thank you very much.  I’ve been speaking with Dr. Ben Kruskal, Director of Infection Control at Harvard Vanguard Medical Associates in the Boston, Massachusetts area.  This is David Harlow in HealthBlawg.  Thanks once again for speaking with me and I hope we’ll have a chance to follow up on the swine flu situation again in the future.  Thank you.

Dr. Ben Kruskal:  Thank you David.

HAI: preventing, reporting and not paying for hospital-acquired infections

Hospital-acquired infection (HAI) is one of the catchphrases of patient safety advocates, health care cost control champions and health care data and transparency wonks.  CMS made some of these constituencies happy when it rolled out its no pay rules last year, and the Massachusetts Department of Public Health has been wrestling with the HAI issue at its Betsy Lehman Center for Patient Safety and Medical Error Reduction (for the out-of-towners: named for a Boston Globe health columnist who died as a result of a medication error) -- culminating in a new set of hospital licensure regs promulgated today which mandate HAI policy and procedure monitoring and inspections in hospitals (by state inspectors) as well as tracking and reporting.  Payor groups (here in MA and nationally) have also laid down the law with their own no pay rules.  (See earlier HealthBlawg post on HAI and various responses here in MA and nationally.)

The annual cost of HAI has been pegged at up to $400 million plus in Massachusetts, $30 billion nationally.  The question arises: aside from inspecting, reporting and tracking, and sanctioning hospitals, what can we do to reduce and eliminate HAI?  Some of last year's Lehman Center report is devoted to answering that question.  One simple approach advocated by some, including Atul Gawande in a recent New Yorker article, involves the use of checklists -- which are put to excellent use in aviation, for example. 

The study of the use of checklists in healthcare settings was, unfortunately, deemed to be research conducted without prior IRB review, etc., etc., by the federales.  As they say, the items on these checklists are not rocket science.  See discussion of the checklist concept and the feds' ban in a recent NY Times piece on HAI by Jane Brody.  So "research" on use of checklists requires IRB approval, patient consent ("Is it OK if I look at my five-point cheat sheet before I start a central line, so I can remember to wash my hands?  Or would you prefer to not be included in this study?"  Hmm . . . ) and the whole ball of wax, unless we heed Dr. Gawande's call to write our men and women in Washington and get them to rewrite the rules.

Update 2/20/08: OHRP has reversed its ban on checklists.  Hat tip to Bob Wachter at Wachter's World.

All of these efforts are worthy, but it would be nice if they were coordinated with each other -- for example, why not standardize HAI measures and interventions in MA to the no pay rules relating to HAI adopted by the federales?  To the parallel Leapfrog rules?  Shouldn't the data collected by DPH be disseminated on the Massachusetts Quality and Cost Council consumer portal mandated by the Massachusetts universal health care law?  On HHS's Hospital Compare website?

Some medical device and equipment manufacturers are jumping on the bandwagon, marketing their wares to hospitals based on their claimed ability to reduce HAI rates and thus avoid incurring costs for unreimbursable care in the face of no-pay for HAI rules.  One nifty tool brought to my attention this week is Cook Medical's catheter cost calculator (see link at bottom middle of landing page).  Cook apparently sells the Cadillac of catheters, and they've built a tool that would allow a hospital to see how much it could save in the long run -- on the unreimbursable cost of treating HAI -- by ponying up for the more expensive items.  The calculator is preset based on a range of assumptions drawn from past research, but you can rejigger the assumptions using handy slider buttons.  Very interesting to see how the HAI policy debate and changes in payment practices relate directly to marketing efforts on the part of medical device manufacturers.

Back to today's DPH regulation:  Commissioner John Auerbach said in an interview after the vote that a hospital with excessive infection rates could lose its license.  I expect that, in practice, intermediate sanctions would be used: for example, DPH controls could be put in place to improve policies and procedures in order to reduce infection rates, and DPH might even be able to bar performance of particular procedures pending improvements.

What I like about this issue is that a lot of different pressures (mostly around dollars) are coming to bear on a discrete set of issues (mostly around patient care), and this time around, the patient care outcomes stand to benefit from the interaction.

-- David Harlow

Massachusetts moves closer to mandated reporting of HAI (healthcare-associated infection, or hospital-acquired infection); $64,000 question is: how does reporting help?

The state released a report yesterday (press release with links to executive summary and full report on mandatory HAI reporting) as required under Chapter 58 (the Massachusetts universal health care law) that will likely lead to regulations requiring HAI reporting in the future. 

Consumers Union has been pushing the idea for a while nationally, and this is all of a piece with pushes towards transparency and consumer-directed healthcare generally.

While laudable, I have concerns about this sort of mandate.  As I wrote about five months ago in a post entitled Of drug-resistant staph infections, public reporting of infection rates, and the consumer-directedness of it all:

. . . I have the constant niggling feeling that some folks out there . . . want to dump the data in patients’ laps and then say: see, we gave you data and now you can decide which hospital to go to, and no sniveling if you pick up a superbug while you’re there.

. . .

Transparency is good, but not just for its own sake.  It's worthwhile so long as information provided (1) is not distorted, (2) may be easily and accurately interpreted by consumers and (3) is actionable.

Here's hoping that the Massachusetts Department of Public Health, its consultants, and the state's hospitals can keep these concerns front and center as they proceed with refinement and implementation of these HAI reporting requirements and the related HAI reduction and prevention measures detailed in the report.

-- David Harlow 

Wisconsin Supreme Court upholds jailing of uncooperative tuberculosis patient

A woman who refused treatment for TB was properly confined to jail for treatment, according to the Wisconsin Supreme Court.  Check out the AP story and the court ruling.

Interesting tidbits: under Wisconsin law, the patient did not have to be confined to the least restrictive setting, and it was OK to consider cost (i.e., jail is cheaper than bringing in guards 24/7 to a hospital for one individual). 

Quite the coda to the tale of the tubercular honeymooning lawyer.

-- David Harlow

The case of the tubercular honeymooning lawyer

Tom Mayo has collected a good deal on information on the question of quarantine raised by the case of Drew Speaker, the tubercular honeymooning lawyer, here and here.

The CDC's proposed regulation linked to in the first of Tom's posts above includes some good background info on the legal bases for imposing quarantine.

Current thinking sees limited value in quarantines, generally, however.  This is why, even though state and local governments have the authority to quarantine individuals as an exercise of the police power, it doesn't happen much at all.

An excerpt from a JAMA article abstract that's a few years old sums it up nicely.  The article is focused on responses to bioterrorism -- though the same conclusions are equally applicable to infectious disease spread by other means, be it TB, bird flu, or other disease.  The conclusion:

Imposition of large-scale quarantine -- compulsory sequestration of groups of possibly exposed persons or human confinement within certain geographic areas to prevent spread of contagious disease -- should not be considered a primary public health strategy in most imaginable circumstances. In the majority of contexts, other less extreme public health actions are likely to be more effective and create fewer unintended adverse consequences than quarantine.

The case of the tubercular honeymooning lawyer may well be one of that minority of cases where quarantine is appropriate, however.  I'll leave it to the infectious disease and epidemiology experts to work that one out.

Let's not even get started on whether the release of his identity is a HIPAA violation.  He never should have been identified publicly, but it was probably unavoidable, given the ever-expanding ring of folks who were brought into the contact tracing exercise.

Update 6/6/07: The WHO says:

local health officials should have told airlines to keep Andrew Speaker from boarding a plane once they concluded he was likely to defy advice and go ahead with plans to fly to Europe to be married.

Update 6/28/07: Tip of the hat to the Health Affairs Blog, which posted last week:

Today (June 22), the World Health Organization and the Stop TB Partnership announced that they were launching a $2.2 billion, two-year plan that aims to set international public health systems on a path to providing access to drugs and diagnostic tests to all MDR-TB and XDR-TB patients by 2015.

-- David Harlow