COVID-19 Webinar Series Session 12 – From Data to Decisions: Mobilizing a Surveillance Infrastructure

2:00 p.m. – 2:05 p.m.     Welcome and Introductions

Sarah J. Dash, MPH

President and CEO, Alliance for Health Policy

@allhealthpolicy

2:05 p.m. – 2:25 p.m.    Opening Remarks

Aaron Miri, MBA, CHCIO, FHIMSS

Chief Information Officer, The University of Texas at Austin Dell Medical School and UT Health Austin

@AaronMiri

Joseph N.S. Eisenberg, Ph.D., MPH

John G. Searle Endowed Chair and Professor of Epidemiology, University of Michigan School of Public Health

James S. Blumenstock, M.A.

Chief Program Officer for Health Security, Association of State and Territorial Health Officials

2:25 p.m. – 3:00 p.m.     Moderated Discussion

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)   0:11 Good afternoon, everybody. 0:19 Good afternoon, everybody. 0:22 Hello. 0:25 All right. Hey, sorry about that little technical problem to get started. But I’m here we are. I’m Sarah – president and CEO of the Alliance Health policy and I want to welcome you to the sixth week of our covid-19 webinar series for those who are not familiar with the alliance welcome. We are a non partisan resource for the policy Community dedicated to advancing knowledge and understanding of Health policy issues. We launched this series to provide insight into the status of a covid-19 response and shed light on remaining gaps in the system that must be addressed. 0:56 To limit the severity in the United States The Alliance for Health policy gratefully acknowledges the National Institute for Healthcare Management foundation and the Commonwealth fund for supporting our covid-19 webinar series. You can join the conversation on Twitter using the hashtag. I’ll help live and follow us at all Health policy. We want you all to be active participants in today’s very important discussion. So please do get your questions ready. Here’s how you do it. 1:23 You should see a dashboard on the right side of your Browser that has a speech bubble icon with a question mark you can use that to submit the questions that you have for the panelists at any time. We’ll be collecting them and address as many as we can during the broadcast and we have an extra long webinar for you today a full hour to ask your questions. So, please do feel free to send those in at any time. You can also use that webinar. I’m sorry that icon to notify us. If you have any technical issues check out our website, I’ll help policy dot-org for background materials and a recording of today’s webinar. 1:56 As policymakers way options to he’s social distancing measures a robust surveillance infrastructure is critical to prevent another surge in cases. This system will require close collaboration between the federal government States localities and many facets of the healthcare system as well as individual behavior during this webinar panelists will explore options policymakers can pursue to strengthen our surveillance infrastructure as we move from mitigation to containment of the covid-19 pandemics. 2:26 Day, I’m pleased to be joined by a group of distinguished panelists first. We’ll hear from Erin Murray the Chief Information officer for the University of Texas at Austin Dell medical school and UT Health Boston. Next is dr. Joseph Eisenberg the janji Cyril endowed chair and professor of epidemiology at the University of Michigan School of Public Health. And finally, I’d like to welcome Jim blumenstock who is the chief program officer for health security at the association of state and territorial health. 2:56 Officials asked. Oh, thank you so much to all of you for joining us today. I’m going to turn it over to each of you for some opening remarks starting with Erin Erin Mary. Go ahead. Hello and thank you all for listening and then the tuning in some of the big things that we have going on here at the University of Texas at Austin particularly as it relates to contact tracing and home monitoring and whatnot. As we battle covid. 3:17 We have found a tremendous willingness and the community to partner and want to get in front of this the outpouring of support from both patients and from just a General has been phenomenal, but with that as you leverage in them and layering technology and whatnot. You always learned some important lessons. So hopefully today I’ll walk you through some of those real time. I walk you through some of the things that we have over common challenges and some of the partnership’s that we’ve done both with local and state authorities and National authorities on trying to advance care and dealing with covid-19 and all Dimensions particularly as it relates to contact tracing and home monitoring. So, thank you. 3:54 Great. Thanks so much, Aaron. All right, and next Joe. Would you like to offer some quick opening remarks? Yeah, I want to just talk a little bit about the role of testing in the midst of an epidemic like we have here in the US just has been much talk about the need for testing. We’ve been told about the success of early on in the pandemics and countries like South Korea and Germany with a testing was talked about his keys. 4:24 Senses to controlling the under the hammock and we’ve also been told that how far behind we are in the number of tests were performing. Although we are certainly observing Civic ramp up Cindy and various States on testing. So I just wanted to touch upon you know, what are we what’s the role of testing and why is it so important to move forward on testing and testing me increasing testing numbers. There’s really two major roles for testing. I can play in controlling the spread of the epidemic first. It’s a essential. 4:54 surveillance tool know without this information about cases of infection and disease were pretty much Flying Blind with respect to developing appropriate intervention and control procedures and there’s two types of test that we can use for surveillance in the first is what we really been talking about quite a bit and that’s a testing for the the presence of the virus in the individual to assessment person who’s infected and the second is to test to see if a person has antibodies against the virus person has antibodies this means that they’ve been Those to the virus and they’ve either experienced symptoms milder severe they didn’t asymptomatic Theory symptomatic infections. And so this provides valuable information on the extensiveness of the transmission missed that’s occurred because it’s capturing these mild and asymptomatic cases that we otherwise would have missed through the conventional testing. And so it’s a really important part of a complement to our surveillance tool box. 5:55 But the second important role of testing and I think we’ve been you know, when we talk about testing numbers is what we’re really focused on is the importance of testing is a tool for control of viral spread. 6:07 So by isolating those tested as well as their contacts, we can contain the spread in a much more efficient way than broad-scale social distancing that we’re doing we’re seeing right now so we can really think about the testing and contact tracing and isolation as a The social distancing approach to control the disease effectively Advocate and as we relax social distancing, we need to increase that testing detainment activity. Ideally, we’re testing all suspected cases regardless of severity and the contacts and in this way, we’re able to prevent case clusters from developing and a way to move forward. 6:47 So these two testing activities provide the essential information needed to again move forward over the next Year or even two and allow us to relax social distancing in a very strategic method on men methodical manner that ensures that we keep the case is low in their numbers and not increasing. 7:08 So tragically we should be relaxing social distancing slowly first allowing work sectors that only result in low probability events, and then by providing appropriate guidance of the work sectors on mitigation, we can maximize You have the economy. So increasing testing and containment allows us to increase the relax your social distancing and maximize again this opening of the economy. So the next major question is really about how much testing is needed and we hear numbers all over the map of wide range some saying 5 to 20 million tests per day in the US. Hello lower-end. 7:50 We’re hearing things like that suggests that we need to increase our capacity like threefold and Michigan and from our capacity is steadily increasing now on the order of a thousand tests. So reaching 15 thousand tests is actually quite doable and largely a simple supply chain problem 2% test positive is an important metric here. So that’s two percent of tests that are positive and Michigan where about 20% and we’d like to see that number decrease attend. 8:24 Some more published studies on testing are used most published studies on testing are used to forecast models to estimate the testing numbers needed to move forward and needless to say these forecasts from these models are highly uncertain and they contain many assumptions about efficacy of social distancing about and contact tracing and isolation. And there’s also a lot of uncertainty about the amount of transmission that has already occurred. 8:51 So this really explains that a wide range of estimates on what testing Ray we need to move forward the more cases the more testing that’s needed. Hence. 9:01 We can move, you know, the percent positive metric is useful indicator on how many test we actually need syndromic surveillance can also do a lot in helping contain and again, you can make our testing much more efficient information on symptom based surveillance provides a quicker response than On a surveillance and case identification and we’re currently lots of people are developing apps now. Our people are beginning to develop apps that are make this even more efficient. 9:36 And lastly, I just wanted to mention that you know population immunity is important piece of this puzzle, but there’s a lot of uncertainty associated with how much protection somebody has its when they do recover and this is likely to be a function of their health status whether or not they had a mild or severe disease and also a function of the virus. So there’s like there’s also a lot of question of how long protection will last. So ultimately, I believe that population immunity will play an important role in protection. 10:06 Initially established it as the virus established herself as an endemic disease and herd immunity is this important concept and number of people needed to prove that were protected and the virus can’t really transmitted and we use this concept in developing vaccines strategies at all the time, you know many people have estimated this level to be a statistic 60 percent of the population, but I you know this point we can only speculate on all these these kind of numbers. 10:36 So that with that that kind of gives a hopefully an overview of the role of testing why it’s important why we need to really ramp testing up in moving forward in the senate in this pandemic as we relax social distancing. 10:53 Great. Thank you so much Joe that was that was a real tour de force. I feel like I was back in epidemiology class and I think you gave us a lot of food for thought. So again for the audience if you have questions follow-up questions, feel free to just go ahead and send those in using your question mark icon. So now I’m happy to turn this over to Jim blumenstock from asked o Dem go ahead. Well, thank you so much and good day everybody, you know first allow me to State the obvious. 11:21 That the nation’s public health system is really on the front lines in this war against covid-19 with our principal Focus right now being I containment and mitigation and as I see it really our work is in for specific tracks or phases that would include response restoration or what’s also be referred to as reopening of Commerce recovery, which we cannot lose sight of and certainly begin to have a vision for and overall Community resilience. 11:51 Just to remind you a quick snapshot of really what our immediate and longer-term response objectives are in the context of covid-19 your state territorial public health and needed to tribal Health agencies or health entities conduct such activities as aggressive an integrated Incident Management maintaining an emergency Operation Center in coordination with other components of their government including Emergency Management and Homeland Security. 12:20 They’re responsible for the health and safety of responders and critically important to any public health emergency, but I think it’s certainly rearing its ugly head it with covid-19 is the issue of Health Equity and that risk and vulnerable populations and trying developing strategies and tactics to address their immediate and unique needs clearly, which I’m sure we’ll talk about in a few moments is the issue of information-sharing not a date not only data as part of analysis intelligence for decision support, but also public information. 12:52 hooting warnings and effective risk Communications another key part which I think is related to Joe’s rebars is around countermeasures and other types of mitigation non-pharmaceutical interventions such as times when we don’t have a vaccine or proven therapeutic as critically important for such things as social distancing quarantine and isolation as not only legal tools, but also effective tactics is a role that state and territorial Health agencies play in issuing monitoring and encouraging voluntary compliance and lastly is around the medical material a lot of discussion about local jurisdictions asking for receiving and distributing the Strategic National stockpile many jurisdictions maintain their own State caches and will probably continue to do so throughout this campaign of covid-19 response and already the the public health system is looking look, forward looking ahead to what a national vaccination campaign can be, you know those of us who are in the field and work during H1N1 10 years ago of a full appreciation for what it’s like to distribute medical countermeasures antivirals when available as well as vaccine when it comes available that has to go above and beyond what is typically available through the capacity of traditional Health Care Systems, whether it be your private physician your pharmacist Or even places of employment so that is certainly a planning effort underway right now as we’re managing this response search staff. I’m not only in the public health field, but also helping their HealthCare Partners navigate some of the licensing and legal requirements and other types of barriers that may exist to ensure an all-hands-on-deck i Mutual a type of environment and obviously infection control. Not only is it work force protection effort, but certainly in high risk. 14:51 So these like nursing homes that were infection control is a critically important aspect is a role where Health Department’s play Not only as Educators, but sometimes as regulators and the last two areas again is biosurveillance, like which I know we’ll talk about it in Great length and during the course of the hour and again getting back to the issue of recovery as you can imagine. 15:14 And for those of you that can sort of draw the analog between major natural disasters like hurricanes Katrina Sandy the Deep Horizon oil spill you can imagine that a recovery of a community certainly measured in months. If not years. Well, you know covid as an infectious disease has a different set of manifestations but the impact on our on our human infrastructure is I think equally equally as vulnerable as our heart infrastructure would be during natural disasters. 15:45 So what does this mean to the Health Care Workforce the public health Workforce the met the emotional Hey Bureau, mental health of our society as we continue through this the programs and services that may be somewhat neglected as a sort of a second-order consequence because we’re moving all of our resources and focus on covid-19. So clearly that’s the only a planning effort but it’s also a long-term longitudinal, you know Community resilience Focus as well. You know before I close I really want to pick up on a point. 16:21 Aunt Jo did an outstanding job overviewing the importance of testing not only what it means to the case to his or her contacts but also the community that’s impacted for the purposes of not only patient care individual counseling but also determining interventions that may be necessary for specific communities being driven by the data that’s available from testing but the second part of that strategy if you will is the issue of tracing and as Joe had mentioned that that is critically important following testing so that you know individuals who are ill can be isolated and individuals who’ve been directly exposed to sit cases can be quarantined and monitored all is it as an effective strategy to contain and basically suppress any outbreaks that may take place in a community and you know, if I asking everybody to go back to two or three months ago when we were in the tainment phase that was all about trying to keep the virus out of our country and when it got here trying to contain it in small pockets of communities for as long as possible in order to allow to sort of ramp up the infrastructure that was where we were on the on the other side of the curve where we’re starting to increase now, we’re sort of approaching that point. We’re going on the back side of the car. So, you know moving across from moving from MIT. 17:51 Asian back to a containment strategy state by state county by county community by Community is becoming a another phase of that type of containment or outbreak suppression effort. So to have sufficient Workforce to go in and respond to cases that have been identified speak an interview and counsel their contacts. So they don’t continue to spread. It’s actually with the community is the success to not only you know full on. 18:21 Reopening but also sort of that Tipping Point of getting into more normal societal activities. So how do we accomplish that? Well, you know again different models different projections, but one thing everyone agrees with that the current Public Health Workforce in this country is woefully insufficient to meet the the labor demands of having contact tracers or disease intervention specialist. 18:49 Do the amount of work that is Necessary to achieve that goal of suppressing future outbreaks as there was pleads pleased to contribute to a product at the Johns Hopkins Center for Health security released two weeks ago which puts that an estimate of a hundred thousand individuals to be Nationwide contact tracers for the next 12 months is a reasonable projection of need that we have to Rally around and basically, you know ramp up that component of our Workforce. 19:21 At a cost estimated to be three point six billion dollars so that that sort of the the sobering point. 19:29 I want to leave you with but I think you know, it’s also critically important to recognize that you know with the emphasis on testing contact tracing is an equal partner in that overall strategy to suppress future disease transmission and to protect the public health matter what the fate of covid-19 is whether you know, whether it’s It just becomes an endemic disease. It becomes a roaring seasonal disease with a second wave the fact that testing and contact tracing contact tracing look still be an integral part of our response platform regardless, so, thank you very much. 20:10 Great. Thank you so much. Jim and Joe and erinite we’re gonna have a great discussion. There’s a lot to talk about here. Alright, so the first thing I want to do is for those who maybe you know are hearing this term surveillance for the first time applied in a public health infrastructure. And you guys have done a great job of laying out some of the components of it, but maybe gem I’ll just start with you surveillance. A lot of people may think of that as like a totally different thing from public health. So what are the essential elements of surveillance? You could just quickly kind of bullet point them out. 20:40 Sure, Well, you certainly it’s all about the structured collection and Analysis of data to basically paint a picture of what’s going on that would basically Drive decisions for for Action that could be ranging from ongoing monitoring to aggressive interventions, you know and everything in between. So in the in the context of covid-19, there are there are multiple surveillance. 21:10 Methods or Pathways that are being used, you know, the one thing that that my observation is that we have. 21:17 We have taken existing Legacy surveillance systems and put them into very effective use with some modification the capture the type of data that we need to really get a fuller picture of how covid-19 is spreading impacting and affecting the health and safety of our community and that would include With everything from obviously the reporting of cases to the reporting of deaths through the existing systems that that exists syndromic surveillance looking at the influenza-like illness platforms that are out there and using them and possibly enhancing that little bit to sort of capture the covid 19 issue another project. I’d like to share, you know on public opinion polling ask though is working with CDC and Harvard to ramp up. 22:10 A fairly significant public opinion polling around public opinion polling effort around covid-19, you know, someone might not think of that as being traditional Public Health surveillance, but I do because you know in capturing through its through a methodology through a structured method of proven approach capturing the data on the Public’s beliefs in values and that how that influences their processing and accepting of messaging around covid. 22:40 Is is important and to me that’s just one sort of offshoot surveillance effort that the Public Health System is using to really try to use data to inform this is decision and action great. Thanks. So I want to turn to Aaron Aaron you’ve written a health Affairs blog about how do we really strengthen and accelerate the data infrastructure around covid-19 or valence? So can say a few words? 23:10 What are some of the key elements that we need as Jim said a surveillance is the structured collection and Analysis of the data? What do we need to do to make it what it what it needs to be to really get back to containing? Covid-19 Aaron. Absolutely. Yeah. No, I appreciate the question and it’s great question and great overview for my co-panelists here with James and Joseph. 23:33 So the degree of a couple things and without getting into too much of the nuances number one, there is not A readily adopted framework nationally for the bulk of the data that we need to be shared amongst the states at a national level at a state level what not. 23:50 There are certain criteria, especially with the new US CDI standards corporate interoperability and others that you know, we must modernize our Frameworks around that our electronic medical record systems are using our syndromic surveillance systems are using so that we’re all talking the same language on a national level to be able to share today if I want to share information with say Awesome public health or I want to share information with a state or even the federal government. Each of those are different types of criteria different types of datasets phenotypes, whatever else there’s not one set criteria for sort of a national superhighway. A lot of that was addressed to 21st century cures, but now as you know, as you all know it’s been delayed a little bit in terms of information blocking and whatnot. But those standards Nations must occur. So that’s number one standards. Number two. We need to make sure that we are really looking at you know, how do we deal with? 24:40 With national provider data submission and points for electronic lab in case reports. How do how do these how are these case reports and lab reports in put it into a central common system as you saw the White House spun up, you know a pretty much a work around saying hey email us every day. You know with what your lab tests are with your volumes are what you’re seeing. You know you low in PPE that’s not the way this is supposed to work that over email, right? 25:03 We need a we need to be able to suss out that data on a national level and be able to ingest it into some sort of central repository so we can Click get actual in size. So we’ve talked about standards. We talked about coding and that we’ve talked about obviously being able to submit data from again lab and case Report perspective. Another one is being able to look at all of the dimensions of care. We focus tremendous amount of time on the inpatient acute setting totally makes sense. 25:28 We understand a lot of patience for covid are presenting in the Ed and then thus going up to ICU or whatever else for recovery, but to the degree of it, there’s a number of ambulatory Health Systems El tax Have facilities Primary Care Facilities in the middle of everywhere America. And those were sort of left out from the American Recovery and reinvestment act and have not got on to Modern electronic medical records or if they are those records systems don’t really necessarily talk to the others. So when we’re looking at and trying to say, okay how many people in Austin Texas potentially could be at risk for covid or what are the demographics there that’s even hard on a local level much less a national level to say. What is the true extrapolation of risk? 26:10 Keep hearing about you know, what are we ever going to achieve herd immunity? Are we ever going to get to this end number and we really don’t even know what that is due to a lack of testing like a data availability and a lack of Standards. So to the degree of it, if you look at those Dimensions as being some of the key criteria that sort of built itself around a framework so that when you’re trying to do something like contact tracing and I’m trying to call air and say hey Aaron who have you encountered at the local hair salon or Barbershop or the mall or you know, you went to buy a new pair of sneakers today and you you know, where symptomatic who were you around? 26:40 And it’s tough to get that data because at the end of the day, we’re only as good as the data is and right now our national infrastructure a public health infrastructure is woefully inadequate. So I implore folks listening to go back look at standards modernization. Look at being able to way to be able to suss out this data from the community and input in a central repository partnering with your local public health authorities and making sure that data is commonly exchange and commonly denominated format and understanding how do we get back to? 27:10 Realizing what’s valuable here, which is the patient at the end of the day. We have some great starting points. You see companies like Apple and Google trying to accelerate contact tracing you look at what the onc is doing and try to put out guidelines and referendums but at the end of the day, we’re only as good as what we have so in a nutshell, that’s what I have to say. 27:29 Thank you so much. Sure and your voice is breaking up to slightly. So I’m going to make sure I heard you correctly you want to know what happens when someone does pest test positive. That’s right. Yep. Okay, no problem. Alright, so today. 27:58 Here at UT Health Austin a couple things one. If a patient does test positive we obviously get let’s assume that they were tested here at UT Health Austin we do get that result immediately an electronic medical record as a critical lab value. We reach out to the nursing triage team to notify the patient of your test result the patient of course can get it near electronic portal as well. We then do contact tracing on the patient to figure out who did Aaron come in contact with within a duration of time around that maybe you’re asymptomatic before your test came back. 28:28 Back, maybe you showed early symptoms and no a week ago. And it took this long to get you a test going. So we try to figure out who have you been around and build a contact list from that contact list. Each of those contacts are given a unique identifiers that we know all the people there and we track them. This is how we’re able to develop, you know, sort of a covert 9 case registry for lack of a better term and understand. Okay, what’s going on here within this cohort of patients and does that have a predisposition to become a cluster a cluster being say a family unit that are all suddenly positive. 28:59 A group of folks that maybe travel in the airplane together those types of things from that. We then share that information with the public health authority and other systems around us to make sure that everybody understands this is what’s going on. This is what we’re tracking from a public health and epidemiology perspective and we’re able to to to work through that whole process on the flip side. If a patient test negative, however, there are eight there symptomatic to some degree. We’re still tracking them. So we create a contact the sort of at that point. 29:28 Point considered a Pui person investigation, you know, what’s going on here. Is there a follow-up appointment to get tested again? Perhaps your tests came back are initially negative. It really should have been positive. We’re seeing a lot of that or early tests were actually false false indicators. So to the degree of it, that’s where home monitoring comes to affect where we’re now asking folks to monitor the temperatures on a periodic basis. We have apps that we’ve deployed here but folks can call it in and other health systems to say. Okay. This is where my temperatures out and suddenly I’m approaching, you know some sort of threshold on different. 29:58 Different metrics there. So at the end of the day like I was saying earlier, it’s about the data. It’s about being timely. It’s about having some sort of decision support in our case. We have a lot of that automated with a rules-based engine sort of baked in there and it’s about engaging with your community. I forget which of my panelists mentioned the total number of contact tracers that may be necessary across the country. But that is a very true number because even with the best of tech even with having phenomenal companies like Apple and Google and Microsoft jump into The Fray, it’s still the human. 30:28 Ament it’s still understanding. Okay, the nuances of Aaron walked into a store, but he didn’t stay there and expose anybody just sort of ran through it. So the chances of exposure are low versus. Oh he hung out in this area for 20 minutes and guess what cost on everybody. It’s there’s a lot of nuance here that it’s very difficult to automate that it does take that Human Condition. So you have to have a good closed-loop process built out. 30:51 You’ve got to understand your population and then in our case here in Austin, we also then had to work with a population of folks that don’t Speak English, they speak Spanish and some folks are very low socioeconomic status. They don’t have smart phone technology. They don’t have ability to get ahold of we call that the disconnected population. We have a send people in to the community to the Salvation Army to the Red Cross to talk to them to understand what’s going on and being able to track and work with them. So it is a very involved process, but that’s what it takes. 31:18 I would maybe somebody positive and when you have someone negative And this is sincere and that was an excellent overview and one additional feature is when you have someone either in isolation or quarantine through the contact tracing that are indispensable. You know Public Health just doesn’t forget about them and just monitor their daily data reporting of their of their situation. I mean, there are some significant demands for wraparound services to really ensure not only compliance but also the most appropriate Health outcome for those individuals. 31:52 The issue of art that you know, do they reside in an environment conducive the proper isolation and quarantine. How are they going to get their medical care? How are they going to get their everyday creature Comfort Care are their education food supply issues security issues. 32:09 So, you know that is that’s basically a public health systems with their with their other partners across state and local government to really ensure that when we when we expect someone to comply with party and isolation that their best interest and their best care is in some way planned for and helped out. 32:30 That’s a really great point and I’m going to I want to get to some of those human human factors in in just