Archive for June 8th, 2020

JEALOUS

June 8, 2020

I was coring strawberries yesterday, after picking 20 pounds of them at a U-Pick spot out near Mt. Pisgah.  I was glad to get out there, and while the place was jammed, I was directed to a spot where I could be away from others. Picking is the fun part.  Washing is fine, but coring is boring, and going through several hundred berries makes for a long day.

My wife came in and had on a radio show from Doctor Radio from NYU Langone. Dr. Leora Horwitz of Health Care Innovation and Delivery Science discussed work in Covid survival in those who had been admitted to the hospital. It was a long session, so as I cored, put a red berry in a second colander, I listened to a study where people got key information from patients who later were admitted, tracking them until discharge. Wow, a hospital actually tracking something in real time, something important, with a lot of variables.  I would have loved to have spent some time doing that when I practiced.  I was jealous.

I looked over to my wife, saying, “I was trying to do this stuff 20 years ago.”  I was jealous.  I was also exaggerating on the low side.  I was doing it 35 years ago in the case of carotid endarterctomy.  I kept statistics for about ten years, until I finally got tired of beating my head against a wall and started doing quality improvement in a nursing home, since I couldn’t get anywhere in a hospital on the other side of the 110th meridian, which ran down Anklam Road between the two. I’ve often wondered how the nursing home did during these past few months. I proved then that one could decrease reporting of weight changes to the state about 80% if patients were weighed on the same scale. That’s an example of saving money and improving quality. I couldn’t get that information to fly over the meridian.

They did good work at Langone.  They found fully 75% of the patients there admitted survived to discharge.  That is useful information and impressive care, which also made me jealous.  I didn’t see too much impressive care in practice, although I sure tried to steer the place towards it.  Langone looked at risk factors and found that some lung conditions surprisingly did not seem to be problematic  They studied 5300 patients.  Of course, they had a lot of throughput and nice computers, rather than the pen and paper and the work I did by myself in medical records, back in the mid-80s and later.

I listened to the whole show and shook my head, now green with enby, which went well with the red on my fingers, my jealousy giving me a Christmas appearance in June.  I never got the chance to work for a group that really was in to dealing with learning like this one.  That’s exciting, when people are engaged in something bigger than themselves and proud of their work.  I had a little of that in the Navy, but only a little.  

I finished cleaning the strawberries and put the last two trays in the freezer. It was a good start for the season.

I have followed the Covid numbers from the beginning, when US deaths were still grouped by county and state, and we were well behind China.  I’ve watched as Mississippi briefly rescinded open up orders when they had a flurry of cases. Turned out, it was a data dump from the prior weekend.  I’ve listened to people who were concerned about our death rate here in Oregon, when on the same graph as New York, there was no daylight between the line in Oregon and the x-axis.  Here, we flattened the flounder.

I’ve watched, as Britain and the US had peaks and valleys in the daily death count, which seemed to be 5 days of the former and 2 of the latter.  Yep, the weekend.  This sort of data dumping wreaks havocs on the models that we are using to deal with the epidemic.  We had a $35,000,000,000 (worth writing it out) information system a decade ago in health care, and it was shut down during the pandemic, because it was taking valuable time away from patients.  

What in the world is wrong with us?  Or with the generation behind mine, where we counted things, pen and paper, made lists on paper, tracked stuff on paper, and knew where we were very quickly?  If an information system is only used for billing, and it slows down patient care, we really have lost our way.  Now I moved to anger.

Well, we need data inputters to do this.  Fine, put out a call. I will volunteer my time. This is bunk.  The Vice President and the Coronavirus Task Force—remember them?— asked hospitals to “please” send numbers of Covid-19 cases in their intensive care units daily. You don’t say please. You say, “Do it.” Finally, we did it, and our numbers are currently at about 17,000, compared to under 1000 in many European countries, about 300 in Italy now. Italy. Brazil is stuck on 8315, where they’ve been for a month, so they aren’t updating it. We aren’t alone. We do share the same type of leadership, however, as do two other countries in the top five, Britain and Russia.

Please?  From this group?  OK, they put out a flow chart how to get Covid tests in California that had precisely three lines. Remember Dr. Birx holding that up?  Amazing.

How difficult is it for any hospital in this country to count, as of midnight every night, the number of Covid-19 cases and the number in ICU?  You don’t need a computer for this stuff. You need someone who can count, write it down, and call it to a central hot line.  Oh yes, we could use email, too, but apparently our tech savvy populace doesn’t like that.  

It’s disgusting, and if it screws up the models we have, it is going to kill people through lack of timely information.  

Because we cannot do things in real time, we need people go back and “clean” the data, and that takes more time.  Fine, clean the data, but get the preliminary out immediately. We need it for planning.  It is easy to do, cheap, certainly not $35 billion, and it is data that everybody interested in Covid-19 wants on a daily basis.  NYU figured it out, but they are good.

I know Americans really don’t like numbers and counting, preferring nice looking software, glossy paper, and lots of colorful worthless pie charts to make the data “look good” (the human brain does not distinguish angles well, so that pie charts are a sub-optimal way to present data.) I’ve had this tirade before when I learned that mortality data, like for breast cancer, was three years old.  We ought to be able to track diagnoses in nearly real time. They have to be made by a pathologist, and there are a limited numbers of pathologists.  Every week, send the appropriate numbers to a central registry.  That way, we have immediate data, and can later use the 3 year old clean data, to compare and see exactly how much error there is and why. 

This is not the first time I offered to count things. I wanted to do it with medical errors with chart reviews with a three part ordinal score of No Error, Possible Error, Significant Error.  This could have been done in every hospital in Arizona, where I once lived, and we could have had a state wide tally of possible errors.  Oh sure, someone would sue, so those who have never been sued, unlike me, wanted to shut the whole thing down or asked me what kind of software I was using.

My brain, That’s the software.

It is soft.  Gelatinous even. That good enough?