Many see the COVID-19 crisis as an opportunity to learn about the value of AI tools.

This article was first published on Friday, May 22, 2020 in Kaiser Health News.

By Ashley Gold

Dr. Albert Hsiao and his colleagues at the University of California-San Diego health system had been working for 18 months on an artificial intelligence program designed to help doctors identify pneumonia on a chest X-ray. When the coronavirus hit the United States, they decided to see what it could do.

The researchers quickly deployed the application, which dots X-ray images with spots of color where there may be lung damage or other signs of pneumonia. It has now been applied to more than 6,000 chest X-rays, and it's providing some value in diagnosis, said Hsiao, the director of UCSD's augmented imaging and artificial intelligence data analytics laboratory.

His team is one of several around the country that has pushed AI programs developed in a calmer time into the COVID-19 crisis to perform tasks like deciding which patients face the greatest risk of complications and which can be safely channeled into lower-intensity care.

The machine-learning programs scroll through millions of pieces of data to detect patterns that may be hard for clinicians to discern. Yet few of the algorithms have been rigorously tested against standard procedures. So while they often appear helpful, rolling out the programs in the midst of a pandemic could be confusing to doctors or even dangerous for patients, some AI experts warn.

"AI is being used for things that are questionable right now," said Dr. Eric Topol, director of the Scripps Research Translational Institute and author of several books on health IT.

Topol singled out a system created by Epic, a major vendor of electronic health records software, that predicts which coronavirus patients may become critically ill. Using the tool before it has been validated is "pandemic exceptionalism," he said.

Epic said the company's model had been validated with data from more 16,000 hospitalized COVID-19 patients in 21 health care organizations. No research on the tool has been published, but, in any case, it was "developed to help clinicians make treatment decisions and is not a substitute for their judgment," said James Hickman, a software developer on Epic's cognitive computing team.

Others see the COVID-19 crisis as an opportunity to learn about the value of AI tools.

"My intuition is it's a little bit of the good, bad and ugly," said Eric Perakslis, a data science fellow at Duke University and former chief information officer at the Food and Drug Administration. "Research in this setting is important."

Nearly $2 billion poured into companies touting advancements in health care AI in 2019. Investments in the first quarter of 2020 totaled $635 million, up from $155 million in the first quarter of 2019, according to digital health technology funder Rock Health.

At least three health care AI technology companies have made funding deals specific to the COVID-19 crisis, including Vida Diagnostics, an AI-powered lung-imaging analysis company, according to Rock Health.

Overall, AI's implementation in everyday clinical care is less common than hype over the technology would suggest. Yet the coronavirus crisis has inspired some hospital systems to accelerate promising applications.

UCSD sped up its AI imaging project, rolling it out in only two weeks.

Hsiao's project, with research funding from Amazon Web Services, the University of California and the National Science Foundation, runs every chest X-ray taken at its hospital through an AI algorithm. While no data on the implementation has been published yet, doctors report that the tool influences their clinical decision-making about a third of the time, said Dr. Christopher Longhurst, UC San Diego Health's chief information officer.

"The results to date are very encouraging, and we're not seeing any unintended consequences," he said. "Anecdotally, we're feeling like it's helpful, not hurtful."

AI has advanced further in imaging than other areas of clinical medicine because radiological images have tons of data for algorithms to process, and more data makes the programs more effective, said Longhurst.

But while AI specialists have tried to get AI to do things like predict sepsis and acute respiratory distress — researchers at Johns Hopkins University recently won a National Science Foundation grant to use it to predict heart damage in COVID-19 patients — it has been easier to plug it into less risky areas such as hospital logistics.

In New York City, two major hospital systems are using AI-enabled algorithms to help them decide when and how patients should move into another phase of care or be sent home.

At Mount Sinai Health System, an artificial intelligence algorithm pinpoints which patients might be ready to be discharged from the hospital within 72 hours, said Robbie Freeman, vice president of clinical innovation at Mount Sinai.

Freeman described the AI's suggestion as a "conversation starter," meant to help assist clinicians working on patient cases decide what to do. AI isn't making the decisions.

NYU Langone Health has developed a similar AI model. It predicts whether a COVID-19 patient entering the hospital will suffer adverse events within the next four days, said Dr. Yindalon Aphinyanaphongs, who leads NYU Langone's predictive analytics team.

The model will be run in a four- to six-week trial with patients randomized into two groups: one whose doctors will receive the alerts, and another whose doctors will not. The algorithm should help doctors generate a list of things that may predict whether patients are at risk for complications after they're admitted to the hospital, Aphinyanaphongs said.

Some health systems are leery of rolling out a technology that requires clinical validation in the middle of a pandemic. Others say they didn't need AI to deal with the coronavirus.

Stanford Health Care is not using AI to manage hospitalized patients with COVID-19, said Ron Li, the center's medical informatics director for AI clinical integration. The San Francisco Bay Area hasn't seen the expected surge of patients who would have provided the mass of data needed to make sure AI works on a population, he said.

Outside the hospital, AI-enabled risk factor modeling is being used to help health systems track patients who aren't infected with the coronavirus but might be susceptible to complications if they contract COVID-19.

At Scripps Health in San Diego, clinicians are stratifying patients to assess their risk of getting COVID-19 and experiencing severe symptoms using a risk-scoring model that considers factors like age, chronic conditions and recent hospital visits. When a patient scores 7 or higher, a triage nurse reaches out with information about the coronavirus and may schedule an appointment.

Though emergencies provide unique opportunities to try out advanced tools, it's essential for health systems to ensure doctors are comfortable with them, and to use the tools cautiously, with extensive testing and validation, Topol said.

"When people are in the heat of battle and overstretched, it would be great to have an algorithm to support them," he said. "We just have to make sure the algorithm and the AI tool isn't misleading, because lives are at stake here."

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Tennessee's commitment to testing so broadly has helped it pull ahead of most other states in its rate of testing.

This article was first published on Wednesday, May 20, 2020, in Kaiser Health News.

By Blake Farmer, Nashville Public Radio

To reopen businesses and public spaces safely, experts say, states need to be testing and contact tracing on a massive scale. But only a handful of states are doing enough testing to stay on top of potential outbreaks, according to a state-by-state analysis published by NPR.

Among those, Tennessee stands out for its aggressive approach to testing. In Tennessee, anyone who wants a test can get one, and the state will pick up the tab. The guidance has evolved to "when in doubt, get a test," and the state started paying for it in April.

It's still rare for a community to encourage such broad symptom-free testing.

"In most places, you still need to show you have the signs and symptoms of COVID-19 to get a test," research professor Sabrina Corlette of Georgetown University said. "It's really patchwork."

Ample testing, preferably including people who are not symptomatic, can help contain future outbreaks of COVID-19 by giving health officials the knowledge to act quickly to suppress any new cluster of cases.

Because of testing shortages, many states still have limitations on who can get a test. Some states, such as Alabama, are inviting people without symptoms to be tested, but only if they qualify as high-risk. A few counties in Nevada have started asymptomatic testing, and Rite Aid in a dozen states has opened up its walk-in testing, but it's still for people who preregister.

Tennessee's commitment to testing so broadly has helped it pull ahead of most other states in its rate of testing. According to NPR's analysis, Tennessee is doing more than double the minimum number of tests needed to control its outbreak.

Tennessee Department of Health Commissioner Lisa Piercey gave credit for much of the state's testing success to private, commercial labs.

"We've called on almost all of them to say, 'We need you to ramp up, because you're about to get a flood of tests,' and that's exactly what we've given them," Piercey said at a daily briefing in late April.

In one weekend, it was more than 11,000 tests.

But private labs are shouldering the testing load in most states. What's novel in Tennessee is that the state guaranteed payment to those companies upfront.

So, rather than making them bill various health insurance plans — which are required to cover coronavirus testing but still create paperwork — the state is picking up the tab. And the typical rate set by the federal government just doubled to $100 a swab.

Memphis-based American Esoteric Laboratories has been processing the bulk of the state-collected swabs. The company declined to comment for this story.

Nashville-based Aegis Sciences Corp. jumped in more recently and is already doubling its capacity to 7,000 tests a day. CEO Frank Basile said the guaranteed payment was a big motivator.

"Clearly, it's beneficial for the lab companies like us to receive the assurance of payment," Basile said. "That's definitely a positive. And it gives us the confidence to put the effort and the capital in to make this happen."

And coronavirus testing requires more investment right now because the swabs and chemicals necessary to do it are in such high demand.

The tax dollars are well spent, said Dr. Ashish Jha, faculty director of the Harvard Global Health Institute, which has been tracking testing capacity by state. He said Tennessee's investment could more than pay for itself since ample capacity is seen as a necessity to reopen businesses. Jha said he's been recommending this approach to government officials across the country.

"If the state says they'll just pay everybody 100 bucks every time you do a test, that strikes me as very smart policy," he said.

Tennessee officials said they're banking on being reimbursed by the federal government at some point.

The Tennessee Department of Health doesn't yet know exactly how much it's on the hook for. But the tab grows by millions of dollars a week. Aside from weekend drive-thru events, the state is also paying to process the weekday testing being done by local health departments in 95 counties.

On a recent Sunday, more than 800 people were tested at a site in Hendersonville. Christine Garner was willing to wait in her minivan as she slowly moved through the parking lot of a local high school. "I said, 'I know there will be a long line, but we'll just sit and wait.' We charged our tablets, and I'm doing sight words with the kids," she said.

Garner closes refinanced mortgages for a living, which puts her in close contact with multiple families a day — often in their homes. Still, she had no symptoms. And her closest contact to someone with COVID-19 was secondhand.

"I'm just hypersensitive to any change in my body at all. I think a lot of people are," she said.

All this testing access is generally a good thing, said Dr. Kelly Moore, a pandemic consultant, formerly of the state health department. She refers to the test takers as primarily "the worried well" since nearly 99% of them have tested negative at some testing events.

"If these highly motivated, worried well people coming out for free tests are not taking up scarce resources we need for someone else, then it's definitely not a problem to test them," Moore said.

But there's a potential downside. All those negative test results improve a state's closely watched positivity rate — that is the percentage of cases coming back positive. A low rate of positives is seen as a sign that a community is doing enough testing. But it's possible to miss pockets of infection among people who might not have the awareness or resources to get tested.

"We can't draw conclusions about what's going on in the whole community based on this self-selected group of people who are so motivated they come out to get tested," Moore said.

Recently, Tennessee started using its testing muscle in a more targeted way and is also testing everyone who lives or works in nursing homes and prisons. And on May 7, the National Guard started testing everyone who lives in public housing in Tennessee.

This story is part of a partnership that includes WPLN, NPR and Kaiser Health News.

Blake Farmer, Nashville Public Radio: bfarmer@wpln.org, @flakebarmer

Numerous pediatric hospitals, like many of the adult ones, face sharply declining revenues and extra expenses.

This article was first published on Tuesday, May 19, 2020 in Kaiser Health News.

By Bernard J. Wolfson

Children have largely escaped the ravages of COVID-19, but children's hospitals have not eluded the financial pain the pandemic has wrought on health care providers.

Pediatric hospitals offered themselves as backups to their adult counterparts in case of a surge of coronavirus patients. They suspended nonemergency surgeries and stockpiled protective gear and virus test kits, according to hospital executives and financial analysts.

But, in many regions, the surge was smaller than anticipated – or hasn't materialized. And children's hospitals that have offered to take sick kids off the hands of adult hospitals, or extend the age of people they admit, have not seen an influx of patients to fill the beds they emptied. As a result, numerous pediatric facilities, like many of the adult ones, face sharply declining revenues and extra expenses.

"We turned off a significant volume of our activity for a surge that isn't going to occur. And since we've had continuing expenses, it's been pretty devastating," said Paul A. King, CEO of Stanford Children's Health, which runs Lucile Packard Children's Hospital in Palo Alto, California.

King said he expected annual net revenue for the hospital and its affiliated clinics to drop about 10%. Lucile Packard's net revenue in 2019 was about $1.7 billion, according to data from California's Office of Statewide Health Planning and Development.

Other children's hospitals have given similarly downbeat assessments.

Many of them — including Lucile Packard and UCSF Benioff Children's Hospital — have furloughed staff members, required them to use paid vacation time, or cut hours or pay.

Robin Leffert, a registered nurse at UCSF Benioff's hospital in Oakland, California, said she's seen a "huge drop-off" in patients. Many staffers have been temporarily cut, requiring the nurses who are still working to perform extra tasks. "The physical environment feels different," she said. "There's an eerie, empty quality to it. But that doesn't decrease the tension we are feeling."

Stay-at-home orders have reduced car accidents, injuries and illnesses that would normally bring kids to the ERs of children's hospitals, while parents' fear of exposing their families to the COVID-19 virus has exacerbated the trend.

In early February, Jennifer Griffin, a 44-year-old mother of two boys, decided against taking her 9-year-old for adenoid removal surgery at Renown Children's Hospital in Reno, Nevada, where they live.

"We were not comfortable with what was going on with COVID and didn't know what the exposure was going to be like," Griffin said.

Renown, like many other children's hospitals, has begun to resume some of the nonemergency surgeries it halted as the COVID pandemic spread. Griffin is still not convinced it's safe to bring in her son, however.

"If people continue to not abide by the distancing guidelines and isolation guidelines, I might wait," she said.

Nicholas Holmes, chief operating officer of Rady Children's Hospital in San Diego, said his facility faces similar parent concerns and is making a push — via social media and in collaboration with local pediatricians — to "make sure families know it is safe to come to the campus."

For all their current problems, however, pediatric hospitals were generally in a stronger financial position than adult facilities before the pandemic, so many of them "are absolutely well positioned to weather the storm," said Kevin Holloran, a senior director at Fitch Ratings.

A 2019 Fitch report based on 2018 hospital audits showed the aggregate operating profit margin of a representative sample of not-for-profit children's hospitals was nearly triple that of nonprofit adult hospitals. The pediatric facilities had enough cash on hand to last 1.6 times longer than the adult hospitals.

In California, the average operating profit margin of children's hospitals was almost three times that of non-children's facilities last year — though individual results ranged widely, from an extremely profitable 25.38% for Rady to operating losses for UCSF Benioff's Oakland hospital (-0.78%) and Lucile Packard (-2.53%), according to the Office of Statewide Health Planning and Development.

Holloran and others say children's hospitals typically benefit from strong philanthropic and public support, and their specialization in complex acute cases results in higher prices while often affording them a commanding pediatric market share.

In 2018, California voters approved $1.5 billion in state bonds to help children's hospitals with capital expenses including equipment, construction and seismic retrofitting. That means they can save some of the dollars they would have spent on such projects.

So far, however, just 9% of that money — $142.1 million — has been distributed, and to only three hospitals, according to Frank Moore, executive director of the California Health Facilities Financing Authority.

Children's hospitals across the U.S. have reported declines in surgery and outpatient procedures of 60% to 80%, with inpatient admissions cut by nearly half as of the end of April, said Amy Knight, chief operating officer of the Children's Hospital Association in Washington, D.C.

At Children's Hospital New Orleans, ER visits plummeted from 4,000 in February to 1,700 in April, said Matt Schaefer, the chief operating officer. Outpatient visits dropped from 1,100 to about 400 over the same period. The hospital, like others around the country, has managed to offset some of the loss in outpatient volume with telehealth.

When COVID-19 was wreaking havoc in southeastern Louisiana, the children's hospital offered to take pediatric patients from adult hospitals and admit patients up to age 30, said George Bisset, the chief medical officer. "But we didn't get a lot of takers."

Children's facilities received virtually none of the first $30 billion in federal relief money intended for hospitals and other providers, though they have received some of a subsequent $20 billion tranche.

Children's hospitals that are part of larger health systems may also benefit from the aid received by affiliated adult hospitals. And belonging to a hospital chain can allow for greater operational flexibility, industry executives say.

Cohen Children's Medical Center in Queens, New York, part of the $13.5 billion, 23-hospital Northwell Health system, redeployed numerous staff members to the adult hospitals that were struggling to cope with an onslaught of COVID-19 cases, said Dr. Charles Schleien, Cohen's vice president for pediatric services.

Cohen also turned over more than half its beds to Long Island Jewish Medical Center, an adult hospital connected to Cohen by a hallway, and converted virtually every available space to more adult beds, Schleien said.

But filling beds with COVID patients doesn't offset the lost revenue from suspending profitable elective surgeries anyway, Schleien said. "The economics of it are brutal, because when you lose elective surgeries, that's where your margin is."

Even though children's hospitals have begun to resume nonemergency surgeries, they will likely continue to face financial challenges.

"If we enter into a recession, and particularly if it is prolonged, that will have an effect on hospitals, including children's hospitals, because people won't have jobs and may be uninsured, or more may be on Medicaid, which doesn't pay as well," said Lisa Martin, a senior vice president on the not-for-profit health care ratings team at Moody's Investors Service.

In California, nearly 60% of children's hospital charges are tied to Medicaid, more than double the proportion for adult hospitals, according to OSHPD data. At some pediatric facilities in the U.S., that figure is well above 70%.

After spending staggering sums to mitigate the consequences of the pandemic, Congress will be looking for programs to prune, said Knight, of the Children's Hospital Association. "One with a target on its back is Medicaid."

Jordan Rau, a senior correspondent for Kaiser Health News, contributed to this report.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson

Coronavirus patients and their families who believe a doctor, nurse, hospital or other provider made serious mistakes during their care may face a new hurdle if they try to file medical malpractice lawsuits.

This story was first published on Friday, May 15, 2020 in Kaiser Health News.

By Susan Jaffe

Coronavirus patients and their families who believe a doctor, nurse, hospital or other provider made serious mistakes during their care may face a new hurdle if they try to file medical malpractice lawsuits.

Under pressure from health provider organizations, governors in Connecticut, Maryland, Illinois and several other states have ordered that most providers be shielded from civil ― and, in some cases, criminal — lawsuits over medical treatment during the COVID-19 health emergency. In New York and New Jersey, immunity is now part of state law. In California, six hospital, physician and long-term care provider groups are pressing Gov. Gavin Newsom to also issue an order assuring immunity.

The efforts are attracting congressional attention as well and threatening to derail the next federal coronavirus stimulus package on Capitol Hill. Senate Majority Leader Mitch McConnell is demanding that Congress include liability protections against COVID-related suits for businesses and health care providers. The contentious issue of legal liability claims in health care has divided congressional Republicans and Democrats for years.

“We are not going to let health care heroes emerge from this crisis facing a tidal wave of medical malpractice lawsuits so that trial lawyers can line their pockets,” the Kentucky Republican said in the Senate on Tuesday. “This will give our doctors, nurses and other health care providers a lot more security as they clock in every day and risk themselves to care for strangers.”

A coalition of 36 physician and hospital associations has appealed as well to congressional leaders for federal legislation.

Some legal experts and seniors’ advocates worry that the state immunity guarantees go too far, leaving patients with no way to hold providers accountable. Supporters argue that health care providers and facilities deserve protection from lawsuits as they battle a deadly virus during an unprecedented public health emergency.

Pennsylvania Gov. Tom Wolf, a Democrat, joined the movement last week, acknowledging that the COVID-19 epidemic has “required our health care providers to broaden their professional responsibilities and experiences like never before.” Like other governors, Wolf included in his order exceptions for the most egregious lapses in care involving intentional misconduct or extreme negligence.

“When you are asking nurses to work around-the-clock and the ICU has 2½ times as many people than it was engineered for, well, my goodness, doesn’t this make common sense?” said Kenneth Raske, president and chief executive officer of the Greater New York Hospital Association, which represents more than 160 hospitals and health systems in New York, New Jersey, Connecticut and Rhode Island.

The group helped draft New York’s immunity measure, said Raske. Supporters also include the American Medical Association, which urged the National Governors Association to use the New York law as a model for other states.

Immunity for providers during the COVID-19 emergency “is good for patients” because it encourages providers to work in extraordinarily tough conditions, said James Hodge, an Arizona State University law professor and regional director at the Network for Public Health Law.

It is an extension of the usual protection for a “good Samaritan” — the doctor or nurse who sees a car accident, for example, and stops to help the injured. The well-intentioned doctor doesn’t have the equipment and support of a hospital and shouldn’t be held to the same standards.

Similarly, some well-intentioned medical providers treating COVID-19 patients work with scarce supplies and overburdened staff and face other conditions often beyond their control.

Since some states offer no virus-related liability protection for long-term care providers — such as skilled nursing facilities, assisted living communities and continuing care retirement communities — during the current crisis, their trade associations are looking to the federal government instead.

“Long-term care workers and centers are on the front line of this pandemic response,” said Cristina Crawford, a spokesperson for the American Health Care Association, “and it is critical that states and the federal government provide the necessary liability protection.”

But Mairead Painter, director of Connecticut’s State Long Term Care Ombudsman Program, said the immunity guarantee could discourage nursing home residents and their families from filing complaints about abuse or neglect, or challenging their transfer to other homes as administrators try to separate residents who have the coronavirus from those without it.

“So they might sort of just let it fall to the wayside, and we don’t want them to do that,” she said.

As infection rates slowly decrease, providers should be expected to follow the usual standard of care, said Barry Furrow, director of Drexel University law school’s health law program in Philadelphia, who has studied hospital corporate negligence.

“These immunity statutes do too much, because now we’re settling back to a more normalized health care situation where we have a new disease vector, which we’re beginning to understand,” he said.

The immunity guarantee covers the duration of the COVID-19 emergency, which could continue for several more months, if not longer, Furrow said, so states are letting providers “off the hook.”

Despite the state immunity guarantees, the Centers for Medicare & Medicaid Services ordered state health inspectors to crack down on nursing homes that don’t follow infection-control requirements, and, starting May 8, required facilities to inform residents or their families by 5 p.m. the day after a new case of COVID-19 is confirmed. And officials in some parts of the country have begun criminal investigations of nursing homes suspected of endangering residents.

The mixed messages are most evident in New York, the coronavirus epicenter in the U.S., which has one of the nation’s most comprehensive COVID-19 shields against medical liability. It protects individual medical professionals as well as health care facilities from both civil and criminal lawsuits involving any patients, regardless of whether they had the virus. There’s an exception for egregious conduct, which Furrow said is a high bar and up to a jury to define.

“This sends a message to the nursing home inspectors to step back,” said Richard Mollot, executive director of the Long Term Care Community Coalition in New York City. “This is an insidious quieting of accountability just when it is needed the most.”

But Dani Lever, a spokesperson for Gov. Andrew Cuomo, said the immunity law “imposes no limitations on the ability of the state to investigate nursing homes.”

About 20% of the 27,450 confirmed and presumed coronavirus deaths in the state by Wednesday have occurred in nursing homes, prompting an investigation by Cuomo and Attorney General Letitia James. When Cuomo described the investigation, he was both sympathetic and critical of nursing homes.

“This is a crisis situation for nursing homes … through no fault of their own,” he said. “Mother Nature brought a virus and the virus attacks old people.” Nonetheless, he added, they must “do their job by the rules and regulations.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.