Telehealth, Testing and Contact Tracing: Dr. John Halamka on COVID-19 Healthcare Coalition

Dr. John Halamka

[ M us ic ]

Female : Welcome to Conversations on Health Care with Mark Masselli
and Margaret Flinter, a show where we speak to the top
thought leaders in health innovation, health policy, care
delivery, and the great minds who are shaping the hea lth ca re
of the future.

This week, Mark and Margaret speak with D r. John Halamka ,
President of the Mayo Clinic P latform, a partnership with
Google and hundreds of other entities across the health care
ecosystem to leverage data, artificial intelligence and other
technolo gies to improve health care. He talks about the
COVID - 19 Healthcare Coalition , he's overseeing the ir
coalescing important data across the whole pandemic ,
infection hotspots , supply chain for ventilators and PPE ,
h elping the nation tackle this foe .

Lor ie Ro bertson checks in Managing Editor of F act C heck.org
looks at misstatements about health policy in the public
domain separating the fake from the facts . W e end with a
bright idea that’s improving health and well - being and
everyday lives. If you have comment s , email us at
[email protected] or find us on Facebook, Twitter, or
wherever you listen to podcast. You can also hear us by asking
Alexa to play the program. Now stay tuned for our interview
with Dr. John Halamka he re on C onversations on Health Care .

Mark Masselli: We're speaking today with Dr. John Halamka P resident of the
Mayo Clinic P latform, a new partnership with the Mayo Clinic
and Google creating a portfolio of digital platform businesses
focusing on t ransform ing h ealth. He's advised several
presidential administrations on health information strategies
and recently formed the COVID - 19 Healthcare Coalition , a
broad based private sector c oalitions to confront the
coronavirus pandemic.

Margaret Flinter: Most recen tly Dr. Halamka was the Executive Director of the
Health Technology Exploration Center for Beth Israel Lahey
Health in Massachusetts, and was the International Healthcare
Innovation Professor at Harvard Medical School. He's the C o -
author of the book Geek D octor . Dr. Halamka , welcome back
to Conversations on Health C are .

Dr. John Halamka: Well, I'm sorry h appy to be here . I only wish we could be in
person.

Mark Masselli: Yes, we do too. B ut I've been thinking about in the context of
the pandemic, about your really long history of advocating for

Dr. John Halamka

wider use of telehealth , your frustration about the interstate
regulation of healthcare providers a nd obviously with the
arrival of the corona virus pandemic, it's illuminated some of
the inherent deficiencies of the A merican healthcare system.
But we saw an enormous amount of regulatory relief that
came swiftly adopting most of the issues you've been
advocating for . I'm wondering how these changes made or
might actually be a catalyst f or some kind of change in the
heal thcare system?

Dr. John Halamka: Well, absolutely , a nd what a wonderful introduction to what's
happ ened over the last eight weeks.

Margaret Flinter: Is it only eight weeks?

[Crosstalk]

Dr. John Halamka: -- d ecade we've said, w ell, if we are going to be pat ient centric,
we want to meet the patients with the kind of care they want ,
and the setting they want that's appropriate to their disease.
I n fact, if this is the setting they want, we should offer it. Oh,
but wait, there are regulations that s tates I can' t practice that
way, or I can't cross the state border, who's go ing to
malpractice insure me ? I n the last eight weeks, every one of
those regulations has been waived. There is no longer a
requirement for state licensure. If I'm sitting in Boston and I
want to provide consultation to New York , n o problem . I f I am
a MD and NP a PA, a paramedic, all have waivers and new
guidance.

In fact what we've had to by force do over the last eight weeks
is enable a health c are system to be patient centric and virtua l .
In the last eight weeks tele health has grown by 1118%. H ow
do I know that ? As part of the COVID coalition change
healthcare con tributed all the claims data de - identified for the
last eight weeks . W e c an actually see who has cl aimed a virtual
visit in the last eight weeks over a 1000% growth. H ow about
this , d on't roll back . E very federal official I've spoken with
certainly every provider, every patie nt, I've spoken with had
said, y ou know, this is actually working pretty well , don't roll
back.

Margaret Flinter : Well, Dr. Hala mka, I just have to think t iming is everything. You
took on this role of President of the Mayo Platform building
partnerships across entities all over the healthcare ecosystem
from provider organizations like Mayo , tech entities like
Google , academia, many players in industry . T hen the
pandemic hits and you shift your attention to really leveraging
these partnerships to confront this public health crisis of our

Dr. John Halamka

time. T alk with us about this COVID - 19 Healthcare Coalition
that you formed, who are your partners in this endeavor, and
what are you trying to achieve?

Dr. John Halamka: Well, sure. W hat a number of us recognized is there wasn't an
opportunity to convene collaborate and communicate as an
entire private sector , and so T he MITRE Corpora tion which is a
federally funded research and development center agreed for
free to simply be the program management office by which we
could convene. W e started with a few key tech players, as you
said, and a few key academic leaders, Mayo Clinic, the
Uni versity of California , Kaiser, we're now up to 800
organizations working together on 14 work groups. T hose
work groups range from such things as contact tracing, how do
we figure out who was exposed and how to get them into
treatment and follow up .

C onvale scent plasma , i f you look at what cures we have
available to us today, probably the leading opportunity is to
say, oh someone had an infection, let's extract their plasma
and give it to three other individuals so they get protective
antibod ies. Not only th e technology platforms , but even
simple things like PPE coordination, ventilator delivery , supply
demand match ing. It 's an extraordinary exciting endeavor
because no one expects to be paid , no one is self - interested,
no one has any IP restrictions. T hat me ans fierce competitors
are working side by side and completely openly.

Mark Masselli: W e're really were waging this war on the pandemic, and really
on so many fronts. Y ou say that one of the most important
weapons in our arsenal is data. I think we're all seeing sort of
the apps that are coming out that tell us about mobility across
the country or in our state down into our community, we can
look at somebody who might self - identify as having the virus
and where they've been tracking in terms of our path. So me of
these pose concerns about civil liberties. But tell us about the
kinds of data that are being amas s right now and with the
COVID - 19 Healthcare Coalition , how you're assembling and
disseminating this complex data to frontline w arriors,
healthcare work ers and public health decision makers ?

Dr. John Halamka: Y ou know that in the world of information technology there's
the techie stuff, but there's also the policy stuff. T hen there's
what I'm going to call t he psychiatry stuff, which is, o h can we
share t his data? How do you feel about sharing this data? It's
very hard to go t o a healthcare system and say, p lease
contribute all your data , because there's very legitimate
concerns about privacy , so w e've worked together to create

Dr. John Halamka

mea surements . W e say things like, o h we want to find out if
ant i - malarial drugs are actually beneficial, or convalescent
plasma is reducing ventilator days. W hat have we done is
working with the electronic health record vendors and
academics and scientists. We've created what we call
numerators and denominators , right, h ere's how you'd
measure this.

T hen we hand those off, and they're baked in to the electronic
health record of each sit e, each site in the country can run the
analysis and report the result. They don't have to send thei r
data to anyone. There are no concerns about p rivacy i f what I
tell you is, o h we've given this therapy and it reduced
ventilator days by two, right? T his is a very federated
approach. But there are other data elements we need. You've
identified what abou t civil liberties and the collection of
contact tracing? What if I agree that working with Google on
Android phones and Apple on iPhones, we're going to give you
the citizen totally the option to participate in a contact tracing
activity? Does it identify who you are? No. All it does is say,
was this phone near a person who identified as a COVID of
positive person ? W e get to define what near means, six feet .
A t that point, we can notify you, a - ha you were near a person
that was infected. T his is the Google Apple privacy protecting ,
c onsumer controlled idea that we hope will motivate the
country to be very cooperative and co llaborative in contact
race.

Margaret Flinter: Well, one of the things that we have talked to our national
partners around the country ar e the unevenness of the
penetration of the pandemic, right, and the unevenness of the
burden on hospitals. You had New York pleading for 40,000
ventilators. M eanwhile, what happens in Chicago and San
Francisco, in South Dakota where we've seen outbreaks, t ell us
a little bit about how you're working together to identify
where the next hotspot is coming ? H ow are the healthcare
members of your coalition working to make sure that they
have primarily the people as well as the rooms to handle
hotspots and surges in hospitalizations as they emerge ?

Dr. John Halamka: First is I think we all need better situational awareness, so you
go t to understand the battlefield , if you will. Well today d o we
understand who needs a ventilator? How m any ICU beds are
occupied toda y? Supply demand cannot be coordinated unless
you have situational awareness. HL7 , which is a standards
organization in this country has worked with companies like
Audacious Inquiry to define new standards, which the
electronic health records are going to now be baking into their

Dr. John Halamka

software that will start to tell us such things from a public
health perspective as who needs what , so t hat's all coming. It's
just unfortunate it wasn't already there at the beginn ing, but it
is coming shortly .

T o your point about understanding who is infected and growth
rates and potentially st affing issues and supply issues ,
numerous companies are working with data from the CDC, and
oddly enough, even from journalists like the New York Times,
which are now coordinating on GitHub data collections of this
nature and providing visualizations. A few moments ago, for
example, Mayo Clinic sent all of its senior management the
situational awareness, Minnesota map showing every test had
been done , every infection by county , by geography s o we
now understand how to deploy resources. T o be honest, we've
actually deployed resources differently b ecause now we
understand hotspots today and what will be a hotspot
tomorrow.

Mark Masselli: We're speaking today with Dr. John Halamka , P resident of t he
Mayo Clinic P latform, a portfolio of new digital platform
businesses, focusing on t ransforming h ealth. It's a new
partnership between the Mayo Clinic and Google, along with
many other healthcare industry entities . H e recently formed a
broad based privat e sector coalition to confront the COVID - 19
pandemic. We've talked earlier about the regulatory relief that
we just put in place because of the virus , and it might well lay
the groundwork for the next pandemic . B ut, you're somebody
who tries to think four to six quarters out I think you say . I
worry that we're s olving t he problem of this pandemic, not
laying the groundwork for whatever comes next.

Dr. John Halamka: Many authors have characterized COVID in a framework. But
here's m ine , I say here's the -- we 're in an isolation phase right
now. But what comes after isolation, testing, much more
testing , all kinds of testing, whether that's the testing for PCR,
do you have the infection, or the Ig G? Did you have the
infection? Might you be immune , b ecause we kn ow we don't
know yet i f having the antibody really confers immunity . Now,
we're going to have what I'll call probabl y a year of pre - vaccine
return to work gradually rebuilding the economy and opening
up some businesses with social distancing. T hen we'll
ev entually have a vaccine, and then we'll have a post - vaccine
rebuilding, and then we'll have the new normal. We have to
plan for all five of these phases , a nd so what kind of things
might you do ?

F or the testing phase radica lly improve access to testing , an d

Dr. John Halamka

s o Mayo Clinic is working on a federated model where it will
be able to coordinate testing across many labs in the country,
and with its data flows to hospitals make it really simple to get
all the tests you need quite rapidly at reasonable cost. W hat if
you are PCR negative? You're no longer infected, an Ig G
positive, you have immunity . Is that a passport to return to
work? D on't know , r ight? W e have to figure out the algorithm
which Mayo Clinic is working on with others now as to what
constitutes safety to return to work , a nd then how are you
going to do that? Well, one notion is what if I gave you a QR
code on your phone that said, based on your tests that QR
code asserts you have a passport to return to work . H ow do
you do that in a privacy protecting non - disclosing way , right ?
We’re working on all that kind of thing.

T hen , of course, as I said, helping with cures and helping with
vaccine development and figuring out there are many vaccine
approaches. We have companies we're partnering with who
are mini ng the world's literature and the experience of COVID
data today to figure out how to best target a vaccine. T hen
finally, the new normal , 20% of our healthcare is going to be
delivered virtually . E very organization has to think about what
is a hospital wi thout walls? I mean, righ t , i t could be
everything from , o h, look, I have a mole , is that skin cancer ? I
just take a photograph and it's a store and forward
asynchronous to we have a virtual visit to I'm sick and I
actually need to run a hospital in my hom e to I have an ICU in
New York that's understaffed , a nd can we bring an ICU
specialist from around the world to help that ? I n fact, Mayo
Clinic is currently staffing a New York ICU remotely. I t's
thinking of all those technologies and the new norma l and
be ing ready for it .

Margaret Flinter: Dr. Halamka t here's a group that we're thinking about a lot,
obviously, first and foremost, our frontline healthcare
providers are in our hearts and minds. But really thinking
about that generation that's coming up today 's residents,
students, and today's younger people who have aspirations of
being doctors and nurses and health care providers of all
kinds , y ou've spent many years at some of our most venerable
teaching institutions. W hen you think about this generation
co ming up, they're looking at the experience of our ER and ICU
personnel and wondering, wow, do I jump into that fire with
both feet? We had former US Surgeon General Vivek Murthy
on recently who talked about his admiration at the way people
are the resident s and the trainees jumping in . P robably
another group of people saying telehealth kind of remote
care ? Ye ah that is exciting as I thought healthcare might be,

Dr. John Halamka

what do you see for this next generation in terms of some
positive impact on their training and t heir future work to be
the great healthcare providers they want to be to maybe avoid
burnout as one of the things that we've all worried about ,
w hat's your though ts on how that training e xperience is going
to change?

Dr. John Halamka: I'm an emergency phys ician, right? I finished my emergency
medicine residency in the early 90 s, right at the really tail end
of HIV.

Margaret Flinter: HIV right .

Dr. John Halamka: My whole training was in the HIV response. W hat did you
learn back in the HIV era? You jumped rig ht in th e situation s.

Margaret Flinter: Absol utely.

Dr. John Halamka: Everyone goes into a medical specialty with a different set of
skills and a different personality. I imagine we're going to
develop a n ew specialty called the virtua list. T oday you have
the intensivist, or the hospitalist, but why not th e virtualis t
where somebody is actually in effect, a Sherlock Holmes, of
being able to look at your body language, listen to your voice,
look at your history, and help diagnose your disease , s o
actually qu ite an exciting opportunity for people. I actually
don't worry. I think that the folks who are graduating from
medical school now and , as you say, I teach all of them Every
day, we're actually looking at a new way to practice, which in
some ways will actua lly be very satisfying. W hen you love what
you do, burnout is not so much an issue.

Mark Masselli: W e run a practice caring for about 150,000 people who live in
poverty providing primary care. But we also run a program
nationally where we provide e - consult s to about 2 million
safety net population , a nd you were talking about the sort of
virtual dermatology . I'm wondering, as a physician, what
message do you have to our patients w ho are starting to see,
even though we've stood up a huge telehealth operation,
diminishing the number of people who are going to a
specialist . W hat's the message i f I'm a patient out there with
this new world in front of me, but I've got my chronic
condition I had before I'm sort of frozen in place i n terms of
accessing the healthca re system . W hat 's the message to
patients out there in terms of how they might get their hands
around what's happening in front of them ? What are your
thoughts as a physician and also somebody who's on the
cutting edge of technology ?

Dr. John Halamka

Dr. John Halamka: T hat 's a great observation. W e need to recognize there is a
digital divide of those who have technological comfort or
literacy or even a ccess to Wi - Fi or a smartphone. Let me give
you an example of why we need to meet the patients at their
level of technologic al comfort. Last year in Boston, a leading
technology company asked if I would take some engineers to
one of our mass health clinics to really understand w hat was it
like to deliver care on the front lines of those who are often
the underserved, may not sp eak English or have education or
income? T hey walk up to a homeless gentleman and they say,
hey sir, we're a bunch of engineers doing some research,
what's your favorite wearable ? H e looked at them and said,
socks, r ight?

Margaret Flinter: Perfect, perfect .

Dr. John Halamka: W e can't assume that people are going to be running
thousand dollar phones and wearables all over their body . W e
have to be able to say, a - ha if that is you, and that is what you
want a nd we will make available care at a distance t hat's very
convenient, great. But if you have lack of access, and you
would prefer an in - person visit, we have to offer that too. I
mean, there's all kinds of balances. A couple of years ago I did
a study on the Medicaid population and asked how many have
SMS t he ability to receive a text? O ver 80% , and s o that's fine ,
w e don't need some sort of fancy video visit, we just text, it’s
okay, a nd meet them at their level of comfort.

Mark Masselli: Great.

Margaret Flinter: We've been speaking today with Dr. John Hala mka , President
of the Mayo Clinic P latform , a new place partnership between
the Mayo Clinic , the digital giant Google supporting a portfolio
of new digital platform businesses focused on t ransforming
h ealth. You can learn more abo ut their work by going to
mayoc linic. org or follow him on twitter @JHalamka or follow
his blog L ife as a H ealthcare CIO . Dr. Hala mka , we want to
thank you for sharing your knowledge and your time with us
during this pandemic, for sharing your unique insights into the
power of tech - based collaborations to transform healthcare
through your passion and your humor and for joining us on
Conversations on Health Care today.

Dr. John Halamka: W ell, thanks so much everyone and be well.

[Music]

Mark Masselli: At Conversations on Health C are w e want our audience to be
truly in the know when it comes to the facts about he alth care

Dr. John Halamka

reform and policy. Lori Robertson is an award winning
journal ist and Managing Editor of F act C heck.org a
nonpartisan, nonprofit consumer advocate for voters that aim
t o reduce the level of deception in US politics. Lori , what ha ve
got for us this week ?

Lori Robertson: In early March, President Donald Trump said that restrictions
he placed on travel to and from China because of the
coronavirus pandemic “ saved a lot of li ves ” . That claim grew to
“ hundreds of thousands by early April ” , but we found no
support for such figures. We asked the White House for
support for the President's claims whether there was support
for his claims of tens of thousands or hundreds of thousand s
of lives saved. We haven't received a response.

The few studies that have been done estimate the US ’s and
other countries travel restrictions regarding China had modest
impact, slowing the initial spread outside of China, but not
st
containing the coronavir us pandemic. On January 31 the
Trump A dministration declared a public health emergency for
the novel coronavirus, and announced travel restrictions to
nd
and from China effective February 2 . As of that date, there
were nine confirmed cases of COVID - 19 in the United States,
though there had been very little testing .

U nder the travel r estriction non - US citizens, other than the
immediate family of US citizens and permanent residents were
prohibited from entering the US if they had traveled to China
within the previous two weeks. The study published in the
J ournal Science estimated that travel restrictions instituted in
Wuh an , China would “ only modestly affect the spread of the
pandemic. ” Travel restrictions could delay but not stop the
spread of the disease , a nd social distancing and hand washing
behaviors would reduce the transmission t he study found.

Another study published in the Proceedings of the National
Academy of Sciences found that travel restrictions and airport
screenin gs in several countries “ likely slowed the rate of
exportation from Mainland China to other countries, but are
insufficient to contain the global spread of COVID - 19. ” It's
possible that the US travel restrictions on China could have
had some impact in slowing the importation of cases to the
United States. But we don't have evidence of that, let alone
evidence that hundreds of thousands of lives were saved.
T hat's my fact check for this week , I'm Lori Robertson
Managing Editor of F act C heck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country's major political players and is a project of the

Dr. John Halamka

Annenberg Public Policy Center at the University of
Pennsylvania. If you have a fact that you'd like checked, email
us at www.ch cradio.com . W e'll have FactCheck.org's Lori
Robertson check it out for you here on Conversations on
Health Care.

[Music]

Margaret Flinter: Each week C onversations highlights a bright idea about how to
make wellness a part of our communities and everyday l ives .
It's estimated that a majority of a person's lifelong health
expenditures are often spent in the final months of life. But
death is one of those topics that generates the least amount of
conversation in the clinical setting for folks who end up
criti cally ill or facing a terminal diagnosis. This can often lead
to poorly communicated end of life wishes being discussed
with the clinician who then often res orts to extreme
interventions.

Dr. Manali Patel : There's this unspoken misconception that by having honest
conversations about prognosis that we are somehow removing
the hope that patients are coming to us looking for. Actually,
most studies that have evaluated this have shown that when
you provide honest prognostic information to patients and
allow pat ient s to be part of the decision making about their
goals of care, they actually have more understanding of their
disease process and better satisfaction with their care overall.

Margaret Flinter: Dr. Manali Patel is a clinical researcher at Stanford Unive rsity
School of Medicine. Her earlier research at Stanford had
yielded an interesting finding. Late stage cancer patients felt
more comfortable talking about end of life issues with a
layperson as opposed to a clinician. She entered fellow
researchers foll owed patients at the Veterans Administration
Palo Alto healthcare system after they were diagnosed with
stage three or four or recurrent cancer. Half the people were
randomly assigned to speak with a lay worker about t he goals
of care over a six month peri od.

Dr. Manali Patel: She learned as she went , a nd she came to that realization that
these conversations really are not scary. We had hired her
specifically because of her service orientation a nd because she
had a very supportive y ear. T hat's really the ma in crux of this
intervention.

Margaret Flinter: 92% of the participants who received the layperson
intervention, compared to only 18% of the control group, were
likely to have end of life directives in their electronic health
record and often choosing hosp ice over emergency room

Dr. John Halamka

interventions. The health cost of both groups varied as well.
The average cost of care for the intervention group in the last
month of life was about $1,000 versus 23,000 for the control
group . Dr. Patel s aid one of the more interes ting findings was
much higher patient satisfacti on.

Dr. Manali Patel: We found th e satisfaction scores went up for the patients in
the intervention arm, but they went down for patients in the
control arm . A s well as the satisfaction with decision making ,
w e found over whelmingly that the patients in the intervention
arm were very satisfied with the decisions that they had made
regarding their medical treatments that the patient in the
control arm really did not have much movement at all in terms
of how satis fied they were .

Margaret Flinter: A low resource compassionate patient centered intervention
that assists terminally ill patien ts their families and their
clinicians to have a frank discussion about end of life wishes,
improving patient satisfaction a t suc h a sensitive and
challenging time. That' s a bright idea.

[Music]

Mark Masselli: You've been listening Conversations on Health Care, I'm Mark
Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Peace and Health.

Female : Conversations on He alth Care is recorded at WESU at
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[Music]