COVID-19: Supporting High-Risk Patients in Our Communities

As we brace for the peak of new COVID-19 cases and deaths in various parts of the U.S., frontline health care workers face a continually increasing influx of infected patients. But what about the crisis taking place outside the hospital walls? In the midst of uncertainty and the need for further social distancing, health care organizations and providers in our communities are burdened with the challenge of continuing to provide care to their patients while protecting those who are at greater risk of developing serious complications from the disease.

Data from those who have been infected suggests that individuals with underlying medical conditions (e.g. chronic lung disease, diabetes, heart disease, chronic kidney disease, etc.) have a higher risk for severe COVID-19 related outcomes than those who do not. Adults 65 years or older, who most often have multiple comorbidities, make up half of those who have been admitted to ICUs, and about 80% of those who died as a result of COVID-19. A recent report revealed that obesity, a previously unrecognized risk factor, is common among those under the age of 60 with COVID-19 admitted to the hospital and in need for critical care.

Living situations are also contributing factors as we have seen during the initial outbreak in places like nursing homes and long-term care facilities. The homeless and jail populations also live in congregated settings, making it easier for the infection to spread among them. People who lack socioeconomic resources, including those among the homeless, poor and immigrant populations, are at higher risk of COVID-19 because they don’t have access to adequate resources. Similarly, rural areas of the country do not have access to the same infrastructure as urban regions such as greater New York City or Los Angeles. As a result, people living in these areas will become even more vulnerable to the disease.

As more data has become available, there is a growing awareness that providers need to find innovative ways to identify COVID-19 risk factors in their communities. Examples of health information technology (IT) being used to better risk stratify patients are emerging. In California, Marin County is establishing an integration between their local Housing Information Management System (HMIS) and their community case management platform to identify and place at-risk homeless individuals through the coordinated entry process, a streamlined system designed to efficiently match people experiencing homelessness to available housing, shelter, and services based on their strengths and needs. In Southern California, Kaiser Permanente providers are using their electronic health record (EHR) to generate clinical reports to prioritize patients by risk level in order to understand patients’ medications and other important aspects of their health history that can impact their COVID-19 risk. They are using this information to support additional treatment and follow-up to those who need it.

EHR, case management system, and other health IT vendors are incorporating risk factor data fields and logic, along with other COVID-19 information, to flag high-risk patients for front-line providers. New York City is using their regional health information exchange (HIE), Healthix, to identify high-risk patients and providing alerts to support COVID-19 response efforts. Privacy restrictions that typically make it challenging for this kind of data sharing to occur have been lifted with New York State Department of Health allowing COVID-19 alerts to be sent to providers without patient consent.

In California, the HIE Manifest MedEx is offering dashboards to provider organizations to explore COVID-19 risk factors among their COVID-positive patient populations, and has also partnered with Riverside County to create a detailed dashboard on COVID in the County. Other California Counties such as Santa Cruz have compiled their own publicly available surveillance dashboards with data from CalREDIE, California’s electronic laboratory reporting repository.

Although some recent COVID-19 data is showing a better outlook than predicted, how we mitigate risks among our diverse population will still be critical. Even when more testing and an FDA-approved medication are made available, how well people do will be significantly influenced by access to quality health care and other vital resources. This pandemic has not changed the priority-level of our most high-risk and vulnerable populations. These individuals will remain high-risk and vulnerable long after COVID-19 has settled and through the next crisis. This pandemic should serve as a turning point in how we capture, manage and share data across sectors. There are innovative examples throughout the country that we can glean from. If we can leverage the opportunity that this crisis has given us to come together in a rapid, coordinated and collaborative way, we can provide healthcare organizations and providers with the information that they need in order to support these populations and save lives.


[2] Centers for Disease Control and Prevention: https://emergency.cdc.gov/coca/calls/2020/callinfo_032720.asp

[3] Jennifer Lighter, MD, Michael Phillips, MD, Sarah Hochman, MD, Stephanie Sterling, MD, Diane Johnson, MD, Fritz Francois, MD, Anna Stachel, MPH, Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission, Clinical Infectious Diseases, , ciaa415, https://doi.org/10.1093/cid/ciaa415

The Calm Before The Storm

The coronavirus has unleashed a series of paradoxes into our lives. We show solidarity by staying apart, with the belief that young people meeting for brunch endanger elders in rest homes. We cease gathering around dinner tables, while hiking trails are packed not with seekers of solitude but with seekers of social connection (for as long as parks stay open). Waiters have lost their jobs, grocery-store clerks serve on the front lines, and there is no traffic on the Bay Bridge.

It is shocking how quickly we have adjusted to this new normal. At Intrepid Ascent, we’re as connected to each other as ever before even though no one has been in the office for two weeks. Most people I know are having more conversations with family and friends, gathering for virtual chats and checking in through an expanding circle of group texts. People are finding ways to help each other navigate dramatically altered times.

Amid these revolutions in daily life, there’s an eerie sense of calm before the storm in health care. Yes, the planners are busy planning and needed space and equipment are being considered, counted, ordered, set aside. But at least here in California, Emergency Departments and Urgent Care centers are relatively quiet. A large medical center nearby has actually emptied out, keeping doctors and patients at home and as healthy as possible in anticipation of the coming waves of very sick people needing intensive care. And many potential patients are themselves reluctant to visit health care settings, which are perceived to be hot-spots for COVID-19.

So we’re rationing health care, both consciously and unconsciously, on a vast scale in response to the crisis. Not yet in terms of which lives to save with a respirator or bed in the ICU, but in terms of who gets tested and receives sustained professional attention. Given the botched testing regime in the US to date, people with COVID-19 symptoms who do not seem to require immediate intensive care are told that while they probably have the virus, they will not be tested, nor will their contacts be traced. They should stay home and follow the guidelines, no matter how many others they live with or how porous the quarantine.

When such a diagnosis of COVID-19, whether remote or in person, is entered into an individual’s electronic health record, it will be coded in a manner that can be shared and communicated widely beginning April 1, thanks to an unprecedented update to diagnostic codes (which otherwise occurs on on annual basis, in October). Nevertheless, as our post on lab data explains, there is a disconnect between clinical and public health databases, and a diagnosis alone will not usually trigger public health to count an individual as an official COVID-19 case. Public health agencies are relying on positive lab test results for that, and we’re not testing nearly enough. So, in this very basic way – knowing who has the virus and who doesn’t – we’re in a fog. Thankfully, bright spots are emerging with the creative use of software tools by front-line staff to assess risk factors for COVID-19 and to coordinate services for vulnerable populations such as the homeless; and the engines of Silicon Valley innovation are revving up.

As the coming storm crashes into our imperfectly prepared institutions, we will need all of the tests, N95 masks, hospital and ICU beds, respirators, courageous medical staff, brilliant data scientists, and enlightened policymakers we can find. But also resilience, empathy, and ingenuity from the rest of us. Staying home and watching Netflix will not be enough. In Wuhan, in addition to aggressive testing and other measures to track and isolate the virus, “many people idled by the lockdowns stepped up to act as fever checkers, contact tracers, hospital construction workers, food deliverers, even babysitters for the children of first responders.”* An outbreak of common spirit is evident all around us, and I am confident that as the challenge deepens, so will the response. Let’s get ready.

*McNeil Jr., Donald G. “The Virus Can be Stopped, but Only With Harsh Steps, Experts Say,” The New York Times. March 22, 2020.