The previous articles in this series described what it’s like to try to get home treatments for COVID-19, and how it would ideally work. This final article looks at particular changes that regulators and health IT practitioners could do to help cope with the next health crisis.
Tracking and measuring the epidemic
We’ve already discussed the most basic information society needs about an epidemic: the extent of its spread. Voluntary reporting and statistical analysis are probably the best we can do. The public holds many clashing opinions about requirements for reporting illness.
Contact tracing really has to be done by human tracers to be accurate, but that approach would require half the population to trace the other half. Yet attempts by European countries to encourage contact tracing through cell phones has been widely criticized and is probably ineffective. One friend told me, “My app just informed me that I was in the grocery store at the same time as someone who just tested positive. What am I supposed to do in response?”
With COVID-19, we can’t even trust mortality rates. For reasons I can’t fathom, many jurisdictions deliberately under-report COVID-19 deaths.
Data sharing is more than a button to click
COVID-19 has intensified the importance of getting data quickly from one clinical site to another. Electronic records have permitted great strides, but the industry still has to make it easier for the patient to transfer records. If records were stored with individual patients instead of with the various clinicians they see, the process would be much more straightforward.
Making sure that you are granting access to the right physician is another hurdle, as is known by anyone who has to design or log into a web site with state-of-the-art security. Organizations such as Direct Trust try to make it easier to authenticate doctors. We need an easy way to hook up the sending and receiving clinicians with minimal effort. The Carin Alliance is working on digital identity with the Office of the National Coordinator (ONC).
Distributing medications
The strange way that the FDA chose to distribute Pfizer and molnupiravir made locating them harder. Normally, manufacturers send medicines to wholesalers, like just about any other product, and the wholesalers make sure to distribute them fairly among pharmacies.
Cary Breese of the pharmacy NowRx, believes this traditional system would work fine for COVID-19 medications. But instead of letting the wholesalers do their work, the FDA sent the medications to about 200 health care providers and a small set of pharmacies. The FDA did not explain or justify their choices. CVS can offer the medications but Walgreen’s cannot, for instance. According to Breese, the system is so opaque that many physicians refuse to prescribe the medications, expecting that patients would encounter too many problems filling the prescriptions.
I won’t speculate on the reasons for the FDA’s decision. If physicians need special training to prescribe medications, that could be arranged in a transparent manner. If the FDA was worried about hoarding or favoritism, the traditional wholesalers have ways to deal with that. For instance, when poorly substantiated reports about Hydroxychloroquine’s effects caused a run on that medication, the pharmacies and wholesalers worked together to ameliorate shortages.
In future crises, we can conclude, a transparently operated distribution network using existing channels will work better than a novel, patched-together system.
Who can issue a prescription?
The shortage or doctors and nurse practitioners can also slow down the distribution of medications. As we saw in Richard Dion’s case, his PCP didn’t respond promptly.
Other health care professionals, notably pharmacists, can do a lot more than they are often allowed to do by regulators and payers. In the particular case of prescribing COVID-19 medicines, a doctor may be required because there are so many risks involving interactions with medical conditions and with other medicines. But future epidemics might be quelled faster by allowing a wider group of professionals prescribe medicines.
Taking everybody’s health seriously
Finally, the bedrock of effective drug distribution is a health care system that reaches everyone. We can start by providing everyone with health insurance and a PCP. But we must go much farther: we have to eliminate barriers and discrimination on the basis of race, gender, sexual orientation, and geographic location. COVID-19 has taught us this. Those whom we leave behind will be our fatal weakness.
