'Bottleneck for U.S. Coronavirus Response: The Fax Machine' diff viewer (2/3)

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Bottleneck for U.S. Coronavirus Response: The Fax Machine	Bottleneck for U.S. Coronavirus Response: The Fax Machine
2020-07-15 03:14:21 UTC	2020-07-15 16:26:22 UTC (about 13 hours later)
Public health officials in Houston are struggling to keep up with one of the nation’s largest coronavirus outbreaks. They are desperate to trace cases and quarantine patients before they spread the virus to others. But first, they must negotiate with the office fax machine.	Public health officials in Houston are struggling to keep up with one of the nation’s largest coronavirus outbreaks. They are desperate to trace cases and quarantine patients before they spread the virus to others. But first, they must negotiate with the office fax machine.
The machine at the Harris County Public Health department in Houston recently became overwhelmed when one laboratory sent a large batch of test results, spraying hundreds of pages all over the floor.	The machine at the Harris County Public Health department in Houston recently became overwhelmed when one laboratory sent a large batch of test results, spraying hundreds of pages all over the floor.
“Picture the image of hundreds of faxes coming through, and the machine just shooting out paper,” said Dr. Umair Shah, executive director of the department. The county has so far recorded more than 40,000 coronavirus cases.	“Picture the image of hundreds of faxes coming through, and the machine just shooting out paper,” said Dr. Umair Shah, executive director of the department. The county has so far recorded more than 40,000 coronavirus cases.
Some doctors fax coronavirus tests to Dr. Shah’s personal number, too. Those papers are put in an envelope marked “confidential” and walked to the epidemiology department.	Some doctors fax coronavirus tests to Dr. Shah’s personal number, too. Those papers are put in an envelope marked “confidential” and walked to the epidemiology department.
As hard as the United States works to control coronavirus, it keeps running into problems caused by its fragmented health system, a jumble of old and new technology, and data standards that don’t meet epidemiologists’ needs. Public health officials and private laboratories have managed to expand testing to more than half a million performed daily, but they do not have a system that can smoothly handle that avalanche of results.	As hard as the United States works to control coronavirus, it keeps running into problems caused by its fragmented health system, a jumble of old and new technology, and data standards that don’t meet epidemiologists’ needs. Public health officials and private laboratories have managed to expand testing to more than half a million performed daily, but they do not have a system that can smoothly handle that avalanche of results.
Health departments track the virus’s spread with a distinctly American patchwork: a reporting system in which some test results arrive via smooth data feeds but others come by phone, email, physical mail or fax, a technology retained because it complies with digital privacy standards for health information. These reports often come in duplicate, go to the wrong health department, or are missing crucial information such as a patient’s phone number or address.	Health departments track the virus’s spread with a distinctly American patchwork: a reporting system in which some test results arrive via smooth data feeds but others come by phone, email, physical mail or fax, a technology retained because it complies with digital privacy standards for health information. These reports often come in duplicate, go to the wrong health department, or are missing crucial information such as a patient’s phone number or address.
The absence of a standard digital process is hampering case reporting and contact tracing, crucial to slowing the spread of the disease. Many labs joined the effort but had limited public health experience, increasing the confusion.	The absence of a standard digital process is hampering case reporting and contact tracing, crucial to slowing the spread of the disease. Many labs joined the effort but had limited public health experience, increasing the confusion.
“From an operational standpoint, it makes things incredibly difficult,” Dr. Shah said. “The data is moving slower than the disease.”	“From an operational standpoint, it makes things incredibly difficult,” Dr. Shah said. “The data is moving slower than the disease.”
The torrent of paper data led at least one health department to request additional forces. Washington State recently brought in 25 members of the National Guard to assist with manual data entry for results not reported electronically.	The torrent of paper data led at least one health department to request additional forces. Washington State recently brought in 25 members of the National Guard to assist with manual data entry for results not reported electronically.
“The obsession with the number of tests obscures an important fundamental: What are we doing with all those tests?” said Dr. Thomas Frieden, a former director of the Centers for Disease Control and Prevention. “This is legitimately difficult stuff that every state is struggling with.”	“The obsession with the number of tests obscures an important fundamental: What are we doing with all those tests?” said Dr. Thomas Frieden, a former director of the Centers for Disease Control and Prevention. “This is legitimately difficult stuff that every state is struggling with.”
Dr. Mark Escott, the interim health authority for the city of Austin and Travis County, says his office is receiving around 1,000 faxes a day, including duplicate results. Some faxes are meant for other jurisdictions, and many are missing crucial information needed for his office to investigate cases. Most such faxes in Austin are being sent to a computer, but they still need to be printed and manually entered into public health databases.	Dr. Mark Escott, the interim health authority for the city of Austin and Travis County, says his office is receiving around 1,000 faxes a day, including duplicate results. Some faxes are meant for other jurisdictions, and many are missing crucial information needed for his office to investigate cases. Most such faxes in Austin are being sent to a computer, but they still need to be printed and manually entered into public health databases.
On average, his office is getting all the information it needs about a test result 11 days after the test is taken — far too late to make contact tracing worthwhile. He has been advising those in the area with virus symptoms to assume they are positive, since the tests take so long to come back.	On average, his office is getting all the information it needs about a test result 11 days after the test is taken — far too late to make contact tracing worthwhile. He has been advising those in the area with virus symptoms to assume they are positive, since the tests take so long to come back.
“When we are receiving results back 14 days after the individual became symptomatic, it’s not useful at all,” Dr. Escott said.	“When we are receiving results back 14 days after the individual became symptomatic, it’s not useful at all,” Dr. Escott said.
Before the pandemic, nearly 90 percent of laboratory test results for diseases tracked by public health departments were transmitted digitally, according to the C.D.C. But the need for widespread coronavirus testing has brought many more players into the public health arena, including companies that usually run tests only for employers, and small clinics that usually test for diseases like the flu and strep throat. That has pushed up the share of lab tests coming to public health departments in other forms.	Before the pandemic, nearly 90 percent of laboratory test results for diseases tracked by public health departments were transmitted digitally, according to the C.D.C. But the need for widespread coronavirus testing has brought many more players into the public health arena, including companies that usually run tests only for employers, and small clinics that usually test for diseases like the flu and strep throat. That has pushed up the share of lab tests coming to public health departments in other forms.
“There are standards that exist out there, but with the onslaught and the drastic increase in volume and the increase in the number of tests, they’re struggling to keep up,” said Jason Hall, who is the lead for the C.D.C.’s Laboratory Reporting Working Group.	“There are standards that exist out there, but with the onslaught and the drastic increase in volume and the increase in the number of tests, they’re struggling to keep up,” said Jason Hall, who is the lead for the C.D.C.’s Laboratory Reporting Working Group.
Nationally, about 80 percent of coronavirus test results are missing demographic information, and half do not have addresses, according to Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.	Nationally, about 80 percent of coronavirus test results are missing demographic information, and half do not have addresses, according to Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.
“When things come in with missing information, we have to try to put the pieces back together,” she said. “We call the provider back or look at other data sources. But that takes time.”	“When things come in with missing information, we have to try to put the pieces back together,” she said. “We call the provider back or look at other data sources. But that takes time.”
The Trump administration issued guidelines in early June that required laboratories to report things like patients’ age, race and ethnicity, so public health officials can better understand the demographics of the coronavirus pandemic. The rules, which do not take effect until August, state that laboratories “should” also provide patients’ addresses and phone numbers but do not mandate it.	The Trump administration issued guidelines in early June that required laboratories to report things like patients’ age, race and ethnicity, so public health officials can better understand the demographics of the coronavirus pandemic. The rules, which do not take effect until August, state that laboratories “should” also provide patients’ addresses and phone numbers but do not mandate it.
This type of information often gets lost, as the typical test data take a journey from doctor’s office to laboratory to public health authority and back to the original doctor, not necessarily in that order. At each stage, technological failures can slow or disrupt the flow of vital information. Doctor’s offices don’t always have digital systems capable of talking to the lab that analyzes the result. Laboratory software often omits information that public health authorities will later need. And transmissions by fax or spreadsheet can require workers to manually re-enter information into their computer systems, increasing the risk of errors or duplicate entries.	This type of information often gets lost, as the typical test data take a journey from doctor’s office to laboratory to public health authority and back to the original doctor, not necessarily in that order. At each stage, technological failures can slow or disrupt the flow of vital information. Doctor’s offices don’t always have digital systems capable of talking to the lab that analyzes the result. Laboratory software often omits information that public health authorities will later need. And transmissions by fax or spreadsheet can require workers to manually re-enter information into their computer systems, increasing the risk of errors or duplicate entries.
~~Updated July 7, 2020~~	Updated July 15, 2020
The coronavirus can stay aloft for hours in tiny droplets in stagnant air, infecting people as they inhale, mounting scientific evidence suggests. This risk is highest in crowded indoor spaces with poor ventilation, and may help explain super-spreading events reported in meatpacking plants, churches and restaurants. It’s unclear how often the virus is spread via these tiny droplets, or aerosols, compared with larger droplets that are expelled when a sick person coughs or sneezes, or transmitted through contact with contaminated surfaces, said Linsey Marr, an aerosol expert at Virginia Tech. Aerosols are released even when a person without symptoms exhales, talks or sings, according to Dr. Marr and more than 200 other experts, who have outlined the evidence in an open letter to the World Health Organization.	The coronavirus can stay aloft for hours in tiny droplets in stagnant air, infecting people as they inhale, mounting scientific evidence suggests. This risk is highest in crowded indoor spaces with poor ventilation, and may help explain super-spreading events reported in meatpacking plants, churches and restaurants. It’s unclear how often the virus is spread via these tiny droplets, or aerosols, compared with larger droplets that are expelled when a sick person coughs or sneezes, or transmitted through contact with contaminated surfaces, said Linsey Marr, an aerosol expert at Virginia Tech. Aerosols are released even when a person without symptoms exhales, talks or sings, according to Dr. Marr and more than 200 other experts, who have outlined the evidence in an open letter to the World Health Organization.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.	Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
Scientists around the country have tried to identify everyday materials that do a good job of filtering microscopic particles. In recent tests, HEPA furnace filters scored high, as did vacuum cleaner bags, fabric similar to flannel pajamas and those of 600-count pillowcases. Other materials tested included layered coffee filters and scarves and bandannas. These scored lower, but still captured a small percentage of particles.	Scientists around the country have tried to identify everyday materials that do a good job of filtering microscopic particles. In recent tests, HEPA furnace filters scored high, as did vacuum cleaner bags, fabric similar to flannel pajamas and those of 600-count pillowcases. Other materials tested included layered coffee filters and scarves and bandannas. These scored lower, but still captured a small percentage of particles.
A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.	A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.
The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.	The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.
The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.	The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.	So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.	Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.	A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)	If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.	If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
Some public health officials say they’ve been especially vexed by the ubiquity of fax machines, with their blurry printouts and analog data.	Some public health officials say they’ve been especially vexed by the ubiquity of fax machines, with their blurry printouts and analog data.
Large, national laboratories typically have software that allows them to communicate electronically with a wide range of hospitals and public health systems. But smaller labs, drawn to coronavirus testing by high payment rates, often don’t invest in expensive software packages when they can simply send data by fax instead.	Large, national laboratories typically have software that allows them to communicate electronically with a wide range of hospitals and public health systems. But smaller labs, drawn to coronavirus testing by high payment rates, often don’t invest in expensive software packages when they can simply send data by fax instead.
“It’s $500 versus, literally, $5,000,” said Bob Kocher, a partner at the venture-capital firm Venrock, who has been helping California manage its coronavirus testing effort.	“It’s $500 versus, literally, $5,000,” said Bob Kocher, a partner at the venture-capital firm Venrock, who has been helping California manage its coronavirus testing effort.
In the early 2010s, the federal government spent billions to encourage doctors to replace fax machines with electronic records. That program, known as the HITECH Act, did not include similar funding for public health departments, to help them automatically digitize faxes and other nonstandard results. Nor did it require hospitals and doctor’s offices to build technology that would automatically send relevant test results to local health officials.	In the early 2010s, the federal government spent billions to encourage doctors to replace fax machines with electronic records. That program, known as the HITECH Act, did not include similar funding for public health departments, to help them automatically digitize faxes and other nonstandard results. Nor did it require hospitals and doctor’s offices to build technology that would automatically send relevant test results to local health officials.
Public health departments, whose budgets have been cut back over the past decade, were unable to finance the digital upgrades themselves.	Public health departments, whose budgets have been cut back over the past decade, were unable to finance the digital upgrades themselves.
“The best way I can describe it is to imagine you’re on the information super highway, but you’re traveling with a bus pass,” said Oscar Alleyne, chief program pfficer at the National Association of County and City Health Officials. “Money was invested to get physician practices onto electronic health records. There was no investment to build up a similar technology to tie public health into that system.”	“The best way I can describe it is to imagine you’re on the information super highway, but you’re traveling with a bus pass,” said Oscar Alleyne, chief program pfficer at the National Association of County and City Health Officials. “Money was invested to get physician practices onto electronic health records. There was no investment to build up a similar technology to tie public health into that system.”
The C.D.C. has modernized public health reporting, but at a smaller scale. In the mid-2010s, the agency used $13 million in Affordable Care Act funds to help state and city health departments go digital. Although that program made some progress, it did not move the country to a completely digital public health reporting system. There have been some smaller one-time grant programs over the last few years, but no long-term funding source for digitization.	The C.D.C. has modernized public health reporting, but at a smaller scale. In the mid-2010s, the agency used $13 million in Affordable Care Act funds to help state and city health departments go digital. Although that program made some progress, it did not move the country to a completely digital public health reporting system. There have been some smaller one-time grant programs over the last few years, but no long-term funding source for digitization.