DataDrivenMD

The challenge to building a screening app is that there is no universal screening criteria (more on this in a bit). Moreover, the criteria has been changing by the day. For this MVP, we decided to stop chasing a moving target. We did the next best thing: link to the testing criteria that a location is using (to the extent that the information is publicly available).

Early in the process of sourcing data for this project, we realized that the CDC guidelines are used as a starting point, and that other factors come into play that are less transparent to the public. For example, there are still many states with extremely limited capacity. In those areas, public health departments have been forced to create lists of patients that would be tested immediately if it were possible. Lacking sufficient testing capacity, they prioritize the list of persons under investigation (PUI) using criteria that they develop internally through a collaborative effort with key stakeholders.

On our site, you will note that there are pockets of the country with lots of testing options. But that doesn't mean that testing is easy to come by. We learned that those areas are enriched for academic medical centers and large hospital systems that have been granted FDA approval for their own (custom) version of the COVID-19 test. Through strategic partnerships with community-based medical groups that predate the pandemic, patients in the broader community benefit from direct access to testing services. But the the problem has resurfaced: the demand for testing is already exceeding supply, and we witnessed the turnaround time for test results grow from 4 hours -> 12 hours -> 24 hours -> 4-5 days since we began this project exactly 7 days ago.

Make no mistake about it: the testing problem is far from resolved. Screening tools are a stopgap designed to lessen the mental anguish experienced by those who are tasked with rationing a (literally) vital resource. We will continue to explore ways to incorporate them into our project, but will approach the decision mindful of our commitment to empower everyone with the information they need to flatten the curve. To the extent that screening tools have thus far played a role in obfuscating where we are on the curve, you can rest assured that, if a screening tool finds its way onto our site, it will serve a greater purpose for a greater number of people.

Yes - all over the place. That was the biggest challenge: sourcing and validating the data. It's also why this is and will continue to be a work in progress: the situation on the ground is dynamic. We need help sourcing and validating data. If you're willing to volunteer, send a note to contact@codersagainstcovid.org

Short answer: they have all been bottlenecks thus far. In fact, that's a big reason why testing hasn't improved as rapidly as everyone hoped it would. The biggest bottleneck now is dwindling supplies of personal protective equipment (PPE) for those involved in obtaining and handling the test specimens.

Yes - Houston data will be coming soon. It took extra effort to figure out how testing was being coordinated among the TMC hospitals and their community-based partners. Stay tuned for updates - we are pushing data out regularly from this point forward.

Appreciate the slow clap - would love your help. See Andrew's note to learn about ways to help.

Also want to share that you're not imagining things: best we can tell, those living in Georgia have very few options beyond their health department. Even Emory is limited in its capacity - last I heard they were hoping to be able to get to 400 tests/day by this weekend. We'll add Emory to the site soon. Even so, I encourage those who live in Georgia to share their insight with us by adding testing locations so that we can help others in their community.

We will also continue to research and update the site as new options become available - including home-based testing. We've already heard from a couple of companies in this space, but we're waiting for them to provide us with proof that their test is FDA validated and approved. Once they do that, we'll add their information to the site as well.

We were careful not to assume that all public health departments would engage in testing. We manually verified the information, and for those public health agencies that explicitly indicated on their websites or through direct channels that they offered testing we marked them as "offers COVID-19 testing".

That being said, there are many areas of the country where the local, county, and state health departments effectively function as gatekeepers. In those communities, people have no choice but to call their health department and hope for the best. If they meet testing criteria, then they are referred to a testing location or fast-tracked through an existing healthcare provider’s queue.

If nothing else, this site crystallizes the fuzzy image that we all had in mind with respect to testing capacity. The situation is changing all the time, and we expect things to get better. You can help by raising awareness, and asking people you know in the Midwest and Southern states to visit our site and share their on-the-ground knowledge of the situation.

Well put. We’re working on the testing site locator right now. We’ve gathered contact info for 3500+ public health agencies, plus starting to add info for urgent care facilities, health systems, community hospitals, and academic health centers. We’ve got CIOs and CMIOs from across the country helping us gather the data we need. The goal is simply to make it easy for people to get tested.

Would be great to have your help. Send me an email if you’d like to learn more (see my profile)

Not being intimately familiar with the limitations of Kalman filters, how susceptible to bias is this approach when hidden states exist? In the case of COVID-19, the asymptomatic cases may be modeled as such, or not, depending on the approach. Also, the incubation and convalescent phase could also present a challenge given that patients can still transmit the virus.

It would be helpful to understand how Kalman filtering approach compares Markov chains, for example.

edit: Could Kalman filters be used to retroactively mark/flag/detect the introduction of a new strain of the same virus? If so, this could prove to be a novel way to quantify the clinically meaningful mutation rate - that is, the rate at which the virus mutates sufficiently to infect a new sub-population (or perhaps re-infect existing ones).

This reminds me of the time I spent at the NIH conducting research on cancer vaccines. After lots of trial and error, I had finally found something that seemed to prevent lung cancer in mice. I rushed to show my PI the results. He listened intently and asked thoughtful questions. Once I finished, I asked if the findings would be worthy of submitting to Nature.

He looked me straight in the eye and said, “I wouldn’t publish this anywhere, we still have work to do.”

“What do you mean?” I asked.

“If Nature published every article that purported to cure a human disease based on a mouse model, then I would be next in line for the Nobel Prize,” he replied.

Harsh but true. The challenge of curing human disease cannot be replicated in animal models. At least not yet.

I want to help. I had posted something here:

https://news.ycombinator.com/item?id=22577611

But will support any effort so long as we get it done. I can help from the medical and the technical side of things. What’s the best way to sync up?

That seems like a harder problem because of patient privacy issues.

Agreed, but even a simple honor system would be better than the current situation. Perhaps verified via a simple browser-based cookie?

Separately: just dawned on me that HN has no obvious way for users to communicate directly. Any suggestions on how to share contact info without begging for spam/bots?

I posted the call to action here:

https://news.ycombinator.com/item?id=22577611

There was a word limit, so I had to comment on my own post to share full details. Sorry, not sorry HN mods ;-)

If we break down the challenge, we can start having an immediate impact. Here’s how:

- Now: there's an immediate need for a single source of truth for all the locations where COVID-19 testing is available. Trump recently said that Google was working on it, but it turns out not to be the case (they are weeks away from an MVP that would only cover the SF Bay Area). I propose we start by solving this problem.

- Next: What is the scope of COVID-19 infection? Today, the CDC doesn't have an accurate count of the # of COVID-19 tests that have been performed because they don't have a way to collect that info from the growing number of labs that are performing the tests. Moreover, there's no way for anybody to know how many people have actually been tested, because the same person can be tested multiple times. We could solve this problem by crowdsourcing that information directly from individuals.

- Next +1: We need to know where the sickest people are right now, and predict where they could be in the near future. This is crucial information for healthcare providers (like me) and public health officials alike. Without this information in hand, it's virtually impossible to know where to direct resources (like doctors, nurses, ventilators, medical supplies, testing equipment, etc.). We need to be able to track demand AND supply in real-time --> this is the point at which the project starts shaping itself into an Uber-like platform.

- Next +2: Enable individuals to post offers to help and for others to request assistance. This would enable individuals with medical training to help meet the need. It would also enable everyone to help in other ways, like delivering food for the elderly.

Sweet. Looked into the KWA's site, seems like a clear use-case. If we were to break down the build into achievable chunks we may have more success, and have a bigger impact along the way.

There's an immediate need for a single source of truth for all the locations where COVID-19 testing is available. Trump said Google was building it, but turns out they are weeks away from an MVP that would only cover the SF Bay Area. I propose we start by solving that problem.

Building on this, we can answer the question: what is the scope of the problem? Today, the CDC doesn't have an accurate count of the # of COVID-19 tests that have been performed because they don't have a way to collect that info from the growing number of labs that are performing the tests. Moreover, there's no way for anybody to know how many people have actually been tested, because the same person can be tested multiple times. We could solve this problem by crowdsourcing that information directly from individuals.

Building on this, we need to know where the sickest people are right now, and predict where they could be in the near future. This is crucial information for healthcare providers (like me) and public health officials alike. Without this information in hand, it's virtually impossible to know where to direct resources (like doctors, nurses, ventilators, medical supplies, testing equipment, etc.). We need to be able to track demand AND supply in real-time --> this is the point at which the project starts shaping itself into an Uber-like platform.

Building on this, we could enable individuals to post offers to help and for others to request assistance. This would allow people like your mom to lend a hand where it is a) safe for her and b) most needed.

The ultimate goal would be to build an open-source platform that could be used by communities around the world with little-to-no deployment overhead. Ideally, it would be possible to clone the repo, customize a few parameters, and deploy instances in less than an hour.

I'll flesh this out a bit more, and submit the idea as an Ask HN topic.

Have you considered the Almond integration for Home Assistant? (https://www.home-assistant.io/integrations/almond/)

Alternatively, you could just fork the Almond project directly and take it from there: https://github.com/stanford-oval/almond-cloud

You raise a related issue, which is critical to address as well. That is, we need people to help manage patients before, during, and after their hospital stay. I’m less concerned about the licensing issues because public health emergency declarations make it possible for state officials to clear the way for someone like your mom.

Where you, and fellow hackers can help, is by offering tech solutions that solve the issue of coordinating/figuring out where your mom’s skills could be most helpful. We will also need to collect information, such as when your mom is available to help. Could be a good time to revisit the concept of an Uber-like platform for healthcare delivery, assuming that it can be up an running in a few days. Hack-a-thon, anyone?

As an anesthesiologist and hacker, I love the enthusiasm here. I’m less concerned about the hospital use-case. It would be helpful to crowdsource solutions to address the need for ventilators after patients leave the ICU. Based on current practice patterns, some patients will undergo tracheostomy tube placement, and then need to be discharged to respiratory rehab facilities. We will need to increase capacity in this setting, and I’m not seeing or hearing anyone address this area. If we don’t solve this problem, we will find ourselves with a backlog of patients who could be discharged from the ICU, but with nowhere to go.

Anesthesiologist here: yes and no. It depends on whether the patient is having difficulty clearing CO2, in which case ventilation is more important. If the patient’s lungs are unable to extract sufficient oxygen from the air such that the blood oxygen levels drop below a certain threshold, then supplemental oxygen becomes important. In fact, excessively high oxygen concentrations in inhaled gas has the potential to damage lung tissue. Hopefully this helps to explain why the ability to titrate oxygen flows is important. If we can do that effectively, we can conserve our oxygen supply for those who need it.

Anesthesiologist here - sedation is ideal for managing patients in respiratory failure, though volatile anesthesia is not commonly used in an ICU setting (at least not in the US). It is more common to use IV drugs such as dexmedetomidine, fentanyl, or dilaudid.

Anesthesiologist here - true, I was a Stanford medical student on an ICU rotation when a Tesla employee crashed his plane into high voltage power lines while attempting to land at San Carlos airport. Electrical power on the peninsula was out for an extended period of time. Battery backups eventually failed, then gas powered generators started failing so everyone with a pair of hands took turns manually ventilating the patients. If push comes to shove, we could get by with a Jackson-Reese circuit and a pair of hands. Obviously we don’t want to find ourselves in this situation.

As with any statistical analysis based on a sample of the total population, there will be biases (as many have already noted). That being said, these results reflect what we’ve seen in the real world in places like Washington state, Italy, Iran, and even S. Korea. More to the point: these data underscore the importance of following the advice of public health officials.

It’s fine to have an intellectual discussion about the merits of the study, but let’s make sure that we keep our eye on the prize. Each of us has a responsibility to do our part in protecting our parents, friends, and coworkers.

TL;DR - This study suggests that many of us on HN will be fine no matter what. But it also demonstrates that, if left unchecked, it’s possible (if not probable) that many of us will be grieving the loss of someone we love. There’s no need to panic, and there’s no room for those who seek to be dismissive, flippant, or ignorant. Everyone will be fine if each of us focuses on doing the right thing.

To be clear: I wasn’t making a political point. Just trying to offer an explanation as to why the numbers differ from those that we’re getting from other sources. The AHA has a history of making contributions to both parties. If my hunch is correct, they were using this deck as a way of stimulating their members to make financial contributions that would then be used to lobby on behalf of their members’ interest. It’s an educated guess, not a political stance.

"The American Hospital Association said the webinar reflected the views of the experts who spoke during it, not its own."

This seems like they're trying to distance themselves from the content, which is odd.

The AHA is huge in terms of lobbying (see https://www.opensecrets.org/orgs/summary.php?id=D000000116), which makes me wonder if this deck was meant to stimulate contributions from its members. One way to sort it out would be to learn more about the people in the audience and to find out if the speakers were paid consultants.

The best and closest to what you’re looking for comes from Johns Hopkins:

- https://data.humdata.org/dataset/novel-coronavirus-2019-ncov...

The GitHub repo with datasets:

- https://github.com/CSSEGISandData/COVID-19

Start there, and reach out to the staff if you’re looking for something more specific. They may be able to point you in the right direction.

It’s possible to contain a small outbreak, much more difficult to contain a large one. Think of it like a California brush fire:

- If someone is witness to the start of the fire, they’re going to call the fire department who will mobilize all resources available to a small area -> fire is contained quickly and with minimal loss of life or property

- If the fire starts in a remote area with nobody around for miles, it will get bigger and avoid detection until it becomes an imminent risk to people. At that point, the same resources will be spread across a larger area. As the wildfire grows, the wind caries embers and sparks other fires miles away, making the situation worse.

I caution against reading too much into the South Korean fatality rates because many of the patients are younger and generally healthy (http://www.koreaherald.com/view.php?ud=20200303000714).

Whatever the global mortality rate shakes out to be in the long-run, it’s impossible to ignore the fact that this virus killed nearly a dozen nursing home residents in the span of 2 weeks. There’s a lot we don’t understand about COVID-19, certainly more than a single metric can tell us.

Based on what we’re seeing in the state of Washington and around the world, it’s safe to say that older patients are at higher risk for developing respiratory failure. Beyond that, it’s simply way too early to draw conclusions.

Consider me skeptical of the practical significance of their findings. IMO, protease inhibitors are a moot point if the they don't also block cell entry via antibody-dependent enhancement (ADE):

- http://viruseradication.com/abstract-details.php?abstract_id...

- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6178114/

- https://jvi.asm.org/content/94/5/e02015-19.abstract

It's been a while since my vaccine research days at the NIH, so take my skepticism with a grain of salt.

TL;DR - If you are a hard-working entrepreneur, let this be a reminder that we're prepared to abandon you when the global economy is in recession. We expect you'll pay it forward by treating your hard-working employees the same way. If you follow our lead, your company may survive long enough to raise money from our firm in the future. This thought leadership blog post is an example of our founder-friendly approach, and demonstrates how we add value to our portfolio companies.

Objectively speaking the advice is prudent. Still, someone should tell their marketing team that this piece is seriously off-brand. It signals to entrepreneurs that the firm's messaging around the notion that "People Build Companies" is not to be taken seriously.

To everyone questioning the false positive and false negative rates: your point is well-taken, and it is the reason why it was necessary to push the FDA to allow non-CDC labs to perform COVID-19 testing based on a fast-tracked version of the clinical validation process.

To those that point out that there are newer/faster/better ways to actually achieve the same results: you're right but that doesn't mean that the machines, reagents, collection media, etc. are ready for prime time in this type of setting. Remember: the entire process needs to be clinically validated in order to earn the trust of doctors and public health officials who are literally making life vs. death decisions.

TL;DR - Your points are valid, and there are real challenges that make certain solutions impractical at this point in time. Consider this a call to action to entrepreneurs who are serious about helping patients at home and around the world.