By Lambert Strether
Let me begin by listing the headlines, in order of increasing hysteria:
- Coronavirus data is funneled away from CDC, sparking worries AP
- Transparency questions after hospitals directed to report COVID data to HHS, not CDC ABC
- Trump Administration Orders Hospitals To Bypass CDC, Send COVID-19 Data To Washington NPR
- Trump administration takes control of COVID-19 data in US Al Jazeera
- Coronavirus hospital data will now be sent to Trump administration instead of CDC CNN
Headlines 3, 4, and 5 are wrong, in that they imply that the CDC is not part of the Trump Adminstration. In fact, the Centers for Disease Control and Prevention (CDC), as a glance at its About Page shows, is part of the Department of Health and Human Services (HHS), and hence part of the Trump administration. The CDC is no sense an independent agency like the SEC or the FAA, and hence is politicized, or not, as any other portion of the executive branch; such independence as its “scientific experts” and other personnel may have is due solely to the Norms Fairy, and is in no way the result of statutes or regulations. (That may be a bad thing, but it is so.)
In institutional terms, for collecting and aggregating COVID data, the administration has phased out the CDC system (National Healthcare Safety Network, or NHSN) in favor of the HHS Protect system (produced by TeleTracking Technologies Inc. of Pittburgh, PA). In this post I will first compare and contrast the two systems; despite the hysteria, I think there’s a prima facie case for the administration doing what it did, because TeleTracking has better tech. I have priors from past lives where I worked in and with companies like TeleTracking, especially on the data side — which is not at all easy — so I feel I know where I am; that said, it’s hard to dope out the contractual relation between HHS and TeleTracking from the news reports, so at times I will have to speculate.) In an Appendix, just for fun, I’ll look at the CDC under Obama. It will be evident that the CDC has had problems — not necessarily of its own making — for some time, long before its COVID testing debacle in 2020.
So now let me run through the differences between centering COVID-19 data collection and aggregation via the CDC’s NHSN, and the HHS Protect. (I’ll leave aside that the Administration is replacing a government program with a public-private partnership, not because I thinik that’s a good idea, but because it’s sadly ubiquitous.)
First, from the perspective of somebody in the trenches trying to move data, descriptions of the CDC’s dataflow raise red flags. For example, under HHS Protect:
HHS said it will also no longer ask for one-time requests for data to aid in the distribution of remdesivir or any other treatments or supplies.
“One time requests” for data under NHSN, especially in a highly stressed environment like that of a hospital during a pandemic, are a recipe for error, evershifting priorities, and a stressed staff. Further, NHSN coverage is incomplete. In addition, it’s slow:
Michael Caputo, an HHS spokesman, said the CDC has been seeing a lag of a week or more in data coming from hospitals and that only 85% of hospitals have been participating. The change is meant to result in faster and more complete reporting, he said. A CDC official, who is familiar with the agency’s system, disputed Caputo’s figures, saying only about 60% of the nation’s hospitals have been reporting to the CDC system, but is collected and reported out within two days.
Since a pandemic is multiplicative, neither a week nor two days are acceptible. Both these red flags provide good reasons for change.
Second, the TeleTracking System is better than NHSN at handling data. From Prepared Remarks from HHS Media Call with CDC Director Redfield and CIO Arrieta on COVID-19 Data Collection:
TeleTracking also provides rapid ways to update the type of data we are collecting—such as adding, for instance, input fields on what kind of treatments are being used. In order to meet this need for flexible data gathering, CDC agreed that we needed to remove NHSN from the collection process, in order to streamline reporting.
From what I can tell, the NHSN provides fields for ICU bed occupancy, Healthcare worker staffing, and Personal protective equipment (PPE) supply status and availability. That’s not very much, particularly if we expect new drugs or vaccines to come online soon. Even better, the TeleTracking System provides a standard schema to structure and validate the fields. HHS, in “COVID-19 Guidance for Hospital Reporting and FAQs For Hospitals, Hospital Laboratory, and Acute Care Facility Data Reporting” provides a number of ways for hospitals to provide data, including:
Publish to the hospital or facility’s website in a standardized format, such as schema.org. Use one of the above alternate methods until your ASPR Regional Administrator or HHS Protect notifies you that this implementation is being received.
The COVID-19 pandemic requires various medical and government authorities to aggregate data about available resources from a wide range of medical facilities. Clearly standard schemas for this structured data can be very useful.
The Centers for Disease Control (CDC) in the U.S. defined a set of data fields to facilitate exchange of this data. We are introducing a Schema.org representation of these data fields.
The purpose of this schema definition is to provide a standards-based representation that can be used to encode and exchange records that correspond to the CDC format, with usage within the U.S. primarily in mind. While the existence of this schema may provide additional implementation options for those working with US hospital reporting data about COVID-19, please refer to the CDC and other appropriate bodies for authoritative guidance on the latest reporting workflows and data formats.
I’m shocked that CDC had not already adopted a schema. If you want to interchange COVID-19 data electronically between many organizations running different systems, a formal and machine-readable definition of the data fields is the way to go (as opposed to human-readable documentation). Further, since Brickley’s schema already expands on CDC’s definitions, I would speculate that TeleTracking’s use of schemas is the source of the “rapid ways to update the type of data we are collecting” referred to by Redfield.
So that is the approach to data. Let me now speculate why TeleTracking was selected, and how they might be useful to HHS in the future.
TeleTracking is in the business of “patient flow.” From “Statement of TeleTracking Technologies, Inc. at the House Ways and Means Subcommittee on Health (PDF):
TeleTracking’s mission is to optimize health system operations by enhancing patient flow with solutions and services that enable the highest quality of care delivery and coordination. What does it mean to enhance patient flow? It means helping hospitals care for more patients without building more physical space or purchasing more beds. It means making sure that patients don’t languish in emergency rooms – or leave the hospital without receiving care – because of long waits for beds. It means harnessing technology to make the most of the resources already within the health care system to improve quality of care, minimize waste, and decrease health system costs. And, it means unburdening care providers so that they can focus their attention on the patients who need them…
This is not just about costs or financial performance. “Forty-six minutes was just enough time to save the life of a new mother” began a recent news story about how the process efficiencies gained at Baptist Memorial Health System are having lifesaving effects. After an emergency cesarean section, a new mother suffered cardiac arrest and needed to be transferred from one facility’s emergency department (ED) to an intensive care unit at Baptist’s flagship hospital. If Baptist had performed like an average US hospital, this young mother would never have had the chance to meet her new baby. Baptist’s streamlined patient flow processes, service standards and technologies supported caregivers in their efforts to save this young mother’s life, and undoubtedly the lives of countless others.
To this end, the Agency for Healthcare Research and Quality (AHRQ) targeted patient flow as a viable improvement strategy in 2011. And, the Institute of Medicine (IOM) identified billions dollars of waste in the health system diverting resources away from patient care…. It is apparent that an operational focus is needed to drive down costs, improve efficiency, and assure all patients receive timely access to care and sufficient time with caregivers.
Needless to say, I have other views on how best to drive down costs, but clearly an operational focus would be needed even under a single payer system. The focus on patient flow motivates the data structures on the one hand, but also motivates the creation of “dashboards” so that executives can make decisions about resources. From Becker’s Hospital Review:
1. Recently, New Cross Hospital in the UK reported that it reached one million hand hygiene observations using TeleTracking’s sensor technology. In that same period of time, only 600 visual observations were made.
2. TeleTracking’s system allows real-time monitoring of patients and availability so rooms can be cleaned and turned over immediately.
3. TeleTracking’s technology tracks the hours of care given to each patient along with the number of staff members that come in contact with each case. The data can be used to reduce waste and plan future staffing and costs.
If I were an HHS administrator, and I was faced with the immediate problem of distributing remdesivir (of which the United States bought the world’s stock) or, later — touch wood — faced the problem of distributing vaccines, the tech that TeleTracking has exactly what I would want. I would want very granular data, I would want to understand capacity, and I would want to dashboard to display all that to my crazy boss. Now, I don’t know if TeleTracking has a contract for that. But I can see that some clever person has put them in a position to secure one, should that become necessary. By contrast, CDC is merely aggregating data. Not very interesting!
My guess is that a Biden administration would retain the HHS Protect system, much as Obama rationalized and consolidated Bush’s programs for warrentless surveillance and assassination.
 HHS Protect seems to have a lot of other functions than collecting COVID-19 data, but those functions are beyond the scope of this post. Palantir is involved with those functions, and yes, I know the business of data can be quite seamy. I don’t think TeleTracking is the prime on HHS Protect, which sounds like a topic for another post.
 TeleTracking looks as legitimate as any other health IT company; the field is littered with smallish firms, many smaller than TeleTracking. Employee reviews are good; it’s not a body shop. They have a good customer list, including the Mayo Clinic, and good reviews. They’ve been in business since 1991, so they’re not a fly-by-night shell company. A search of OpenSecrets shows no campaign contributions either by TeleTracking or by its CEO (adding, although Zamagias is a Republican donor).
 The current moral panic is that the Administration will use HHS Protect to jigger the data, as Florida seems to have done. For one thing, the use of a schema means more transparency, not less. For another, there are too many eyes on the dataflow. For a third, both Big Pharma and the hospitals would be very unhappy were revenue to be taken away from them via undercounts, and they would be very willing to share their unhappiness with others. And for a forth, CDC is a branch of HHS, hence part of the executive branch. If Trump wants to damage the dataflow, he doesn’t have to set up a new system to do it; he can use the one he already controls.
PPE shortages. Fortune, 2014:
This week, registered nurses will gather in cities across the country—from Bangor, Maine, to St. Louis to Sacramento—to call on the Obama administration and Congress to institute standards for protecting front-line healthcare workers from Ebola.
The rallies, which have been organized by National Nurses United, the nation’s largest union for registered nurses, are the latest in a series of actions the group has taken to protect nurses from the virus since—as NNU co-president Deborah Burger puts it—”our worst fears were realized.”
Budget Cuts. Mike the Mad Biologist, 2010:
the Obama Administration has decided to massively cut the funding for the CDC’s antimicrobial resistance and vaccination efforts. I thought this was the kind of anti-science bullshit that the Bush Administration did. Even the Bush Administration wasn’t this bad. I am not feeling hopey or changey.
Weak Authority. Reuters, 2009:
Jeff Levi of the Trust for America’s Health, an advocacy and study group often critical of U.S. health policy… argued that the agency’s director is often a passive diplomat with fewer powers of direct persuasion than a state or city health officer and that the organization must wait to be invited by state authorities or governments to intervene.
And the CDC itself agrees, in its deservedly famous post on the zombie apocalypse, in 2011:
If zombies did start roaming the streets, CDC would conduct an investigation much like any other disease outbreak. CDC would provide technical assistance to cities, states, or international partners dealing with a zombie infestation. This assistance might include consultation, lab testing and analysis, patient management and care, tracking of contacts, and infection control (including isolation and quarantine). It’s likely that an investigation of this scenario would seek to accomplish several goals: determine the cause of the illness, the source of the infection/virus/toxin, learn how it is transmitted and how readily it is spread, how to break the cycle of transmission and thus prevent further cases, and how patients can best be treated. Not only would scientists be working to identify the cause and cure of the zombie outbreak, but CDC and other federal agencies would send medical teams and first responders to help those in affected areas.
Note that the CDC failed at “lab testing and analysis.”
General Failed State Fecklessness. From Health Affairs, in 2014:
There is no question that public- and private-sector leaders involved in the Ebola response, including Frieden, made serious mistakes. Frieden, Texas authorities, the President himself and others were overconfident – at times cocky – that the U.S. health system could handle infection control, contact tracing, isolation, and containment responsibilities if faced with an Ebola case. That proved drastically wrong for Texas Health Presbyterian Hospital, a 900 bed, highly respected institution that fumbled badly at several turns. Frieden and others in the administration were slow to reverse course and admit they had underestimated the need for intensive training of hospital staff, better protocols, faster dispatch of CDC ‘swat teams,’ and far more stringent oversight of those who had been exposed and possibly infected.
Politically, Frieden and other officials failed to appreciate just how swiftly a small number of Ebola cases in Dallas could ignite fear across the nation, raise the risk of panic, and begin to erode public trust. Sadly, that fear built upon Americans’ surprisingly high skepticism that their public health institutions are in fact capable of competently protecting them.
Sound familiar? Adding: The Obama adminstration didn’t understand either a multiplying process or the Precautionary Principle. Not a recipe for success, as we have seen.