Current Events

Just-in-time vs. building resilience: Finding the balance

Siddhartha Mukherjee has a great article in The New Yorker titled “What the Coronavirus Crisis Reveals About American Medicine“. Much of the article details some of the fundamental problems that causes major failures in the U.S. health care system’s response to COVID-19.

Resilience in our medical system will involve more than considerations of physical supplies. Take the debacle of the C.D.C. detection kit. Here’s where attention to “mature quality systems” matters. South Korea has so many test kits that it’s now exporting them for use in the United States. What was its approach? The government identified more than twenty reputable venders, certified their products through a sound evaluation process, and set their factories loose to meet the demand. That’s what the C.D.C. should have done, long before the pandemic arrived on these shores. In preparation for a future pandemic, the C.D.C. could run the equivalent of fire drills, identifying the capacity…to create and mass-manufacture such kits during a time of crisis. The organization, rather than closing itself off, working chiefly with state and military labs, could fortify lines of communication with the commercial and clinical labs that actually serve the vast majority of patients. The F.D.A. could have had a streamlined E.U.A. [Emergency Use Authorization] form already in hand—preferably without a requirement that it be sent by pigeon post—rather than having labs waste critical time placating its bureaucracy. Before the next public-health crisis emerges, the F.D.A. must think hard about how to balance speed and oversight, adjusting the ratio to meet the moment but abandoning neither

So clearly, we just need more resilience, more slack in the system, right? Well, that can’t be the only answer. People adopted just-in-time systems for a reason: they are cheap and efficient in most typical times. Building in excess inventory and capacity can be costly.

As [Alex] Greninger [the assistant director of the virology lab at the University of Washington.] put it, “Right now, I have machines and reagents to test tens of thousands of patients for sars-CoV-2. That’s basically all the clinical virology lab is doing. What will happen when the epidemic is over?” Once the incidence of covid-19 subsides, so will the sense of urgency when it comes to building infrastructure, or stockpiling equipment—masks, ventilators, reagents—that might sit unused in warehouses for a decade or more. We need purchasing procedures that control costs without creating conditions in which critical supplies vanish during a crisis. We need a Strategic National Stockpile that has sufficient inventory to ease temporary shortages. But, most of all, we need an identified capacity—a network that can be activated on demand, repurposing manufacturing lines, recalibrating agency protocols.

Another thing that the COVID-19 pandemic crisis has taught us is that electronic medical records need to be re-engineered.

Finally, we need to acknowledge that our E.M.R. systems are worse than an infuriating time sink; in times of crisis, they actively obstruct patient care. We should reimagine the continuous medical record as its founders first envisaged it: as an open, searchable library of a patient’s medical life.

A scathing indictment demonstrating how the U.S. health care system has to do better.

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