Thread by @puhfu

Buckle up people. This is a tale of poor EHR #UX, possible institutional malfeasance, missed opportunity, broad #COVID19 disease spread, and mild personal inconvenience.
Tl;dr: I am going into self-quarantine b/c it turns out that I gave Stanford $$$ to give my kid #COVID19 1/

Act one: some definitions

Isolation means separating people who have a communicable disease (like #COVID19) from those who do not. 2/

Quarantine separates/restricts movement of well-appearing persons who may have been exposed to see if they become ill or who have disease w/o symptoms. Self-quarantine is when you quarantine yourself. You can also be quarantined by public health order. Don’t make them do that. 3/

For #COVID19, the quarantine period is 14 days which should be enough to develop symptoms and be contagious. How did they get 14 days? Early data shows that #COVID19 incubation lasts about 5d and 99% of infected persons will develop symptoms by 14d, but 1% will take up to 17d. 4/

See SA Laurer et al The Incubation Period of COVID-19 From Publicly Reported Confirmed Cases in @AnnalsofIM ncbi.nlm.nih.gov/pubmed/32150748 5/

Oh, what do you do if you’re in quarantine? You stay at home. You wash hands frequently. You don’t share towels or utensils and you don’t eat off someone’s plate. You don’t have visitors. You don’t have playdates. You stay >6 feet away from other people at home. Sound fun yet? 6/

Social distancing means avoiding close contact with other people. You don’t have to stay home – but if you absolutely positively must be out in public, keep a >6 foot buffer zone. If you can smell the Santal 33, you’re too close. 7/

Act two: a chronology
2/26 Stanford cancels Italy study abroad program
2/26-27 Stanford hosts Family Weekend, which “provides families with a glimpse of their undergraduate student's life at Stanford with activities and informative sessions, including faculty lectures, ... 8/

... campus tours, a resource fair and open houses and receptions.” We couldn’t attend so …
2/28-3/1 daughter comes home for some family time
3/6 Stanford goes online for last 2 weeks of winter quarter
3/10 daughter develops very mild sore throat, congestion, and dry cough 9/

3/10 Stanford pretty please asks undergrads to leave at the end of winter quarter
3/12 daughter tells us, her mother and I freak, ask her to get tested because my mother has Stage IV NSCLC, is immunocompromised, and has chemo scheduled the week daughter is coming home. 10/

She is told earliest that she can test is 3/14 and she goes into isolation in her dorm room.
3/13 daughter’s symptoms completely gone
3/13 Stanford reports first #COVID19 positive undergraduate and tells everyone to clear out by 3/18
11/

3/14 daughter does drive-thru testing, is told that if negative she will see it in the patient portal (yay!) or if positive, she will be contacted within 24h 12/

3/15

13/

3/16 daughter drives home with her BFF, gets very delayed by snow on the Grapevine, gets a room in a large chain hotel in which only 2 rooms are occupied (including hers)

14/

3/17 meets me for lunch, about to eat lunch when student health nurse calls and asks if she has seen her lab results, daughter says yes, it’s negative, nurse says no, it’s positive, and she will be called by a nurse with instructions on what to do.
15/

16/

Act three: bad #UX aka CMIO heartache
Turns out, the coronavirus result that daughter saw on both the portal and the mobile app was for the routine viral respiratory panel which screens for seasonal coronavirus. But it doesn’t say seasonal. It just says coronavirus. 17/

What’s another common name for SARS-CoV-2? Coronavirus. Strike 1.

(No, I didn’t check it myself. She’s a big girl. They said they’d call her if she was positive. Silly me. I know they’re crazy busy.)

18/

Turns out, they have the SARS-CoV-2 test result set to manually release. I agree! This is smart, especially for something that is causing a great deal of public agitation. BUT! You have to make sure that the #workflow that supports the manual release is solid.
19/

Telling someone that if you are positive then you will be contacted in 24h and then NOT CONTACTING THEM while RELEASING APPARENTLY NORMAL RESULTS is not solid. Strike 2.
20/

This is preventable but easily overlooked if not familiar with the VRP report. Like many of my colleagues, we’ve added language to the VRP result to clarify that it is not #COVID19 in an attempt to make sure that our patients do not come to a wrong conclusion. 21/

I hope @StanfordHealth does the same.

22/

Act four: some mild inconvenience
3/16 I started with slight dry cough, but I have allergies and post-nasal drip and chronic rhinitis and two dogs one of which am allergic to. I cough occasionally. My EHR optimization director says I look off. But I feel great.
23/

I PR’d on my @peloton that morning! (LB name #ride4donutholes – friend me!) Phooey on her.
24/

3/17 see Act two. We spend the next 12 hrs doing contact reporting with Santa Clara and Orange County public health and figuring out what we need to do.
25/

She’s been asymptomatic for 4 days now and per the CDC Discontinuation of Home Isolation for Persons with COVID-19 (Interim Guidance) she’s free to move about the country (not literally) cdc.gov/coronavirus/20…
26/

But per OC Public Health, she is supposed to stay in her room. I plan to argue with them from self-quarantine between standing up a telehealth program remotely and occasionally coughing.
27/

Act five: amateur EIS hour
Let’s count back days.
3/13 first positive @Stanford undergrad
3/12 likeliest SARS-CoV-2 test date
2/29 12 days average for symptom presentation
2/24 5 days incubation

28/

When did classes go online? 3/9
When was Family Weekend? 2/27-28
Do both of those events fall between 3/13 and 2/24?

29/

Some somewhat rhetorical questions:
How likely were there COVID19 shedding undergraduates during Family Weekend?
Why did Stanford send students home when it was likely that the prevalence of COVID19 was high but b/c of the extreme scarcity of tests was not measured?
30/

Why didn’t Stanford give homebound students strict instructions to self-quarantine?
Why weren't Family Weekend attendees directly notified about the risk and advised as to course of action given probable exposure to at least *some attendees*
31/

#FlattenTheCurve means doing everything we can to slow the spread of a virus so that fewer people need to seek treatment at any given point in time. This is critical to ensure that we have enough resources when we need them ...
32/

... like ICU beds for critically ill patients and PPE for our front-line EMS and healthcare professionals delivering care. Part of that everything is taking unpopular steps like #SocialDistancing or massive disruptions like #ShelterInPlace.
33/

A lot of it is knowing that you are taking short-term pain in order to reduce long-term morbidity and mortality. All of it is what @UofCalifornia @carrie_byington described as the “civic duty to protect others”.
34/

We need people and institutions to step up and do the right thing. We need well-endowed universities to lead and not follow. We need to understand that we will be trashing the economy to save lives.
#FlattenTheCurve
/fin