Reference

Reimagining Health Systems in the Wake of COVID-19

Introduction

COVID-19 is a burning ember with various potential final outcomes. It could slowly continue to burn, causing significant illness and death, or it could also fire the imagination to conceive new ideas and plans for a better day. The choice is ours.

With reimagining American health systems in the wake of the pandemic as the topic, Abbott diagnostic Divisional Vice President, U.S. Commercial Operations, Jeremy Schubert interviewed five leading CEOs (see biographies below) from across the United States over the course of several days.

This panel of outstanding healthcare leaders shared their wisdom, direction and optimism for the future through and beyond COVID-19. Their insights and ideas serve as the foundation for this educational thematic analysis of how health systems can be reimagined in the aftermath of COVID-19.

This paper explores solutions to difficult questions facing health systems right now. How do we overcome the challenges brought about by the pandemic? What lessons can we learn? What are the key objectives moving forward? And how do we navigate to a new normal and thrive as healthcare providers once again?

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Understanding COVID-19’s Impact on Healthcare and Beyond

COVID-19 is not solely a healthcare issue; it’s a public health concern with far-reaching impact beyond the clinical domain. It’s not a pathogen we can endure; it is one that must be proactively fought and ultimately overcome. The CEO panelists provided insight into understanding the big picture of COVID-19 and its ramifications throughout society.

COVID-19 has adversely affected those who have become ill and the families who care for them. That’s clear. However, the CEO panel members emphasized the impact doesn’t end with the boundaries of acute care. COVID-19 has also significantly and indirectly impacted the health of those who have not been diagnosed with COVID-19, both physically and mentally, while eroding the financial stability of many health systems and communities at large, putting the most vulnerable in our population at further risk. “How can health systems be part of a broader community effort to deal with socioeconomic issues—housing, homelessness and other social determinants of health? That’s the challenge facing us,” said Thomas Priselac, President and Chief Executive Officer, Cedars- Sinai Health System.

Dr. K. Ranga Rama Krishnan, Chief Executive Officer of Chicago’s Rush University System for Health, experienced swine flu and the sequelae of SARS epidemics during his time as dean of the Duke-National University of Singapore Graduate Medical School. He said recovering from COVID-19 will require investments in public health infrastructure, better efficiencies in the health system, reassured workforces and communities, and different approaches to health plans. “Progress will be measured by our ability to address weaknesses with solutions,” he explained. “It’s a chance to reinvent.”

Overcoming the Challenge of Deferred Care

One detrimental impact of COVID-19 is individuals deferring or postponing healthcare due to temporarily closed elective services or fear of exposure to the virus. Many of the CEOs noted marked decreases recently of patients presenting with heart attack and stroke symptoms in their emergency departments. “People didn’t stop having heart attacks and strokes, but they stopped coming to the ER,” said Warner L. Thomas, President and Chief Executive Officer of Ochsner Health, which serves Louisiana and the Gulf South. The potential negative impact of deferred care is tremendous. For example, National Cancer Institute Director Ned Sharpless said recently that deferred cancer diagnoses, treatments and surgeries due to the COVID-19 pandemic may increase cancer mortality within the next few years, the first uptick in cancer mortality since 1993 (Ong, 2020).

Those suffering from heart attacks, strokes and cancer are not the only patients adversely affected. Surgeries, routine care for people living with chronic disease, and general engagement with healthcare providers have been delayed, as well. These interruptions in care can tip patients, who would have remained healthy under normal circumstances, into a negative spiral, creating enduring health challenges and undermining population health in many communities.

Deferred care is also having an adverse impact on the financial standing of health systems, with the CEOs reporting declines in inpatient admissions, outpatient visits and procedures, emergency department visits, ambulance traffic and more. An American Hospital Association report estimates that total hospital losses from COVID-19 will total more than $200 billion through June 2020 (AHA, 2020). “Only labor and delivery have stayed the same,” stated Michael Rose, President and CEO of Southern New Hampshire Health. “To get back to business, we must demonstrate that we have a safe environment, with no risk of exposure and with adequate COVID-19 testing and PPE.”

Addressing the Social Impact of the Pandemic

The economic hardship caused by COVID-19 is not confined to the healthcare sector, of course; it continues to reverberate throughout virtually every aspect of society. The stress and depression resulting from the attendant uncertainties and civil restrictions are taking their toll on individuals and communities. Health is more than physical; it’s mental, emotional, social, even spiritual, with each being interconnected in some fashion. COVID-19 is assaulting each of these domains of health.

COVID-19 is widening the health disparities gap, with social determinants continuing to have an adverse impact on the health of many Americans. The CEOs had concerns about increased domestic violence and other examples of social malice. “Reports of domestic violence and demand for child protective services are down dramatically because kids aren’t going to school, where this kind of thing is picked up. These reports will be delayed,” Rose said. “Manchester (N.H.) has a significant homeless population, with subsidized housing and shelters available. But the homeless are choosing to stay away from shelters, from fear of exposure.”

To stunt and reverse these impacts, health systems need to be proactive in their approach into the community. It’s not just about healing a person; it’s about healing a community. The first step toward that goal is taking care of healthcare workers. “We have to take care of our team members first, because if you give them the tools and resources necessary to do their work, which includes mind, body, spirit, they are able to bring their very best to caring for patients,” said John Couris, President and Chief Executive Officer, Tampa General Hospital.

Lessons and Insights Learned from the Pandemic

Three themes emerged from the discussion with the CEOs about what the pandemic is teaching us about the United States health system:

It has strengths, and there are opportunities for improvement
The system is not set up for managing public health problems
Fear is a compounding pressure of the virus

The U.S. Health System Has Many Strengths, as well as Opportunities for Improvement

“The pandemic reflects and magnifies both the good and bad of the U.S. health system,” said Priselac. “When it works well, it’s truly the best in the world functioning as a rescue system. Its ability to respond and treat patients generally has been impressive.”

A practical example of this level of response came from Dr. Krishnan. He described how the new Rush Hospital Tower, which opened in 2012 on Chicago’s West Side, was designed to have expansion capabilities during an acute care surge. “We were fortunate,” he explained. “We were able to open up walls to expand ICUs, beds and other facilities to double our capacity.” The Rush team also assisted in establishing a 1,000-bed field hospital at Chicago’s McCormick Place, an exhibition space and convention center, by installing an electronic health record system there within a few days.

Clear opportunities for improvement were shared by all. “On one hand, I was so impressed with our ability to respond in a coordinated fashion to this national public health emergency, but I was also struck by the frailty of the American health system,” said Couris. When the first wave of COVID-19 arrived, the U.S. did not have enough personal protective equipment (PPE) and testing. “Job losses and furloughs seemed to happen overnight,” he recalled. The public health infrastructure that so many assumed was there simply was not.

Investing in epidemiologic surveillance and constantly minding public health system preparedness will be necessary to avoid a repeat of the present scenario, experts agree.

Having studied the SARS and MERS epidemics delivered by coronaviruses, Dr. Ali Kahn, professor of epidemiology and dean of the College of Public Health at the University of Nebraska Medical Center, said “this is about lack of imagination. . . A disease anywhere is a disease everywhere.” (Quamman, 2020) In his book, “The Next Pandemic,” he offered this metaphor: “The time has come for us to move beyond seeing public health as the ax in the display case, where the sign says in case of emergency, break glass.”

The U.S. Health System Is Not Set Up to Manage a Public Health Crisis

Dr. Kahn’s advice leads into a second theme discussed among panel members: how the U.S. system is set up to effectively manage acute care but is not well aligned to managing a public health crisis. Pandemics require coordinated responses across the country and even beyond national borders. Pandemics require fast testing capabilities in high abundance. Fighting a contagious virus requires strategies pertaining to contact tracing, physical distancing and quarantines, as well as public education about why these precautions need to be endured. Pandemics require efficient supply chains for PPE and ventilators.

The U.S. has a great acute care system, the CEOs agreed. But along with most other nations, save perhaps a few countries having experienced quickly developing epidemics in the past, the U.S. now has an opportunity to improve in the execution of a well-coordinated public health response.

Couris described the U.S. health system as a “patchwork—everyone is doing it differently. We need to be able to flip a switch and respond as a virtual system using artificial intelligence and predictive analytics to manage clinical and operational flow,” with coordinated planning among localities, states, the nation and international partners.

Fear Is a Compounding Pressure of the Virus

Health systems need to prepare for how to address the influence that fear has during a pandemic. Fear takes a toll across the healthcare domains (physical, mental, social and spiritual). Fear keeps people from engaging in care and from the social activity important for a quality life. Fear has its foundation in uncertainty. It’s this uncertainty health systems must address.

A recent poll conducted by Verdict (2020) found that 79 percent of respondents said they would avoid going to a hospital at any cost. Health systems must reverse these kinds of attitudes by demonstrating the safety of their environments, the importance of receiving timely healthcare, and the low risk of obtaining this care when proper precautions are followed.

Key Objectives for Moving Forward

The CEO panel recommended targeted outcomes for what they and collectively “we” should try to achieve. Three themes emerged on building to the new normal:

Build the Community. Health systems play a major role beyond the physical well-being of the population. They enable the physical, emotional, social and financial flourishing of the people they serve. Particularly now, health systems need to lean in and take a stronger leadership role in strengthening the community.

Build Confidence. If fear is as big a threat as the virus, building community confidence must be an ongoing focus for each health system. People need to feel informed and safe and know they can count on their health system to underpin their well-being.

Build for the Future. There is more good than bad in the U.S. health system. This situation offers each system an opportunity to reimagine what it does and how it does it—and to accelerate and expand change to achieve more capabilities and impact.

Navigating to the New Normal

So, how do we navigate to the new normal? The CEO panel provided insights along five themes:

Methodically Build a Bridge to the Future

Much has been made about accelerating a return to normal, but speed, while important, is not necessarily the main measure. Recovering from COVID-19 is about building a bridge to the future through a methodical and thoughtful approach, the CEOs agreed. By moving deliberately and nimbly, but not too quickly, health systems can manage and contain COVID-19 while simultaneously building community confidence.

“We can’t look at the recovery like we’re turning on a light switch,” Priselac said. “It’s more like building a bridge. One immediate implication of the pandemic is the opportunity to work together with public health. Testing needs to expand, and we need to work together to educate the public, gradually reduce the need for social distancing, and recreate a robust economy.”

By conscientiously engaging the community in decision and policy making, health systems can integrate the goals of all stakeholders into a common approach that’s supported by public health and social services agencies, schools, the business community and other community resources. The end result will be a safe and economically robust community in which all individuals are supported and empowered.

Building this bridge will require thinking big. With governments acquiring more debt by the day, the answer likely lies in collaboration and innovation. Private and public sectors must work in tandem to build a bridge that lasts.

Collaborate

It’s often an overplayed axiom that healthcare is a team sport. But teamwork and collaboration are essential, particularly when merging a health system’s efforts with public health activities. “It’s not us and them. Everything is us,” Dr. Krishnan noted. His statement succinctly summarizes the need for collaboration.

The CEOs all spoke of the necessity for the nation to respond to the health crises with a shared strategy focused on achieving the greater good. For example, Tampa General Hospital and the four other health systems in the Tampa Bay market established the collaborative sharing of information during the COVID-19 surge, Couris said. With this collaboration in place, the CareComm (2019) center developed as a result of a partnership between Tampa General and GE Healthcare enabled the area health systems to monitor flare-ups, as well as pressure room, ICU and ventilator capacities, in real time. “If there’s a surge, another hospital can take patients,” Couris explained. “We’re fierce competitors but we locked arms. We’re going to deal with this together for the community.”

He continued: “Partnerships are all about partnering with organizations that are already doing it well and that share your values, morals and ethics. Together, you become an unstoppable force.” Couris also spoke of his opportunity to serve on an executive task force with Florida Governor Ron DeSantis to reopen the economy in three phases. He said the task force is an apolitical, data-driven group that has been effective in assisting hospitals during the surge. “We’re not Democrats or Republicans. We’re Floridians called to serve,” he stated. “Our number one focus is the safety of citizens.”

Rose said the level of cooperation among providers in southern New Hampshire was “amazing.” Southern New Hampshire Health joined with Elliot Hospital and Health System, Catholic Medical Center, and St. Joseph Hospital to create the Front Lines NH Challenge Match. This initiative matches individual or corporate donations of up to $2,500, dollar-for-dollar, made through FrontLinesNH.org. “This single fundraising portal amplifies group opportunities to overcome critical needs and shortages,” Rose explained.

“An entire array of community providers came together to prepare for the surge,” Rose said. “Not just hospitals, but public health, local government, the National Guard to stand up alternate care sites, and more. The level of cooperation was great. We shared resources back and forth. We need to keep this going and moving forward.”

Implement Public Health Tactics

To truly attack and resolve the COVID-19 pandemic, health systems must augment a clinical and operational mix of activities to take on more public health capabilities such as proactive screening, contact tracing and surveillance, the panelists agreed. As the COVID-19 acute case surge gradually decreases, health systems will play important roles as testing and contact tracing efforts intensify and post-acute care needs become greater.

While using testing results to inform clinical care, health systems will contribute to broader epidemiologic efforts, as well, particularly those centered on hotspots and underserved populations. Health systems must also prepare to participate in a health maintenance world with integrated testing and assessment for local businesses, schools, and other community organizations.

Ochsner is developing the capability to geo map COVID-19 hotspots down to specific neighborhoods. “Testing must be targeted to areas where we see issues. We can deploy a testing team and we’re working on contact tracing, but we need testing capability,” Thomas stated.

Rose said Southern New Hampshire Health is “pursuing all avenues” to diversify access to testing. “Tests remain scarce, and we need an abundance and a broader screening program,” he said.

Rush is sending testing teams into nearby neighborhoods on Chicago’s West Side, including homeless shelters and nursing homes, to prevent a surge of sick patients. “If the West Side doesn’t do well, we won’t either. We don’t want a river to turn into a flood,” Dr. Krishnan explained.

Build Confidence

Fear is overwhelmed when confidence abides. Building confidence within the community will help health systems to attract patients who have deferred needed health care during the crisis.

Returning to a semblance of normal will require creating confidence about the safety of entering hospitals and other public buildings and spaces. This confidence is required to propel progress until the pandemic is over. Under significant strain during the COVID-19 surge, healthcare team members and patients are dealing with burnout, emotional and financial challenges and home-related issues. There’s fear of job loss, even among health system employees, he said.

Job number one is doing everything to create confidence among healthcare providers and patients that they are safe. Hospitals have begun providing antibody testing to employees and have begun screening all patients, not only those showing symptoms, for COVID-19.

Enabling hospital team members and patients to know their COVID-19 status builds their confidence and sends a strong message about the value placed in their well-being.

Rush developed COVID-19 point-of-care testing in-house, facilitating the placement of inpatients and avoiding public health department backlogs. The tests provide next-day results. The medical center has begun providing antibody testing to patients and employees, with no false negatives so far, and plans to extend this testing into the community. Rush also is encouraging patients and employees who test positive and recover to donate convalescent plasma for COVID-19 patients.

Across the nation, COVID-19 and antibody testing locations, including drive-throughs, are opening in increasing numbers to test essential workers, those who have been in close contact with others who have tested positive, and others seeking peace of mind. “You have to stand up for your employees and do the right thing for your community,” Thomas remarked.

Providing Leadership

There is no replacement for leadership. In the context of the pandemic, the panelists agreed, leadership is about taking care of your teams, demonstrating organizational values, and proactively integrating services into communities. Within communities across the nation, health systems are engaging government, public health agencies, workplaces, schools and universities, and social service providers to achieve optimal health outcomes and close gaps in disparities. Working together in this fashion will achieve resilient supply chains, leverage the resources of all community partners and enable the safe reopening of our society.

In the wake of COVID-19, Priselac sees a tremendous opportunity for leaders to reinforce organizational values. “It’s important to recognize opportunities for change and engage with employees in what those changes might be.” Thomas also emphasized the opportunity to engage with team members to find new solutions. “It comes back to people—great people do well in these situations,” he emphasized.

Reimagine the Future

Health systems have traditionally been built and organized to treat sick patients. The COVID-19 pandemic is challenging health systems to extend services beyond the walls of hospitals. So, how do we use this time as a catalyst for the future?

Embrace a vision of 21st-century healthcare – “hospitals without walls”
Address social determinants to close gaps in health disparities
Place greater value on care coordination to prepare for life coordination

Hospitals without Walls

Health systems will make important contributions to community health by bursting through traditional walls with telemedicine and other digital tools, by helping to improve health literacy and education and having a strong focus on population health.

The most stunning sign of health systems adapting to this new reality is a rise of telehealth. Ochsner is having 4,500 telehealth sessions a day now, compared to 3,600 per quarter pre-COVID-19, Thomas said. All of the CEOs reported similarly rapid increases. “The rapid emergence of telehealth—it’s here to stay,” Rose stated. “Most patients and providers are satisfied with it as a way of delivering care. It will be a larger part of healthcare delivery, especially for primary care.”

A Frost & Sullivan report predicts a 64.3 percent increase in telehealth activity this year due to disruptions to in-person care. The report also forecasts a compound annual growth rate of 38.2 percent by 2025. “The critical need for social distancing among physicians and patients will drive unprecedented demand for telehealth,” said Frost & Sullivan analyst Victor Camlek (Miliard, 2020).

Both Thomas and Dr. Krishnan spoke of further advances in digital healthcare using data, phone apps, Bluetooth capabilities and other methods to deliver care remotely. “The use of data and the ability to connect and be remote will accelerate. It’s not going back; it will continue to evolve,” Thomas said, with the pandemic accelerating the emergence of these technologies.

“Things won’t be the same as before,” said Dr. Krishnan, who described developing partnerships as key to adapting to an increasingly digital world with telehealth, remote monitoring and more. “What would have happened in three to five years will now happen in one to two years.”

Tampa General Hospital is placing its focus on “asset-light” improvements to care, expanding its network of outpatient locations to 50 – with sites stretching from the east coast of Florida to the southwest region of the state – over the past few years mostly through acquisition and having these practices feed patients into the main hospital. A common electronic health record platform serves the entire network, creating a seamless and cost-efficient experience. “Bigger is not better,” Couris emphasized. “Better is better. Let’s do a better job with what we have and leverage technology to build a 21st-century health system. That’s the journey we’re on. It’s less about brick and mortar and more about better coordination of care.”

Address Social Determinants to Close Gaps in Health Disparities

In the future, health systems will need to expand their remit to more broadly consider social determinants of health for members of their communities, the CEOs agreed. These determinants are the social and economic factors impacting people’s lives, factors such as food insecurity, housing instability, language barriers, income instability, transportation needs, and substance use. Social determinants represent the intersection between social and healthcare programs and their funding.

With COVID-19 further intensifying social determinants’ impact on communities, now is the perfect time for U.S. health systems to evaluate their local social determinants map and ideate how their models could adapt to better preserve the well-being of their communities. For example, Cedars-Sinai has contributed more than $2 million to 10 different grantees providing housing, food assistance, access to care and emergency relief to those in need during the pandemic (Cedars-Sinai, 2020). This funding comes on top of the $15 million Cedars- Sinai committed last year in support of safety net organizations and the communities they serve, Priselac said.

Placing Greater Value on Care Coordination to Prepare for Life Coordination

Health systems have continued to evolve and adapt over time. The value they increasingly bring to the table transcends traditional acute care and drives into the role of care coordination. “A 21st-century health system is not brick and mortar. It’ll be a network of partnerships and collaborations that delivers excellent care coordination,” said Couris. “We are in the coordination of care business.”

Taking a mind, body and spirit holistic view of health, Tampa General recently made a $500,000 donation to fund a not-for-profit organization that convenes, allocates and coordinates mental health in the community, Couris continued. Throughout the hospital’s service area, Couris and his team are looking for ways to build healthier and happier communities through coordination and collaboration.

When you consider the concept of a health system without walls, the expanding definition of health and the needs of each community, it’s easy to see how the role of the health system could expand to the level of “quality of life” coordination.

“We need to help people understand how to lead healthier lives—can this pandemic be a catalyst for this?” Thomas asked. The pandemic will force the acceleration of health systems integrating what they do into the community’s everyday life. “We must harmonize health systems, community services and people’s lives and transcend the traditional definition of health,” Couris said, through partnerships with organizations that have community improvement as their mission.

Summary

In the post-COVID-19 world, no organization providing healthcare services stands alone. No health system is an island. We are still in a time where we are not out of the pandemic yet, and just emerging into this new normal. Now is the time to begin reimagining health systems working in coordination with government, public health agencies, and other community stakeholders to create a future where everyone is invested, healthy and safe.

The current pandemic is not an end; it’s a beginning to the value health systems can provide, not only in their traditional role as medical care providers but in virtually all aspects of society. For all health systems, progress will be measured by the ability to build on their strengths and address weaknesses with solutions, as Dr. Krishnan stated earlier. It’s a chance to reinvent. Health system leaders everywhere are supporting efforts to achieve new and better ways of doing things.

Dr. Krishnan believes the public at large will learn through its present experience and be better prepared, more confident and less fearful next time. “Once you experience an epidemic, you’re afraid of it and you prepare for it,” he said. “This is not new for me. It’s not going away tomorrow, but I tell my team members, ‘we’ll get through this. I guarantee it 100 percent.’”

This will result in health systems reimagined.

Health System CEO Biographies

John Couris
President and Chief Executive Officer, Tampa General Hospital

Couris took the helm of this 1,006-bed organization with more than 8,000 team members and 1,500 physicians in 2017. He has achieved success through innovation, operational excellence and strategic collaborations. He is best known for creating an organizational culture that thrives on authenticity, kindness and transparency, and he believes that focusing on the well-being of his team drives positive experiences for patients. His inclusive leadership style allows him to engage frequently with team members at all levels of the organization.

Dr. K. Ranga Rama Krishnan
Chief Executive Officer, Rush University System for Health

Dr. Krishnan became the second CEO of the Rush University System for Health in 2019. He is leading innovation of care delivery at Rush, organizing providers around patients and diseases and conditions, rather than by department or division, to enable greater collaboration. This service line approach enables providers to share expertise, ultimately improving patient care, quality and safety.

Thomas M. Priselac
President and Chief Executive Officer, Cedars-Sinai Health System Named President and CEO when the health system was formed in 2017, Priselac presides over a network including Cedars-Sinai Medical Center, its physician network, major medical education and research programs and various other affiliated medical centers and physician networks located in southern California. Priselac also serves as an adjunct professor at the UCLA School of Public Health.

Michael Rose
President and CEO, Southern New Hampshire Health

Rose serves in the dual role of CEO for Southern New Hampshire Health and Chief Financial Officer of Solution Health, the parent organization. Rose leads a team of 7,000 employees and 700 physicians working in five medical centers, three specialty centers and various primary and specialty practices. His team is rich in knowledge of the New Hampshire communities it serves.

Warner L. Thomas
President and Chief Executive Officer, Ochsner Health

Named one of Modern Healthcare’s Top 100 Influential People in 2019, Thomas believes in setting industry best practices and forging innovative partnerships with major companies. He spearheaded innovation Ochsner to revolutionize patient-centered care. His expertise was nationally recognized through his appointment to advise Congress on the Medicare Payment Advisory Commission.

John Couris
President and Chief Executive Officer, Tampa General Hospital

Jeremy Schubert
Divisional Vice President, U.S. Commercial Operations, Abbott Diagnostics

Having dedicated his entire professional career to Abbott, Schubert assumed his current role in 2017. He has held several commercial and leadership positions across multiple divisions of Abbott, including Managing Director for northern Europe and Divisional Vice President of Latin America and Canada. He is a member of the International Health Economic Association and has earned master’s degrees in public health from the University of Liverpool (U.K.) and business administration from Northwestern University’s Kellogg School of Management.

“Any day you can learn something is a good day. We thank these distinguished executives for providing their insights on how we can tackle the challenges presented by COVID-19 and create healthy communities, human flourishing and better lives for all. At Abbott, our goal is to help leaders play an active role in helping communities return to normal and reimagine and rebuild health systems.” – Jeremy Schubert, Divisional Vice President, U.S. Commercial Operations, Abbott Diagnostics

References

American Hospital Association. May 5, 2020. New AHA report finds financial impact of COVID-19 on hospitals & health systems to be over $200 billion through June. Retrieved from: https://www.aha.org/special-bulletin/2020-05-05-new-aha-report-finds-financial-impact-covid-19-hospitals-and-health

Cedars-Sinai. March 27, 2020. Cedars-Sinai giving more than $2M to help those affected by COVID-19. Retrieved from https://www.cedars-sinai.org/newsroom/cedars-sinai-giving-more-than-2m-to-help-those-affected-by-covid-19/

Miliard, M. May 15, 2020. Telehealth set for ‘tsunami of growth,’ says Frost and Sullivan. Healthcare IT News. Retrieved from https://www.healthcareitnews.com/news/telehealth-set-tsunami-growth-says-frost-sullivan

Ong, MBH. May 15, 2020. Sharpless: COVID-19 threatens to reverse long-running trend of decreasing cancer mortality. The Cancer Letter. Retrieved from https://cancerletter.com/articles/20200515_3/

Quamman, D. May 4, 2020. Why weren’t we ready for the coronavirus? The New Yorker. Retrieved from https://www.newyorker.com/magazine/2020/05/11/why-werent-we-ready-for-the-coronavirus

Tampa General Hospital. August 20, 2019. New Tampa General Hospital center uses human ingenuity and artificial intelligence to improve patient care. Retrieved from https://www.tgh.org/news/media-resources/new-tampa-general-hospital-center-uses-human-and-artificial-intelligence

Verdict Medical Devices. May 20, 2020. Public reluctant to visit hospitals during COVID-19 emergency: poll. Retrieved from https://www.medicaldevice-network.com/news/people-reluctant-to-visit-hospitals-during-covid-19/