Q&A with Accolade Chief Medical Officer Shantanu Nundy, MD

Accolade Chief Medical Officer Shantanu Nundy, MD, recently presented to HR executives, benefits leaders and benefits consultants about the three phases of COVID-19 and the steps employers can take to help their people stay healthy and well throughout the crisis. His remarks were delivered in a webinar hosted by EBN/EBA titled “Why Employers Need a Comprehensive Approach to COVID-19.”

Shared below is the audience Q&A that followed Dr. Nundy’s prepared remarks. You can access the entire webinar recording here.

Question: Some sickness can be handled by telemedicine, but what about the conditions that need a more detailed assessment?

Dr. Nundy:

That’s such a fantastic question. It turns out that if you look at primary care, which is what I practice, 90 to 95 percent of concerns can actually be handled virtually. That’s a pretty startling stat. I think when you look at the evidence about physical exams or things that are part of the tradition of medicine, a lot of those things haven’t been proven over time to be evidence-based. But we also know that with distributed access to say lab testing—and that lab testing facilities often can take blood pressures and take vital signs—that’s why 90 to 95 percent can be handled virtually.

But there clearly is that five to 10 percent of concerns that can’t be managed virtually. What we’re doing in my clinic, and I think so many other clinics are as well, is ensuring our clinic is COVID free. There is no patient with coronavirus, no patient with flu-like illnesses, within our four walls—those patients are being managed virtually. They’re being managed with drive-thru testing sites that we have in the parking lot at my clinic, and they’re being managed in an emergency room or in a hospital. That’s allowing us to manage 90 to 95 percent of people virtually and then for those that need in-person care, we feel very confident that they can come into clinic and be seen safely for the things that require an in-person visit.

Question: Is there the possibility of having a COVID test that would be accurate, inexpensive and something an employer can administer daily?

Dr. Nundy:

There is interest in a true point of care virus test for COVID-19. As of now, the tests that exist either have to be run in a very large laboratory, or they can be run in a smaller laboratory, but they’re done through batch samples. So the short answer is, today there isn’t such a rapid test that could be done for the virus point of care, but there are efforts underway to develop such a test.

I think the question for us is going to be how do we have the right partners that can keep up with that pace of innovation so that if and when that test becomes available, we’re able to get it to the right people, deploy it fast enough, and do it in a way that meaningfully drives outcomes.

Along that same vein, is it possible that the saliva test, the antibody tests and eventually a vaccine could be widely available at outlets like CVS, Rite Aid, or Walgreens—similar to flu shots?

Dr. Nundy:

Absolutely. Flu shots—that’s a great analogy. I think pregnancy tests are a great analogy, too. Diabetes tests—that’s a blood test that people do at home—is another great analogy. So there is absolutely that conversation happening nationally. I spend a lot of my time on the phone with the FDA, trying to create this picture to say that we need a better approach for at-home testing options, including self-serve options like going to your local pharmacy. All those options should be on the table. We’re rapidly building that evidence. Last week we had the very first at-home test approved by the FDA. We have a lot more work to do but we’re moving in that direction for sure.

Testing is just a snapshot in time. How often should we be requiring each of our employees to test if we go back to the in-office environment?

Dr. Nundy:

That’s a great question. For us it’s critical to always follow the evidence and the national guidelines. And the national guidelines with the CDC are that we should be testing people with symptoms—and they just made an update this week about a bunch more symptoms—and for people that have a known close contact exposure. Those are the people that require testing. There currently is no guidance on testing everybody or folks that either don’t have symptoms or don’t have a close contact. So for us, that’s really the starting point.

But clearly there’s concern about asymptomatic spread. We know that people who don’t have symptoms can also pass it on. So I can understand the desire to want to test people who even have no symptoms and no contact. But in my view, there's so much room to go by simply executing on that comprehensive lifecycle goal. If you know 100 percent of your employees who have COVID-19 and you’re able to contact trace with 100 percent of the context that they face, and you’re able to manage them through that process, and then verify through medical clearance and biological clearance that they can return to work, then you can effectively reduce your workplace exposure to COVID dramatically. That’s what we’re really focused on.

And then we can ask if there are even opportunities to tie systems together? The moment that someone says that they need to take a day off for sick leave, is there a way to say, “hey, that’s great. Can we have you call this nurse?” And then from that moment we’re tying sick leave to support. That way we can get closer to that 100 percent coverage so that we don’t have employees who are leaking through. We have full visibility into who’s dealing with COVID. We’re able to provide support for them and we’re able to proactively outreach to anyone they may have been contacted with. We think that’s really the most evidence-based comprehensive approach that we can take right now.

You spoke of establishing a narrow partnership for COVID-19 to help with triage and getting to appropriate testing. What is that partnership?

Dr. Nundy:

I’m happy to speak to that. We partnered with a company called PlushCare, a telemedicine company. PlushCare is our partner for COVID-19 and assessment in COVID-19 testing. We chose to partner with PlushCare based on a few critical variables. Number one, we really believe in their clinical philosophy; they take very much a whole-person approach similar to how we approach supporting people.

Number two is they have the capacity. We were seeing capacity constraints on the physician side across our customers, and so we wanted a company that is able to meet the demands of our customers with physician supply. Number three is the ability to innovate very rapidly, because we know that the testing options are going to continue to change. For example, last week when Quest came out with the first antibody test that’s available across all Quest centers, PlushCare became the first telemedicine company nationally that was able to provide antibody testing and had a very clear clinical protocol for that. Those were the three criteria for partnering with PlushCare.

I think what’s really critical, though, is engagement in that solution. We know that there’s a long history of great solutions that don’t get utilized by employees, so that’s where our partnership comes in and our ability to navigate patients to that. Second, we also know that doctors are very busy. They’re able to help with that diagnosis and that testing, but they weren’t able to provide that full complement of support that people need to get through the quarantine process. And for us, that’s really where the magic is is that partnership to be able to provide that sort of whole person population perspective, get them to the latest and greatest testing—But also be able to hold that employee’s hand through that whole process because we know how stressful and potentially dangerous that can be.

How do you target a specific population when you don’t have access to who is considered high risk because of privacy concerns? Are there ways other than educating through a general communication campaign?

Dr. Nundy:

That’s a really great question, and one that we haven’t directly come into contact with because we have the benefit of being integrated into benefits and into claims. But certainly as a clinician in my practice that’s an issue we deal with very commonly. My belief has always been use whatever data you have access to, even if it’s simply people’s age, that’s better risk stratification than nothing. I also think that there’s an opportunity to deliver very lightweight types of health risk assessments to a population.

I think particularly in a time of COVID-19, when you’re able to convey the context for such a survey, you could be able to push out a simple survey that’s able to ask about people’s comorbidities or their health risks and I think if you explain that as, “Hey, the reason for this is because we’re trying to understand who’s at highest risk and how we can support those people that are higher risk.” I think that there’s going to be more uptake for that. I know a lot of the industry has moved away from health risk assessments, but I would say that a lot of the data that you can get from there, you could collect rapidly and can be useful for stratifying your population.

Even if you test negative, how do you know the person isn’t positive the next day or the next week?

Dr. Nundy:

Any test we do in medicine, there is a certain sensitivity and a certain specificity, meaning that there’s a chance that we can miss positive cases, and that’s just a fact of any tests that we use. Certainly that’s been the case for the viral test that we’re using for COVID-19. There are known cases of what’s called false negatives.

One approach is to take more of that old view of clinical assessment and not simply rely on a test to tell us what needs to be done, and that goes back to my point about biological and medical clearance. If I’ve seen a patient that has a negative test but has a recent exposure and has all the right symptoms, I can use clinical judgment to say, “You know, despite the fact that your test is negative, I want to be extra sure here and let’s have you quarantine another day or two and test you again.” So I think that’s where that partnership comes in, and I think that’s where a pure self-service model isn’t going to be sufficient. We need to leverage the medical community, the nursing community, and have a more comprehensive approach.

If an employer is taking temperatures at a site prior to entry, is there a minimum temperature an employee should show to be sent home?

Dr. Nundy:

I think using a low grade temperature of 100.4 is a good starting point. I will emphasize that I think temperature checks make sense, but they are just one tool of what has to be a comprehensive approach. We know that there are people completely asymptomatic—no temperature, no fever—and so while temperature check makes sense, it has to be in the kind of broader lifecycle approach in our view.

Register to view the entire webinar here.

About Shantanu Nundy, MD, MBA

As chief medical officer of Accolade, Dr. Shantanu Nundy oversees the company’s clinical strategy and solutions to improve health outcomes for individuals and families, as well as the experience and relationships they have with their providers. Dr. Nundy is a practicing primary care physician in the D.C. area and an expert in global health policy. He has conducted research at Harvard Medical School, Johns Hopkins, and the Centers for Disease Control and Prevention.