Deborah Abrams Kaplan

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PillPack, Amazon Care, Haven, Amazon Comprehend Medical, and yes, Alexa.

This is not an exhaustive list, but these are some of Amazon’s forays into healthcare and its one-fifth share of American gross domestic product. The Seattle-based online retailer has also become an infrastructure company with major market positions in logistics and cloud storage. Predictions that Amazon would be transforming American healthcare perhaps shot too high, but healthcare is very much on its agenda.

Although it’s impossible for Amazon to operate in total stealth mode, the company hasn’t shared a sweeping vision of its healthcare strategy publicly, although analysts and reporters do pick up nuggets here and there from earning reports and company press releases. When Bryan Niehaus, vice president of Advis, a healthcare consulting firm in Mokena, Illinois, looks at Amazon’s various entry points into the industry, it shows him that the company is perusing and being selective. “They’re learning about the healthcare industry and picking their spots on where to get involved. Some areas might be disruptive, some are extensions of their current business,” Niehaus says.

The potential disruption may result from attempts by Amazon Care and Haven (although Haven has struggled to find its footing) to provide direct patient care and influence quality and cost. Extensions of their current business includes PillPack, a consumer prescription delivery model, and the various data storage and analytics efforts.

Amazon bought PillPack in 2018, when it was already a full-fledged mail-order pharmacy able to dispense in 50 states, with local brick-and-mortar pharmacy relationships. Amazon has a Midas-touch image, but that talent isn’t always so homegrown. “Not everyone thinks of Amazon being innovative in mergers and acquisitions,” says Nathan Ray, director of healthcare mergers and acquisitions at West Monroe, a business and technology consultancy headquartered in Chicago.

PillPack had not only a growing business model, but also the regulatory expertise Amazon needed to get into the pharmacy business. They had the licensing and the infrastructure to supply retail pharmacies and mail-order services. “Clearly they saw the opportunity to break into this large market and connect to their existing consumer base,” says Niehaus. PillPack has the potential to be a digital front door for customers to add to the goods and services Amazon offers. “Maybe they can partner with a large electronic health record (EHR) system and have a sign-on space,” he says. This could allow them to consolidate across prescriptions, medical devices or other medical supplies.

Blue Cross Blue Shield of Massachusetts announced a deal with PillPack in December to offer the pharmacy services to plan members, including free delivery of multiple medications. In its press release, the Massachusetts Blue plan said it was the first health plan to offer “direct integration” with the PillPack’s services.

Another possible fit with PillPack, say Niehaus and Ray, is telehealth services. “The possibilities are wide in how they can approach and streamline disparate parts of the health system,” Niehaus says.

Aside from Amazon Care, which currently serves some Amazon employees and their dependents in Seattle, the company doesn’t offer its own telehealth services. But that doesn’t mean Amazon is a total bystander. A large fraction of the telehealth services launched amid the COVID-19 pandemic use Amazon Web Services (AWS) data centers, notes Ray.The connection between telehealth and AWS is a reminder that almost anything having to do with the internet is a business opportunity for Amazon. Combine telehealth with the data collection and analysis from wearables and remote monitoring, and this could be the biggest healthcare change of our lifetime, says Ray. Amazon has made advances in technology-enabled care, but “I would have expected them to move faster,” in terms of telehealth, he adds.

In September 2019, months before the COVID-19 pandemic whetted appetites for virtual healthcare, Amazon took the prescient step of launching Amazon Care, a virtual health program offering telehealth visits and in-person follow-up care to a subset of Seattle headquarter employees. Among the eligible employees are those living in 105-designated ZIP codes with Amazon-sponsored health plans (as opposed to those with Kaiser Permanente plans). Vin Gupta, M.D., a pulmonologist and high-profile public health expert, was hired in January as principal scientist. In February, the endeavor was expanded to include dependents of those employees. Amazon Care is very interesting, says Ray, because Amazon, in a sense, is experimenting on itself and its staff with a new care model.

As a large employer with some of the deepest pockets around, Amazon has the scale to save money and innovate simultaneously. Large companies are often centers of healthcare innovation, Ray says, sometimes helping payers with utilization management for specific populations. Amazon Care has the opportunity to remove access barriers with convenient hours and proximity of care. “All that sounds small, but it’s enormously instrumental in conceiving ... different ways to receive and manage care,” he says.

Ray says he wonders what success will look like for Amazon Care if it were expanded to include employees at its warehouses and subsidiaries across the country. Large, self-insured employers actively participating in employee health management can get better valueand offer more services than companies with commercially insured plans. The Amazon Care model could be extended to other sites across the country or even to other companies.

Amazon Care’s primary care clinics could become a great proving ground for healthcare innovation.

The prospects for Haven are perhaps cloudier, especially considering the once sky-high expectations that surrounded the enterprise. Launched in January 2018, Haven is a joint effort of Amazon, Warren Buffett’s Berkshire Hathaway and JPMorgan Chase. Healthcare’s chattering class was talking about the “Amazonification” during its perinatal period. The naming of Atul Gawande, M.D., as CEO of Haven added cachet.

But Gawande announced in May that he was stepping down as CEO. The Haven website says its goal is to pursue “a number of commonsense fixes, as well as innovative approaches, to address issues like making primary care easier to access, insurance benefits simpler to understand and easier to use, and prescription drugs more affordable. We are looking at new ways to use data and technology to make the overall healthcare system better.” Those are admirable but middle-of-the-road objectives. “They’re encountering some existential questions about how they go about effecting change,” says Niehaus. “What is Haven’s true goal? Cutting costs in healthcare is a wide one. How they’ll go about doing so hasn’t become clear at this point.”

So far, Haven has only one concrete achievement: Working with Cigna and Aetna, employees at JP Morgan were offered plans with more price transparency.

Comprehend Medical, an outgrowth of AWS, is a natural language processing and artificial intelligence (AI) service. It’s complicated to pull data out of medical records because EHR systems were developed more for billing than data capture and clinical analysis. Amazon is offering not only transcription services that put the data into the appropriate fields but also data standardizing to healthcare clients so they can better access and use their data. AI is also used in imaging studies to identify potential abnormalities, but algorithms are developed for specific-use cases, making it a slow process to develop new functionality. “These concepts are valuable but incrementally being brought into how things work,” Ray says.

Anthem Blue Cross and Blue Shield has a program in 12 states that lets members use Alexa, Amazon’s smart speaker, to refill prescriptions, schedule appointments and answer insurance-related questions about claims and deductibles. “The larger trend here is, how do we simplify the experience for our members?” says Rajeev Ronanki, Anthem’s chief digital officer. Anthem offered the service for informational questions starting in 2018, providing the nearest doctor or pharmacy information without Alexa identifying the user. “Once the technology partners like Amazon got HIPAA certified in 2019, we started looking into more specialized services,” he says.

National Health Service in Great Britain partnered with Amazon for Alexa to provide general health guidance in 2019. Niehaus wonders out loud whether the Alexa of the future would prompt users on what purchase to make based on the questions she is asked.

With so many points of entry into Amazon’s data reach, the natural question is how are they using the collected data? In the context of the deal with National Health Service, Amazon told 

 that the company was not building health profiles or using health information to recommend or sell products. The devices record what is said, however, and there have been cases of the smart speakers sending recordings without user consent. Amazon also retains recordings to help train its AI algorithm.

Ronanki says that Alexa is not storing any member information. “We’ve verified that through our contract,” he says. Alexa authenticates the member’s voice to ensure it’s the right person, and Amazon sends a passkey to the user’s phone for each unique conversation. The resulting action is confirmed, like a scheduled appointment or prescription refill, based on the member’s stored preferences.

However, even without retaining health data, Amazon can use the lessons learned from the experience to develop systems for other organizations, Niehaus says. Amazon will have, for example, access to all the information gleaned from the entire British population that can be applied elsewhere. But there are clear restrictions about which data Amazon can access from healthcare organizations using AWS, precluding Amazon from mining that data. “It’s fairly common for cloud services to host data in accordance with HIPAA. There’s no evidence they’re inappropriately accessing the data,” says Niehaus.

The bigger concern for Ray is the potential consumerization of the healthcare data for marketing purposes. “One of the largest areas of healthcare is marketing, especially around Medicare Advantage. Do I worry about what data they’re mining about my parents,” resulting in targeted ads? Yes, he says.

Amazon’s future in healthcare may partly depend on how the entrenched players respond, says Niehaus. With continued industry consolidation, other players are building market share. With COVID-19, there’s been an accelerated focus on catering to patient convenience, and the relaxation of regulations has helped telehealth take off. Amazon may be on the sidelines now, and telehealth company valuations are high so there’s no bargain to be had. But Amazon bought its way into mail-order pharmacy when it bought PillPack. It could do the same with the purchase of a telehealth company.

Amazon’s overall healthcare strategy still hasn’t come into focus. “It’s unclear if there’s one person directing all the efforts,” says Niehaus, adding that he isn’t sure if Amazon will try to serve as a connection point or focus on specific healthcare services.From a mergers and acquisition perspective, says Ray, the challenge for Amazon is integration: how to fit together the various technologies.

Amazon has an opportunity now to acquire other companies that are short on capital because of the pandemic. That could be a company complementing PillPack — a competing supplier, for example. With more healthcare migrating to the home due to the COVID-19 pandemic, wearable devices and remote monitoring are likely to become more important. “The hub around your health,” says Ray, “will probably answer to the name Alexa in the not-so-distant future.”

Deborah Abrams Kaplan is a regular contributor to Managed Healthcare Executive.®

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Whether the online giant has larger healthcare ambitions is unclear.

Amazon’s Quiet, Selective Forays into Healthcare

The alphabet soup of healthcare C-suite titles seems to be in constant flux, with new titles popping up as part of the leadership. Some of the titles — chief people officer, chief wellness officer — may induce eye rolls because of the touchy-feely factor. But in many cases, they reflect new priorities and cultural shifts. The CEO and healthcare systems’ boards of directors are adding to the C-suite or renaming old positions as a response to competition and the need for greater accountability.

Determining the size of the C-suite and the titles within it is a case-by-case proposition. 

“The C-suite should only be as big as it needs to be to be responsive to the needs of that business,” says Joseph Fournier, J.D., M.H.A., president of InveniasPartners, a healthcare executive search and strategy company in Chicago. The core leadership almost always includes the CEO, chief financial officer (CFO), chief operating officer (COO) and, for healthcare systems, chief nursing and physician executives, he says. 

“Then we need to start filling in around that,” Fournier says.

Trendy titles may be relevant even if they sound less traditional. They often represent new challenges or a focus affecting the culture and bottom line.


With the growth in electronic health records and other digital initiatives, the chief digital officer(CDO) role is gaining prominence, according to Fournier. The chief information security role is also picking up steam because of cyberattacks and the risks posed by health and financial information data breaches. The CDO might also oversee the chief analytics officer (CAO), who is responsible for sifting through the terabytes of healthcare data that many healthcare organizations have at their disposal because of EHRs and that old mainstay, claims databases. “There’s a need for usable data that tells real stories about patients and can connect to health information,” Fournier says.

The CAO’s position also is climbing up the organizational charts of payers, notes Thomas Quinn, senior partner and managed care practice leader at WittKieffer, an executive search firm in Boston. Harnessing data to make quick decisions is critical when a member is at high risk of hospital admission or is a high utilizer. Identifying and sharing that information with the care management team can affect the patient’s health and care, as well as associated costs and revenue. “We’re seeing that role being elevated, put under the CFO or sometimes the COO,” Quinn says.


In 2017, California’s Stanford Medicine became the first academic center to add a chief wellness officer (CWO). Since then, at least a dozen more centers have added a CWO, sometimes called chief well-being officer. The focus has been on helping physicians and other caregivers with burnout and making sure they have appropriate services to deliver safe and effective care, according to Fournier. But the position and the person in it have a broader role, he says.

“A chief well-being officer can really understand the goals of the business and the needs of the patients and (can) integrate well-being into the culture and DNA of the organization,” Fournier says. The position may not succeed in all healthcare organizations — leaders who stick to traditional thinking may not be receptive to a role that can be thought of as coddling, he notes.


Among payers, the chief growth officer (CGO) is catching on, says Quinn. He differentiates the role of CGOs from traditional sales because CGOs are supposed to think and act more strategically. It’s the CGO’s job to scout out potential partners and alliances to grow membership and suss out new market segments. The role uses “a different skill set than a traditional sales guy who works the brokers,” says Quinn. Whereas the marketing staff may have undergraduate degrees, a CGO probably has a master’s degree —or at least that skill set.

Another hot title is chief of government programs (CGP)or government markets, says Quinn. Margins have been better in Medicare and Medicaid dual programs in the past four to five years, he says, and the role, which spearheads federal solutions, reflects that.

Adding C-suite titles can help solve real problems as well as give an organization additional cachet. But the titles also can be a luxury. Smaller and midsize hospitals are not typically adding the management titles seen elsewhere, with the exception being some academic institutions that are more willing to invest at the C-suite level, says Brandt Jewell, senior vice president at Coker Group, a national healthcare advisory firm in Alpharetta, Georgia. “Smaller and midsize hospitals don’t have that bandwidth,” Jewell says.

Physician leadership positions lag in systems with fewer than hundred providers, observes Jewell. Partly it’s because the systems may not have enough doctors to invest in the chief medical officer role. But Jewell says he’s observed that doctors tend to be less interested in working with the profit-and-loss statements and more interested in value-based care. That’s an area where physicians can be more easily recruited for leadership development.

Boards and organizational leaders use titles to delegate accountability for things they consider important. “When I see C-suite invest in a new C role around something like value-based care, it’s saying, ‘This is important to us, and we need someone with the highest level of expertise to focus on it,’” says Jewell.

Fournier says organizational leaders — often the governance committee of the board and the executive committee — need to hash out what they are trying to accomplish. In a highly competitive environment, executives should look at the factors that make their organization stand out. If a certain factor or experience is critical to success, the organization can signal that strength with a position and a title — and with putting a strong leader in that role, says Fournier. This doesn’t mean the position needs to be at the C-suite level, but the person needs to have the operational abilities and budget to succeed. “The executive team needs to think about how to attach people and strategy … and look at the critical bodies of work to see where that role needs to sit,” Fournier says.

Payers and providers used to live in their own bubbles, but healthcare systems are expanding how they do business, including entering into joint ventures. A person running a joint venture may have the title of president without having many executives reporting to them, says Jewell.

The CEO, the CFO, the COO, the CIO — those are C-suite constants that aren’t going away. But Fournier says C-suite organization and titles should be viewed as dynamic, notstatic. Roles may emerge and then fade away. “Or they may decide after a while that it’s not a role that matters, because the C-suite roles become synthesizers of information. They’re really there to tie together workstreams for leaders,” Fournier says. A chief experience officer might, for example, oversee the work of those responsible for both the employee experience and patient experience. The chief legal officer may oversee the risk portfolio, including the chief compliance officer and general counsel.

Mergers are another time to reconsider the structure of the C-suite. “In general, consolidations have taken away more executive jobs than they’ve created,” notes Quinn. Many of these deals are set up to allow the local hospitals to continue running themselves, at least for a few years, says Jewell. “Every local hospital has their own C-suite to go along with the regional and national C-suites. A lot of systems are hesitant to blow that up locally,” he says.

Often the layoffs occur at the operational level, affecting employees in human resources, revenue cycle management and technology as those functions get pulled into a centralized operation in the name of efficiency and standardization. With many acquisitions, the C-suite stays put for two to four years, and then changes may be made.

C-suite roles will continue to change with healthcare trends. Roles may disappear when a particular person leaves; the executive committee and board may use the departure as an opportunity to tweak a role and title — or abandon it because more pressing issues have arisen.

It would not be surprising to see positions added related to emergency preparedness, diversity and inequity — if not to the C-suite, at least to the level in the organizational chart that reports to the C-suite. “As different needs emerge in the organization and at different times, some roles become more prominent or get more attention than others,” Fournier says.

Deborah Abrams Kaplan covers medical and practice management topics.

Where some see bloat and trendiness, others see nimbleness and responsiveness. 

Has the C-Suite  Gotten Too Big?

During the past decade, physicians, dentists and other providers latched on to electronic reminders to get patients to come to appointments by pinging them with text and email messages. Patients now are getting nudged (some may argue they’re being nagged) to take their medications.

Yet adherence problems persist. “In patients with chronic disease, nearly half do not take their medicines as prescribed, and more than a quarter of newly written prescriptions are never brought to the pharmacy to be filled, including those for high blood pressure, diabetes and high cholesterol,” said Katie Koziara, director of public affairs at PhRMA, in an email interview.

Research and experience have shown that reminder texts and emails go only so far when it comes to adherence. Patients need to be motivated, especially because many medications for chronic diseases don’t necessarily make a person feel better right away. Positive feedback comes when patients see the medication control the disease and influence results of laboratory tests.

Patients definitely have the most at stake because their health is on the line. But aside from wanting to do right by their patients, providers participating in value-based care programs also have a financial incentive to encourage medication adherence, because nonadherent patients make it harder to meet financial benchmarks. They also will jeopardize good grades on quality metrics. For payers, the nonadherent patient stands a good chance of being the more expensive member or beneficiary because of the well-documented association between nonadherence and expensive events such as rehospitalizations. Adherence also is a factor in ratings systems that govern payment levels, and it makes the pharmaceutical industry’s products more effective, which presumaby translates into sales.

Available technologies addressing adherence range from embedding medications with ingestible sensors to digital reminders to patients to take their pills.

Here are three technology companies that use a varied approach to adherence, combining chatbots, artificial technology (AI), ‘gamification’ techniques, real-time monitoring and personalized messages:

Groove Health, a Chicago health tech company, works with payers, hospitals, and Medicare and Medicaid plans to target patients at highest risk of nonadherence. Using an analytics platform, the company mines client data to identify those who would most benefit from the program, including patients who are likely to cost the company the most money because of low adherence. Its mobile app populates the medications from insurance company claims data. Patients schedule reminders to take their medication and log in to mark when it was taken or give a reason it wasn’t. “We get a good sense about adherence levels for a particular person and how they manage their medications,” says CEO and founder Andrew Hourani.

Groove Health also uses conversational AI and its Maxwell chatbot to help identify barriers to adherence. “Nearly everybody will have their own unique reasons for not taking a medication. It could be needing a ride to pick it up or a side effect,” Hourani says. The members of the patient’s care team are alerted about the barriers on their dashboard, so they can follow up. Patients also receive specialized content and resources to address the potential barrier to adherence.

One common barrier: thinking medication is unnecessary when feeling fine. The system sends the patient educational messages about why it’s important to stay on the medication regardless of how they feel.

Not all technology programs integrate with providers, but Groove Health does. “I don’t think there’s any replacement for human-to-human interaction,” Hourani says. “Technology can automate a lot of the initial tasks relating to data collection and engagement, but technology and human-to-human interaction are complementary.” The web-based platform allows for real-time data views by providers who then use the information to compile call lists and get in touch with patients directly.

Despite the perception that technology may flummox elderly patients, Hourani says, the Medicare population is highly engaged with it. Groove Health partners with Medicare Advantage plans that are interested in improving their CMS star ratings, because medication adherence measures are highly weighted in determining reimbursement levels.

HealthPrize Technologies in Norwalk, Connecticut, works with patients and drug companies, using gamification, behavioral economics and loyalty marketing techniques to encourage medication adherence. “Human behavior is complex,” says Vishal Khanna, the company’s vice president of marketing and communications. “Even simple technology solutions like a reminder app or feed aren’t enough to get a person to take medications for chronic diseases that (they) don’t want to take or (that remind them they) have a disease and are facing fears of mortality.” Technology solutions that don’t work with the negative thoughts and feelings people have about taking medications will have only a limited effect, he says.

Rewards programs such as those used by airlines or credit cards don’t work for medication adherence, according to Khanna: “You can motivate the person once or twice, but you have to think long term.”

HealthPrize blends human behaviors with health and motivational techniques that have been validated in peer-reviewed studies. The program starts extrinsically, giving patients points for every action taken to help them develop habits. Interventions are added sequentially to give short educational lessons over long periods of time. These messages might include the type of medication information given after an in-person visit, but in HealthPrize, it’s broken down into smaller pieces. The program moves to intrinsic motivations when the patient finds value in their actions, not just rewards for taking them, Khanna says.

Still, HealthPrize is true to its name and uses rewards and prizes. According to Khanna, patients log on an average of five times a week, for about 2 minutes, 10 seconds each visit. That adds up to 30 to 40 minutes a month. Patients get points for reporting whether they took their medications; the points vary daily to keep it interesting. The company offers prizes such as gift cards for reaching certain levels, and patients can use points to earn health-related items or make charitable donations. No one wins a car or an all-expenses paid trip to Las Vegas. Prize amounts are capped at $75 a year, in keeping with Medicare and Medicaid regulations.

HealthPrize also gives patients daily tips about general health and wellness or their medications. Quizzes test knowledge and convey disease information, but about a third of the daily content is unrelated to health so that patients aren’t continually reminded about their condition. The site hosts weekly competitions, based on the number of check-ins, between participant groups.

Khanna says HealthPrize’s program results, on average, in a 50% increase in medication adherence over the pharmaceutical company’s baseline (ranging from 44% to 66%, depending on the disease program). That results in an average of 2.2 extra verified fills per year compared with copay card programs that patients had been involved in previously. The point system rewards people for filling their prescriptions. If patients are taking their medications more regularly, presumably their condition is better controlled, which will improve their health.

HealthPrize’s clients are pharmaceutical companies; it has no relationship with providers. Patients can make a PDF of their adherence statistics to share with their physician, Khanna says.

Medisafe uses an app that collects patient information and creates data algorithms to personalize patient messages. Its software creates a personal profile, using demographic and medication information. The Boston-based company has collected more than 15 billion data points from patient usage and used them to refine its Just-in-Time-Interventions messaging, which incorporates interventions used with other patients and identifies what worked best. The interventions include a reminder with therapeutic or scientific content and anonymized patient stories. Medisafe has found that simply asking patients why they didn’t take a missed dose can be a useful intervention, says Omri Shor, CEO and co-founder of Medisafe.

Medisafe lets patients document biometrics such as blood pressure, blood glucose levels and blood oxygen levels and correlate that information with their medication adherence. The software also allows patients to connect with a drug company’s support center if they have questions about the medication. The company has business arrangements with pharmacies to provide home delivery of medications, which has been helpful during the COVID-19 pandemic, Shor says. Medisafe says its app results in high adherence rates in a population that, on average, takes five medications per day.

Medisafe contracts with the pharmaceutical companies, and the app becomes “part of the drug experience for the patient,” Shor says. Medisafe has content portals in the app for specific drugs that partner with the pharmaceutical company.

In addition to receiving personalized content and push notifications to take medication, patients can have alerts regarding a missed dose sent to an interested person. Medisafe also integrates coupons and discounts from the manufacturer. “It’s everything you need in the process of using that drug,” Shor says.

The pandemic is increasing the use of technology solutions, Hourani says. “With COVID-19 and quarantine, that’s accelerating the shift to digital health, not only for those employing telehealth, but (also) for patients using telehealth for the first time. Patients are seeing that it can help with their healthcare management.”

Chatbot use is also rising, offered by healthcare organizations and insurance companies to help identify medical issues and direct patients to the right resources.

“Adherence as a patient issue has everything to do with COVID-19,” Khanna says, because there have been fewer in-person visits, fewer new prescriptions and new indications not necessarily being managed, along with continuity-of-care issues. “Patients are dipping in adherence 15% to 20%, from the data I saw,” Khanna says. Fill rates of 90-day prescriptions rose in mid-March, he says, and now are dropping below that level, a clear trend toward nonadherence.

It’s essential to think about adherence. “Those who haven’t come up with adherence solutions are behind the times. The new normal will have to provide a level of digital support,” Khanna says. Patients and providers will need to adopt more digital ways to engage with each other.

Medication adherence requires a holistic approach, said Koziara, the PhRMA public affairs official. Technology is just one tool, along with patient education, counseling, decision-making strategies, medication therapy, refill synchronization policies and innovative contracting arrangements.

“Technology is one component of that overall care plan, and it can be dialed up or down depending on the patient’s goals and care preferences,” said Koziara.

Companies are using rewards and ‘gamification’ to encourage patients to take their pills as prescribed.

Fun and Games for Medication Adherence

Early data from China suggested that CT scans of the lungs might be used to diagnose COVID-19. Recommendations to use CT scans came from both published and anecdotal reports, notes Harold Litt, M.D., Ph.D., division chief of cardiothoracic imaging at Penn Medicine in Philadelphia. “Colleagues of mine (in China) told me what their policies were. They were scanning everyone who showed up at the hospital because at that moment, they didn’t really know what they were dealing with and didn’t have adequate testing.” 

Several studies conducted early in the pandemic in China compared noncontrast chest CT scans to real-time polymerase chain reaction (RT-PCR) swab testing for diagnosing COVID-19. Published online in mid-February in Radiology, a study by Yicheng Fang, of Affiliated Taizhou Hospital of Wenzhou Medical University, and colleagues found chest CT 98% sensitive for COVID-19 compared with 71% for RT-PCR. The authors suggested using CT chest screening, especially if RT-PCR testing was negative. 

A study conducted by Tao Ai, of Tongji Hospital in Wuhan, and colleagues also published online in February in 

 and found chest CT sensitivity at 97% for those with positive RT-PCR results. In patients with negative RT-PCR tests, 75% had positive CT scans. Authors recommended CT as a primary COVID-19 diagnostic tool.

But as COVID-19 spread beyond China, RT-PCR testing improved, and researchers had more time to compare those initial studies with practices in other countries. The availability of RT-PCR is still an issue in the U.S., but recommendations for using CT scans to diagnose COVID-19 haven’t been adopted by major medical organizations and societies.  

The American College of Radiology  noted in a March 11 statement that CT scans should not be used to screen for COVID-19 or as a first-line test to diagnose the disease and that they should be used “sparingly and reserved for hospitalized, symptomatic patients with specific clinical indications for CT.” The Society of Thoracic Radiology and American Society of Emergency Radiology also do not recommend routine CT screening for COVID-19. Their joint statement said chest CT scans can be restricted to patients who test positive for COVID-19 and are suspected of having complications involving the lungs.

But the Fleischner Society, an international, multidisciplinary thoracic radiology society, took a more nuanced stance and included CT scans on its decision trees. The Fleischner group recommended against CT scans (and chest X-rays) for screening COVID-19 in patients with no or mild symptoms unless they show “worsening respiratory symptoms,” but recommended imaging - either CT scans or chest X-rays - for people with “moderate to severe features” of COVID-19.  The society’s recommendations say that chest X-rays are of little value early in disease but have a role in more advanced disease. 

Litt and other radiologists also see problems with study design, biases and selection criteria used in some of Chinese CT scan studies. 

Clinicians at the hospitals in China scanned any symptomatic patient, with little understanding of where patients are in the disease process, says Litt. In the U.S., patients with mild to moderate symptoms have been told to stay home unless they have trouble breathing. Litt also notes that the study showing 71% sensitivity for RT-PCR testing used throat swabs. “We know [throat swabs] will miss quite a few positive patients compared to nasopharyngeal swabs,” says Litt, who also questions the high sensitivity rate of CT scans, adding that, “98% sensitivity is too high for anything in medicine.”  

In addition, American College of Radiology says specificity is a problem with CT scans for COVID-19 because results can overlap with findings for pneumonia and lung issues stemming from other sorts of infections, including influenza. Moreover, says Litt, “we need to make a distinction between (the) coronavirus infection and COVID-19 pneumonia” because people can test positive for COVID-19 but haven’t developed pneumonia. 

Expense is another consideration. It is impossible to put a single price on a CT scan; it is going to vary depending on the payer. It’s not negligible, though,  and claims for CT scans range from several hundred dollars to several thousand. 

The availability of CT scanners hasn’t been an issue at most U.S. facilities, says Litt, because of canceled or postponed elective procedures and other ordinary medical care. What is an issue is that scanning  patients increases the likelihood of staff members contracting the virus. “We’ve instituted universal cleaning protocols because we don’t know who has the [undetected COVID-19],” says Litt.  

Then there’s the incidental finding, a common problem with imaging tests. Determining how to report and share them led to Litt and his colleagues publishing a Radiological Society of North America expert consensus statement on incidental COVID-19 findings. The statement proposed categorizing them into one of four categories: typical (of COVID-19), indeterminate, atypical or negative. 

“This specific question of, ‘Is this abnormality reflective of COVID-19 pneumonia or something else?’ is going to be one with us for a while,” notes Litt, “and viral testing will be the way to resolve that.”   

Deborah Abrams Kaplan covers medical and practice management topics. 

Early studies from China suggested that CT scans of the lungs could be used to diagnose the disease. But as PCR tests became available, radiology groups said CT scans should be used more sparingly and in confirmed cases.

Author | Deborah Abrams Kaplan

Articles

Amazon’s Quiet, Selective Forays into Healthcare

Has the C-Suite Gotten Too Big?

Fun and Games for Medication Adherence

CT Scans for Diagnosing COVID-19? Not So Much.