Telemedicine and remote services have been and will continue to be important ways of providing care to patients during the “new reality” created by COVID-19. However, important care that requires an in-person interaction, such as administering a vaccine or performing necessary procedures, has been postponed and should no longer be delayed.
Therefore, a comprehensive approach to safety is needed so postponed surgeries can be rescheduled and physician offices can be reopened.
Also reopening is a debate on terminology, as it becomes more apparent that definitions for words like “essential” and “elective” depend on one’s perspective.
“We should stop using the term ‘elective’ surgery,” tweeted Susan Turney, MD, CEO of the Marshfield Clinic Health System in Wisconsin.
“What is elective to you may not be elective to the person that is uncomfortable and living in pain and has a knee surgery coming up,” Dr. Turney added. “As providers, we do procedures that are medically necessary. Some are preventive. Some are routine but could safely be put off for 30–60 days. Some are urgent. Some are emergent. But all of these procedures are medically necessary to keep our patients and communities healthy.”
A similar point was made by Steven Sheris, MD, senior vice president for the Atlantic Health System in New Jersey, who is focused on preventing a non-COVID-19 public health emergency created by inattentiveness to preventive care such as screenings for cancer, heart problems and lung disease.
“If all these things go unseen, untreated and unevaluated in the next few months, we could be facing a different kind of problem that will compound the COVID crisis,” Dr. Sheris said in an Atlantic Health Facebook Live video.
His concern extends to pediatric care.
“We identified immunizations as a need that could not go unmet,” said Dr. Sheris, who is also president of Atlantic Medical Group, the system’s multispecialty physician network. He added that appointments were “batched” to minimize contact between well children coming in for immunization and others coming in due to illness.
Basics for getting started
An AMA checklist has been developed as a guide for safely reopening practices. It builds upon guidance offered by the Centers for Disease Control and Prevention (CDC) and offers these tips on getting started.
Comply with governmental guidance. The AMA has developed a chart detailing state-by-state actions regarding the resumption of postponed medical services and procedures.
Make a plan. Chart what needs to be done prior to reopening and order enough medical supplies and personal protective equipment so that sporadic deliveries do not disrupt services. Develop procedures for what do if a clinician, employee, patient or visitor is diagnosed with COVID-19 after visiting the practice and how long employees who interacted with a diagnosed patient should stay home from work.
Open incrementally. Prepare for a soft opening and identify which services can be delivered via telehealth and continue to conduct those visits remotely. Begin with a few in-person visits a day and consider bringing staff back in phases. Administrative staff whose work can be done remotely should continue to work from home.
Institute safety measures for patients. These include:
- Modify schedules to avoid high volume or density.
- Designate “well” and “sick” waiting areas.
- Limit patient companions to those whose participation is necessary to the patient’s care.
- Require all people entering the practice to wear a mask.
Ensure workplace safety. Make sure staff knows COVID-19 symptoms and stays at home if they exhibit them. Rearrange workspaces to provide distance between employees and consider dedicated workstations and patient rooms so fewer people touch the same equipment.
Implement a teletriage program. Patients seeking an in-person appointment may be better served by being redirected to a hospital or COVID-19 testing site. Discussing a patient’s condition and symptoms in advance can help put them on the correct path.
Screen patients before in-person visits. At least 24 hours before an in-person visit, staff should review with patients the reopening logistics and protocols. Patients should be screened before entering the practice. There can be a dedicated ante room or space in the parking lot for this purpose. Persons accompanying the patient need to be screened as well.
At Atlantic Health, Dr. Sheris noted that workspaces have been reconfigured, so staff are at least six feet apart and, where possible, waiting rooms have been eliminated.
“In some practices, you literally go from your car to the exam room back to your car,” he said in the video, adding that staff and visitors must wear masks, and patients are screened before visits and asked if they have a fever or cough.
Patient anxiety is a big challenge
Recently, the AMA Integrated Physician Practice Section and the Integrated Care Consortium held an online discussion on reopening.
Participants reported they are opening with phasing-in strategies and are still balancing the immediate need for COVID-19 care with the need to provide care for the backlog of patients with other needs. This included actively reaching out to patients whose visits or procedures had been postponed.
Patient anxiety over visiting a health care facility is a significant challenge to returning to normal, participants reported.
Dr. Sheris agreed and said in the video that this was the “single biggest problem” confronting his organization in recent weeks—this includes patients ignoring acute conditions out of fear of going to a hospital and contracting COVID-19.
Similarly, Adnan Munkarah, MD, the executive vice president and chief clinical officer for the Henry Ford Health System in Detroit, said in the online discussion that patients are hesitant to come in for surgery.
Dr. Munkarah explained that Henry Ford has tiered its rescheduled surgeries and procedures with the first tier being those that are the most time sensitive. About a third of patients in the top two tiers are asking to delay their surgeries for two to six weeks, according to anecdotal reports, while many needing orthopedic joint procedures are considering waiting another three to six months, he said.
“The patient anxiety is huge,” said Thomas W. Eppes, MD, with Privia Health’s Central Virginia Family Physicians (CVFP), in the online discussion.
The group is encouraging its physicians to accommodate patients by letting them wait or be seen in their cars and they are even conducting drive-up blood draws.
In contrast, Dr. Eppes said patients have become comfortable with telehealth visits and that the platform used by Privia Health was in place the year before the outbreak and was well vetted, so physicians were able to ramp up telehealth operations quickly in February and March—very quickly, in fact
Privia Mid-Atlantic jumped from about 120 virtual visit a day for the first week of March to 5,000 a day by the end of the month, Dr. Eppes said.
For conditions that required an in-person visit, CVFP designated one walk-in site a “sick” facility with others designated as “well” sites. Patients with a scanned unexplained fever or COVID-19 like symptoms were triaged to the sick center allowing the well centers to be perceived by patients as safer, Dr. Eppes said.
Physicians and providers also use personal protection equipment to further enhance safety perceptions as routine care is provided.
Keys to success: preparation, people
Preparation and staff attitude appear to have been vital ingredients to surviving the worst of the COVID-19 surge and its aftermath.
“No physician or provider has backed down from caring for patients,” Dr. Eppes said.
Dr. Sheris noted a similar feeling at Atlantic Health.
“Everything that we invested in our people over the last 10 years really paid off in this crisis,” he said in the video. “You can buy ventilators, you can buy medications, you can build beds as we did, but you can’t create people, you can’t create culture overnight in the middle of a crisis—and that’s what saw us through.”
The Atlantic Health, Henry Ford, Marshfield Clinic and Privia Health systems are all AMA Health System Program Partners.