Follow federal, state, and local guidelines—and don’t apologize for change.
Southern California’s Hoag Medical Group followed guidelines from the Centers for Disease Control and Prevention (CDC) and their local health authorities to the letter. Then, the moment those guidelines changed, Hoag leadership announced the change to physicians and staff. This provided consistent messaging and allowed them to manage expectations.
“The minute you go out on your own, you become very vulnerable to criticism and accusations of lack of fairness or lack of taking responsibility. Following the guidelines protects you, and then you just have to be nimble to change course as quickly as the recommendations change,” said Martin Fee, MD, senior VP and chief clinical officer at Hoag Memorial Hospital Presbyterian in Newport Beach, California, and an infectious disease specialist.
Do change your own mindset to succeed.
Andrew Racine, MD, PhD, system senior VP and chief medical officer at Montefiore Medical Center in the Bronx, New York, reflects on his experience with COVID-19 at the heart of the crisis in NYC: “Everything about what you are used to doing and how you are used to doing it had to be discarded, had to be put aside . . . Where were you going to do things? What kind of equipment were you going to use? Who was going to do things?” He advises, “You have to be flexible. You have to adapt to the circumstances.” And, “You have to be proactive.”
Plan for what’s coming next.
Dr. Racine says that Montefiore has systematized lessons learned: “We have a very detailed plan about what will happen if we get 10 percent more patients than we currently have, if we get 20 percent more patients than we currently have, if we get 100 percent more patients than we currently have.”
And Dr. Fee describes contingency plans that incorporate not only medical realities, but political ones—factoring for predicted executive actions from California’s governor.
Communicate with honesty, empathy, authenticity, and consistency.
Dr. Racine describes the need for empathy in effective communication: “People were frightened. They were anxious. They were angry, they were grieving. And the communication had to acknowledge that.” In addition, Dr. Racine stresses authenticity: “People were not going to accept communication coming from just anybody”—which was why Montefiore’s communications came from their CEO.
Dr. Fee notes a communication lesson learned: “Initially, I was trying to be very reassuring with the physicians and saying, ‘We're going to get through this and everything's going to be OK and this will be over soon.’ In retrospect, that's not true . . . What I would have done differently is say, ‘We'll have to just see,’ but maybe not be too reassuring.”
Recognize the pandemic’s silver lining: Innovation.
Dr. Fee says Hoag had been planning on a nine-month telehealth implementation in 2021, “but all the regulatory and financial barriers came down and we were able to launch that very quickly.”
Overall, the rerouting of usual workflows “forced us to be innovative quickly,” says Dr. Fee, “which I think was a silver lining.”
Chad Anguilm, MBA, VP of in-practice technology services at Medical Advantage Group, a subsidiary of The Doctors Company, says that sustained shifts across technology and workflows are already progressing: “Like we saw with telehealth—the big boom in the spring—we're seeing something similar with wearables now where we're getting many requests to start integrating wearables into the EHR systems. To have that constant flow of data from those with chronic conditions” could positively impact physicians’ ability to treat patients in real time.
Do telehealth right: It’s a long road ahead.
“Obviously, telehealth is having its moment right now,” says Anguilm. “However,” he cautions, “We still have a ways to go to make it stick,” and the technology itself is no longer the obstacle: “It’s more about eliminating barriers, and proper reimbursement.”
Anguilm says, “Truly long-term decisions are going to be based on the quality of care we can provide through telehealth services.”
For telehealth, beware of access gaps.
Patients who don’t have technology access for a virtual visit “often tend to be sicker people,” says Eugenio J. Hernandez, MD, VP of clinical affairs for Gastro Health in Miami, Florida, citing higher risks for diabetes, hypertension, and other conditions among the same populations who may lack telehealth access.
Acknowledging this, David L. Feldman, MD, MBA, CPE, FAAPL, FACS, chief medical officer for The Doctors Company Group, points out that the access question cuts both ways: “We know that these sometimes are the same patients who can’t afford the cab fare or bus fare” to see a doctor in person—but when telehealth offerings are accessible by cell phone, vs. laptop, many low-income patients can access virtual visits.
Anguilm agrees: “The ability that the EHR vendors and some of the telehealth vendors have to utilize cell phones has made it a lot easier, and some of the disparities are much less of a problem as they were . . . But the rural communities are facing broadband issues. There's a lot of money being pumped into getting broadband across the country, but for now, there have to be other means—whether it is in person or the use of a telephone—to reach care.”
Anticipate a boom in treating chronic diseases via telehealth.
Dr. Feldman sees great potential for ”some of the asynchronous ways of communicating, such as having patients with diabetes send you a list of their daily blood sugars that you can review during a subsequent visit.” In-person visits for physical exams will still occur, but more consultative visits can be completed while reducing infection risk, travel time, and overall hassle for patients—which may enable more frequent consultations.
“Even should some of these rules (that make telemedicine easier during the pandemic) go back, it's opened our eyes to these possibilities to really help, especially patients with chronic conditions for whom an in-person visit may not be so necessary,” Feldman notes.
Envision a future where your annual physical kit arrives in a box.
Dr. Hernandez describes a futuristic-sounding invention that already is being produced by an Israeli company: “an entire physical examination kit that’s attached to an iPad. They drop it off at your house in a box.” Via video visit, the patient participates in, for instance, a cardiovascular exam. The visit is recorded, and the kit is then returned to the provider company for analysis.
Similarly, Gastro Health partners with a company that remotely monitors patients with inflammatory bowel disease—for intervention before symptoms worsen and patients land in the emergency department (ED).
As Anguilm points out, technology that links patients to physicians is more cost effective and risk preventive than patients missing visits.
Expect malpractice claims to increase—know what to document and transfer risk.
John E. Hall, Jr., Esq., of Hall Booth Smith, P.C., predicts filing of COVID-19-related cases will peak in 18 months to two years. Mr. Hall encourages physicians and practices to document daily life now, because juries will forget. He recommends documentation of daily infection control measures, as well as noting who is working hard to procure personal protective equipment (PPE), coordinate with labs, and so on. This will make it easier later to contact staff members who can attest as witnesses that providers made their best effort to reduce risks.
Awareness of risk transfer opportunities may also be protective. Jacob Zissu, Esq., of Clausen Miller, P.C., points out: “It may be that the injury alleged is attributable to the acts or omissions of your vendor or an independent contractor.” He advises, “Think about risk transfer as if it’s a Swiss Army knife with multiple tools . . . The best position to be in is to have multiple risk transfer options available.”