Learning from the COVID-19 Experience: Strategies to Continue Care

Within weeks, coronavirus disease 2019 (COVID-19) went from being a novel virus in 1 Chinese city to a global disruptor. For rural family practices that oftentimes care for an elderly patient population, the speed to move from routine medicine to telemedicine can present significant technical, operational, and staffing challenges.

However, several critical categories to focus on may offer valuable guidance for any practice, including:

• Don’t wait for patients to call you—call them first
• Protect confidentiality and document consent for telehealth services
• Err on the side of patient safety

Telemedicine is a new experience for many practices. For instance, some patients in rural communities may not even own a smartphone. Yet because most are elderly and many have underlying chronic conditions, they are among the most at-risk for contracting COVID-19. They are precisely the people who should not come into the office if there are any other alternatives.

To make sure they continue to get the care they need, it is important to reach out to them proactively. A telephone may be “low-tech,” but it has turned out to be the best communication tool.

In our case, the floor nurse went 3 months back into the schedule and simply called each patient. She told them that the practice is still open and that we’re now allowed to conduct appointments with them through video and over the phone. One suggestion for all practices: Try to avoid using unfamiliar, healthcare-specific terms like “telehealth” or “telemedicine” when talking with patients.

This outreach allows practices to better gauge which appointments to postpone, which patients to see in person, and which patients to see appropriately via telehealth. As a result, practices can better estimate and manage workflow.

At our practice, the daily in-office volume has dropped from about 50-60 patients to about 10. My partner and a nurse practitioner remain in the office to perform any in-person visits that can’t be postponed. Also still on-site are our laboratory and X-ray staff.

Like many other providers, the ability to offer curbside services when possible can be impactful. Anyone who calls with symptoms of COVID-19, for example, is asked to drive up to our laboratory door, where a lab technician can swab the patient from their car.

Since I am a diabetes patient myself, I now work from home and conduct all our telemedicine visits. So far, the best workflow seems to be 1 of “virtual rooming:”

• The floor nurse calls the patient and confirms that they’re comfortable having a video or phone appointment.
• She then asks if they have any way of checking their blood pressure, pulse, and temperature at home.
• She enters all information she obtains into the electronic health record (EHR), including medication lists, refills needed, and consent to a telehealth visit, then texts me to say the patient is ready to speak with me.
• I then call the patient, again confirm and document their consent to a telehealth service and begin the virtual visit.

With so many different platforms and devices, the fact that most insurance companies are temporarily allowing audio-only telemedicine instead of requiring video capability has been a big help. Only about 60-70% of the patients at my practice can support video. Although we prefer to use video apps like Skype or FaceTime, the reality is that we don’t have unlimited time to try to establish a video connection. If we can’t get video running quickly, we simply continue the visit by phone.

Overall, most patients seem happy with virtual visits and the new operations. Still, it is vital to remain as HIPAA-compliant as possible while adapting services. That is why it’s critical to not only document patient consent for virtual visits, but also use patient initials for any communication done outside the EHR. For example, if I need to follow up with the nurse after a visit with Jane Doe, I’ll text, “Would you please schedule a dermatology appointment for JD?” It may not be perfect, but at least it shows due diligence regarding confidentiality.

There is no question that it’s harder to practice medicine without the usual ability to conduct physical exams and diagnostic tests. That reality makes it more imperative than ever to remain grounded in patients’ day-to-day clinical conditions, to ask the right questions, and to listen carefully to the answers. We cannot afford to focus so much on COVID-19 that we hesitate to bring patients into the office or send them to the emergency room when warranted.

Despite all the challenges COVID-19 presents today, it’s sobering to think what would have happened had this virus emerged 20 years ago—before EHRs and telemedicine capabilities. Technology has been a godsend, allowing all providers to care for patients as safely as possible. Technology, together with the supportive relationships found among providers and clinical networks, let us continue to care for patients when they need us most.

Michael Turner, MD is from Iron City, PA. The presented analysis reflects his views, not necessarily those of the publication. 

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