The Morning Report
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There are a million mini-crises (and mini-miracles) swirling the COVID-19 pandemic. But as U.S. infection rates soar, even above China, a strong supply of healthy medical professionals will be indispensable.
The best way to ensure this? Keep doctors separate from patients, both healthy and sick, until absolutely necessary.
Lobbyists representing doctors and health care workers on Capitol Hill won a years-long battle this month when President Donald Trump’s administration waived restrictions on virtual doctor visits. Before, it was unclear whether public and private insurance would pay doctors for checking out patient’s healing scab or stiches via video conference.
This was especially hard on low-income, elderly patients using Medicare to fill prescriptions or get a checkup without showing up at a clinic. Medicare often didn’t reimburse doctors for keeping those appointments.
But the federal government has changed its tune now that those populations are the most at-risk of COVID-19 infection.
What’s more, federal regulations written with the intent to protect a patient’s privacy prohibited doctors and patients from seeing each other over the web except on software that offered deep encryption. That’s OK for larger hospitals or clinics that can afford top-of-the line tech. But smaller clinics often aren’t equipped, either financially or technically, to use it.
Now, patients with popular software apps like Skype, Zoom and FaceTime can legally host a conference call with their doctor. (That includes mental health or psychiatric visits.)
“Family physicians … usually are the frontline of care,” said Lisa Folbeg, who leads the California chapter of American Academy of Family Physicians, which represents 11,000 doctors in the state.
In China, there is no comprehensive primary-care system like that in the United States, which might be one of the reasons COVID-19 spread out of control so quickly in Wuhan as patients clamored in mobs at hospitals seeking testing and treatment, wrote David Hessler of The New Yorker.
Folberg said, due to the shortage of gowns, masks and hand sanitizer, U.S. doctors are left with “wrenching decisions” of having to decide between their staff’s health and turning patients away in their greatest moment of need.
Hospitals and clinics in San Diego revealed they were in “short supply” on basic protective equipment. It’s a crisis that touches the entire country as doctors posted photos of their needs, with one anesthesiologist tweeting a photo of himself wearing a plastic bag over his head during a procedure.
After some pushback, Trump finally invoked a Korean War-era law on Friday giving the president power to command U.S. factories produce goods like these that are in the national interest. He directed General Motors Co. to sharply ramp up production of ventilators used to treat coronavirus patients.
Scripps Medical Center, Jacobs Medical Center at UC San Diego Health and Kaiser Permanente San Diego Medical Center, to name a few, disclosed what they need on a national donation website started by a coalition of emergency room physicians called GetUsPPE.org. (PPE stands for personal protective equipment.) High-filter masks (N95s), surgical masks, face shields, disposable booties, safety goggles, gloves, gowns, hand sanitizer, disinfecting wipes and thermometers are all needed.
In the current U.S. chapter of COVID-19, social distancing is now imperative to maintain. Telehealth is key to ensuring that, Folberg said.
UCSD began offering telehealth for certain types of appointments three years ago. Then COVID-19 really hit California. The Trump administration lifted telehealth restrictions on March 17.
“We did more telehealth visits at UCSD in the first three days of (that) week than we have done in three years,” said Christopher Longhurst, a hospital spokesman and associate chief medical officer for quality and safety.
UCSD spent the weekend after Trump’s announcement developing an online remote training through Zoom for 300 doctors and 150 schedulers to convert their in-the-flesh appointments to digital. As of March 24, UCSD saw almost 60 percent of its patients virtually.
[box title=”Here’s What to Do if You’re Feeling Sick”]
- If you’re worried you may have COVID-19, and you have severe symptoms (dry cough, fever, difficulty breathing, exhaustion), they are not going to turn you away from urgent care or the emergency room.
- It’s safest for everyone if you call ahead (at the hospital or your local clinic) so they are prepared (and in protective gear) to receive you. Check if the hospital has a COVID-19 nurse line to schedule a video visit or a test.
- If you have mild symptoms, also get in touch by phone where you can also schedule an online consultation with a doctor.[/box]
The university health care system operates on a platform called Epic, a behemoth health care software company based in Madison, Wisconsin. Epic provides software to hospitals in all 50 states and almost a dozen countries.
“Telehealth has advanced 10 years in a matter of weeks,” said Taylor Seale, an Epic software developer. “It’s just exploded.”
The majority of Epic’s staff time is devoted to developing web trainings to get hospital staff up to speed on conducting telehealth appointments. Its telehealth services are provided to patients via a smartphone and desktop app called MyChart.
The shift has been essential in protecting health care workers, since COVID-19 spreads through the air from water droplets produced by coughing or sneezing. If those droplets hit another person’s eyes, mouth or nose they could become infected.
Telehealth is especially important at this time for vulnerable patients or those who already have weakened immune systems due to respiratory illness or cancer, elderly patients or need post-operation check-ups.
But making the switch to virtual health care is not easy for all clinics, especially smaller ones like Julian Medical Center in eastern San Diego County. The clinic has just one doctor and one registered nurse. The population in Julian hovers around 1,000 with an average age of 60.
The clinic isn’t doing video calls regularly. Instead, they’ve been doing basic doctor consultations and prescription refills over the telephone, the regular one, you know, with the digits.
“We have a lot of elderly patients here and we don’t want to expose them by coming to the facility,” said Alvaro Delgadillo, the clinic’s manager. “A lot of people here aren’t up to date with their new technology. They don’t have WiFi at their house.”
The clinic does have a smartphone app called Teams in which doctors can invite a patient to a video call. Doctors can see these patients while working from home via a special laptop, though the patient would still need to visit the clinic in order to see the doctor.
Many clinics are cancelling or rescheduling regular check-ups, which means less revenue for the clinic. Delgadillo said Julian is postponing those types of visits another six weeks. Productivity has decreased due to COVID-19, he said.
For others, like the Perlman Clinic (a group of 11 clinics in San Diego) telehealth business has boomed. It developed a smartphone app almost two years ago called PocketDoc that allows patients to log on and see the next online available doctor almost instantly.
Pre-COVID, patient volume was “modest,” said President Ian Perlman.
In fact, because it’s so easy, the app has garnered interest from patients in Los Angeles, San Francisco and even New York, said Perlman. San Diegans with COVID-19 symptoms can use the app to then schedule a drive-in test at one of the clinics. But Perlman said they’ve been turning away non-local patient requests.
Before the pandemic, telehealth companies were operating in the U.S. kind of like an “Uber service,” Perlman said. You would schedule an appointment and then get a doctor based on another coast. The biggest change from COVID-19, Perlman said, is that traditional doctors offices are getting into telemedicine. That’s why Perlman developed their own app, he said, because “we just didn’t feel like there was a good solution for a doctor’s office out there.”
Like many clinics, Perlman is also turning away regularly-scheduled check-ups. But due to the success of the app, they probably won’t be hurt “as much.”