Physician practices on front lines of coronavirus fight

The primary care office has turned into the front line in the war against the novel coronavirus (COVID-19) racing across the globe.

As patients-some sick, others worried but well, and still others chronic patients with acute concerns-all turn to their primary care physicians, personal protective equipment (PPE) supplies dwindle and staffing gets tighter. Clinicians are being asked to provide telemedicine in lieu of office visits-in some cases without the proper infrastructure or reimbursement.

As the battle against this virus rages on and Americans are increasingly confined to their homes to flatten the curve, physicians and other healthcare workers may feel as though they are fighting alone. But help is available.

Resources to help

While state governments scramble to piece together a national strategy against COVID-19 in light of what even national health leadership calls a failed response, physician and healthcare organizations aren’t wasting time developing guidelines and best practices as best they can on this developing pandemic.

The American Academy of Family Physicians (AAFP) began making preparations weeks ago when the first case hit our shores. The result is a complete resource page that is updated often with the latest guidance on testing, resources, advocacy, and practice readiness. AAFP has also offered advice on how to navigate new telehealth rules and procedure codes for testing. The American College of Physicians and the American Medical Association has similar guidance, as well as the CDC and the American Hospital Association.

Telehealth’s moment?

Telehealth, developed and championed across healthcare over the last several years, is being leaned on to stem the rush of patients seeking help, but hadn’t really taken root in most health systems prior to this pandemic.

This could change all of that, says Gary L. LeRoy, MD, FAAFP, a practicing family physician in Dayton, Ohio, and president of the AAFP.

“We have had a patient portal for quite some time, but it hasn’t gotten much traction at all,” he says. “With COVID, patients are going to see the value of using these elements of telemedicine.”

LeRoy spoke to Medical Economics as he reviewed his own patient schedule, determining which appointments could be rescheduled and which patients would still need to be seen-either remotely or in the office.

“The real intention is to thin out the people who would be sitting in the waiting area,” LeRoy says. “Telemedicine is an evolved tool that has been under-utilized. Now I think we have good reason to dust it off and amplify what it has the capability of doing.”

An established relationship with a physician helps make telemedicine work, but in times like these, it can protect sick and well patients, in addition to clinicians and medical resources. Primary care is home to so many patients, and primary care physicians are who patients will turn to first for guidance and treatment.

“It’s going to get much more challenging,” LeRoy says. “We are on the leading edge of this whole thing in the United States. There is a concern from the medical community in primary care and family medicine that we are on the front line of care for these patients. There’s a trusted relationship, so we know they’re going to come to us first with those symptoms. It’s important to know the process works, and how to triage our patients and protect ourselves.”

Testing best practices

This involves testing with prudence-many practices didn’t have tests until recently, have limited amounts, or are still waiting-setting up designated areas for suspected cases, and knowing the local resources that are available outside your immediate practice, LeRoy says. It also means protecting supplies of personal protective equipment. While some larger health systems worked to stock up in anticipation of this crisis, there likely won’t be adequate supplies in many areas for a long-term pandemic, and in some smaller practices these supplies are seldom used and not kept on-hand.

“It’s about getting the PPE out there in the hands of the people who are on the front line of healthcare that are in need, or who need the test kits or information about how well things are going, and realizing also that one size does not fit all as far as each community,” LeRoy says.

That’s especially true in the South Bronx, where Sarah C. Nosal, MD, FAAFP, works as a family physician and has seen roughly half of her patients-primarily low-income patients with chronic disease-with respiratory symptoms that are suspect for COVID.

“We already have some of the worst health outcomes that we’re really trying to fight and battle against. Two weeks ago, we knew something was coming. Monday, we were seeing what was happening around the world. By Thursday, we saw many patients sick with illness like we hadn’t seen before, and we have no tests,” Nosal says.

Only patients who met CDC screening criteria could be tested and were often directed to off-site testing centers. Nosal says this is a mistake. She says she worries about her disadvantaged and minority patients getting the appropriate care and testing. In her practice, she knows who recently had pneumonia or who is recently hospitalized. She knows who is high risk among her patients.

“I worry that my patients won’t have access or won’t be assessed properly,” she says. “It’s really hard to be a clinician. We sort of have a really realistic view of this situation. It’s already out of the bag-we’re just trying to slow the spread, and we don’t have proper equipment or testing.”

Nosal says her practice and the hospital partners in the area are all running low on masks and gowns already.

“People are reusing their masks, but there isn’t enough even then. It’s not going to sustain. And the cost for a private office is insurmountable from our normal cost of supplies,” she says. “We’re going through in a day what we went through during the whole flu season up until now.”

There are barriers to telehealth at smaller practices that haven’t had the infrastructure, reimbursement, and resources to develop these systems, she adds. Add to that the disadvantaged patient population that really requires a positive test result to change behaviors in most cases.

“If someone knows for sure they are positive, I think they make different decisions,” she says, adding that it’s difficult to choose between self-quarantine and food on the table without a positive result. “We need rampant testing. We want family doctors and community health to work together to liberate testing guidelines. Test everyone with symptoms and known exposures. That’s how we can stop this disease and really flatten the curve.”

It’s about doing what it takes to provide care in any way to patients right now, be it over the phone or video chat, and fighting for reimbursement later, she says. It’s also about considering the burden practices will face in the aftermath-in losing the volume of visits that keep practices afloat regularly while dealing with the crisis. And it’s about keeping clinicians safe in order to do no harm to patients-allowing immune-compromised and high-risk caregivers to stay home-and still having the staff to provide effective care.

The uncertain future

When and where this will end is anyone’s guess, LeRoy says. It will certainly look worse before it looks better, with numbers increasing as testing ramps up. Whether increased numbers reflect an uptick in cases or better surveillance, or whether our efforts to flatten the curve our enough will remain a question for some time, he adds.

“We don’t know what we don’t know yet, as a nation,” LeRoy says.

All we can do, he says, is learn from the countries hit with this before us and try not to make the mistakes that have already been made.

“We have the technology to see around the world what’s happening,” he says. “We don’t have to make those mistakes that have been made in the past. We can be more proactive with it.”