COVID-19: Dealing with patients amid pandemic

As the COVID-19 pandemic continues to alter life in every corner of the country, ophthalmologists have been forced to evaluate the needs of their patients, shift schedules and change the way they manage their practices.

COVID-19 also is altering how patients approach healthcare, and the impact of these changes could last long after the pandemic is over, according to a survey of 500 healthcare consumers in the United States by healthcare consultancy Sage Growth Partners and Black Book Market Research, published by Medical Economics, ® a sister publication of Ophthalmology Times.®

Concerns about the safety of healthcare settings is driving more interest in telemedicine, such as virtual visits and remote health monitoring. In fact, 59 percent of survey respondents said they are more likely to use telehealth services now than in the past, and 36 percent would switch their physician in order to have access to virtual care.

In March, as the COVID-19 pandemic began to spread, the American Academy of Ophthalmology issued a statement noting that all ophthalmologists should cease providing any treatment other than urgent or emergent care. AAO also offers a list of procedures deemed urgent or emergent. As a result, ophthalmologists nationwide are adapting the way they manage their practices, instituting changes to ensure patient and staff safety.

A changing world

According to Eric Donnenfeld, MD, founding partner, Ophthalmic Consultants of Long Island and Connecticut, a multi-location ophthalmology practice, clinical professor of ophthalmology at New York University, and a trustee of Dartmouth Medical School, Hanover, NH, the world of ophthalmology has changed dramatically over the past several weeks with the COVID-19 pandemic and the way ophthalmologists interact with patients.

“We are implementing telemedicine and spending a great deal more time speaking with patients over the phone,” he said. “In addition to the normal person on call we are now triaging patient questions to the primary doctor responsible for their care. That doctor can advise the patient over the phone or if needed refer the patient to one of our physicians seeing emergencies.”

Dr. Donnenfeld noted that his offices also have a list of patients that are scheduled for the following week and physicians all evaluate the patients on the list and those that need to be seen are referred to the doctors seeing emergencies.

“Otherwise the staff is rescheduling patients for a month later,” he said.

Patients scheduled for surgery are called by the treating ophthalmologist and advised their procedure will be postponed for the time being.

“We have found that patients very much appreciate speaking directly with their doctor and overwhelmingly have been very supportive of our decisions,” Dr. Donnenfeld said.

Notting the offices are now only doing emergency surgery. Dr. Donnenfeld noted that a couple of second eyes in patients with significant anisometropia had cataract surgery last week and that is the end of cataract surgery.

“Our OR is open only for emergent cases such as retina corneal perforations and glaucoma,” he explained,

Skeleton crews

Dr. Donnenfeld noted that the practice has opened regional emergent offices that are staffed by a skeleton crew of office staff, a retina and a glaucoma doctor.

“We have a cornea person on call but not seeing routine cases,” he said. “All of our offices are being cleaned several times a day, family members stay outside in their cars and only the patient is allowed in the waiting or examining room. We have outfitted all of our slit lamps with home-made splashguards.”

The practice continues to follow up with some post ops from the last few weeks but the busiest part of the practice is anti-VEGF retina injections. The main OR is only open two days a week for emergencies.

Moreover, the practice also is taking steps to ensure the safety of its physicians, including those in a higher risk category

“We have taken any physician over the age of 70 and are not allowing them to see patients for any reason,” Dr. Donnenfeld said. “There are six people affected. We have about 100 ophthalmologists in the practice and on any given day only 10 are seeing patients. We have seven ODs in the practice and they are not working at all.” 

One of the biggest problems, according to Dr. Donnenfeld, is that the practice has had to close three offices because a staff member was exposed to someone at home with COVID-19. This forced a move to another office. The only offices that are open have retina capability.

The painful part, according to Dr. Donnenfeld, was the necessary decision to furlough many of the staff. Partners are not taking a paycheck and associates are continuing to be paid based on productivity, which he noted is not a lot.

“We are continuing health insurance for all,” he added. “Our management is doing an exceptional job and they could write a book about how to respond to a crisis.”

Dr. Donnenfeld has an update two times daily with management leadership and they keep their lines of communication open with physicians and staff through frequent emails and personal calls when needed.

“We are taking Draconian steps but I believe they are necessary and we are confident we will come out the other side stronger than ever but there is a good deal of pain right now,” he said. “Most importantly, only two of our staff or physicians has tested positive and they are both doing well.”

Challenges for specialists

Andrew G. Lee, MD, who is affiliated with the Blanton Eye Institute, Houston Methodist Hospital, and specializes in neuro-ophthalmology, said working in today’s environment can be challenging.

“We have been closely tracking and following the guidelines from the national public health organizations and our American Academy of Ophthalmology,” Dr. Lee said. “In our clinic, we have rescheduled all of our routine and stable patients and only urgent or emergent patients are seen in person.”

Dr. Lee noted that non-urgent cases have been diverted to telephone or virtual care although the limitations of virtual tele-neuro-ophthalmology have been a challenge including the lack of a fundus exam.

“Unfortunately, a lot of neuro-ophthalmic conditions are potentially vision or life-threatening and so we have been working hard to balance the needs of the patients against the needs of society to flatten the curve,” he explained. “Amazingly however, we have been able to diagnoses a lot of the efferent neuro-ophthalmology however with video and this past month we diagnosed an INO from MS, a sixth nerve palsy, and downbeat nystagmus.”

For the afferent patients Dr. Lee said staff can check their visual acuity, color vision, and visual field with online apps but it has been difficult.

“Usually we are relying on testing that has already been performed prior to their visit with us,” he added.

Dr. Lee said his office also balances social distancing as individuals with the need for medical proximity for the eye exam.

“We limit talking during the exam, we wear a mask and had breath shields installed on our slit lamps,” he explained. “We have been limiting our testing of visual fields and OCT to medical necessity for decision making that day.”

Dr. Lee added that there ultimately could be downstream changes in neuro-ophthalmology after the social distancing requirements are removed.

“Neuro-ophthalmology was already facing a backlog and a manpower shortage before COVID19 and so some of the disruption has actually sped the rate of innovation and the adoption rate of telephone triage and tele-neuro-ophthalmology,” he said. 

In the future, Dr. Lee said he suspect that there will be some changes that will be permanent in terms of social interactions (minimizing hand shaking as a greeting, social distancing, more rigorous hand washing).
 

Changes are appreciated

Cathleen M. McCabe, MD, chief medical officer, The Eye Associates in Bradenton and Sarasota, FL, said several changes have been instituted at the practice, and they have been met with appreciation from patients.

“Patients have been very understanding and appreciative of our efforts to ensure their safety, including screening temperatures, asking questions about symptoms, limiting the number of patients in the waiting room, offering telehealth and delaying in-person visits as much as possible,” she said. “They also appreciate that we have remained open with a skeleton staff for emergent and urgent care.”

Like so many practices across the country, traffic has naturally slowed at Dr. McCabe’s practice.

“We are now down to about 10% of our normal volume in clinic for everything other than our macular degeneration injection clinics, which are also down in volume but not as severely,” she explained.

Moreover, the patients that have to undergo emergent and urgent care are more than accepting of the safety measures in place.

“Patients have been impressed with the level of concern we have shown for their overall health and safety,” Dr. McCabe said.

Going forward, Dr. McCabe offered some times for working with patients amid the COVID-19 pandemic.

“It is important to continue to communicate with patients often and on many different platforms,” she said. “Two of the best sources of information in a constantly changing landscape are your practice website and your call center.”

Dr. McCabe noted her practice is continually updating its website with practical information such as hours of operation of its different clinics, what the screening process is and how patients can access the products they may need in the short term, such as contact lenses, glasses, and supplements.

“Our call center has a script that we update frequently regarding frequently asked questions and the information available on our website,” she said. “We are also offering telehealth and a virtual audio check in with our providers in order to answer patients concerns, especially when we have had to reschedule visits to a date weeks or months later.”

CMS updates policies

Last week, the Centers for Medical and Medicaid Services (CMS) announced in a press release it released a number of new policies to help physicians and hospitals during the pandemic. These actions include Medicare coverage for telephone services, significant additions to the list of covered telehealth services, such as emergency visits, greater clarify on the use of remote patient monitoring for acute conditions like the virus and allowing Ambulatory Surgery Centers to contract with local healthcare systems to provide hospital services.

CMS sets and enforces essential quality and safety standards for the nation’s healthcare system, and is the nation’s largest health insurer serving more than 140 million Americans through Medicare, Medicaid, the Children’s Health Insurance Program, and Federal Exchanges.

In the press release, CMS Administrator Seema Verma noted that very day, nurses, doctors, and other healthcare workers are dedicating long hours to their patients.

“This means sacrificing time with their families and risking their very lives to care for coronavirus patients,” Verma said in a statement. “Front line healthcare providers need to be able to focus on patient care in the most flexible and innovative ways possible. This unprecedented temporary relaxation in regulation will help the healthcare system deal with patient surges by giving it tools and support to create non-traditional care sites and staff them quickly.”

Providers also can bill for telehealth visits at the same rate as in-person visits. Telehealth visits include emergency department visits, initial nursing facility and discharge visits, home visits, and therapy services, which must be provided by a clinician that is allowed to provide telehealth. New as well as established patients now may stay at home and have a telehealth visit with their provider.

In addition, CMS is allowing physicians to supervise their clinical staff using virtual technologies when appropriate, instead of requiring in-person presence.