How Have Physicians Accommodated Patient Care Amid COVID-19?

Nationwide, hospitals and physician practices have implemented preventive measures to protect patients and providers from the coronavirus disease 2019 (COVID-19). The emergence of telehealth has provided a safe and effective option for those with or without COVID-19 to receive care from the safety of their homes.

However, for those with diseases that require surgery, such as cancer, many of these vital procedures have been delayed. Moreover, the reluctance of patients to report symptoms of conditions such as heart attack and stroke, that would require them to be admitted to a hospital, threatens the safety of patients and overall care received.

In an interview with The American Journal of Managed Care^®, Brian LaMoreaux, MD, medical director of Horizon Therapeutics, spoke on a myriad of concerns precipitated by the COVID-19 pandemic, primarily the issue of bringing patients back to physician offices. As a rheumatologist, he noted the difficulty in examining an older patient population that is not technologically proficient and highlighted the nuances of in-person visits versus via phone.

LaMoreaux also provided recommendations on what steps physicians and hospital systems can take to provide timely care for both COVID-19 and non—COVID-19 patients.

Transcript

AJMC^®: Hello, I'm Matthew Gavidia. Today on MJH Life Sciences News Network, The American Journal of Managed Care^® is pleased to welcome Dr Brian LaMoreaux, medical director of Horizon Therapeutics.. Can you introduce yourself and tell us a little bit about your work?

LaMoreaux: Absolutely, yeah. Thanks for having me! I'm Brian LaMoreaux—I'm a rheumatologist. I've been a medical director with Horizon Therapeutics for just shy of 4 years. In that role, I mostly research, educate, and work with the community on gout and uncontrolled gout. As part of that, as well, I do volunteer at a free clinic in downtown Chicago. So, every 2 to 3 weeks, I head down to community health in a Ukrainian village and we mostly take care of Spanish and Polish speaking immigrants, sometimes undocumented immigrants, and provide the absolute best health care we can for them.

AJMC^®: As you just alluded to, as a rheumatologist, you spent time at a Chicago clinic during the COVID-19 pandemic. Can you discuss some notable requests from patients and whether some of these requests have led to innovations in care?

LaMoreaux: Yeah, thanks for the question, it's been interesting. This is a teaching institution so a lot of the local universities—Rush, Northwestern, others—they send internal medicine residents and in March, they took all of them out. So, all of the house staff or residents went entirely to telehealth virtual visits. As I'm an attending, I was given a choice. Rheumatology, which I'm sure we’ll discuss, sometimes patients have to be seen. So, I've been going on site and seeing some patients calling others.

In terms of the requests from patients, if anything, they're just really hesitant to come in. The clinic has—we do symptom screens before they come in. When they come in, we do temperature checks. I do a pretty comprehensive symptom screen before I even start talking about their rheumatological issues and medicine. So, what we've seen is that you almost have to talk some of these patients into coming. So, that's 1 of the major adjustments, especially the patients really are concerned and they tend to want to just stay at home if possible.

AJMC^®: With more non—COVID-19 patients staying away from hospitals due to fear and risk of infection, how have physicians adjusted to provide these patients with timely and effective care?

LaMoreaux: Right, so telehealth is the most obvious and probably the safest for all involved. One of the challenges, you kind of have to keep track of your patients that haven't been seen in a bit and different systems and electronic medical records have different methods of doing this. Down there, I don't follow a huge panel of patients—I'm probably between 50 and 75—but pretty much all of them have true rheumatic disease and are on anti-inflammatory medications.

So, just being aware of some of your vulnerable patients, especially those that might not want to come in. For larger practices, you almost have to rely a little bit on automation. When do I want this patient to be seen? Have they missed visits? Have we not touched base recently? In those cases, even a quick phone call is much, much better than nothing because even through that, you can put in some lab orders, maybe put in medication refills where appropriate, and it might count as a pseudo patient visit. I mean, ideally, you want to have video and really do a detailed assessment much like you would do in a clinic, but keeping tabs of these patients in any way is better than losing track of them.

AJMC^®: As you just touched upon, can you discuss some optimal ways to engage patients in using telehealth? Especially those who may not be technologically proficient?

LaMoreaux: Yes, so this has been a challenge overall. A lot of the patients in rheumatology clinics sometimes skew a little bit older. So, you may come across some of those issues. At community health, our patients, by and large, don't have access to video technology. I mean, they all have smartphones, but they might not have data plans, might not have access to WiFi. So, the business that I've done that has been virtual have been completely by phone. So, it's a bit of a challenge—you want to maintain the structure of the visit, make sure that they tell you whatever they want to tell you because by phone, not in person, it's tough to see if there's any hesitation there that would normally prompt me to follow up on that thread and say, wait a little bit there, what else can you tell me about that?

So, that part becomes much more nuanced and a little bit challenging. Video is by far preferable because all of that non-verbal stuff, at least some of it can get through, and the physical exam for rheumatology, you want to see how things move, you want to examine joints, the patient's can squeeze their joints. It's not quite the same as a physician or rheumatologist doing it, but it is far superior to just phone where your exam really is limited to the patient's speech and their patterns, whether they sound pressured or anxious, and then essentially asking them—is anything swollen? Does anything look red or abnormal to you. So, normally that would really not count as a good physical exam, but if that's all you have access to, then of course, you're going to do that and do the best you can.

AJMC^®: From your experience so far, what apps and/or approaches are working and not working amid the pandemic?

LaMoreaux: So, there are a lot of different apps to facilitate and kind of ease the transition into telemedicine. We do most of our encounters by translator so I will end up calling the translator designated for me whether it's Spanish or Polish, and then the 2 of us will call the patient. So, what I've done really is just pure phone, but there are many apps out there. Probably the most important consideration is to make sure you have some degree of security because these are truly protected health information patient encounters, and they should be treated as such on both ends.

The physician usually will have access to a quiet private office, and you want to hope that the patient does as well. So, when you have that privacy on both ends, hopefully some silence, and use an app or platform that is secure, that's probably the ideal situation for these patients; but, again, with community health, our patients are not able to download these apps and use them. So, we've been a little more limited. We use athenahealth there, and so their app has been very natural to residents I've talked to.

AJMC^®: How can health care providers and employers ensure they’re providing the best coverage options for recipients?

LaMoreaux: Yeah, so a number of states—I think most of them, in fact—have mandated that televisits are reimbursed at the normal rate, and that's taken a huge step: these encounters really work. All that widely considered or used prior to this, including in rheumatology, I mean, there's a few rheumatologists out there that were active in telehealth well before 2020, but it really wasn't the majority. Rheumatologists, the way that we train and practice, we all kind of view—you need to be in front of that patient, need to be listening to them and touching their hands and joints and really assessing them; but when that option was basically taken fully off the table, the community adapted.

So, the reimbursement when that concern went out the window, it was very reassuring. So, then you can kind of get back to the basics of just keeping track of your patient panel and making the most of all of these individual patient visits. There is a component of fatigue with being on the phone or on video that seems to not take place in person. So patients will, which is quite unusual for most physicians, patients might find themselves wrapping up the encounter because they're tired of talking on the phone, whereas in person, usually they just want to tell you more—as a doctor, you have to direct to the key things for that visit. So, all of that I think plays a pretty big role.

AJMC^®: As many non—COVID-19 patients may be falling between the cracks of the health care system and may prove a significant risk for a subsequent wave of delayed care, have physicians reached out to some of these patients and how so?

LaMoreaux: So, again, your vulnerable patients, whether you're a cardiologist or a rheumatologist, usually, those ones stick in your mind a little bit, and you'll probably keep tabs on them, but they're not the only ones that are at risk for these problems. We do have emerging data that the number of patients showing up to hospitals with things like heart attacks is down from this same time last year. The heart attacks are taking place—statistically, they're out there—but the patients don't want to come, don't want to be seen, or they're simply delaying until there's no question; you're passing out or you can't function.

So, in a way, it's just encouraging patients that the things that would have concerned you before this, they should concern you now. You don't want to be suffering at home with shortness of breath or chest pain or abdominal pain. If that's really the case, you really should go be seen, and if you're on the fence, maybe call your primary care doctor, and they're probably going to default to telling you, you need to get evaluated.

Each state is different right now, in terms of its rate or occurrence of these COVID cases and some states are thankfully on the decline, the hospital systems are a bit better positioned to manage COVID and non-COVID. Other places are still on the rise a little bit, and so patients are going to be concerned, but the bottom line is, if you're having a serious medical problem at home, you need to go in, you need to be seen because the alternative, hypothetical risk of COVID, that also can be dealt with and certainly no one—you don't want to expose anybody to this, but to me that far outweighs trying to ride out a heart attack at home, which we know could be catastrophic for patients.

AJMC^®: What further steps can physicians and hospital systems take to provide care for both COVID-19 and non—COVID-19 patients?

LaMoreaux: We’re thinking about how to take the best care of both COVID and non-COVID patients. Early when this was happening, they set up kind of COVID and non-COVID areas of the hospital. When COVID was peaking, especially in some states, that simply wasn't possible, but now that this is a bit more manageable, and we're back to contact tracing and kind of looking at how things go, again, you can divide out. Now, the one place where you really can't do that is the ER [emergency room] because everyone's going to get filtered through there. A lot of the COVID patients have either atypical or no symptoms, and so you can fully be positive and present with none of the typical symptoms of fever, cough, change in sense of smell, GI [gastrointestinal] symptoms. Those can be absent in patients that are still positive.

So, you do your absolute best. Rigorous testing upon presentation to the ER, admission to the floor, so that if someone happens to be or become positive, they can be moved. Then, of course, the healthcare providers using PPE [personal protective equipment], which is now a bit more available than it was during the most critical periods of this. There's still not an abundance, but more and more facilities are having larger stores and better access to this. So, those are a lot of the steps to me—aggressive screening both subjectively with symptoms, objectively in the ER, on the floor, and then making sure that everyone has access to, knows how to use, and really properly uses all the PPE that will protect them, their families, and their patients.

AJMC^®: Thanks, Brian!

LaMoreaux: Absolutely!

AJMC^®: To learn more, visit our website at ajmc.com. I'm Matthew Gavidia. Thanks for joining us.