Donna Seminara, MD, MACP; John R. Maese, MD, MACP; Zeel Shah, MD
In the past two months we have been confronted with a life altering pandemic. COVID-19 has changed everything we do for the foreseeable future. All major sporting events and cultural activities like concerts and plays are on hiatus. In New York City, at the crossroads of America, 42nd Street is a ghost town. Doctor’s offices which were once thought to be recession proof have been closed because of lack of personal protective equipment and an unwillingness of patients to come for care despite being confronted with urgent and emergent situations. Practices have tried to adjust by offering telemedicine services but reimbursement has been spotty at best. The cash flow needed to operate the offices is nonexistent. Practices need to reopen with a new methodology going forward. One size does not fit all practices when reopening. Yet all practices need to assess their capabilities and decide what’s needed for the kinds of patients they see. Patients and staff need to be reassured that the office is safe. Currently there is no clarity around how to reopen. This article will review some of the steps necessary to move forward to reopen and do business in a different way.
To start, you must order personal protective equipment (PPE) as soon as possible because the lag time in obtaining these supplies may be weeks if not months. You need to decide what level of protective equipment is needed based on the procedures performed in your clinic. N95 masks are the most protective but require staff to be fit tested to ensure proper use. As of now, there are not enough PPE to give staff new masks after every patient or even each day. Staff needs to reuse N95 masks with a process in place in your office on how to store the masks at the end of each day and guidance on how to keep them clean. A less expensive surgical mask can be used over the N95 mask to help preserve the integrity of the N95 mask. There is no data that shows that cotton masks are protective in a clinical setting when aerosol and droplet spread of infection is anticipated. Based on the procedures that are done in the office you will decide whether staff will need the protection of glasses, goggles or face shields. Gowns are currently in short supply and if available the cost of each paper count can be prohibitive. You need to think about giving staff scrubs or uniforms that can be cleaned and disinfected. Booties are also important to cover shoes or staff needs to have work shoes and home shoes so that they don’t bring the virus back to family members who may be at risk. Containment of the virus is essential. The practice needs to think about the supplies your practice needs going forward and what will be in demand in the future. We anticipate that more patients will come in for vaccinations. Influenza vaccination will be particularly important in the fall to help distinguish the “flu” from COVID-19. You will need to order more and you will need a vaccination plan to meet the needs of all your patients. You should consider ordering more influenza vaccine since that will be in short supply and in high demand. Additionally, any other vaccines that you think you need should be ordered now such as Pneumovax and Prevnar. You will also need to order more disposable supplies such as paper towels, speculums and other devices. There will be an increase in use of soap and hand sanitizer which needs to be accounted for in your ordering. The practice must develop inventory controls so that when supplies are running low they can be ordered effectively and with enough time to receive them. Monitoring the use of disposable equipment will be essential for the practice or you will end up with too many gowns and not enough masks or vice versa.
The next step is to assess your office. You need to look at the physical plant to determine how patients will enter and leave to minimize exposure and the spread of coronavirus. You need to look at your front desk to make sure that your staff is protected with appropriate Plexiglas barriers to open areas that need to be sealed to minimize staff- patient contact. If you do procedures in your office, you may want to consider having Plexiglas shields designed so that you can visualize the area to do the procedure and maintain direct visualization with a physical barrier in place to prevent infection. If you don’t take credit cards, you might want to consider the use of credit card technology to avoid the exchange of checks or cash from patients and staff.
Minimizing the spread of COVID-19 in the air is important. COVID-19 spreads by droplets and can remain aerosolized for 3 hours. If your office is small and/or you do a lot of procedures that aerosolize particles, you might need to consider HEPA filters for the exam rooms and waiting area. You will also want to check the airflow in your exam rooms to see if you can minimize COVID-19 particles in the air. If your office is in a building with a high ventilation capacity similar to healthcare facilities, you will need to discuss with the building management the existing HVAC system. How often does the HVAC system do exchanges and can it accommodate high efficacy or adopt a “clean-to-dirty” directional airflow. Ceiling fans with upward airflow rotation with upper-air ultraviolet germicidal irradiation (UVGI) disinfection can also be used. A safe alternate in low humidity situations is to have outdoor spaces with cross-draft airflow enhanced with evaporative coolers. There are ways to calculate airflow for a given space. This might not be possible for many physicians since most offices have not been designed to deal with this level or complexity of airflow and very few outpatient areas have a reverse airflow room. If your office has been closed for an extended period of time then you need to check that there are no expired medications, fire extinguishers and other items that have expiration dates. You may need to check air filters on air conditioning and heating systems. In general, you will want to minimize the number of patients in your office at any one time. The new normal will be that no one should be waiting in the waiting room.
The third step is a great opportunity to redesign your office flow and how your staff works. There are very few chances in life to reset how your business works. COVID-19 provides that opportunity. Practices often do the same thing they have done for decades because of lack of time to consider change. Often there is economic pressure to process patients to maintain cash flow to assure fiscal viability. Practices don’t introduce technology because they cannot spend the time to evaluate the benefit. If you are an independent practice you should have applied for small business association (SBA) loans to support some incoming revenue. As you redesign your office you need to think about several important issues. How can you provide high-quality care while keeping staff and patients safe? How many patients are needed to be seen in the office and evaluated telephonically to keep the practice financially viable? Once you determine those numbers then you have to think about how to reschedule your patients. Patients will not come into a crowded waiting room. Patients need to be reassured that the office is safe. You need to be creative on how you’re going to schedule your patients. You will need to establish when you will do telemedicine visits and when you will see patients in the office. You might decide that you’re seeing healthy patients in the morning and sick patients in the afternoon. You need to schedule patients probably every half hour to minimize contact of patients coming in and out of your practice. You will need to decide whether you’re going to put a mask on all the patients that enter your office or just those who are sick. You need to decide what to do with patients that cannot wear a mask and decide what kind of protective personal equipment your staff should have. Remember that the burn rate for PPE in your office will be higher than pre-COVID-19. The cost of that additional PPE needs to be factored into your costs to operate the office. You need to have your office cleaned and disinfected every day. Examination rooms will need to be wiped down after every patient. Ordering additional cleaning products becomes essential. The CDC has excellent guidelines on how to keep your office safe and clean. Cleaning the offices frequently will be important to staff and patients. New technologies will be available to clean office space such as ultraviolet light (UV) robots. Ultraviolet light disinfection robots are equipped with technology including UV sterilization lamps and some even have automatic disinfectant sprays. These robots automatically reposition themselves close to surfaces and minimize exposure by healthcare workers. It takes approximately 12-15 minutes to disinfect and once the lights of the robot are turned off, someone can immediately enter the room. These robots have the capacity to work in small and large spaces. Despite the benefits, these new technologies may be cost prohibitive for small businesses. This could be a shared expense with several practices joining together to purchase or rent one.
The fourth step is scheduling patients. This becomes critical to prevent overcrowding, minimize contact between staff and patients and patients with patients. The first step is developing a questionnaire similar to ones that have been developed for other infectious disease outbreaks. The questionnaire should be an inventory of infectious disease symptoms like known exposure to a COVID-19 patient, travel history regarding areas that are endemic for COVID-19 and presence of a fever. How the patient answers the questions will determine when they are scheduled and what type of visit the patient should have. You may decide that this is an in-office visit, an “in-office” visit where the patient remains in the car (car-side visit), telemedicine visit or a home visit. The workday and week may need to be extended so that enough patients can be accommodated to keep the practice fiscally viable. If you have multiple providers you may want to stagger them so that you have an early shift, late shift and weekend shift. You will need to have telemedicine capability that will be HIPAA compliant in the post-COVID-19 era. If you live on a state border and many of your patients live in the other state you should consider getting a license in that state. Start the process now because the licensing process takes time and you don’t want to miss that opportunity for revenue. The current best practice seems to be scheduling patients every half hour per provider so that the waiting room does not get crowded. You can mitigate waiting room crowding by having the patients stay in their car while waiting. The patients can text into the office that they are outside and staff can acknowledge that the patient is there. You also need to consider how to do an evaluation of a patient who is uncomfortable coming into the office and is outside in the car. The practice may decide that some patients who appear infectious based on the symptoms need to be seen in the car to minimize the spread of coronavirus to staff and other patients. This will usually require a provider and a medical assistant to go out and see the patient. This drive-through approach will definitely be a different workflow than practices have done before.
When one patient leaves the next patient can be texted to come in and be placed directly in either a waiting room or exam room. If there is a new patient joining the practice then mailing out the forms, completing them online or sending them out by email may be beneficial. All patients should complete their forms prior to coming into the office. The documentation can be reviewed in advance and processed quickly to minimize wait time and potential contact with another patient. Medication reviews can also occur prior to the patient coming into the office. The practice should be considering the type of patients they have and how best to minimize contact time between patients, other patients and staff. The same standard of care needs to be maintained in the post-COVID-19 period as in the pre-COVID-19 period. If you participate in any quality programs or chronic disease management initiatives then you need to make sure you capture every bonus dollar. Honest communication with staff members about revenue and expectations are essential during this time, especially if you anticipate some reductions in pay because of lower office volumes and disruption in cash flow until there is widespread reliable testing or a vaccine.
The fifth step is to improve your ability to communicate with patients so that they know that your office is open and available to them. In your communication, you need to assure patients that the office is safe and that you are doing everything you can to minimize potential infection. You might consider sharing with patients what you’ve done to clean the office and what new protective practices are in place. You need to develop communication strategies that include email but remember that the email must be HIPAA compliant. Be sure you have accurate email addresses for your patients and that the office consent includes the ability to contact them via email, text messaging and telehealth. You will need to make sure that you develop an Internet presence or an E shingle. That Internet presence needs to be updated regularly so that patients can rely on the information that is available to know accurate office hours. A Digital Communication Strategy is essential as the practice goes forward. You will need an active internet presence. his will give you the ability to update policies and keep patients informed. For example, you might post when you extend hours. The Internet presence might also be a portal via which telehealth visits take place. You need to educate your patients on what kinds of cases you will see via telemedicine, when those hours are available, and how to access the practice via telemedicine. In the post-COVID-19 era, if regulations are not relaxed as they are now, you will not be able to use FaceTime or non-HIPAA compliant technologies so you need to ensure that patients know how to use those new apps that might become part of your practice. You might want to consider doing some telehealth from home. That might require an upgrade to your home computer and Wi-Fi speeds.
Finally, practices can survive in a post-COVID-19 era provided that they are vigilant in terms of patient and staff safety. Practices must be creative and innovative. Monitor reimbursement for services rendered so that there is enough cash flow to keep the business moving forward. Remember that there is the potential opportunity to invest in new technologies that can provide care remotely so that patients in the practice are kept both healthy and safe.
Check List
1) Order Supplies.
a. Hand sanitizer, hand soaps and cleaning supplies.
b. Tissues, paper towels toilet paper.
c. Garbage bags.
d. PPE – N95 masks, surgical masks preferably with the elastic, paper gowns, booties, facial barriers such as glasses and goggles, and any other disposable product you need in the office.
e. If you use paper documents then you might want to order disposable pens and give them to each patient to keep after use.
f. Consider having the staff wear scrubs that can be laundered each evening and used only at work (which means staff need a place to change).
g. Order needed vaccines early and anticipate high demand.
2) Office physical plant review.
a. Need to review patient flow into and out of the office.
b. Waiting room chairs need to be at least 6 feet apart.
c. Need to make sure you have appropriate Plexiglas dividers between staff and patients at the front desk.
d. Need to create a hand sanitizer station on entrance into the office.
e. Need to understand the airflow in your office and make sure the air circulates/exchanges according to current standards.
f. Consider HEPA filters for the exam rooms, front desk, and waiting room.
g. Need to designate an area where staff can store their N95 masks for the week.
3) Review CDC guidelines on use of PPE and Cleaning the Office.
4) Redesign office workflow.
5) Develop a Digital Communication Strategy for the practice.
Conflict of Interest: The authors declare that they have no conflict of interest.
References
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