“In three words I can sum up everything I’ve learned about life: it goes on.” ~ Robert Frost
Whatever happens in 2020, the corona virus will most certainly be included on the short list of life changing events. As I consider the simple things I do every day, the impact of COVID-19 is present. I don’t leave the house without germicide and a mask for everyone in the car. It is not life as I remember but a new norm.
Occasionally I encounter a supply chain issues with limited purchase quantities on items I took for granted. Toilet tissue is beginning to reappear on the shelf but seems to disappear quickly dispite a limit of only one per customer. Shelves have groceries but they don’t seem to be stocked too deep.
I still inventory my pantry. What has changed? While toilet paper, soap, and germicidal agents have a permanent place on the grocery list, they don’t always end up in the shopping cart. When shopping consider the items that are consumed every month or more frequently. The greater the consumption the closer to the top of the shopping list. I’m not suggesting blowing the grocery budget on pantry inventory or hoarding but rather buy what you need now and then one extra for later. Keep in mind your favorite meals and snacks. With time you’ll have a little surplus that could make your life less stressful later.
College begins in the Fall at our house. Students will be expected to wear masks and class size will be limited to support social distancing. Class schedules are now a blend of some classroom time and an online component to support an excellerated semester that will be finished before the beginning of influenza season. There will be online only education opportunities during an extended winter break. Spring semester resumes at an undetermined time at the end of influenza season.
My daughter’s part time job resumed with limited hours. Sadly, the corporate office will close this store and others before the end of the year. The COVID-19 has affected the business bottome line also.
My IT sons will continue to work at home through 2020 and maybe beyond. Their employer has discovered some cost savings and work efficiencies with remote employees.
My nurse practitioner daughter was sent her home also. Her patient care became virtual. As the state and communities have opened up, her virtual care has expanded to include limited face-to-face appointments for the most demanding diagnoses.
Our dentist office’s waiting room is now the inside of our automobile in the parking lot. We call to let them know we have arrived, our temperatures are checked without contact and we are provided paperwork to complete. One by one we are called inside for a dental cleaning that was originally scheduled weeks earlier. A similar procedure was followed at the orthodontist.
Yes, things are different. As we go forward, there will be a new norm. Some of these changes will remain forever. It is estimated healthcare will consume 18% of the United States’ gross domestic product in 2020. Yes, health care, too, will see changes.
Face-to-face visits will be supplemented with virtual visits. Face-to-face patient flow will be re-examined to check for potential social distancing “choke points” such as registration and check-in areas.
Traditional face-to-face health care is busy finding the best way to meet patient needs virtually. Whatever you call it — virtual, telehealth or telemedicine — virtual care continues to develop. While sheltering-in-place, third party payers and Medicare waived some of the rules associated with virtual visits to facilitate ongoing health care. Hands-on physical exams were waived. Chief complaint or reason for the visit and medical decision-making is still required for reimbursement. Medical decision-making depends on medical history, review of systems, and/or past medical or family social history; a medical exam, labs (or status data) and/or diagnosis; and/or counseling. With medical access limited to a virtual format, there have been new learning curves to support the business of health care.
Keeping up with the changing rules regarding virtual visits has been an ongoing challenge. Clinic staff are continuously receiving updates regarding reimbursement from third party payers and Medicare.
Implementing virtual visits has changed the day-to-day practices in the provision of care:
Pre-COVID-19 clinic environments fostered team collaboration that working from home or with limited staffing may compromise. The health care provider cannot walk around the corner to see if the diabetes educator or dietitian can squeeze in a visit before the patient leaves. Now support staff must be referred to after the virtual visit and coordinate with that patient at a future time. There’s a potential loss of efficiency here that needs to be recovered to meet the demands of a health care system. Clinics will be creative.
Virtual visits have the potential of being time consuming. Health care has realized this and now tries to gather useful information about patient status and/or needs before the visit. The absence of a medical exam means virtual visits need patient data BEFORE a virtual visit to support medical decision-making. There are some diagnoses that are better suited for virtual visits. Diabetes management is known to include data collecting devices as a routine part of care: glucose monitors, continuous glucose monitors, smart insulin pens, insulin pumps and numerous management apps that can track diet, activity, medications and biometric monitoring. The challenge for virtual health is the sharing of that data with health care providers. Barriers to data access may include:
- The patient and/or the support staff’s understanding of technology in uploading device data from blood glucose monitors, insulin pumps and/or continuous glucose monitors could make data collection difficult. Let’s face it; they don’t teach internet technology as a routine part of the health care curriculum. Knowing how to retrieve data from so many device options available to patients is a potential issue.
- While diabetes devices have long supported data uploading, there is no common upload language shared by medical devices. Each device has its own upload system that may be via bluetooth, internet, FAX, or data cable. If patients have never been taught or required to upload a device, teaching this skill can be difficult. Additionally, the patient may have misplaced data cables if required. Also, many patients do not have home internet or computer devices to make upload possible.
- If diabetes device data can be uploaded, sharing with the clinic may or may not be a simple process. There is no continuity between devices. If the device data cannot be uploaded, options may include:
- Patient may bring device to the clinic for upload. This results in the patient making a special trip to clinic just for this purpose. Disadvantage: travel, time, and potential exposure risk.
- A patient may reproduce device data and take photos with digital devices to email, FAX, or share via patient portal with the clinic.
- For the patient without internet, computer, smart pad or smart phone, they can share device data or log book with staff over a phone; this is sometimes a slow process.
The pre-virtual visit preparation alone could be extremely time consuming. Yet the collection of data before the visit is critical to the medical decision-making success of the virtual visit. It should be known, no third party payers are reimbursing this pre-visit data collection process at this time. It is the responsibility of the clinic to determine how to collect the data. Going forward, healthcare will most certainly include device recommendations that support easy and complete data sharing to support virtual healthcare.
The preferred virtual visit format is real-time audio video allowing healthcare provider and patient to see each other during the visit. Where technology may be a barrier, a telephone call initiated by the healthcare provider becomes the visit format. Either is eligible for reimbursement under current virtual visit rules.
While virtual visits do have challenges, they also have legitimate advantages:
- There can be no denial that virtual visits reduce a patient’s exposure to the stress and sometimes hazards of driving. No matter the season, virtual visits provide a driving commute most people appreciate.
- Not having to drive to the clinic will also save the patient time as many arrive early for appointments.
- While social distancing has been demonstrated to be one of the best preventitive measures to avoid exposure to contagious illnesses, virtual visits are one of the best socially distancing options in healthcare. There’s no sitting in a waiting room with potentially ill patients.
- For persons living in remote areas, virtual visits increase access to healthcare specialists and their support staff by reaching across the miles to provide care.
Going forward everyone should recognize symptoms of influenza like illnesses and COVID-19:
- fever* or feeling feverish/chills
- cough
- sore throat
- runny or stuffy nose
- muscle or body aches
- headaches
- fatigue (tiredness)
- some people may have vomiting and diarrhea, though this is more common in children than adults
- Shortness of breath or difficulty breathing (unique to COVID-19)
- Loss of taste or smell (unique to COVID-19)
While we know things will be different as we go forward in a world with a virus we do not yet have a handle on, we will adapt. Man has always adapted. Adaptation is what has made man’s survival on earth successful.
Healthcare will change also. Don’t hesitate to let your healthcare provider know if the changes are too difficult for you . . . health care is committed to taking care of the patient. We, too, can adapt.