Aine Cryts

Before the novel coronavirus was declared a pandemic in March, Deanna Tith spent her days as a medical secretary and team leader at Newton, MA-based health system Atrius Health. Most of her time was devoted to scheduling surgeries, coordinating with the surgeons on her team, and taking patients’ vital signs. 

But now Tith’s days are spent at home staffing Atrius Health’s Covid-19 triage line, where she answers calls from patients about the infectious disease caused by the coronavirus. She’s part of a home-based workforce that includes 65 registered nurses, 17 medical secretaries, and one licensed practical nurse who triage calls from symptomatic patients with Covid-19 and what Jane Connor, RN, associate chief nursing officer, calls the “worried well,” or people who are anxious and uncertain about the highly infectious disease. 

Approximately 85 percent of the calls are from patients with symptoms of Covid-19, while 15 percent of the calls come from patients who are worried about navigating life safely during the pandemic, says Connor. Tith and the other staff answering patient calls are only working from home, which means they’re not at Atrius Health practices seeing patients in person. 

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The triage team, which received its first call March 9, fielded 11,000 calls from patients during a busy three weeks from the end of March to mid-April. During that time, fewer than 100 patients were directed to the emergency department. The number of staff answering patient calls has flexed up and down, in response to patient need, says Connor.

In mid-April, Massachusetts was “right in the middle of a surge [of Covid-19 cases],” said Governor Charlie Baker, as 

 by WBUR, Boston’s NPR news station. At 528 cases per 100,000 people, at that time, the state had the third most cases per capita in any state. During the surge in cases, Connor saw an increase in talk time while the number of calls went down. That’s likely because it was a sicker population of patients who were calling the triage line, she explains. 

Keeping patients out of the ED; responding to questions

Keeping patients out of the emergency department was the initial goal, according to Connor. Triage team members can connect patients with resources such as drive-through testing, care in their homes, telehealth consults, urgent care, or a hospital visit, if necessary. Connor also wanted to keep staff members and other patients safe from the highly contagious disease. That meant phone-based triage was the right approach, she says. 

The nurses and medical secretaries on the triage team also answer many questions from patients who are anxious and uncertain about living safely during the pandemic. For example, Deborah Helen, RN, clinical patient safety and risk management specialist, who works on the team, explains that it’s easier for a mother to tell an 11-year old child than a toddler why she can’t hug them if she has Covid-19. 

Patients also ask about breastfeeding and pet safety, among other concerns. To respond to these questions, Helen and her team access the latest information from the CDC and the Massachusetts Department of Public Health. As of May 6, most people two years of age and older who can’t safely practice physical distancing in public are required to wear a face mask or face covering in Massachusetts. But convincing young children to wear a mask can be a challenge. Her advice? Color the masks and make it fun.

Patients who have Covid-19 are concerned about keeping their children and other family members safe, says Helen. She recommends that they use a separate bathroom from other family members, if that’s possible. 

Speaking in a clear and concise manner and providing examples to patients is important, explains Helen. Connor says that patients who are really anxious can be referred to a nurse practitioner, physician assistant, or doctor for a consult by video or phone. 

Patients who call one of the Atrius Health practices because they’re symptomatic or have questions about Covid-19 are immediately patched through to a member of the home-based triage team. Each member of the triage team has access to a list of scenarios that help them provide the most up-to-date, accurate information about Covid-19. For example, if a patient thinks they have the disease, the nurse or medical secretary will ask about their symptoms to determine if access to a Covid-19 test or a telehealth visit with a physician is appropriate.

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Every weekday morning before their shifts start at 8 a.m., triage team members participate in a 30-minute “virtual huddle” meeting where they learn about new symptoms, testing criteria, and guidance from state and federal agencies about Covid-19, says Connor. When patients call outside those hours, their calls are picked up by a different team of medical secretaries and nurses who have gone through the same training protocols as the weekday team. Connor adds that patients who call during the weekend and after-hours can also have access to a nurse practitioner or a physician assistant by video.

Smaller practices that want to set up a phone-based triage team should ensure they have coverage between the hours of 7 a.m. and 7 p.m. at a minimum, advises Connor. That’s because the majority of calls arrive before people leave for work and after work in the evening, she explains. 

Take-aways about the Covid-19 triage call team

Helen says the ability to alleviate patients’ fear is the most rewarding part of taking calls on the Covid-19 triage line. “This is new to everyone. We’re all nervous about this virus and how it can impact our lives and our families’ lives,” she explains. 

The team huddle, where team members can ask questions at the start of the day, helps ensure everyone’s communicating a consistent message with patients, says Helen. Patients have found the telephone-based care and telehealth visits to be so convenient that they don’t want them to end, she adds. 

What’s next for the Covid-19 triage call team? Connor says Atrius Health continues to evaluate patient call volume on a daily basis. One variable she uses to adjust staffing levels is the length of the calls from patients. She expects call volume to go down over the summer, but Atrius Health is planning for a potential Covid-19 symptom surge in the fall. “[We] will be prepared to bring our team back together at any time to restart our call center when needed,” says Connor. 

 that the state’s three-day average of Covid-19 deaths is 67 as of May 22, signaling the eighth day of decline. Hospitalizations of patients with Covid-19 are also trending downward.

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Curious about launching a remote patient monitoring program at your practice? Here’s a compelling reason to start one: remote patient monitoring costs approximately $1,500 a year per patient, while a single hospital admission can cost thousands of dollars.

Katie Nunn, CEO of Bright Ideas Medical Consulting, defines remote patient monitoring as collecting data from patients and receiving the data at the physician practice remotely. Examples of data collected from patients include weight, activity level, blood pressure, respiration, and blood-glucose levels, said Dunn during an April 16 session at MGMA20 | The Operations Conference, which took place virtually. Nunn counselled that this is a passive approach to monitoring, which means the physician office won’t be notified if the patient’s heart rate increases rapidly. Rather, it’s likely the practice will deploy a nurse who monitors patients’ vital signs on a daily basis using a dashboard.

Remote monitoring starts around $1,500 per patient, whereas hospital admissions cost thousands more.

Ten things to know before launching a remote patient monitoring program

People with moderate to severe asthma may be at higher risk of getting seriously ill from Covid-19, the infectious disease caused by the novel coronavirus. That’s according to the U.S. Centers for Disease Control and Prevention (CDC). 

The best way for patients with moderate-to severe-asthma to prevent succumbing to Covid-19, as with all patients, is to avoid exposure to the virus. 

To reduce the risk that his patients with asthma will contract Covid-19, Matt Dougherty, MD, a St. Louis physician, is using telehealth to treat patients. He starts by thanking his patient for participating in a telehealth visit because the doctor’s office may not be the safest place to go right now. Dougherty explains that participating in a telehealth visit can keep them safe and out of the emergency room or a hospital that may be filled with people who can put them at greater risk.

"I have found that families really appreciate that we realize the limitations of what we can do in the office right now and love that we’re trying alternative ways to keep [them] healthy proactively,” says Dougherty.

What follows are eight additional tips from clinicians on establishing an empathetic connection with patients during a telehealth visit.

Slideshows

Tips from clinicians during the surge in telehealth demands.

Establishing empathy via telemedicine

One of the main differences between providing care in ordinary times and during a pandemic, such as the world is experiencing with the novel coronavirus, is the need to depart from what’s done in the best interests of the individual patient when there are limited resources, says Carl Coleman, JD, professor at Seton Hall University School of Law in Newark, N.J. He specializes in the legal, ethical, and public policy implications of medical treatment, research, and public health.

“When there are limited resources, it’s not possible to give everything to patients that might benefit them. Thinking about it from that perspective, it’s about what’s best for the community. That’s the shift-to a thoughtful use of limited resources to achieve the best outcome for the population as a whole,” says Coleman, acknowledging that this requires a mental shift in perspective.

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, and other parts of the country to increase resource capacity. Of primary concern are access to doctors and nurses to treat patients with Covid-19, and the availability of ventilators and hospital beds.

 the Society of Critical Care Medicine, there may be more than 200,000 ventilators in the United States, but shortages are expected. In response, U.S. automakers Ford and General Motors are partnering with ventilator manufacturers to ramp up production, but the 

 that these efforts will likely deliver ventilators after the peak of Covid-19 cases projected to occur in mid-April.

Kathy Butler, JD, a St. Louis-based attorney at Greensfelder, Hemker, and Gale law firm, says that her healthcare clients are looking at ways to stretch their resources by looking at alternative treatment sites and considering the need to double up patients on ventilators. 

The Hastings Center, a bioethics research institute and think tank based in Garrison, N.Y. 

 that healthcare organization’s institutional ethics services conduct focused preparation for the “[t]he foreseeable uncertainty and distress that clinicians and teams will face under contingency or crisis conditions call for focused preparation.”

“The real crisis is going to be in the hospital setting,” says Coleman. “The thing that people are most worried about is that there aren’t enough ventilators, or there soon will not be enough in some places. So, decisions will have to be made about who should get priority for a ventilator and potentially taking people off ventilators who aren’t responding in order to give them to those with [a] better prognosis.”

He stresses that access to critical care or a ventilator aren’t decisions that should be made by individual physicians. Key aspects of guidance should include the following:

A transparent process for applying the guidelines

A required separation between the person who decides about access to resources and the physician caring for the patient.

The people participating in developing this guidance for healthcare organizations should include medical ethicists, doctors, nurses, administrators, lawyers, and social workers, advises Coleman.

In addition to paying attention to their healthcare organization’s protocols, Kathryn Zeiler, JD, law professor at Boston University, advises physicians to look for guidance from their state’s department of public health, as well as the American Medical Association and their state’s medical association. These guidelines, especially about triage, should be short and very clear, she adds.

AMA’s guidance on triage decisions during pandemics 

the American Medical Association’s (AMA) guidance on public health emergencies, such as pandemics, the “commitment of fidelity to the individual patient is counterbalanced by the need to protect the welfare of a population of patients... and to be prudent stewards of limited societal resources entrusted to them.”

She explains that the guidelines tell doctors what to take into account and what not to take into account regarding triage.

Here are two circumstances doctors should take into account:

The allocation of any scarce resource, including their time, based on the urgency of the patient's need as the doctor assesses it. 

The likelihood and anticipated duration of the benefit of the doctor’s intervention and the change in the patient’s quality of life. 

Zeiler also gives two examples of characteristics a doctor can’t take into account:

Social worth. These considerations come into play when a doctor is presented with, for example, a patient who’s a scientist developing a cure for Covid-19 and the person who picks up the trash. The doctor shouldn’t take into account a person's employment, she explains.

The person’s contribution to the illness. For example, if the patient says they haven’t practiced social distancing, a doctor can’t take that into account in determining triage. 

Kay Van Wey, JD, a Dallas-based personal-injury attorney and patient safety advocate, points out that practices will also need to keep in mind access to care for patients who are managing chronic or other non-Covid-19-related conditions. Covid-19 testing will strain resources at lab testing facilities, in particular. 

Her advice to clinicians is to document their decision-making. For example, if a patient needs a STAT lab test but the lab is closed, the clinician can recommend that the patient order an at-home test online, and that should be documented. In addition, the clinician can advise the patient to go to the emergency room if their symptoms get worse and have a nurse call the patient the next day to check in. 

Patients with symptoms of Covid-19 will also be calling physician practices. Butler advises physicians to triage these patients based on their symptoms and related comorbidities and direct them to the appropriate level of care, per the Centers for Disease Control and Prevention’s 

. For example, an otherwise healthy patient in her thirties will likely be told to manage the condition at home and, hopefully, survive. She contrasts that with a patient with a heart condition or diabetes who’s having trouble breathing; that patient needs to go to the emergency room because they may crash and need someone to help them.

Individual physicians should not be determining critical care and ventilator use.

Triage complications resulting from COVID-19

Video-chat tools such as Apple FaceTime, Skype, and Zoom are now available to physician practices that want to treat patients on a remote basis, 

March 17 guidance from the U.S. Department of Health and Human Service’s Office of Civil Rights (OCR), which enforces HIPAA.

Michele Madison, JD, an Atlanta-based healthcare attorney at Morris, Manning, & Martin law firm, points out that OCR won’t enforce penalties for physician practices that use “non-public-facing video and audio technology that’s not secure and they won’t require business associate agreements.” Still, she advises practices to take the following steps: 

Validate that the physician or other clinician is licensed to provide care by telemedicine in the state where they’re providing the service.

Secure verbal or written confirmation that patients understand the platform used to receive telehealth-based care isn’t secure. 

Communicate to physicians and clinicians that they must fully and completely document the interaction with patients, including their clinical findings, medical decision-making, and other necessary variables to support the CPT code used by the billing department. 

According to the OCR guidance, platforms such as Facebook Live, TikTok, and Twitch are examples of public-facing video communications platforms and shouldn’t be used when providing care to patients. 

Investigate ability to bill for telehealth visits

Elizabeth Litten, JD, a Princeton, NJ-based healthcare attorney and chief privacy and HIPAA compliance officer at Fox Rothschild law firm, points out that practices need to ensure that they’ll be reimbursed for the care provided using telehealth. Kelli Fleming, JD, a Birmingham, AL-based attorney at Burr Forman law firm, advises practices to check with health insurers to ensure they’ll be paid for the patient visit. 

 that Medicare will reimburse healthcare providers for treating patients using telehealth for Covid-19 and other medically reasonable purposes from offices, hospitals, and residences such as homes, nursing homes, and assisted living facilities. The federal agency noted that Medicare Advantage plans may offer additional telehealth services beyond what was included in their approved 2020 benefits.

States “have broad flexibility to cover telehealth through Medicaid, including the methods of communication (such as telephone, video technology commonly available on smartphones and other devices) to use,” according to April 2 

 from CMS. In addition, states aren’t required to seek federal approval “to reimburse providers for telehealth services in the same manner or at the same rate that states pay for face-to-face services.”

Fleming highlights that OCR’s March 20 

 says that telehealth-based visit doesn’t have to be for a Covid-19-related condition. That means, for example, that a physician can use telehealth to consult with a patient about an earache, she says.

 provided insight on ways that healthcare providers can disclose PHI about a person who has been infected by or exposed to Covid-19. Healthcare organizations can disclose PHI, including the name and other identifying information about the person under the following four circumstances:

When first responders may be at risk for an infection

When disclosure is necessary to prevent or lessen a serious and imminent threat 

Fleming points out that this allows a call center employee or an EMT to communicate with a physician or other clinician that the patient has been around someone with Covid-19 or has tested positive for the infectious disease. It allows healthcare providers to adequately respond and protect themselves, she explains. But she points out that this type of communication has always been 

 between first responders and healthcare providers. 

, which generally means that only essential personnel need to show up physically at their places of work. 

 on April 2 that it won’t impose penalties for violations of some provisions of the HIPAA Privacy Rule against healthcare providers and their business associates “for good faith uses and disclosures of protected health information (PHI) by business associates for public and health and health oversight activities during the Covid-19 nationwide public health emergency.”

, Roger Severino, director of OCR, said, “The CDC, CMS, and state and local health departments need quick access to Covid-19-related health data to fight this pandemic. Granting HIPAA business associates greater freedom to cooperate and exchange information with public health and oversight agencies can help flatten the curve and potentially save lives.”

Some clinicians may be able to provide telehealth consults from their home offices, whereas administrative employees who aren’t patient-facing can work remotely, with the right guidance. Alissa Smith, JD, a Des Moines, Iowa-based attorney at Dorsey & Whitney law firm, points out that employees providing administrative and billing support can work from home. Her advice for physician practices with billing employees working from home includes:

Keep billing files and other patient records away from others in the household.

Use safeguards, such as firewalls, encryption, and a private network to prevent patient information from being hacked. 

Fleming recommends that practices require billing staff who are working remotely to log in to the practice’s systems using two-factor authentication. That requires a code to be sent to the billing employee’s cell phone for an additional level of security, she explains. 

An additional safeguard is to discourage employees from saving any files on the hard drives on their computers at home, says Fleming. In addition, the employee’s computer should also be set up to require an additional log in if the computer isn’t in use for three minutes or even less. Employees should also be told to limit printing of any patient information, she adds. 

Most payers allow providers up to a year to drop a claim, says Fleming. But waiting to send claims to health insurers will hurt the practice’s cash flow. Physicians tell her that billing employees “are essential, they help me keep my doors open,” she adds. 

HIPAA, telehealth, and managing billing staff working remotely

Physician practices should implement the Centers for Disease Control and Prevention’s 

 on social distancing to prevent community spread of Covid-19. That guidance includes maintaining a distance of approximately 6 feet between people and preventing crowds. Applying social-distancing principles in the physician practice environment requires thoughtful planning and coordination, advises Michelle Strowhiro, JD, a Los Angeles-based attorney with McDermott Will & Emery.

The waiting room is one area where social distancing should be exercised, she says. 

Two strategies to enable social distancing in the waiting room are to limit the number of patients waiting at any given time and to ask patients’ family members to wait in the car or outside the practice. Strowhiro recommends telling patients about the second policy when the appointment is scheduled or by phone the day before their visit. 

In addition, she advises physicians and other clinicians to observe a six-foot distance with patients. Still, Strowhiro admits that this isn’t always an option. 

Responding to patient panic about the Coronavirus

Observing social distancing in the waiting room may require extending the hours of operation, which could be taxing on physicians and other clinicians, she admits. “You certainly have to balance the fact that physicians and clinicians can’t work 24 hours a day, which very well may require a reduction of patients per day.”

Tista Ghosh, MD, MPH, an epidemiologist and senior director of impact evaluation at San Francisco-based Grand Rounds, says practices should consider using telehealth to treat patients, which is another way to limit physical contact among patients and clinicians. In addition, some patients may have access to a virtual healthcare provider through their employer, adds Ghosh, who previously served as Colorado’s director of public health and chief medical officer. 

While practices may have to navigate through employee wage and hour considerations, Strowhiro is strongly encouraging her clients to let most administrative and back-office employees work remotely. 

Leveraging the practice’s virtual private network (VPN) is a must for remote employees, says Elizabeth Litten, a Princeton, N.J.-based healthcare attorney and HIPAA privacy and security officer at Fox Rothschild law firm. She also advises practices to provide remote employees with the tools they need, such as letting them take home a big monitor rather than having them work on a small laptop.

Mitigate risks associated with other building tenants

One concern for physician practices that are located in the same building as other businesses is the need to work with the landlord or property management company to reduce access to the building and increase awareness about the practice’s presence.

Rose Willis, JD, an attorney with Detroit-based law firm Dickinson Wright, says the practice administrator should coordinate with the landlord or the property management company if the office is located in a building that has more than one other tenant and shares a common area, such as a lobby or bathrooms.

Specifically, Willis recommends limiting the number of entrances to the building and assigning someone to capture the names and body temperatures of the people who enter the building. Practice administrators should also help increase signage to notify building visitors that there’s a physician practice in the building, in addition to coordinating with the building manager and other tenants on stepped-up cleaning protocols.

As more governors move to shut down non-essential business in their states and many employees are working from home, this is an issue physician practices may not have to deal with going forward, says Benjamin Widener, JD, an attorney and shareholder with Stark & Stark law firm in Lawrenceville, N.J.

Depending on the type of care they provide, practices will be impacted differently by their state governors’ mandates related to non-essential businesses. For example, in New Jersey, where Widener practices, all elective medical and dental procedures were cancelled as of March 27 

in response to Governor Phil Murphy’s executive order

. “Dental practices were the first to close. There will be lots of others,” he says. “More practices that focus on elective, non-essential procedures will close their doors. I suspect we’re going to see waves of that.”

Widener’s advice to physician practices? “Pay very close attention to the day-to-day shifts of the legal landscape on the federal level and the local level to see if there are any new orders or legislation that might impact their business.”

Make thoughtful decisions to furlough or lay off employees

An outpatient cardiology practice Widener advises had to furlough some of its cardiologists. He says the practice has retained a few cardiologists who will visit patients in the hospital. 

That’s just one of a handful of approaches a practice can take, according to Widener. Another option is to retain all employees and reduce everyone’s hours or reduce everyone’s pay. Alternatively, the practice can choose to reduce staff to only essential functions, which could include retaining a few doctors, in addition to a billing employee and the practice administrator. 

Strowhiro says some of her physician practice clients are putting employees on a temporary leave of absence, which may or may not be paid. This approach works best, she explains, when team members understand that it can help sustain the practice and, hopefully, open with the same doctors and clinicians in the future. 

With layoffs, specifically, Widener advises practices against making guarantees to employees that they will be hired back. In addition, practices have to decide about paying employees for unused vacation and sick time, he adds. 

Communicating and being transparent with the methodology behind staff reductions is important, he adds. Team members should be told the reasons for the reductions. For example, everyone in the practice will notice they’re seeing 50% less patients this week than the previous week, and that means a reduction in revenue, he explains. 

For additional guidance, physician practices can consult the American Academy of Family Physicians COVID-19 preparedness 