Crisis at the Doctor's Office

The media spotlight is on hospitals. That's where the drama is—where people are going to live or die. But the fight against COVID-19 is also taking place on the frontline of healthcare—at ambulatory practices—with the very survival of many doctor's offices now at stake. 

Excruciating financial pressure

In hard hit areas of the country, practically no patients are coming to the doctor's office. I practice medicine in New Jersey, about an hour's drive from New York City. We can't see patients in-person unless it's a life-threatening situation. The risk of infection to staff and other patients is too great.

This sudden drop off in activity places many doctor's offices under excruciating financial pressure; especially practices not affiliated with a hospital-based healthcare system. With no warning, cash flow dried up. 

Practice owners and administrators face difficult questions and must make painful decisions: How much cash do we have on hand? How fast can we get a business loan? Do we need to furlough or lay off employees? How much longer can we stay in business? Such are the challenges being faced by practices small and large, primary care and specialty, as well as some health systems.

Emotions run high

Ambulatory medical practices are, for the most part, intimate work environments. Physician practice owners commonly know their employees well and work with them for many years. Together, they share meaningful aspects of work and life, including the profound experience of patient care. In the shadow of layoffs, emotions run high.

The consequences of closing a practice are more than financial. Physicians may invest a decade or more caring for patients with chronic illness. Now they must suddenly relinquish their role as caregivers—without knowing what will become of their patients. 

The fear factor

Fear is affecting medical practices in many different ways. The phone is ringing off the hook, with patients asking questions that range from reasonable to off-the-wall. The reason for the upsurge in calls—patients are afraid. Doctors are struggling to finding a rational way to deal with the volume of calls. We now make difficult medical decisions at a previously unfathomable pace. 

Staff are afraid too. Numerous stories tell of staff refusing to come to work. The front desk staff, for example, may all call out sick on the same day. They don't want to be exposed to the patients in the waiting room. Fears are made worse because practices don't have enough personal protective equipment to go around. 

Healthcare providers themselves are not immune to fear. Many have families. The fact that they put their families at risk, especially when providing hospital care, causes some to question their oath to treat the ill. Most remain dedicated to their chosen profession.

Welcome to your virtual visit 

In the midst of this crisis, practices must turn to virtual visits—to provide continuity of care, safely protect patients and staff, and stay in business. Overnight, telehealth has become the new normal for delivering healthcare and providers have had to learn how to use virtual visits.

For many medical practitioners, this is our first experience with video visits. We have to figure out how to schedule them, how to talk to patients through them, and what we can and can't do during these visits. It's a new world for most of our patients as well.

Last week was my first week of exclusive virtual visits in medical practice using NextGen Virtual Visits™. More than 90% of my patients were able to use the online video tools—both younger and older people. Prior to my consultation with them, patients were asked by a nurse if they had any way to provide objective data, such a thermometer or a home blood pressure monitor.

These were a range of visits—I consulted with people concerned that they might have COVID-19, checked in on elderly patients, conducted check-ups on people with chronic conditions, responded to medication refill requests, introduced myself to a few new patients, and dealt with symptoms of severe anxiety, such as heart palpitations and high blood pressure. 

The unexpected emotional intimacy of virtual care

My first week of virtual medicine was a fascinating experience. My initial conclusion: It’s not a bad way to practice medicine in many situations, not bad at all. As a physician I’ve been talking to patients on the phone for 15 years, yet I am amazed how powerful the addition of video is to each conversation.

People are worried. They want to see a face and talk with a doctor with whom they're familiar. People want to show you what they're thinking through gestures and facial expressions, which makes video a superior medium for healthcare than voice alone. 

Some of the advantages that video brings to the medical practitioner are subtle. The patient can see that their doctor is listening to them—creating a trust that is hard to duplicate on the telephone. Participants are less likely to talk over each other in a video chat. It brought me directly into the patient's home—almost made me a part of their home. 

Given current stay-at-home orders, often family members are in the room, and may interject comments. (One of the funniest: I was reviewing with a patient any factors that might be contributing to their symptoms, and a voice from the background chimes in, “Does smoking marijuana count?”). People showed me their pets and pictures of their children. Video allowed for a surprising therapeutic intimacy, different than a medical office, at a time when people are especially vulnerable to feelings of disconnection.  

Beyond telehealth

While telehealth is a vital solution, this capability alone cannot make up for the dramatic loss of revenue. The level of reimbursement that insurance payers will provide for telehealth services is unknown. 

From a financial perspective, many medical practices are experiencing the harsh economic effects of the coronavirus pandemic. Practice owners are advised to keep abreast of government action to lessen the economic harm. The Coronavirus Aid, Relief, and Economic Security (CARES) Act includes many provisions to help businesses and the healthcare sector. For more information about this new law, read the NextGen Healthcare blog post Congress passes $2.2 trillion coronavirus relief bill. 

Many practices may qualify as small businesses and meet the requirements for the Small Business Administration's new Economic Injury Disaster Advance Loan program. Consult with your accounting firm, business advisor, or attorney about this opportunity.

NextGen Healthcare's mission is to "empower the transformation of ambulatory care." Transformation means change and change does not always occur in ways we want or expect. The forced entry of virtual visits into ambulatory medicine will transform healthcare forever. I encourage you to push this new medium to the fullest extent possible, adding it to your arsenal of tools to care for your patients. 

As a practicing physician, I too am learning and adapting. But my role as the chief medical information officer for NextGen Healthcare remains the same—to help empower you and your practice—no matter what the circumstances. Please reach out with your questions and comments.