From Neurology Today
By Susan Kreimer
While serving scores of patients via telemedicine in socially distant times, neurologists foresee the challenges of reopening their offices before the COVID-19 pandemic ends.
Many patients are requesting traditional face-to-face visits, said Brad Klein, MD, MBA, FAAN, chief operating officer at Abington Neurological Associates, Ltd. In Willow Grove, PA. “They feel there’s more value in that in-person evaluation.”
The reasons vary. With certain neurological disorders, physician contact is critical. Even when it isn’t, patients may lack a viable internet connection, computer with a camera, or smartphone. Troubleshooting the technology could be too cumbersome. Others “may not be ready to transition to this approach, do not trust it, or just feel more comfortable with an in-person visit regardless,” Dr. Klein said.
On the flip side are patients who worry about setting foot in a doctor’s office during a pandemic. “The more reasonable course for most is to not come in due to the risk of exposure,” he said.
About 20 percent of patients in his group’s practice declined to try telehealth visits. Despite reassurances of their reliability in follow-up assessments, mere thoughts of a video-based appointment stirred up anxiety.
That said, he added: “There’s an impressive push within my community to convert to in-person visits,” he said. How to accomplish that safely is “the interesting dilemma that we’re now in.”
Both private and university-based neurology practices are taking more infection-conscious measures as they reopen their doors, at least partially, in regions across the country. Protecting staff and patients from viral transmission will continue to be a major undertaking during the transition of some telemedicine care back to the clinic.
The AAN has developed a series of checklists as guidance for reopening—including general operations strategies, as well as considerations to account for the safety of patients and staff, scheduling, and other practice needs.
Among the recommendations, the checklist advises practices to consult with federal, state, and local guidelines regularly regarding reopening and continue to use telemedicine as appropriate.
The AAN acknowledged the likelihood that “subsequent waves of COVID-19 may suspend in-person visits again” and urged practices to exercise flexibility, which would entail being “prepared to close again or scale back quickly in event of a recurrence.”
Among the safety considerations for opening, for example, the AAN recommends that practices “assess and secure appropriate personal protective equipment (PPE) and other supplies.”
Procuring enough masks during the height of the pandemic presented a formidable challenge for some private and academic practices across the country. Replenishment of precious reserves became a top priority, said David A. Evans, MBA, chief executive officer of Texas Neurology in Dallas, a private practice with two physician offices and a third location housing a sleep center.
A supply of 10,000 three-layer medical masks has assuaged concerns over a potential shortage, which would affect the 18 neurology providers, who offer imaging, infusion, and electrodiagnostic services and employ a pharmacist on staff. The practice collaborated with several sizeable neurology groups to purchase a large quantity from China, Evans said.
“There have been issues with getting long-term supplies, and initially, it was really hard to get any mask,” he said. “But now, we’ve got a pretty robust amount, and we’re trying to maintain that inventory, not knowing if there’s going to be a second or third wave” of the virus outbreak.
To ensure that every patient would have a mask upon entry, the practice’s operations manager identified a few staff members who were interested in assembling face coverings on site.
“Patients actually like them,” Evans said of the double-layered masks. Some people come in with a mask and really want another one. And we say, ‘No, it’s for someone who came in without one.’
“Patients and providers also receive face shields before procedures, which often require close contact. Clinicians are keenly aware that a sneeze, even when largely confined to the inside of a mask, could release contagious droplets into the air, Evans said.
The practice also emphasizes the importance of maintaining ample physical space between patients. Employees screen patients before entry into the building, inquire about potential virus exposure, take temperatures, and check to ensure their masks fit properly. At higher-volume times and when patients have specific needs, Evans noted, they’re instructed to wait in their cars until a text message signals it’s their turn to come inside for an appointment.
Restrictions on bringing additional visitors, implemented with safety in mind, have upset some patients, Evans noted, even those who do not need a caregiver or a translator to assist in the clinic. To avoid confrontations, the staff recently relaxed those rules a bit, Evans said.
Medical Specialists of the Palm Beaches in Atlantis, FL, which was slated to reopen June 1, intended to schedule only a few face-to-face appointments. The independent practice plans to manage the majority of new cases and follow-up visits via telemedicine “to minimize office traffic and exposure,” and walk-ins will not be accepted, said Casandra I. Mateo, MD, a neurologist and epilepsy specialist at the practice.
“We are aware of the risk for a second peak in Florida,” Dr. Mateo said, citing fears of more aggressive virus resurgence. “Therefore, we will continue to enforce strict precautions,” including the requirement that everyone wear masks.
In addition to limiting the number of procedures, the practice will continue to disallow vendors, pharmaceutical sales representatives, resident physicians, and medical students. Only companions who are deemed necessary to a patient’s care will be permitted, she said.
No more than two or three physicians, nurse practitioners, and other staff can be in the office simultaneously. They will abide by alternating schedules, with the rest of the group continuing to work remotely via telemedicine, Dr. Mateo said.
“The checklist provided by AAN is very helpful and simple to follow,” she said. “We are adhering to each of the recommendations provided, with special attention to the safety considerations.”
Additional guidance from the AAN includes offering hand sanitizer, a hand-washing station, or both to patients and visitors when they come into the facility; removing shared items such as magazines, toys, and the coffee machine; spacing waiting room chairs to promote social distancing; and managing patient flow so that people enter and exit through different doors to avoid passing through common areas more than necessary. The AAN also suggests laminating paper signage for regular cleaning and installing plexiglass barriers between staff and patients.
“Certain restrictions are going to have to apply in a time of a pandemic,” said Mary Zupanc, MD, FAAN, FAAP, professor and division chief of pediatric neurology at the University of California, Irvine. “We all have to make collective sacrifices.”
Now more than ever, it’s important for health care professionals to set an example for others to emulate. At CHOC Children’s Hospital in Orange County, CA, Dr. Zupanc said there have been strict limitations on how many people can accompany or visit a sick child.
Before the pandemic, the hospital often allowed both parents, siblings, aunts, and uncles. Not anymore, said Dr. Zupanc, who is also co-medical director of the CHOC Children’s Neuroscience Institute.
Only one parent can be with a child at any given time. The protocol aims to protect them and others in a setting of immunocompromised pediatric patients with serious illnesses. “Parents get it,” she said. “They understand.”
With the AAN guidelines and life in general, “we’re trying to balance safety with preventing the economy from collapsing,” Dr. Zupanc said. “I weigh in on the side of public health. This can be a very dangerous virus.”
By tracking the spread of the virus on the websites of local county and state health departments, Lori Noorollah, MD, and her colleagues at two HCA Healthcare hospital-based neurology clinics in the suburbs of Kansas City, MO, are developing plans to resume in-person care.
“Our strategy for transitioning patients back to the clinic involves phases based on the level of risk to the patients and the level of transmission within the community,” said Dr. Noorollah, a neurologist and director of sleep medicine at Centerpoint Medical Center in Independence, MO, and Menorah Medical Center in Overland Park, KS.
“We are starting to bring back patients who cannot be managed realistically via telehealth,” she added, referring to those who require a hands-on physical exam, emergent EMG, or botulinum toxin injections.
Because the clinics are located in an area that “currently falls into the mild to moderate community transmission category,” Dr. Noorollah said neurologists initially will see younger patients without high-risk medical conditions or comorbidities.
The practice will advise most patients older than age 60, or those with significant heart disease, lung disease, or immunocompromised states to wait until local transmission drops to a minimal or nonexistent level, she said. In addition, “as we bring people back to the clinic, we are working on ways to adjust the flow of traffic in order to avoid having multiple people in the waiting room at once.”
At Kaiser Permanente medical centers and offices in Washington, DC, Maryland and Virginia, physicians and patients are using separate entrances, and, once inside, everyone must don a mask, said Ejaz A. Shamim, MD, MS, MBA, FAAN, chief of neurology for the region.
“We have taken steps to preserve our protective equipment during the pandemic,” Dr. Shamim said. Temperature screenings, hand washing, and hand sanitizer have become staples in the prevention of infections. Only one physician works in the office at a time; the rest see patients via telemedicine.
“A lot of our patients are very happy with the virtual visits,” he said, explaining that due to virus concerns, “some patients are afraid to come into the clinic if they don’t have to.”
The decision to fully reopen will hinge partly on how long the Centers for Medicare and Medicaid Services (CMS) and commercial insurers allow pay parity for telehealth visits.
“We can’t stay in business offering services without receiving fair compensation,” said Bruce H. Cohen, MD, FAAN, professor of pediatrics and integrative medical sciences at Northeast Ohio Medical University and director of the Neurodevelopmental Science Center at Akron Children’s Hospital in Akron, OH.
Furthermore, CMS is waiving state licensure requirements for telehealth services, which enables clinicians to provide care for patients in states other than where their offices are based. With Akron Children’s Hospital’s proximity to the borders of Michigan, Kentucky, and Pennsylvania, patients often venture outside of their state to receive care, Dr. Cohen said.
For telemedicine in the current environment, “the payment is the same as face to face,” he said. “A lot of the regulatory burdens have been pushed by the wayside as well.”
Continued pay parity for telehealth visits is also an important consideration for Dr. Klein. In early May, when he and his colleagues reopened their office in Pennsylvania, “we dipped our toes in the water” with botulinum toxin injections and a few other nonurgent cases, he said. Later in the month, he noted, the practice of 10 neurologists and two advanced practice providers was operating at “full throttle.”
Meanwhile, their contract to provide inpatient neurology care at Abington Hospital in Abington, PA, has remained in force throughout the COVID-19 pandemic—and they are holding steadfast to that commitment.
“When asked to answer that call, I’m there to help because the community needs neurological care,” Dr. Klein said. “That’s what we signed up for in medicine—to take care of people. Regardless of the diseases they deal with, it’s our job to figure out a way to help them through it. It’s just the oath we took, and to the best of our abilities, we’re going to do it.”
