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Lasting Change: Assessing the Potential Long Term Impact of COVID-19

By COVID-19, HealthNo Comments

“Real change, enduring change, happens one step at a time.”

Ruth Bader Ginsburg

Associate Justice, U.S. Supreme Court

The economic, medical, political and psychological tsunami unleashed by the COVID-19 virus is unlike anything we have seen in our lifetime. The traumatic disruption of 9-11 was limited in comparison to our current crisis. While impossible to include up to the minute statistics, already more than 15 million cases have been confirmed with at least 620,000 deaths, and U.S. unemployment is approximately 11%. Is it possible that any good will come of these months of tragedy and lock-down? What do we know about the immediate and longer-term consequences on us as humans, on the health care community and neurosurgery? I have been given the monumental task of trying to peer into that future as the Neurosurgery Blog’s focus on COVID-19 draws to a close.

Silver Linings: Our World

Today, the canals of Venice are clear, and dolphins have returned — an amazing and rapid transformation. During the pandemic lock-down, our environment improved dramatically with blue skies seen across India, air pollution around major cities visibly and measurably improved, leading to improved health, and images from space revealing stunning clarity. Beyond recognizing how reversible the damage to our physical world is, we have witnessed the very best of humanity in our communities. Touching stories have filled our news feeds:

These represent the many things individuals are doing every day to make the lives of those around them safer and more fulfilling.

To fill the void left by social distancing, many have become facile with video technology to provide essential human contact during long weeks of isolation. Religious services, theaters, concerts and more have rapidly adapted to provide their communities invaluable connection and engagement.

Silver Linings: Health Care and Neurosurgery

As grim headlines unfolded, the health care community united. Traditionally competitive institutions have reached beyond those boundaries to share expertise, resources and staff to provide the best care for patients. Necessary innovation has blossomed creating change that will survive beyond COVID-19 such as:

The Centers for Medicare & Medicaid Services (CMS) authorized payment for telemedicine services, with many private insurance companies following on their heels. This marks a crucial advance and should herald a new era of health care delivery. A world free of many of the inconveniences associated with a visit to the doctor — days off work, parking, travel, navigating complex hospital corridors — is no longer a figment of the imagination. Reimbursement for these services will drive technological innovation that will enhance the value and experience of these visits. While there will always be an essential role for the face-to-face appointment —especially in the surgical disciplines such as neurosurgery — and the importance of human touch, the provision of telemedicine care should be more comfortable and more convenient.

Neurosurgery stepped up and came together in many meaningful ways. Many of our national and international organizations, as well as neurosurgical publications, provided state of the moment information to connect us around the world. Neurosurgeons continued to keep their practices afloat to provide care to those with emergent conditions despite considerable risks to themselves and, by extension, their loved ones. Many stepped into roles of supporting other physicians overwhelmed by the sheer volume and acuity of COVID-19 patients. In contrast, others assumed leadership roles helping their hospitals and communities in many ways — designing systems for surge redeployment of staff and creating new operating room policies to enhance airflow. Each institution has found ways to protect their resident team while ensuring they continue to receive valuable education and feel fully supported during a time of great strain.

Not All Roses

Still, many vulnerabilities were revealed, and scars will be left from the crisis. Neurosurgery lost one of our most beloved colleagues when COVID-19 took the life of James T. Goodrich, MD, PhD. Questions arose, such as how could things as simple as masks, gloves and gowns become such a challenge to procure? Known health care disparities were shown to exist, likely reflective of such differences at every level of medical care, but poignantly and tragically demonstrated in COVID-19 related deaths, morbidity and availability of resources. This was further brought into the spotlight by the death of George P. Floyd, Jr. and the dramatic national response that followed. Finally, people learned it isn’t so glamorous or pleasant to wear a mask, as neurosurgeons have known our whole careers.

Lasting Change

Most meaningful change does evolve incrementally; however, cataclysmic events like the COVID-19 crisis instigate sudden and dramatic change. Given the potential for positive unintended consequences, here is my wish list (please add your own!) for enduring gifts we deserve from COVID-19:

  • A deep appreciation not only for the fragility of the world around us but also its capacity for resiliency — let us remain mindful of how all of our actions impact the earth, our health, and our fellow humans;
  • A new dawn of real innovation in medicine that builds new frontiers of access and engagement by leveraging the best of augmented intelligence and melding it with the personal touch that only humans can provide;
  • Restoration of travel because of all the good it brings but with a profound sensitivity on how to preserve the beauty of the natural and man-made world; and
  • A renewed and sustaining appreciation for the difficult work done by neurosurgeons and all physicians, along with their dedicated teams, to care for patients and their loved ones every day.

We thank our readers for following Neurosurgery Blog as it recorded the real-time impacts of the COVID-19 global pandemic. As the world emerges from these trying times, we invite you to continue the conversation on Twitter by following and using the hashtag #COVID19. With new therapeutics and promising vaccines, the glimmer of hope becomes stronger with each passing day.

Deborah L. Benzil, MD, FACS, FAANS
Cleveland Clinic, Vice-Chair, Neurosurgery
Cleveland, Ohio

Telemedicine During the COVID-19 Pandemic and in a Changing Health Care System

By COVID-19, Faces of Neurosurgery, Guest Post, HealthNo Comments

The COVID-19 crisis has produced seismic changes in the practice of neurosurgery. For weeks elective surgeries have been eliminated and shelter in place orders implemented. Patients still develop herniated discs with neurologic deficits, present with brain tumors and need neurosurgical treatment. Telemedicine has provided one option for remaining connected to our established patients and caring for new patients during the pandemic.

CMS Changes

The Centers for Medicare & Medicaid Services (CMS) has been nimble in issuing rules and guidance around the use of telemedicine. CMS is now paying for telehealth visits at the same rate that they pay for an in-person visit. Documentation requirements have been modified and now focus on medical decision-making. Now you can bill based on time spent during the visit or on the complexity of medical decision making required in your assessment. CMS will pay for telemedicine if the physician is licensed in the state where the services are provided — regardless of where the patient is located.

There are several video conferencing and chat platforms that physicians may use. Setting up Health Insurance Portability and Accountability Act (HIPAA) compliant solutions may be beyond the capabilities of small practices, especially when they are trying to see patients now. If physicians act in good faith, CMS is currently allowing physicians to use other platforms without worrying about triggering an Office of Civil Rights audit for the failure to comply with HIPAA during this national public health emergency.

CMS has also issued specific guidance for teaching hospitals and addressed numerous questions about how learners may fit into the broader utilization of telemedicine. The agency has stated that teaching physicians can provide services with medical residents virtually through audio/video real-time communications technology, with the caveat that this does not apply in the case of surgical, high-risk, interventional, or other complex procedures, services performed through an endoscope, or anesthesia services.

Outpatient and Inpatient Visits

These new rules are not just for outpatient clinic visits. Inpatient consultations and emergency room care are also included in the list of services where telehealth is an option.

The use of telemedicine carts has been widespread in the evaluation and management of stroke patients. This same platform could be used to conduct consultations and rounds, supported by colleagues at the bedside. Some of the challenges around this concept require novel solutions, such as the creation of a tele-presenter role to:

  • Be onsite and available through the paging system;
  • Deploy the telemedicine equipment as directed by the physician;
  • Introduce and explain the telemedicine process to the patient;
  • Stay in the patient’s room while the consult is performed to assist with the exam;
  • Interact and coordinate telemedicine deployment across multiple specialty teams; and
  • Basic troubleshooting of any equipment malfunctions.

Potential Issues

Technological innovations have enabled practices to continue to see patients while maintaining social distancing. While telemedicine may have a long-lasting and impactful future, and the health care system may not have explored all potential avenues of virtual health care delivery, there are some potential issues. For example, how are physicians who are currently working from home enabled to respond to the occasional inpatient consult that may arise during the day? Physicians working remotely may produce unique challenges.

Additionally, patient consent specific to telehealth is required for all visits. The consent needs to specify the unique risks of providing care virtually with a patient. Unauthorized access, breach of patient privacy and the inability to provide a thorough physical exam are limitations of telehealth.

Finally, the lack of a physical exam cannot be understated. Some aspects of the physical exam can be assessed, including height and weight, pulse, respiratory rate, observation of motor status and gait/balance, extraocular muscles, and facial symmetry. Many aspects of our examination simply do not translate to a virtual platform such as deep tendon reflexes, pathologic reflexes and a thorough sensory exam. Furthermore, direct patient contact is essential for fostering trust and in developing the doctor-patient relationship. The feeling of partnership with your patient when facing a difficult diagnosis may be challenging with a visit conducted through a smartphone screen.

Looking into the Crystal Ball

During the COVID-19 public health emergency, we have incorporated telehealth visits into our practices. In our experience, the move to telehealth has improved clinic efficiency and increased clinic throughput. Telehealth visits are an effective way to screen patients and provide an easy way to quickly assess whether a patient needs to be seen in person to determine the need for surgery.

While Medicare (and other third-party payors) has adopted these changes for the duration of the COVID-19 public health emergency, it is safe to say that telemedicine in neurosurgery is here to stay — and will have even further impact on our practices in the future.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following and using the hashtag #COVID19.

John Ratliff, MD, FAANS, FACS
Chair-elect, AANS/CNS Washington Committee
Stanford University Medical Center
Palo Alto, CA

 

 

Clemens M. Schirmer, MD, PhD, FAANS, FAHA
Chair, AANS/CNS Communications and Public Relations Committee
Geisinger
Wilkes Barre, PA

COVID-19 and Neurosurgery: Response, Adaptation and Action on Behalf of Our Patients

By COVID-19, Faces of Neurosurgery, Guest Post, HealthNo Comments

 “Death, be not proud, though some have called thee.
Mighty and dreadful, for thou art not so.”
John Donne

The COVID-19 pandemic is a generational event. It has disrupted every aspect of modern life. Businesses are shuttered. Schools and universities are closed. Social distancing has altered our normal mores for connecting with our neighbors, friends and colleagues. Although many in medicine are dramatically affected by the pandemic as they are on the ‘front lines’ of the crisis, the pandemic has had a ripple effect through the entire health system.

Neurosurgery is no exception. The pandemic has been a significant disruption to the way neurosurgeons interact with and care for their patients. It has been remarkable how the medical community has come together and has been able to pivot on the spot to adjust the way we deliver care to our patients. There certainly is no single best approach, and there’s much to learn from each other.

Over the next several weeks, the Neurosurgery Blog will highlight some of the ways that COVID-19 has affected our practices, our lives and how many in our specialty have responded to the challenge.

We began by highlighting the experience of colleagues from the University of California, San Francisco — who proposed a way to manage neurosurgical cases in The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm. We also shared an overview of The Global Impact of COVID-19 on Neurosurgical Practice, Parts I and II, as recorded by several reports in the Journal of Neurosurgery (JNS). Both the JNS and Neurosurgery will provide weekly COVID-19-related updates from neurosurgeons from across the world.

Neurosurgeons have been personally affected by the virus with results that speak both to the tragedy of the current situation as well as the hope of recovery. Tragically, our specialty lost James T. Goodrich, MD, PhD, from New York City, who died from complications of COVID-19, and we take the opportunity to celebrate his life and achievements.

Neurosurgeons are also playing various clinical roles during this crisis. Aiming to protect patients and create surge capacity, surgeons have been asked to manage their patients and practices by abiding mandatory orders halting elective surgery. Scott A. Meyer, MD, FAANS, will share his experience in “Keeping Neurosurgical Practices Operating During COVID-19 and Beyond,” an issue that is undoubtedly vital for those who practice in solo or small group practices.

Others have been asked to assume alternate roles for their health system as demand requires, which will be discussed by S. Alan Hoffer, MD, FAANS, in “COVID-19 Answering the Call: From Neurosurgeon to Critical Care Physician.” Myron Rolle, MD, will report on “Neurosurgeons on the COVID-19 Frontlines,” based on his experience dealing with one of the epicenters of the outbreak in Boston. Shelly D. Timmons, MD, PhD, FAANS, will be tackling another very tangible aspect of this crisis — the lack of personal protective equipment (PPE) — in “SOS: Send More PPE Now!”

Neurosurgery has also responded by adapting the way we care for and interact with patients and colleagues. These last four weeks have seen an unprecedented expansion of the use of telemedicine at a rate perhaps higher than over the previous decade. Of particular practical interest may be “Telemedicine: During the COVID-19 Pandemic and in a Changing Health Care System” by John K. Ratliff, MD, FAANS, and Clemens M. Schirmer, MD, PhD, FAANS.

COVID-19 has also had a profound effect on medical education on all levels. Face-to-face interaction and departmental teaching and working conferences have been eliminated. The need to keep training going has been a driving force to explore other ways to deliver education. Ashok R. Asthagiri, MD, FAANS, and the CNS education team, will share some lessons and experiences in “Innovations in Continuing Medical Education in a COVID-19 Environment.” In addition to issues related to continuing medical education, we will hear from medical students and residents from two programs in New York — Mount Sinai and the University of Rochester — highlighting how the crisis has affected their training and what the future may hold for those medical students with ambitions to pursue our specialty.

Finally, our former Neurosurgery Blog editor, Deborah L. Benzil, MD, FAANS, also tries to look forward to the end of this crisis and moving forward through her piece “Hope and Recovery, Life After COVID-19.”

We hope to highlight some of the resolve and resilience that neurosurgeons have brought to this crisis in service to our patients. It is too early to tell whether we can simply return to normal or whether a new normal state must be found in the aftermath of the pandemic.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following and using the hashtag #COVID19.

Clemens M. Schirmer, MD, PhD, FAANS, FAHA
Chair, AANS/CNS Communications and Public Relations Committee
Geisinger
Wilkes Barre, P.A.

 

 

Kristopher T. Kimmell, MD, FAANS
Vice-chair, AANS/CNS Communications and Public Relations Committee
Rochester Regional Health
Rochester, N.Y.