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Evolution of Florida's COVID-19 care

(Greenway Health)

COVID-19: The Evolution of Care

When the first wave of COVID-19 cases began hitting Florida hospitals in March 2020, there wasn’t a lot providers could offer beyond supportive care, such as supplemental oxygen, fluids and mechanical ventilation for those struggling to breathe. A year later, physicians have a better understanding of the disease and more tools at their disposal, including several medications that can improve outcomes if they’re used early in the course of the illness. Here’s some of what they’ve learned — and what they want patients to know.

Rethinking Ventilators

COVID-19 is different from other types of pneumonias in that respiratory failure can develop rapidly and with few outward signs. “People will be sitting there in the intensive care unit, watching TV with the channel changer, and their oxygen level is so low that they need to go on a breathing machine, and you have to say, ‘I’m sorry Mr. Jones, your oxygen is low. It’s time to FaceTime your family, spend some time with them, and then I have to put you on a breathing machine.’ And they’re like, ‘Well, can I finish this program first?’ So they’re not struggling for air. They are what we call ‘happily hypoxic,’ ” says Dr. Kirk Voelker at Sarasota Memorial Hospital. But while patients with severe COVID infections were routinely placed on ventilators early in the pandemic, poor outcomes caused physicians to rethink that strategy. “We don’t go as early on the ventilators now,” he says. “We try to get them lying on their stomachs, prone positioning, with (supplementary) oxygen before we go to the ventilator.” Proning helps to increase lung volume, redistributes blood and air flow and leads to better gas exchange and higher blood oxygen levels. It’s hard to say just how many lives the low-tech maneuver has saved, but a small-scale study by clinicians in China found that the 90-day survival of patients who were flipped on their stomachs was 57%, compared to 24% for those who remained on their backs.

Early Treatment Helps

Research suggests that patients with severe COVID pneumonia go through two phases of infection. In the first phase, the virus enters the body, begins replicating and causes initial symptoms. It’s during this replication stage, when the virus is multiplying in the bloodstream, that convalescent plasma, anti-viral medications such as Remdesivir and monoclonal/polyclonal antibodies can help patients by slowing and stopping replication of the virus. But there are few drug therapies to help patients who enter the second phase of illness — a catastrophic inflammatory response known as a cytokine storm. When that happens, “Your body goes crazy; your lungs shut down; your kidneys shut down,” says Dr. Kirk Voelker, a critical care pulmonologist at Sarasota Memorial Hospital.

“Once your body’s immune system explodes, we don’t have good medicine other than (the steroid) dexamethasone,” he says, though trials are underway for new anti-inflammatory medications. Sarasota Memorial is currently exploring opportunities to join clinical trials focused on treatments that suppress extreme inflammatory responses to the virus.

Last Resort: Life Support

Extracorporeal membrane oxygenation (ECMO) was introduced more than 40 years ago as a method to save newborns with underdeveloped lungs. Over the past year, it’s been used as a last-ditch intervention for more than 4,700 COVID-19 patients around the world. The life-support technology works similar to heart-lung bypass machines during open-heart surgery: The patient’s blood is diverted from the body via tubing to an artificial lung that removes carbon dioxide and adds oxygen before warming it and pumping it back into the body. ECMO comes with its own risks, including bleeding, blood clots, strokes and infection, but the device is showing promise for those with acute lung failure who aren’t responding to ventilator therapy. A study spearheaded by Dr. Jeffrey Jacobs, a professor of surgery at the University of Florida Congenital Heart Center, and published in the Journal of Thoracic and Cardiovascular Surgery in December looked at 100 patients who were placed on ECMO and found that half survived. Survivors tended to be younger and spent an average of 10½ days on the machines. AdventHealth — which has one of the largest ECMO units in the nation — has reported survival rates of about 60%. ECMO is available at more than two dozen hospitals across the Sunshine State, according to a registry run by the Extracorporeal Life Support Organization.

Dangers of Waiting

Dr. Paula Eckardt, chief of the infectious disease division at Memorial Healthcare System, says some patients with COVID wait too long before seeking medical care. “They come in when they can’t breathe. When you come in like that, it’s harder to get you back from that. Once you are intubated, the likelihood of you getting off that is very low,” she says. Among those who should seek care sooner are those with underlying conditions, such as diabetes, obesity, heart disease or lung disease. Eckardt says those who are at high risk for COVID complications might want to purchase a pulse oximeter to monitor their blood oxygen levels at home. For most people, a normal reading is between 95% and 100%.

No Silver Bullets

Those on the front lines say the best way to beat COVID-19 is not to get it in the first place, and they encourage people to stay vigilant by wearing masks and socially distancing. “Once patients get critically ill with COVID, you can apply the standard of care for critical illness and the mortality rate is still extremely high, even with some of the therapies now that are somewhat effective, like Remdesivir, like convalescent plasma, like some of these monoclonal antibodies,” says Dr. Aharon Sareli, chief of critical care medicine at Memorial Healthcare System, a safety net hospital system in Broward County that has treated more than 26,461 COVID patients. “I do think we are able to keep more patients from getting to that level with some of the therapies that we have, but if they get critically ill, there are no silver bullets.”

Legal Perspectives
Erin Smith Aebel Shareholder
Trenam Law,
Tampa

A board certified health law specialist by the Florida Bar, Aebel has more than two decades of experience representing doctors, hospitals, imaging center and other health care providers. Recently, she’s been helping clients grapple with everything from COVID to new requirements under the 21st Century Cures Act, which requires health care providers to give patients access to clinical notes in their electronic medical records at no cost.

Access to Clinical Notes: “Patients already have a right to access their records in any format under HIPAA. What this does is it says, if you have electronic health information as a patient, you should get free and almost immediate access to that information — that’s the gist of it. Health care providers and health care technology companies cannot engage in information blocking, like unnecessary billing. A reasonable delay under the regulation would be, for example, ‘We’re doing some site maintenance and there’s been a temporary interruption so we’ve not going to be able to get your records for the next four hours.’ That’s something that can be expected, but generally the concept is that patients have this right to immediate access of their electronic health information.”

Putting Context in Records: “I was on a panel discussion on this topic at the end of last year, and some of the doctors talked about some of the challenges of that. Because what if you get your test results before they got explained to you. How is that going to be put into context in a way that’s meaningful to you and understandable? It’s one thing to get health records. It’s another thing to understand them and put them in context and create a treatment plan. Another thing that a lot of health care providers say is maybe it will change the way health care records are created — maybe they’ll be more conservatively created or created in a way that’s understandable to a patient and not just a physician.”

COVID Compliance: “My clients are telling me that volume is still down because people are still afraid to go to the doctor for their regular preventive care. That has affected providers across the board, and then on top of that, they’re looking at the laws of general COVID compliance. I just spent hours with a larger provider trying to redo their COVID policies, which touch upon health law, infection control and employment law, but knowing as we’re spending hours doing this that the law will probably change and the CDC could come out with different recommendations. It’s just a lot that they’ve had to deal with, and to the extent they’ve had to put their limited resources into extra infection control, extra masking and things like that, it’s just taken it away from something else. Maybe they couldn’t buy a piece of equipment. Maybe they couldn’t hire that extra person. Maybe they weren’t able to take as much care of their cybersecurity as they were the year before.”

Enforcement Actions: “There were fewer False Claims Act whistleblower cases enforced during the Trump administration than were during the Obama administration, so I think we probably are going to swing back toward white-collar crime enforcement of compliance with the complex federal regulatory scheme. I look at it as, of course, we want to fight the big bad fraud and abuse, but also, being on the defensive side, I do sympathize with health care providers who have to deal with gray regulations and unclear things and may not have an intent to commit a fraud but still could have a violation too. I think the areas that they’re probably going to focus on, although it’s very early, are all of the COVID-19 stimulus funds that have been given to providers. That’s going to be a high area of enforcement if those funds were misused or improperly used — or anything with vaccines. If people are stealing vaccines or not complying with the roll out of vaccines, I think that’s going to be a hot area, and I think there’s going to be more anti-trust scrutiny as well.”

Silver Linings: “Health care is a strong area, and I do think health care is OK and probably better than a lot of other industries, but for sure they’re feeling the strain of coronavirus. One thing that it’s allowed them to do that I think is a positive thing is be more flexible with their workforce. A lot of doctors have realized that their entire billing staff does not need to come into the office. They don’t need space for them. They can work remotely and securely as long as they’ve got their stuff encrypted and they’re not leaving a laptop at Starbucks. But they can work at home. So a lot of people have put some of their staff at home that aren’t patient facing and are probably not going to invite them back. So they have saved money there. Another thing that they have realized is the importance of telemedicine and the use of telemedicine. I see it a lot in mental health.”

Electronic Tools
Dr. Michael Blackman Chief Medical Officer
Greenway Health,
Tampa

When COVID-19 hit, Greenway Health, a Tampa-based electronic health records company, developed and launched several products and services aimed at helping physician practices with billing and telemedicine. The company is also collaborating with Amazon Web Services to create a platform called Greenway Insights that uses data and analytics to help practices meet reporting requirements associated with performance-based and value-based reimbursement initiatives that are replacing fee-for-service models in health care. Blackman weighs in on the challenges ahead and how health IT companies are helping.

Telehealth Considerations: “Looking ahead to 2021 and beyond, telehealth remains critical, especially as it relates to payer rules and reimbursements. Health care practices must ensure they are receiving telehealth reimbursement, as there are three types of virtual care services outlined by CMS — the classic telehealth visit, virtual check-ins and e-visits. These differences influence coding, as well as which patients are eligible to be seen, who can provide telehealth services and how they can provide these services. It’s important to understand the different types.”

Vaccine Administration: “Health IT companies play a key role in supporting the vaccine administration process by supporting the documentation requirements, including needed codes. Both of Greenway’s EHR solutions offer vaccine administration documentation templates that incorporate the CDC recommended screening questions. In addition, EHRs have the ability to track and document vaccines and should have the functionality to allow for reporting to public health and vaccine registries. We have to get this right as the industry works together to help end the COVID pandemic and be better prepared for future events.”

Beyond Telehealth: “In addition to regular visits, telehealth can facilitate providers’ ability to better triage patients and direct appropriate care. Limiting inperson visits while continuing to provide quality medical care can help limit the spread of COVID while still providing needed assessments, advice and treatment. Remote patient monitoring devices, when integrated with the EHR, can close gaps by providing more consistent monitoring for patients between visits or someone who is confined to their home. Patient portals and patient messaging capabilities allow providers to communicate COVID vaccine availability, if desired, to specific patient groups, prompt patients for scheduling and send appointment reminders as well.”

Interoperability: “In the background, we also have the 21st Century Cures Act, which is designed to help accelerate interoperability among systems. Continuing to improve interoperability is critical as improving information sharing, with appropriate patient permissions, must happen seamlessly and securely to support the collaborative ecosystem that must exist to continue health care quality improvement.”

 

Read more in Florida Trend's April issue.
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