The outbreak of the novel coronavirus is transforming the nature of health care delivery across both the planet and the greater San Antonio area.
As providers grapple with the current disease and its staggering impact, physicians and other medical professionals are formulating plans to combat future pandemics.
Edith Ambrester went through breast-cancer management, chemotherapy, surgery and radiation. Everything not requiring in-person consulting, from treatment-preparation instructions to follow-up, was done by talking to doctors and nurses using a computer from the comfort of her Stone Oak home.
“It was actually kind of fun,” said the 58-year-old survivor, recalling her telemedicine visits over the last few months. “I see people doing more of this in the future. It was no different than sitting in front of Dr. (oncologist Sylvia) Zubyk in an office.”
Dr. Lynnette Watkins, Baptist Health System’s chief medical officer, has seen admission questions at hospitals and clinics change from: “Have you traveled anywhere recently?” to “Are you sick?”
Routine temperature checks, triage to send people to different waiting rooms depending on possible diagnosis and masks for all could be the order of the day for a long time to come, she added. Dr. Robert Leverence at UT Health San Antonio and chief medical officer of UT Health Physicians no longer wears a tie at University Hospital or the Medical Arts & Research Center. They’re not washed like scrubs and other clothing and are now considered repositories for harmful microbes.
Gone also are the handshakes among colleagues.
These are all signs of the times thanks to COVID-19. By mid-October, the outbreak contributed to more than 1,200 Bexar County residents’ deaths and 60,000-plus positive cases, which hospitalized thousands and put hundreds in intensive care.
“The pandemic has touched just about everything that we do,” Watkins said. Many precautionary measures from screening to conferring with patients over the internet are likely here to stay.
While this infection is considered a once-in-several-lifetimes event, increasing population density and new pathogens mean humanity could see similar emergencies stretching the health care system to crisis levels more often.
“You can’t predict any of this. We have to rely on science to drive policy” and stay prepared, said Dr. Ian Thompson, president of Christus Santa Rosa Medical Center. “As humans, we are incredibly resilient and adaptive. A lot of this will be short and intermediate impacts.”
Without ongoing vigilance, however, “we will have to learn all over again in 10, 20 or 100 years,” he said.
Fifteen San Antonio doctors, nurses and health care executives surveyed by LOCAL Community News outlined what things could look like for the next few years. The consensus was health screenings upon entry, wearing masks – especially at flu season– and employing telemedicine, are here to stay.
98.6 degrees and 6-feet apart
Screenings with instant-read thermometers have been used since March to detect fevers, which could be a telltale coronavirus symptom. Such measures are likely to remain even past the pandemic, especially during flu season, medical professionals said.
“The hospital is a safe place,” Watkins said. “That vigilance won’t let up. Besides controlling spread of infections, screenings and preadmission or visit questions need to persist so patients can trust the care.”
Because those with other ailments postponed doctor appointments or treatment, due to fears of contracting COVID-19, “we’ve seen a rising severity of patients with heart attack or other issues,” she said.
Dr. Katherine Whiteley, who practices at University Health System’s Family Health Center-Southwest, said folks should know they could safely tend to preventive procedures such as mammograms, bone-density tests and colonoscopies.
After arriving at a clinic or hospital, patients and visitors are often directed to one of several waiting rooms, depending on the condition. These spaces are no longer a sea of chairs separated by an occasional end table filled with magazines, but appropriately distanced seating with those symptomatic sent to another area.
In some clinics, guests fill out paperwork on computer tablets and stay in cars until called. While screenings won’t stop, and forms will more often be done beforehand over the internet, Whiteley hopes parking-lot waiting disappears as the pandemic dissipates.
At University Health System’s ExpressMed clinic at the downtown Robert B. Green campus, front-door analysis determined if the visitor was a candidate for a telephone conversation where prescriptions could be made, or whether future tests needed scheduling. Maintaining two separate lobbies allowed staff to put those with COVID-19 symptoms into immediate isolation to be seen by a doctor in full protective gear, while non-COVID-related patients went to another area.
“This is going to leave a footprint for a long time,” said Dr. Bhoja Katipally, ExpressMed medical director. Plus, wiping chairs, counters and exam-room surfaces likely will linger for some time.
To limit exposure with one another, physicians call patients after tests to discuss results and next steps, even if the patient is still on the grounds, Katipally said.
“I think this (protocol) may continue. I can’t tell you how long,” the physician added.
The clinic now employs an online app check-in process, which lets providers know when patients are en route, how long until arrival and assigns them a time to minimize waits. An atrium kiosk has been installed for registration without staff contact.
Implementation of electronic medical records and providing a seamless transition from clinic to hospital emergency room, and then, if necessary, to an inpatient bed, was already envisioned as a streamlined UHS service.
“We had to close all the gaps to make all the parts move more quickly and efficiently,” Katipally said. “The patient experience is the heart and soul of all of this. It didn’t happen overnight and we didn’t plan it for the pandemic,” but it was put to the test to relieve the extreme stress on the system from as many as 250 patients a day, just coming through the downtown clinic.
When hospitals were pushed to the brink with most beds full, the governor ordered all elective surgeries halted.
Christus Santa Rosa-Alamo Heights, a 36-bed surgical hospital, took on the role of performing necessary surgeries that couldn’t be put off while COVID-19 patients went to Christus Santa Rosa Hospitals in the South Texas Medical Center and Westover Hills, said administrator Sherry Fraser.
“This hospital is growing, and we remain a safe-services site,” Fraser added.
While hospital systems with multiple locations were able to establish some facilities as sites without COVID, developing freestanding contingency infirmaries to keep elective surgeries going in future epidemics is unlikely.
Thompson said staffing such a facility would be a stretch. More likely is a continued effort to build patient rooms to quickly transform into intensive-care unit beds as his hospital did, expanding from 14 ICU patients to 52 over the summer.
Doctors go digital
Military medicine has long been on the cutting edge when it comes to adapting technology fully, often after being tested in battlefield conditions and training a massive medical staff across many countries.
Telehealth was no exception when it came time to put it to use on a larger scale for more patients at Brooke Army Medical Center.
“Like many other facilities, we expect to be able to translate lessons learned around the use of telehealth to stay in place for the foreseeable future,” said Air Force Col. Dr. Heather Yun, deputy commander for medical services at BAMC. “While we were using telehealth before the pandemic, this has greatly accelerated utilization across the disciplines and has enabled us to reach patients in ways that are efficient, convenient and effective for them.”
Air Force Col. Dr. Patrick Osborn, deputy commander for surgical services at BAMC, said they’ve increased virtual health visits 50-fold since the pandemic’s start “and it is not going to go away.”
Yun said after the crisis, the use of telehealth will continue to evolve and become even more convenient for patients so they don’t have to travel to the hospital or clinic and take time from work, school or family.
“As we continue to refine our use of telehealth, we expect it will translate into an increasingly patient-centered experience,” she said.
The Methodist Healthcare System, with hospitals and clinics throughout the city, saw doctors use telehealth methods sparingly in January. However, by April, they conducted 10,000 remote visits, and year-to-date through September, the number swelled to 55,000.
While online scheduling to mitigate waiting-room crowds and interactive registration for an ER visit has helped, virtual conferences have been an important part of the mix for medical personnel and patients, said Brandon Webb, senior vice president of strategy and business development for Methodist.
Fields employing online visits the most were cardiology and primary care, which combined accounted for 96% of telehealth utilization, Webb said. Most of those were existing scheduled patients or follow-ups after discharge.
For in-person guests, Methodist is adding more access points to the system, which will make for distanced isolation from potentially sick patients and shorten waiting-room downtime. That includes the acquisition earlier this year of five freestanding ERs. After remodeling, each will have seven to nine treatment rooms with on-site pharmacy and lab rooms.
“These are a little bit smaller, so we’re spending a lot of time on workflow and patient flow through the clinic,” Webb said.
UT Health’s Leverence said that while telehealth has been around in some form since the 1980s, the technology has only been good enough to make it work well for the last decade. Access to a good online connection and a video device such as a smart phone, tablet or laptop also has grown by leaps and bounds across the city.
“The next step is to add more tools,” such as inexpensive stethoscopes with connectivity to computers for patients to transmit heartbeats or breathing to doctors, Leverence said. The same could be done with at-home otoscopes to let physicians see inside a baby’s ear via computers.
For medical professionals meeting with online clients, the process is better if there’s an existing relationship, said Dr. Hilda Draeger, a rheumatologist at University Family Health Center behind North Star Mall.
“Once they know each other from a personality standpoint, then they prefer telehealth,” she said. “Patients are more relaxed and they’re more talkative.” Also, the doctor can see the patient’s in-home environment and know if it could have had an impact on the client’s condition.
Telehealth is less successful if there are a lot of complicated issues and possible causes need to be individually eliminated, Draeger said. In-person visits also are key if folks are downplaying chronic diseases, such as arthritis.
Lorri Dinkins, a registered nurse who is an oncology nurse navigator for the Baptist Network for Cancer Care, assists breast-cancer patients to maintain treatment plans, connect with community resources, provide emotional support during the caring process, and act as liaison between patients, family, doctors and other providers.
In the last six months, all this has been done mostly online.
“The technology has proven itself, but people have been reluctant,” Dinkins said. “COVID changed a lot of things, though. I don’t know why it took a pandemic.”
While some of the visits are over the telephone, she prefers to do them in a virtual face-to-face online meeting, such as Zoom, so she can see if the patient is upset or pensive about something.
Telehealth won’t completely replace in-person connections for those who need physical reassurances, but the tradeoff is a more efficient system for patient and provider.
“Not being able to give that big hug to a woman in my office crying just breaks my heart,” Dinkins said, “but we’re able to help so many more people now.”