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Covid-19 — Implications for the Health Care System

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Covid-19 — Implications for the Health Care System

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I chose this article because of its relevance to our current healthcare systems and the challenges arising from the COVID-19 pandemic. Pandemic has spawned healthcare crises including insurance coverage, financial loss, racial disparities, and crisis in public health. The pandemic has significantly undermined health insurance coverage in the United States. A sudden surge in unemployment — exceeding 20 million workers — has caused many Americans to lose employer-sponsored insurance. A recent Commonwealth Fund survey showed that 40% of respondents or their spouse or partner who lost a job or were furloughed had insurance through the job that was lost. Most people rely on employment-sponsored insurance, and when pandemics affect employment, insurance coverage becomes difficult and impossible. The article explained the design of the Affordable Care Act has helped people get coverage, although during pandemics people are not educated on time as their eligibility to the ACA marketplaces. Covid-19 has increased demand for specialized acute care that has overtaxed some hospitals and imposed unexpected costs on many more. On the other hand, precipitous declines in demand for routine services have reduced providers’ revenue. Black persons account for 20% of Covid-19 cases and more than 22% of Covid-19 deaths, as of July 22, 2020. Hispanic persons account for almost 33% of new cases nationwide. People of color are more affected by non-medical threats such as food, place of living, and cost of living. This article addresses opportunities we as providers can do to reform and change our healthcare services, address racial and ethnic disparities, and secure the finances of the healthcare system.

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Covid-19 — Implications for the Health Care System

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COVID-19 vaccine misinformation persists in Oregon, as well as the resistance to vaccinate. According to the CDC, 33.1% of the state's population is currently unvaccinated as the omicron variant has yet to reach its' predicted peak later this month.
This CDC website provides tools for clinicians to address misinformation that is prevalent in our communities in a clear, concise way.
I like that the recommendations can be customized to address any flavor of misinformation out there, as we all know that the internet provides a buffet for paranoia to feast on.
I chose this public health resource because of it's value in addressing misinformation in my own community. I am part of a large Russian network both here in Portland and in the Bay Area in California. The Slavic community has a long history with vaccine defiance and misinformation. It was the epicenter of the 2019 measles outbreak in Vancouver, WA, and remains the least vaccinated patient population in Washington state.
Russian-speaking clinicians are at an advantage that just by virtue of speaking the language, they acquire the trust of the community. However, I have been seeing a rising hostility towards all clinicians, with practitioners being called traitors, liars, and even killers (I have been called all three multiple times).
Tools such as these provided in the article help clinicians stay on topic and provide factual recommendations.

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Vaccine & Immunization Information for Health Care Providers

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CDC vaccine and vaccination information for U.S. health care providers.

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Recent projections from OHSU anticipate the number of COVID-19 hospitalizations to peak on 1/27/22 (see p. 24). Local hospitals benefit from OHSU’s projections because they can use the data to inform their planning and preparations. For example, hospitals may preemptively cancel elective surgeries or rearrange units to create additional space for COVID-19 patients.  Not only does the COVID-19 information from OHSU help other healthcare systems, but it can also help the general public. I have been using the projections to make personal decisions.
Understanding the risk for contracting COVID-19 is greatest over the next few weeks, my husband and I have majorly restricted our social gatherings.  In addition, I received a booster the same day I became eligible to be fully protected before the peak.

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According to CDC, only 31% of pregnant people in the United States were vaccinated against COVID-19 back in September, 2021. Although there is no scientific evidence to suggest that the COVID-19 vaccines cause fertility issues or pregnancy complications, many pregnant people are still reluctant to get vaccinated. On the other hand, COVID-19 severe illness can cause dangerous health situations in pregnant people and they are included in the "increased risk" category for severe COVID-19. I found the rate of vaccination among pregnant people startling and chose to look up where the latest clinical guidance is. I decided to share the website for The American College of Obstetricians and Gynecologists (ACOG). They are a professional membership organization for Obstetricians and Gynecologists and provide up-to-date information and clinical practice guidelines. With regard to COVID-19, ACOG provides a wealth of information on updated practice guidelines for COVID-19, vaccination, and resources for patients. I appreciate their tools and resources for conversation prompts and communication techniques aiming to alleviate vaccine confusion for patients.

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Supporting Obstetrician-Gynecologists and Their Patients During COVID-19

The COVID-19 pandemic continues to rapidly evolve, posing unprecedented challenges for you and your patients. ACOG is here to support you by keeping you informed on the latest data so you can provide the best care, helping you protect your practices through financial relief, advocating for your safety as frontline health care workers, and promoting equity and access for your patients.

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The COVID-19 pandemic continues to rapidly evolve, posing unprecedented challenges for you and your patients. ACOG is here to support you by keeping you informed on the latest data so you can provide the best care, helping you protect your practices through financial relief, advocating for your safety as frontline health care workers, and promoting equity and access for your patients.

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Clinical informatics during COVID-19 pandemic 

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Clinical informatics during COVID-19 pandemic 

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I chose this article as I currently work inpatient as a COVID Nurse and have the pleasure to float to the emergency department one night. At the start of the COVID-19 pandemic, the hospital I work at was overstaffed and seemed prepared for high numbers of patients. The increase in COVID-19 cases and new variants are currently overrunning the hospital. The increase in patient numbers and decrease in staff calls for a new look at how we can utilize technology to provide care to the community. This article highlights how clinical informatics aided in clinical decision making, virtualizing medical care, coordinated communication, and defined workflow and compliance during a hospital’s response to rapid COVID-19 cases. While this article highlights clinical informatics the information is relevant to public health as it will assist in the effective tracking of COVID-19 cases. Furthermore, as we progress through the continuance of the pandemic, innovative ways must continue to be implemented to ease the throughput of the healthcare system.

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Abstract

In response to a pandemic, hospital leaders can use clinical informatics to aid clinical decision making, virtualizing medical care, coordinating communication, and defining workflow and compliance. Clinical informatics procedures need to be implemented nimbly, with governance measures in place to properly oversee and guide novel patient care pathways, diagnostic and treatment workflows, and provider education and communication. The authors' experience recommends (1) creating flexible order sets that adapt to evolving guidelines that meet needs across specialties, (2) enhancing and supporting inherent telemedicine capability, (3) electronically enabling novel workflows quickly and suspending noncritical administrative or billing functions in the electronic health record, and (4) using communication platforms based on tiered urgency that do not compromise security and privacy.

INTRODUCTION

The global coronavirus disease 2019 (COVID-19) pandemic has thrust into the spotlight the importance of disease surveillance, diagnosis, treatment, and research. With the adoption of the electronic health record (EHR) with the American Recovery and Reinvestment Act in 2009, many health networks would have less than a decade's worth of opportunity and experience with the utility and limitations of this computer-based tool in improving healthcare quality, population health, and health system efficiency, while the medical community has been familiar with strengths and weaknesses from decades of practiced medical informatics. Informatics, in its many forms and classifications and in association with health information management, is the ideal confluence of people, process, and technology., Many of the principles of informatics with regard to computers, software, Internet connectivity, and telemedicine have been described in the literature within the area of disaster mitigation and preparedness. However, resources elucidating the practical clinical application of informatics toward a pandemic response require further exploration., Swift clinical practice changes can be challenging within the confines of a large health organization, even with an abundance of research and evidence.

We intend to describe the role of clinical informatics in aiding clinical decision making, virtualizing medical care, coordinating communication, and defining workflow and compliance during the rapidly evolving response to the COVID-19 pandemic at NewYork-Presbyterian, a nonprofit healthcare network comprising 2 academic medical centers within 1 affiliate hospital serving the New York City metropolitan area. Of note, the healthcare system is currently transitioning to a single unified EHR (Epic Systems, Verona, WI) by a phased implementation approach that began in 2018 and is due to be completed by the first quarter of 2022. Clinical departments across the network have been tasked to standardize practice as one of the guiding principles of the project. Practicing clinicians, with predefined roles within governance committees, participate in the clinical informatics process as a volunteer or as a designee by their respective clinical departments. All clinical departments participate in the informatics governance process.

COVID-19 diagnostic and treatment order sets

Computerized provider order entry (CPOE) has been described as introducing several types of unintended adverse consequences, many of which revolve around creating new workflows and workflow demands on clinicians. Order sets, defined as collective grouping of diagnostic or treatment orders within a CPOE system for a particular medical condition or purpose have been widely adopted for guidance, ease of use, and efficiency advantages despite the paucity of studied evidence. Default settings and preselection of orders have been shown to reduce variability and drive clinician ordering habits.

Our healthcare system decided to rapidly introduce COVID-19 testing and initial workup, emergency department (ED) COVID follow-up, and postintubation order sets despite the inherent barriers of interoperability between different EHRs at different hospitals. A COVID-19 informatics committee was formed with weekly meetings that included key stakeholders and clinical experts from appropriate departments (emergency medicine, laboratory medicine, infectious disease, hospital medicine, pulmonary medicine, and critical care). Debates concerning clinical utility were resolved by consensus to provide a consistent user-centric experience. Consensus decision making followed a Quaker-based model ( Figure 1).

As the disease process became further elucidated, these order sets were continuously updated based on the most recent data and policy. Availability of a specific test or treatment (high-sensitivity troponin, interleukin-6) within each hospital compendium was denoted to ordering providers at each site. Order set updates were reviewed weekly by the committee for consistency with up-to-the-minute policy updates and testing guidelines. Clinical decision support for the documentation of quarantined travel advisories and the suggested ordering of rapid-resulting (hours) vs standard-resulting SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) tests according to patient symptoms were introduced. While the COVID-19 testing and initial workup order set had been utilized over 24 000 times since inception in March 2020 (third most frequently used order set), a formal user evaluation system had not been instituted.

Current ED order set for initial workup examples:

1. Isolation orders auto-generated with placement of COVID specific test orders ( Figure 2)

2. Laboratory orders with default selections for ease of entry ( Figure 3)

3. Radiologic orders with COVID precautions ( Figure 4)

Added clinical decision support examples:

Facing the possibility of increased ED visits, a safety measure for discharged ED patients was introduced. The ED COVID follow-up order had been created to be placed by the treating provider for our nurse practitioner (NP) pool to initiate a follow-up telephone call the next day. The telephone call served 2 purposes: (1) to relay postdischarge results and (2) to provide a safety net for the subset of patients that show more severe symptoms as the disease progresses. The follow-up calls had been conducted daily, 7 days a week, with the option of transitioning from a telephone call to a telehealth video visit as per the discretion of the NP. This measure was implemented in the early stages of the pandemic as a response to the conservation of inpatient beds with stricter admission criteria and have been used on average 3.5 times per day throughout the pandemic.

Virtualization of services

Telemedicine and virtualization of medical services had been described as near-perfect milieus for enabling social distancing and practicing quarantine measures., Telemedicine has relied heavily on medical informatics principles with regard to providing patient-specific information remotely in conjunction with rapidly accessible epidemiologic and statistical information. The ED telehealth program at our institution consisted of (1) ED Express Care in which patients presenting to the ED would be treated by a remote physician and (2) a direct-to-consumer telemedicine service for at-home patients. NYP OnDemand allows patients to consult directly with our board-certified emergency physicians as an Internet-based virtual healthcare service (Amwell; American Well, Boston, MA). Our direct-to-consumer telemedicine visits at our institution jumped from 30 calls daily to over 300 calls daily ( Figure 7), which correlated to the rise of COVID-19 cases in New York City ( Figure 8).

Pragmatically, the increased call volume to our direct-to-consumer virtual urgent care telemedicine service required increased physician staffing, primarily filled with emergency medicine physicians. Our institution's executive order to cancel elective and nonemergent surgical cases led to an enterprise-wide strategic staffing model to redeploy physicians to areas of highest need. These new medical providers required provisioning and onboarding with the EHR systems to function, needed access to our telehealth Web application and information systems, and desired ongoing briefing and education about evolving COVID-19 guidelines.

Despite evidence contrary to the quality of templated or copied notes, the large influx of patients primarily concerned with COVID-19 symptoms and treatment favored the use of templated notes and patient instructions as an expeditious method of visit documentation and treatment plans. These templated notes and treatment plans, as Microsoft Word documents, have been easily updated and distributed through the ED's wiki (Confluence 6.6.16; Atlassian, Sydney, Australia) as guidelines evolved throughout the pandemic. The ED COVID-19 Response Committee (chaired by an ED physician) had been charged with the maintenance and content update of uploaded documents which were made available to both ED and telehealth patients ( Figures 9 and 10).

Beginning in March 2020 and over the next 2.5 months, there were over 60 redeployed physicians across 15 medical specialties that cared for over 2500 patients on our virtual urgent care telemedicine service. Determination of the impact of this service toward a reduction of ED visits is difficult to quantify, but we believe that, at a minimum, a certain percentage of these patients would have sought care at an ED, as primary care physicians had yet to ramp up their own telehealth capabilities.

Additionally, existent videoconferencing technology was co-opted for telemedicine evaluations (Avizia [American Well] and, Cisco Jabber [Cisco Systems, San Jose, CA]), allowing physicians and other medical providers to interview patients in the ED while maintaining isolation precautions. Remote physicians conducted histories, simple physicals, and patient education while on-site ED personnel concentrated on in-person COVID-19-related testing and procedures ( Figure 11).

Supporting novel patient care workflow creation and suspending noncritical functionality

Supporting new workflows with regard to patient care and healthcare provider interaction is paramount to a well-functioning healthcare system. Specific examples from our experience include: creating an EHR-based order for the (1) mildly symptomatic ED patient follow-up with a hospital dispensed pulse oximeter, seen via telemedicine; (2) normally admitted hypoxemic ED patient that had been discharged with remote patient monitoring and home oxygen; and (3) a newly discharged inpatient that had required close follow-up for resolution of symptoms. Each patient cohort was followed by a different discharge service depending on presenting and discharging location and disease severity, along with differing levels of EHR access and accountability ( Figure 12).

As a corollary to expediting simple and organized electronic order entry for radiologic procedures during a disaster response, suspension of noncritical compliance requirements for CPOE had been an important factor in order to decrease alert fatigue. Alerting logic for patient location requirements for intensive care unit-only reserved medications (ie, propofol by infusion) had been removed as recovery units and floor beds expanded into overflow intensive care units. Observation of the rights of clinical decision support (right information, right person, right intervention format, right channel, right time in the workflow) supported the suspension of prerequisite documentation for the New York State mandate of offering HIV testing before placing a hospital admission or ED discharge order. Instituting clinical decision support reminders for providers to order COVID-19 polymerase chain reaction testing and to check for the result had the potential to lead to expedited bed assignment and patient cohorting.

ED providers (physicians, physician assistants, NPs) suggested these changes through their Clinical Leadership Group representative and were instituted to respond to the growing amount of temporarily redeployed medical personnel that had been unfamiliar with routine ED workflows. Intended consequences, such as a decrease in HIV testing offers, were considered and deemed inconsequential. Other unintended consequences (increased walkouts, increased length of stay) were not observed with regulatory requirements and liability suspended by state government emergency mandate.

Medical provider communication

At the core of clinical (medical) informatics has been the retrieval of information coupled with knowledge base management and transmission. With almost ubiquitous searching and instant access to medical information on the Internet,, the increasing acceptability of social media,, and the use of real-time crowdsourced communication tools,, the distribution of institutional and departmental policy and procedures has been paramount.

For redeployed physicians and medical providers now providing telemedicine support, a wiki-type content management system (Atlassian Confluence 6.6.16) was constructed as described. Additionally, medical providers engaged in real-time on-shift support with medical peers through an Internet-based chat mobile app (WhatsApp [Facebook, Menlo Park, CA]). The WhatsApp group was a private chat group enabled to provide real-time advice to other providers working clinically, members of our core leadership team, and our technology support team. This group chat helped respond to the needs of the new providers, giving them real-time support and "on the job" training as well as continuing education. The use of real-time group messaging had been described elsewhere with regard to the care of diagnosis-specific patient groups with concerns over potential security and privacy settings., Future operational research detailing messaging content and Health Insurance Portability and Accountability Act privacy compliance had been planned.

Medical provider communication adapted throughout the COVID-19 pandemic. The traditional departmental email listserv delivered daily updates from ED leadership concerning evolving operational issues such as personal protective equipment and staffing changes. Interactive video conferencing (Zoom [Zoom Video Communications, San Jose, CA], Cisco Webex [Cisco Systems]) was deployed and was encouraged throughout the institution as a communication tool as a substitute for in-person meetings and medical student education lectures despite inherent concerns for privacy and effectiveness.,

CONCLUSION

The disruption of normal everyday workflows from the COVID-19 pandemic extends from the ED to the inpatient and outpatient clinical departments. From the evolution and universal adoption of the EHR, to the expansion of Internet-based knowledge management, and to the adoption of modern media and communication tools, it is imperative that the practice of clinical informatics guides the interaction of people, technology, and information.

In summary, clinical informatics principles need to be implemented nimbly, with governance measures in place to properly oversee and guide novel patient care pathways, diagnostic and treatment workflows, and provider education and communication.

We recognize that the "lessons learned" presented here are to be taken as one institution's response during an unforeseen crisis and that further study and development are required. Implications for clinical operations are interdepartmental and rely on a strong and cooperative informatics governance infrastructure.

FUNDING

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

AUTHOR CONTRIBUTIONS

All authors had substantial contributions and meet criteria for authorship.

CONFLICT OF INTEREST STATEMENT

Our authors have no competing interests to declare.

DATA AVAILABILITY

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

References

This work is written by US Government employees and is in the public domain in the US.

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Clinical informatics during the COVID-19 pandemic: Lessons learned and implications for emergency department and inpatient operations

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In response to a pandemic, hospital leaders can use clinical informatics to aid clinical decision making, virtualizing medical care, coordinating communication, and defining workflow and compliance. Clinical informatics procedures need to be implemented nimbly, with governance measures in place to properly oversee and guide novel patient care pathways, diagnostic and treatment workflows, and provider education and communication.

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Did you know there's now been more than 313 million total cases of Covid-19 since the pandemic began? I chose the John Hopkins Coronavirus Resource Center & Map because, in addition to giving HCP real-time infectivity and vaccination rates, I think it gives a nice reminder and visualization to us all of how Covid-19 is truly a global problem that needs global cooperation and treatment. While we're fortunate in the US that we're able to develop effective vaccines with new state-of-the-art technology, it's disappointing that these vaccines are disproportionately shared or sold to wealthier nations while developing and poorer nations continue to struggle with vaccine and Covid-19 treatment access. By scrolling on the John Hopkins map (bottom right), one can easily see the continent of Africa is vastly under-immunized compared to other continents. If there's anything that Omicron taught us, it's that we'll likely continue to see more infectious variants develop until we realize that developing countries have to be included equally in vaccine availability and our Covid-19 response. I hope in the future countries will agree to have more of a coordinated effort to minimize Covid-19 variants and decrease our risk of future pandemics. If I could dream--I'd hope that maybe one day when Covid-19 is controlled, countries would agree to give the WHO more authority and regulatory powers in order to help us ensure the risks and consequences of future pandemics are minimized and treatment is more equitable.

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Johns Hopkins Coronavirus Resource Center

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COVID-19 Map - Johns Hopkins Coronavirus Resource Center

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Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU)

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Is It Safe To Have Surgery After COVID-19 Infection? 

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I work in the Pre-surgery Care Clinic providing preop care and am extensively involved in providing preop clearance to surgical patients. The extent of the COVID-19 pandemic means that a significant number of patients who had SARS-CoV-2 will require surgery. The multisystem involvement primarily the pulmonary and cardiovascular systems has created additional challenges. Given the short-term and long-term consequences, the timing of surgery needs careful consideration. It also must take into account the severity of the initial infection; ongoing symptoms of COVID-19; comorbidity and functional status; and complexity of the surgery. The consensus after systematic review and expert opinion is to defer surgery for seven weeks from the time of a known COVID-19 diagnosis. For adults who are immuno-compromised, diabetic, or have a history of hospitalization should be deferred eight to 10 weeks after diagnosis. Those with a history of intensive care hospitalization should be deferred 12 weeks. If the risks of deferring surgery outweigh the risk of postoperative morbidity or mortality associated with COVID-19 then surgery must take place.

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Though surgeons are well aware of these guidelines, it's important for patients and their family members to understand the reasoning behind a decision to delay a surgery, even for a person who feels perfectly well. "We want to provide this information to patients so they can have a discussion with their surgeons and providers," says Roberta Hines, MD, chair of Yale Medicine's Department of Anesthesiology. "Each decision should be made at the individual level, and we want to stress that the patient is an active participant in their care."

For example, a patient who has cancer that requires surgery may want surgery as quickly as possible. For some, the risks of waiting to have the surgery may be greater than delaying it, while for others it may be smarter to wait. Every situation is different and what to do in a particular case is a decision that should be made jointly by patient and surgeon.

Emergency surgeries to "save life or limb" will still be done as needed. However, says Dr. Ahuja, "Semi-elective surgery accounts for the majority of our cases, especially with cancer care. These are surgeries that don't need to be done tonight, but there is a certain window of time. However, if someone comes to the hospital after a car accident, we won't delay surgery because they had COVID."

All patients must take a PCR (polymerase chain reaction, which is the most reliable of the various types of available tests) COVID-19 test before surgery. That will not change, and is key to picking up active infections [not prior ones] patients never knew they had, Dr. Ahuja adds.

The connection between COVID-19 infection and surgical complications seems logical given how research suggests a link between COVID-19 infection and inflammation. "Plus, an infection creates an inflammatory state in the body, and that can perpetuate for at least six weeks," Dr. Ahuja explains. "So that is why we recommend delaying surgery at least six weeks, so that your body is not still dealing with the effects of the virus."

It's not only the surgical procedure but the anesthesia as well that can exacerbate inflammation in the body, Dr. Hines notes.

"COVID-19 is an emerging disease and we are still learning about its acute and chronic repercussions. We initially thought it was a respiratory disease, but now we have learned about blood clots and a complex inflammatory process," Dr. Hines adds. "Six months from now, we may have different guidelines as the data is evolving."

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Is It Safe To Have Surgery After COVID-19 Infection?

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Though surgeons are well aware of these guidelines, it's important for patients and their family members to understand the reasoning behind a decision to delay a surgery, even for a person who feels perfectly well. "We want to provide this information to patients so they can have a discussion with their surgeons and providers," says Roberta Hines, MD, chair of Yale Medicine's Department of Anesthesiology.