1 April 2020

Good night and good morning: a COVID-19 day in the life of a GP

Communication COVID-19 General Practice

Dr Nathan Pinskier is a Melbourne GP and prominent figure in the country’s digital health scene, including being a significant campaigner for appropriately regulated telehealth.

During COVID-19 he’s been wearing many hats in trying to help co-ordinate the response of primary care. But at the end of the day, he’s a GP. As I do on many occasions, I asked Nathan a few questions to help me with context for stories. He always get’s back. Yesterday, the second day of universal telehealth, was obviously a big one.  Here’s his response.

Hi Jeremy,

“Yes it’s all been very challenging.

I have been in virtual meetings with different groups people hour after hour every day by Webex, Zoom, Amazon chime and many ordinary phone calls, etc etc. Confusion everywhere.

Everyone is trying to figure out how to make this work. Medical centre clinical and business models have been flipped on their heads. The new model of care is to focus on telehealth, minimise in-clinic appointments and keep the waiting rooms as empty as practical. How will this impact on practice viability? Will we need to find innovate ways to keep the practice operating?  Can we retain all our staff? Will we need to seek assistance from the bank? Talk to the accountant. Revise the budget forecasts. Lots of assumptions. Not very scientific. ELO songs pops into my head: The waiting rooms are empty now. (I am a baby boomer and child of the 70s.)

Lots and lots of changes to be made. Need to stay on top of things. Read and re-read all the medical, professional college and government COVID bulletins and newsletters. Dial into the DoH biweekly webinars run by Michael Kidd. Daily TV briefings from Scott, Greg, Brendan, Dan, Gladys  Brett, emails from Harry and Tony, updates from Jeremy, Geir and Kate. They all now feel like personal friends. I’ve added them to my speed dial. Remember who’s at risk, who needs to be tested, who shouldn’t be tested. Stay focused, stay on message. Talk to the RACGP, dial into the weekly Practice Technology and Management (PTM) committee meetings, talk to and email frequently with Mukesh, Rob, Trina, Penny, Oliver, Stephen, Michael, John, Karen, Jags and many many other GPs and colleagues. Schedule TCs with the after-hours and deputising doctors. Get briefings from the public hospital.

Update the clinic website, the phone waiting on hold message, the internal message screens. More posters everywhere, Meet with the staff and doctors, Change protocols, send out frequent emails to the team, install slack, monitor the changes, change the changes, reassure everyone. Focus on OH&S and infection control. Remember you have a duty of care. Clean, clean re-clean everything. Did some mention PPE?

Purchase webcams and headsets to prepare for universal telehealth. Got some but not enough. There has been a run on webcams. People are working from home. Order more online via eBay. Track the Oz Post delivery number. Taking forever to arrive. Upgrade the internet speed. Buy a 4g wireless backup service – just in case. Do we have sufficient phone capacity? We use VOIP. Have done so for over a decade. So capacity should be sufficient. Also it’s easy to add extra lines. It should all be OK as long as the internet doesn’t collapse. Another ELO song pops into my head: COVID, Don’t bring me down …

Doctors, nurses and staff are anxious, concerned, frightened, scared. Stay at least 1.5 meters from the patients and each other. Wear a mask, don’t wear a mask, stay safe, OK find a mask, only five left in the clinic, how does that work? Call the PHN no masks left,  OK they will send us one box, yes one whole box. Great. It will last a few days. Battle on. Decision made to shut the clinic doors and screen patients via a front of house staff concierge service prior to being admitted. ”Admission by appointment only.” Sounds exclusive!

Rigorous patient screening process are in place both online, by phone and at the front door. Despite this last week a patient manages to bypass the screening process and during the consultation advises the doctor that she is a healthcare worker and had an episode of shortness of breath a few days ago. Now feeling OK. No known contact with any COVID +ve persons. No international travel in the past month.

What to do? Better play it safe and call the DHHS COVID advice line which is open 24 x 7. (Department of Health and Human Services Communicable Diseases Section).

Isolate the patient, call the ambulance, get the patient transported to hospital to be assessed and tested. Now clean clean and clean the room, remove it from use for the rest if the day,  support and advise the doctors and staff re their concerns and risk of contacting COVID. The doctor goes home to self-isolate and is joined by three staff. An overreaction. Who knows? Did someone mention PPE? Ran out of goggles.

Now the waiting begins. How many days before the result is back? 48 hours later a negative result is returned. Phew, dodged a bullet.

Thank heavens universal telehealth has been introduced. Less patients in the clinic less risk. Doctors and staff feel somewhat reassured and perhaps a little bit safer.

Now to make telehealth work, by phone or by video? Which video service? How do we send all that paperwork to the patient, to the specialist, to the path and DI providers and also send prescriptions to the pharmacist? Everyone wants us to fax and/or post or use ordinary email. I hate fax. I’m the axe the fax guy. Need more stamps, Send staff to the post office to stand in line to buy more stamps and post mail. Hang on this is madness. Why am I exposing our staff to an unnecessary risk?

How is that possible? The medical suppliers have none. Mad dash to three Bunnings stores to buy lots of goggles. Play human dodgeball. Buy about 20. I hope the tradies don’t get upset.

Two doctors decide they are at risk and decide to work from home. They need IT support. It’s sorted. But how can they sign prescriptions which are printed out at the clinic? It’s a dilemma. No option but to have them break the social isolation and come into the clinic. Not very sensible. Why paper scripts in an electronic era of smartphones, tablets, apps, Instagram and tap and pay? Why can’t we just email the ETP barcode? Dr Rob tests this proposal with the local pharmacy and confirms that it works. Maybe we can convince governments that this is a feasible interim solution. More calls to the RACGP team. Develop a position statement. Lobby the pharmacists, call the digital health agency, try to figure out the policy and technical challenges. Battle on.

A decade of digital health and the seamless digital solutions still seem out of reach. Why is this so? Have we been focusing in the wrong solutions? How do we fix this?

How does it all integrate? How do we make the workflow more seamless?

Call Grahame [Grieve]. Maybe Mr FHIR has some suggestions. He does. Clinic Arrivals patients SMS notification is born. Now to test it. One small but possibly significant achievement.

Day 2 of universal telehealth. Less patients in the waiting room. More phone calls, more video calls. It seems to be working. Doctor, nurses and staff appear to be coping OK. Patients seem comfortable. Sample size one – my 94 year old mother who lives in her own home.  A telephone consultation is organised with her doctor in our clinic How was it, I enquire? No big deal she says. The doctor asked me a few questions and I answered them. I needed some prescriptions. The practice manager took them to the next door pharmacy and he home delivered them. Clear message – if everyone had a doctor son or daughter the health system would work seamlessly.

The cleaning company advises it will stop servicing the clinic effective at the end of this week. It’s too risky for the cleaners to come anymore. Ok, I guess the staff should be able to do it for while, I hope.

Where to from here? Confirm that accreditation is postponed till post recovery. Clarify whether or not we need to meet the ePIP requirements for the current and next quarters. Review the patient numbers and billings.  Check the bank balance. Are we keeping our heads above water?  Do we need to make further changes? Have the rules changes again? What else have we forgotten or failed to consider?

Take a breathe, Go for a walk and a talk with my wife every day. Play human dodgeball again, walk 12,000 steps. Eat dinner at home. Discover the joys of home-cooked meals again. Watch ABC 24 +++ and Netflix +++ Survive without AFL (is that at all possible???) Talk, webex, Whatsapp my mum and my Dr bro Henry and my kids and all my friends and family. More than ever digital rules my life.

Wake up every morning hoping we are one day closer to the of this crisis. Another ELO song pops into my head: I’m alive and the world shines for me today …

Stay positive. Did someone mention PPE?”

Best

Nathan

Good night & good morning

 

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