Article In Brief
As the COVID-19 infection rate declines, many neurology practices are opening again. Here, practice leaders discuss what they have learned during the pandemic and the changes they foresee because of that experience.
As COVID-19 infection rates wane, Raleigh Neurology Associates, a North Carolina practice with more than 50 providers, is slowly bringing its administrative staff members back to their offices to work. More than 80 employees have been working remotely for more than a year, and they are returning in phases that will take two or three months to complete.
CEO LeeAnn Garms likens the process to military personnel returning home after a year-long deployment. “We are using a thoughtful, gradual approach in part to help with assimilation,” she said. “Team members need time and our support to effectively acclimate back to life back in the office.”
She expects almost all her staff members will return to their offices full-time, but that does not suggest that the practice will return to its pre-pandemic “normal.”
“The pandemic has provided us with amazing opportunities to improve and to think about things differently,” she said. “Now it's up to us to continue to innovate to determine what works within our style of practice.”
Meanwhile, practice leaders are deciding how to transition from emergency mode to managing COVID-19 as a safety threat for the foreseeable future, said Jaya Trivedi, MD, medical director of ambulatory neurology at University of Texas (UT) Southwestern Medical Center.
“My work right now is focused on finding the right mix of telehealth and in-person [patient visits] and how to handle this in a way that is sustainable in the long-term, rather than just what we did as an emergency,” she said.
She is assessing this balance in three areas: new-patient versus established-patient visits; advanced practice providers versus physicians; and within different subspecialties.
For example, new-patient visits typically generate several follow-up steps, such as imaging orders, laboratory orders, and physical-therapy referrals, all of which require a physician's signature. While the new-patient examinations for some neurologic conditions can be conducted via video, being able to hand the patient the signed paperwork all at once at an in-person visit is easier than mailing or emailing documents to the patient after the virtual visit.
“So it's not simply the convenience of video platform, the downstream operational work must be considered.” The decisions will affect everything from practice finances and staff satisfaction to provider burnout and patient engagement. Almost every element of practice operations needs to be considered. For example, Dr. Trivedi pointed out masks make it difficult for a patient to see that a physician empathizes with their problems.
“Right now I don't think masks are going away,” she said. “So it's important for physicians and practices to recognize that you have to do a lot more to make sure that patients engage [with you] and they have a good experience. The human connection is not the same with a mask.”
She and other practice leaders shared with Neurology Today what they have learned during the pandemic and the changes they foresee because of that experience.
As COVID-19 vaccination rates inch upward, many neurology practices are seeing a surge in demand for their services.
“Our providers are extremely busy—it's been years since their next-available appointment has been this far out,” said David Evans, CEO at Texas Neurology, a 15-provider practice in Dallas. “Every week, we talk about the need to get more doctors and more advanced practice practitioners to accommodate patient volumes and avoid provider burnout.”
On the other hand, demand for ancillary services has not yet returned to pre-pandemic levels. Evans estimated that the volume of sleep studies and EEG is about 40 percent below normal, while diagnostic imaging is off by about 20 percent. He thinks patients are postponing non-urgent sleep and EEG exams out of fear of exposure to COVID-19, financial concerns, or some other pandemic-related reason that will eventually fade away.
The drop-off in diagnostic imaging is more concerning, Evans said. “We think it may reflect fewer new patients in the general population, since most imaging correlates with new-patient workups.”
At Noran Neurological Clinic, a 45-provider practice serving Minnesota and Wisconsin, Executive Director Brad Montgomery said this year's first-quarter revenue topped that from the same period in 2020. “Sleep studies are still lower than normal, but for EEGs and the rest of our procedures, we are almost back up to where we were before,” he said.
First Choice Neurology, with 130 providers working in more than 40 offices across Florida, is also seeing revenue growth. Jose Rocha, director of the central business office, sees that as a byproduct of increased telehealth visits.
“Telemedicine opens up rooms that were being used for [evaluation and management (E&M)] visits, so now we are doing more procedures,” he said. “It used to take a month to get in for an EEG and sometimes six weeks. Now it might take two weeks.”
For Allen Gee, MD, a solo-neurologist practice in Wyoming, the relaxation of telemedicine restrictions when COVID-19 hit supported his long-time goal of reaching patients who live too far from a neurology practice to receive specialty care. His practice, Frontier NeuroHealth, has opened two new offices—in Gillette and Jackson Hole—in addition to his Cody office and hired mid-level providers to support the growing patient base.
“So my business has grown considerably, and more importantly, we provide better access to neurology care for patients across not only the state, but even beyond the borders of the state,” he said.
Streamlining Patient Visits
The need to keep patients and staff safe when COVID-19 emerged triggered new administrative processes for in-person patient visits, and practice leaders expect these will continue to evolve.
“We had already started migrating to tools that speed up that [check-in] process, which we leveraged during COVID,” Garms of Raleigh Neurology Associates said. “We have mobile check-in and pre-appointment preparation that patients can do online.”
“I think we're going to have a healthy amount of in-person interaction when our patients are scheduling what can be complex testing and treatment appointments,” she said.
In Minnesota, staff members at Noran Neurological's six clinics handle check-in, but they are moving to virtual check-out procedures. “I think virtual check-out is going to be huge,” he said. “Do you really need a patient to sit in front of a staff person to check out and get their other appointments scheduled? Or can that be done efficiently outside of that visit?”
At First Choice Neurology, a solo-practitioner office has been experimenting with all-virtual administrative functions since February. The neurologist is the only person working in the clinic; registration and check-out are both handled via secure text, audio/visual interaction or email messages sent from the central business office.
The pilot test for the no-staff office is going well so far, Rocha said, although he thinks it might not work well for larger clinics. “A few other managers have shown interest, but we want to keep testing it,” he said.
The increased use of telemedicine and digital administrative processes may allow neurology practices to reduce labor and real estate costs.
“For the individual practices, there's a reduction in the number of people that they need,” Rocha said. “And in the corporate office, we don't need as many as before because we're doing things a lot more digitally.”
Montgomery at Noran Neurological estimates that about 60 percent of all staff members are still working remotely.
“A lot of our people, such as our scheduling and revenue cycle staff, are all remote to this day,” he said. “With a good chunk of my physicians working a couple days a week at home, do we really need all this space? What do our clinics look like in the future? That's what we're toying with right now.”
At Abington Neurological Associates, an 11-provider practice in suburban Philadelphia, the COVID-19 crisis revealed that slow computers were impeding many processes such as front desk check-in, medical assistants entering patient vital signs and providers ordering medications or answering telephone requests.
“Since we had to slow in-person patient flow as well as look at remote access, we sat down with our staff to figure out where they felt bottlenecks,” said practice leader Brad Klein, MD, MBA. “We were surprised to learn that many staff felt slow computers were normal.”
Upgrading computers and servers during the pandemic “isn't the shiniest change,” but [it has] made a remarkable difference, said Dr. Klein, chair of the AAN Medical Economics and Practice Committee. “As a result, our staff are less frustrated, patients feel the office visit is smoother, and the providers can get through their days more quickly not only in the clinics, but work they may do virtually through remote access,” he said.