Coronavirus in Context: How Are Hospitals Preparing for Reopening?

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You're watching Coronavirus in Context. I'm Dr. John Whyte, Chief Medical Officer at WebMD. When is it safe to go back to the hospital for non-COVID symptoms? When can you have that surgery that you've been waiting to have done?

To answer these questions, I've asked Dr. Stephen Jones, the President and CEO of Inova Health System, to join me. Dr. Jones, thanks for spending some time with us this morning.

Pleasure to do so. Glad to help.

Let's start off with, you're at Inova Health System outside of Washington, DC in northern Virginia. That's a different location than what we're seeing on the news in New York City. What are you seeing on the front lines?

It's interesting. We are probably a-- a very warm, if not emerging hotspot. We saw our first case, now, believe it or not, two months ago. And at this point, we keep hoping we're seeing a flattening. But there has been a pretty steady climb over time.

We went over 400 patients in our system for the first time this week, and it's backed off a little bit in the last couple of days, so we continue to have a little hope, but recognize that the predictions, I think, are-- are completely impossible to follow right now. So we're-- we're prepared for either direction.

Why do you think those predictions are hard? Is it because the modeling keeps changing, there's lack of transparency, it's-- it's hard to estimate behavior changes in people?

Yeah. Having published earlier in my career on, uh, decision models, I've had a lot of experience on it. And I think the real challenge on this is that all the models are based on, you know, less than four months of data.

And, in addition, there's so many variables that come in from differences in populations. I think we now see that this disease appears to affect people differently for reasons that we don't yet fully understand, including, um, certain even demographic issues that seems to act differently.

Then in addition, you throw in social distancing or access to health care, and the fears of people being willing or not willing to come in, I think the models have so many variables that aren't even in them yet that I-- I think they just don't-- I think we've now proven they really don't tell us what's really going to happen more than a few days out.

Now, you have multiple hospitals in your system. How is surge capacity working at the institutions that you oversee?

Fortunately, we started that very early on, recognizing and seeing what happened in, for example, New York and in Europe. And so we started, uh, getting the right equipment, preparing our people, cross training people, to assure the-- uh, that we had enough to take care of folks.

Because people keep out about number of beds. You know, you can put beds anywhere. It's a matter of having the expertise and the equipment to take care of them. And so we probably increased by 30% or 40% our potential capacity, including getting licenses for those beds under the emergency order here in the commonwealth.

But so far, we've not had-- had to come even close to filling those beds, because as you are well aware, most of our other patients aren't showing up to the hospitals. So we're still well below our normal capacity.

And that's a good point that you brought up, that other persons are not coming to the hospital. So to protect surge capacity can also impact, um, the financial health of a health system, because they're not having those elective surgeries.

We talked to Michael Dowling a week or so ago, and he talked about how Northwell Health may lose a billion dollars this year. What's the impact on Inova and other health systems?

We would have been, uh, barring what happened in the last eight weeks, we would have been a $4 billion revenue health system this year. Very clearly, we won't come anywhere close to that.

In the early weeks of this, we were off, uh, actually above $100 million per month in revenues. Now, some of that has softened a little bit, as we've both seen, you know, COVID patients coming in.

There is some revenue. Nowhere near what we would have from our-- our normal business. And we've made another-- other measures to address that challenge. But 100 million in a month, it adds up to a big number pretty quickly.

We are anticipating the likelihood that some of our surgery will, you know, change that. But right now, even after restarting a week ago today, it's been pretty slow so far.

So even if the virus starts to dissipate, and hopefully it-- it will, in some areas, continue to do so, the fear of the virus isn't going to dissipate. So I wanted to talk to you about, you mentioned some of these surgeries may resume.

How are you communicating to patients? How do we help them decrease their fear of coronavirus? Because care that's being delayed often can have an impact on folks. And-- and sometimes you don't think about that. Waiting a couple of weeks or even a month or two is OK. But waiting many months is going to be problematic.

Well, it depends on the condition, of course, you know. So people with a heart attack we know are not coming in. And especially in other parts of the country. We haven't seen that quite as much here, but we have seen clearly, people with symptoms of stroke waiting longer to go in, or families begging them to come in, they're afraid to come in.

And so we've been pretty consistent on messaging that. COVID is dangerous, but there are a lot of things that are way more dangerous than COVID. Um, we talked to our own staff. They now pretty frequently express the fact that they feel more comfortable and more safe in the health care environment than they do out at, name whatever other place that they might go.

I think one of the things that the public-- and we're doing our best to educate, you know, no one's better at preventing infection than health care. And so, you know, it's a core of what we've done forever. Preventing this infection is yet one more of those.

And we-- you can never make it zero, but we are very concerned about the number of patients not getting their care for more serious conditions.

Right. So how do we help them recognize that it's OK to come back in? And, for many weeks, we've been saying, don't come to the hospital. You know, call your public health department, call your doctor. Just don't come.

And I think that's resulted in people delaying, in some cases, emergency care that they might have needed. Now we're saying it's OK, but they're seeing pictures on television that may not even be in their area where it doesn't look so good.

So how do we help folks understand, certainly if you have chest pain, if you have, you know, confusion, dizziness, you need to call 911. But there's other reasons why you need to come into the hospital.

One are, of course, these conversations, John. I think it's ironic that, uh, as a physician, as you know, patients don't always listen to your advice. And it seems like this is the first time they really fully listen to our advice.

But the important caveat, and we're trying to message this in-- in any way we can, including, you know, public messaging, working with our local officials, et cetera. Is that, in the first days of this, we really did need people to stay away for a few days so we could change to the new normal, or what we call it at Inova, the next normal.

And so, you know, we needed to change some workflows, se-- segregate patients who had COVID-type symptoms from other symptoms as they came into the emergency department. So we did need that week or two to do that.

But now we are very prepared. This is our new normal. And so we're used to taking care of COVID alongside our-- our patients who don't have known COVID. And so we'll-- we'll take every way that we can communicate.

But a lot of it, as you know, is the position, reassuring the patient, the nurse reassuring the patient. That's-- some that's just literally hand to hand.

You have a new cancer center. There's been a lot of data recently that has talked about mammographies are 80% to 90% down. Colonoscopies the same. There is always the concern that people are going to present too late with a lesion.

What is the cancer center doing in terms of getting folks to say, you know what? We can do some by telehealth and telemedicine, but some, you still need to come in.

Of course, we are significantly increasing our virtual visits, and that will be part of our model moving forward. We're doing over 2,000 virtual visits a day right now. And, you know--

What was it-- what was it before COVID? Two?

[INAUDIBLE] You've seen our reports, I can tell. So-- so it's completely changed that. And frankly, I've tried for the last five years to push virtual visits as part of the model. And now, of course, it push themselves.

In the early days, the one place where we didn't see a significant drop was in our cancer center. The patients who had cancer and knew it, they-- they knew that that was a serious enough condition.

They are now starting to see that, and hopefully a lot of that will get transferred to virtual visits. But I do have a great concern. Oh, and by the way, in assuring that infection prevention, of course, think of it in the cancer center, of course you're always working on cancer prevention because of the risk of those-- those patients. But I do have a real concern that, indeed, the patients who aren't getting their mammographies and colonoscopies now, down the line, will be the patients who are unfortunately dealing with advanced disease. And so, you know, we've got weeks to change that, but we don't have years to change that.

Kaiser Permanente has said 80% of their visits right now are telehealth. And obviously, they've always been a leader in that, you know, space. But they did say it's not going to be 80% six months from now. What do you think telemedicine telehealth will be six months from now?

Of course, having to make a pretty guess, I bet it'll be half and half by that. I think you'll still-- you'll see patients coming back because they want that in-person. My-- my own mother has expressed concern. She's not necessarily comfortable with the digital interaction, you know?

My children, the millennials, they probably would have every single interaction moving forward be by that way. So I-- I would guess half and half is likely. And we're preparing our ambulatory areas to have so people can simultaneously do in-person visits for the patients who prefer or that's necessary, alongside with virtual visits, at least for the foreseeable future. I think that'll be the model.

Are hospitals more prepared if there is resurgence in the fall?

Yeah. I think there's going to-- people talk about the-- the second wave. And again, we're all make your own predictions for second wave.

[INAUDIBLE] We don't know. For sure. I-- I believe there will be multiple waves. And what I think that you'll see is that, if there is a significant surge at any point in time, whether it's two weeks from now or two years from now, that hospitals will-- it won't be a new thing and shocking anymore.

And so we don't look at it as, um, we don't look at it as, there will be a second surge. We believe that our normal will be the care of COVID patients. Sometimes a lot, and hopefully [INAUDIBLE] usually not many, at least until there's an effective vaccination.

What should patients do if they're thinking, you know what? Maybe is the-- now is the time to consider getting that knee replacement because of chronic pain, or that hip replacement, or some other surgery that they've been delaying.

Do they still need to wait a few months? Should they call their, you know, surgeon or doctor? What advice would you give them on-- in terms of whether it's time to reconsider that surgery that they've delayed?

Fir-- first, of course, is how acute the need is. So if someone truly can't walk because of pain, then that's a real issue that needs to be addressed. I think a lot of it depends on where they are.

So if they're in an area that's just inundated, then they probably need to wait a few weeks. If you're in an area like ours where yes, we have COVID patients, but, you know, we have the ability to protect you from that risk, then I think they should speak with their surgeon.

And if it's appropriate to move forward and if their hospital has the capacity, which most hospitals will in the near future, we certainly do right now, they probably should go ahead and thoughtfully, uh, schedule it.

You know, the big question is-- is right now, what's the appropriate testing for people. And, you know, people get this concept, I had a test. I'm negative. What-- what it means is, you got a test and it was negative at that point in time, also recognizing the tests aren't perfect, of course.

So, you know, what we do is we're testing most of the patients a couple of days ahead of time and then asking them just to isolate in that next couple of days, and then come in. That is probably an abundance of caution.

You know, most people are asymptomatic, clearly don't have COVID, and probably didn't benefit from testing, nor did their care team benefit. But the assurances is, by itself, worthwhile.

You know, One of the things I was asked the other day by a patient was about cataract surgery, right? So it's not a big surgery. It's not emergent. But it significantly impacts someone's quality of life.

And-- and the question was, when can they, you know, get their cataract surgery. And, you know, a couple weeks ago, the answer still was clearly no. Do you think the answer is going to change more and more to yes outside of those hot spots in the next few weeks?

There probably are places where, right now, it should change, and that that should be continued to be done. But the biggest challenge for any health system opening up for-- for returning elective care is to have all the resources in place.

So space is the one that gets talked about. Almost everybody has enough [? COVID ?] beds. But do they have enough PPE and medications to assure the care, both of the COVID patients and the surgical and other patients?

So we fortunately had enough time to prepare where, so far, it's going extremely smoothly. But we're still at only about 70% of our normal surgical volume. So we're letting it go up very thoughtfully. And literally a check in every couple days to make sure that I've signed off, that we feel prepared for the future.

If we saw a big huge surge coming forward, we could, almost on a dime, say there are certain procedures that we're going to hold off until later because of whatever surge that we saw. Fortunately, we haven't seen that and we're hopeful we're seeing the opposite direction now.

When do you think it may return to not necessarily a full schedule as you had pre COVID, but pretty close?

I think that within probably two or three months, barring a huge surge. I think that that's likely. It's-- it's given us all time more to get the-- the materials that we need, being one of the big things. Gives the patients more time to develop comfort.

So I'm hopeful that within the next two, three, four months, that we'll be back pretty close to normal. But our workflows are going to be different.

I was going to ask. Then you're going to have this influx, potentially. Are people going to have to-- are we going to be doing [? DNO ?] procedures, you know, midnight and 1:00 AM? Are surgeries going to be done on-- on Saturdays and Sundays that typically aren't done? How are you going to make up all that slack that folks haven't come in and now they need care?

I'm absolutely convinced that there's not going to be that big surge. I think that people are going to be too concerned for too long to where we're-- you know, I'd-- I'd love to have that problem that we're inundated with people who have our needs, but I don't see that happening. I think it'll-- it'll be a very gradual deal.

I think this is a new normal for us. And-- and-- but, you know, to your point on Saturday, Sunday, as a-- as a practicing surgeon myself, I've always wanted to have the hours open-- on Saturday and Sunday, because [AUDIO OUT]. And so we would take that problem, John.

OK. And then finally, you're outside of Washington, DC. I know you don't like to get political. But it is important to address whether you feel the government is doing enough to provide support for hospitals and health systems.

You-- you mentioned early on that many hospitals are taking a hit to their bottom line. Many hospitals are in fragile financial situations to begin with. And some of the processes in terms of how hospitals and health systems are going to be reimbursed are challenging.

So has-- has the government done enough, or what do they have to do to help health systems be restored financially?

You know, on the financial front, you have to take-- and, you know, you heard Michael say the impact to his organization, you know, we right now are $100 million per month behind and trying to address that quickly.

So-- so the amount of direct financing, there's no way it's really going to make up for it. And so we are deeply appreciative of the fact that our elected officials have taken on and seriously recognized that our warriors, you know, we can't lay everybody off like some industries.

Our warriors are right there now, working very hard to assure that the safe care of our communities, this community that we're here in right now. And so we-- we appreciate it. But-- but I think we should never think that that will be close to enough so that, if there's opportunity for additional funding or additional changes in policy, you know, even just making sure that we can continue to do virtual visits, which up until this, we couldn't get compensated for.

So the more that we can support not only financially, but helping us with the-- the business and the care delivery model will be an important part of what happens moving forward.

What keeps you up at night?

It's interesting. Early on, what kept me up at night was assuring that we could protect our own people. I had absolute confidence in their ability to provide the care, and they exceeded that confidence, you know, by far.

When-- when we look at the outcomes in our clinical areas, uh, both the-- the recovery of patients, the taking of patients who are on at ECMO, you know, extracorporeal [INAUDIBLE] oxygenation, early on people said, you can't survive from that.

The overwhelming majority of our patients who go on ECMO, even, are now starting to survive and thrive and get home. So I don't worry about the care. But early on, I really worried about our ability to assure the safe environment for our own team, and of course, the patients they're taking care of.

But it goes back to what I said. What-- when I walk the halls now, although there's still some fear, of course, we would be naive to think that. The courage and the confidence that I see in our hospitals and in our ambulatory areas is, people kind of have that, I've got it. I've seen this come forward. It's now part of our new model. COVID is really a service for us.

And so I don't worry anymore that we can effectively protect our people. And we will do-- continue to have that be the biggest focus of what we do so that none of us has to lose sleep over it.

Well, Dr. Jones, I want to thank you for sharing your insights this morning.

Thank you so much. It's been a pleasure.

And I to thank you for watching Coronavirus in Context. I'm Dr. John Whyte.