‘60% of all visits in the future could be done via video’

Even as COVID-19 cases surge across the nation, hospitals and physician practices are working to figure out how to bring back some non-emergency services and procedures that had been put off for months. Questions remain about what this new normal will Dr. Richard Isaacs, look like. For one thing, virtual care is here to stay, says CEO and executive director of the Permanente Medical Group, and president and CEO of the Mid-Atlantic Permanente Medical Group, Kaiser Permanente’s two largest medical group practices. He expects roughly 60% of Kaiser members’ visits will be virtual in the future. He recently spoke with Modern Healthcare Managing Editor Matthew Weinstock. The following is an edited transcript.

MH: How are your medical groups handling the recent spike in cases?

Isaacs: I’ve been very impressed with the physician groups on both coasts, and in (Northern) California, we were one of the first areas that received patients from Japan via plane, and also via ship. This was around the middle of February, and we learned (a lot) about coronavirus, and it was unprecedented. There was a fair amount of uncertainty, and there continues to be uncertainty, but we helped lead the state’s effort in dealing with these patients, who were scheduled to be disembarked from the ship and be repatriated to Travis Air Force Base. However, the Department of Defense felt that, at that point, it was a national security issue, so we were involved in repatriating COVIDpositive patients to various hospitals across Northern California, and about 50% of our hospitals received the first COVID patients here in Northern California. We were very much involved in the suppression strategies, and we were excited because early on we flattened the curve like nowhere else on the globe. California was the frontrunner in preventing (the spread of) this disease.

However, over the last three to four weeks, we’ve been seeing another surge of the disease across the entire state of California, and (more than) half of the states are currently surging.

MH: What does that mean for practices that are trying to balance the surge, but also bringing back non-emergency procedures?

Isaacs: Early on, we continued to take care of all of the patients who had essential needs. We took care of all emergencies, all cancer surgeries were managed, which was about 50% of our normal volume in Northern California, which we did in February, March and April. About three weeks ago, as the shelter-in-place orders were lifted, we started opening back up. We take care of 4.5 million members in Northern California and another 800,000 in the mid-Atlantic region. We have patients who have been waiting for their elective care. The biggest challenge for me right now is the delay in screening. When people were sheltering in place, they weren’t getting their typical mammography, colorectal cancer screening, so there’s some queuing of patients who really need to get this essential screening care.

MH: How do you start building that back into the routine?

Isaacs: The priority has been patient safety and also staff safety. We’re working very hard to ensure that we maintain social distancing in the medical office buildings and in the hospital, and that we encourage people to come in when they’re healthy. We do screening at the entry of every medical office. If someone has symptoms of COVID-19 or they have fever, we take care of them in a different setting. So the goal is to keep COVID-free medical offices and manage patients for their essential needs.

MH: You’ve talked about battling the pandemic on two ends— COVID-19, but also the pandemic of fear. How are you talking to patients about coming back when they may be fearful of exposing themselves in a medical setting?

Isaacs: The medical office is the most trusted place where you can be, because we have regular processes that sterilize and sanitize the hallways and the medical examination

rooms. People are doing essential grocery shopping. It’s much safer to be in a Kaiser Permanente facility than in any place in the community today.

MH: Kaiser was at the forefront of using telehealth even before the COVID crisis. How has that grown during the pandemic?

Isaacs: We started our video-first strategy in March. We knew that patients were sheltering in place, and there was that pandemic of fear. We encourage patients to pursue the video-first strategy and see their primary-care physician on video. We’re currently doing close to 80% of all examinations and medical care on a video-first platform, and the patients who need to be seen are then triaged into the appropriate venue for care.

We’re seeing tremendous satisfaction with the care from home. We deliver supplies and medications right to their front door, and it’s hugely satisfying for our membership.

MH: Are there specialties where you started offering telehealth because of the pandemic that you hadn’t done before?

Isaacs: The Permanente medical groups have been leaders in telemedicine. The first foray was dermatology, and in a pre-COVID world, 90% of all initial dermatology consults were being done via video or secure message with a photograph. We’re very experienced with telemedicine, but in the COVID world, with sheltering in place, it pretty much spanned every specialty—pediatrics, OBGYN, primary care, family medicine, mental health, internal medicine are all doing large percentages of video visits, and my job now is to harvest all of these learnings from the COVID experience, because this is an incredible way to deliver care. I’m very pleased, and the doctors are excited, because it’s very userfriendly for the physician, their care team, and also the patients.

MH: Does this become the new norm post-COVID? How does that permanently transform what you’re doing?

Isaacs: I believe it’s going to completely transform. It’s the integration of technology with care delivery, and we will have the ability to do video 24/7, 365, and ideally, you’re having a video with a patient and a physician who knows you very well. With our electronic medical record system, we’re able to connect all 12.5 million members that we take care of across the United States. … We have all of their information at our fingertips. If a patient needs a physician or advice at 2 in the morning on a Saturday, they can reach us and get a video visit with a provider who will have all of their information.

MH: How do you address it from a physician-training standpoint? How do you make everybody on your team feel comfortable doing it on an ongoing basis?

Isaacs: We developed protocols for how to do video care effectively, and we train our physicians in the appropriate technique. Obviously, this is a secure environment. We want the patients to understand that it’s a one-on-one evaluation, and we just provide the environment for the physicians to do their job.

As we learn in medical school, the majority of all diagnoses are achieved (when) taking the (patient’s) history. The physical helps clarify some things, but the majority of diagnoses are made during the initial contact and conversation.

MH: Do you expect your physicians will return to an office setting, or will they be doing most of their work remotely now?

Isaacs: We’re trying to determine what’s the appropriate mix. I think that there will always be a need for face-to-face and office examinations. Right now, it’s looking like 60% of all visits in the future could be done via video, with an exam for the other 40%, when needed.

MH: Getting back to the surge in cases, how are you managing burnout and morale among your physicians?

Isaacs: I talk a lot about the trifecta of uncertainty, which does contribute to some burnout, because we don’t know how long this is going to last. The trifecta is: When will there be a vaccine? When will we have enough herd immunity that we can go back to some semblance of normalcy? That’s No. 1.

No. 2 is the uncertainty of the economic recovery, and it looked like we were heading back toward job recovery about three, four weeks ago in several states, and now the governors are talking about sheltering in place again.

The third uncertainty, and unfortunately this whole COVID-19 with the economic sequelae, (helped reveal) the racial unrest, social injustice, and (expose) years of systemic racism in this country.

As far as the burnout goes, it’s really about collaborating as a team. We’re all in this together, and the Permanente medical groups are integrated multispecialty groups that actually care about each other, and more importantly, care about the care delivery to the population. It’s amazing to see how our subspecialists have really risen to the occasion and are supporting everyone in primary care, as there’s been a shift in burden from some specialty care to primary care.

My job is to make it easy for people to do the right thing. Having the resources, the tools, the technology helps eliminate some of that burnout, and just knowing that you’re in this together has been very helpful.

“When people were sheltering in place, they weren’t getting their typical mammography, colorectal cancer screening, so there’s some queuing of patients who really need to get this essential screening care.”