By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“When we have nations, institutions and advocates working on this collective response, we do see remarkable impact.”
     -Bill Gates at the 2020 COVID-19 Conference

There are several timely updates that we know would be of interest to primary care clinicians. Please forward on to your staff.

Surge of Cases Nation-wide Leads to Testing Delays
Public testing sites sponsored by the State in several counties have found long delays in results for the lowest risk groups, as the state announced criteria for prioritizing testing. OptumServe and Verily sites sponsored by the counties are affected. County health lab and local hospital lab turnaround (including Kaiser) is faster, but capacity is limited. Home testing is being rolled out by Lab Corps and soon Quest will join them. We will include more information on this in the next update.

Although point of care RNA testing (Abbott and others) is less sensitive than PCR-based testing, but some public health experts feel that a less sensitive point of care test that turns around results quickly, is better on a population level for screening than a more accurate PCR test with results available in 10-14 days.

All COVID tests are covered by PHC when done by any lab provider with a Medi-Cal provider number, up to 2 tests per day, for both diagnosis and screening.

Remdesivir Shortage Leads to Narrower Treatment Criteria
On a call with one of our local health officers, we understand that Remdesivir treatment is now being delivered to those who are inpatient requiring low-flow supplemental oxygen, as these patients have the most likely benefit for the treatment. Patients not requiring oxygen and those on high flow oxygen or intubated are less likely to benefit and are not being prioritized. A five-day treatment regimen has become standard for most patients.

Eye Protection Recommended in Health Care Settings with Moderate Community Transmission
The CDC recommends that eye protection be worn in health care settings where patients with unknown or positive COVID status are being cared for. The eye protection should not have gaps between the skin and should not rest on the protective covering around the face, meaning eyeglasses are not sufficient (see CDC recommendation for details). We understand that CDPH is considering making this recommendation into a requirement in California.

Familial Autosomal Recessive Mutations Associated with Higher Risk of Severe Disease in Younger Patients
In a study that gives insight into the pathogenesis of COVID-19, a case series of 4 young male patients with severe COVID-19, were found to have a previously undiagnosed immune deficiency: a relatively rare putative loss-of-function variants of X-chromosomal TLR7 were identified that were associated with impaired type I and II interferon responses.

Obesity an Independent Risk factor for Severe COVID-19
A report from the American College of Physicians noted that Obesity is associated with an increased risk for intubation and death in COVID-19 patients under age 65, but not for those over age 65.

“Broken Heart Syndrome” Increased During COVID-19
An observational analysis of patients without COVID-19, receiving echocardiograms at the Cleveland Clinic, found an increased percentage with stress cardiomyopathy (also known as takotsubo syndrome or broken heart syndrome). The rate ratio before COVID-19 was 1.5 to 1.8%, while the rate ratio during the lockdown rose to 4.6%.

Stress cardiomyopathy is a physical manifestation of sustained psychological stress. This study shows the degree of population stress that the response to the pandemic is having on the community.

Childhood Immunization Rate Rebounding (Somewhat)
The graphic below, from the California Immunization Registry, shows that the rate of immunization for MMR (a proxy for overall childhood immunization activity in young children) has mostly rebounded in California in the past month. Overall, though, there is a remaining backlog. Without in-person school in many parts of the state, the usual August bump in immunization rates may not occur this year. Next week, PHC will be starting a state-mandated phone outreach campaign to children under age 2 to remind them of the importance of vaccination and well-child visits.

By Jeff Ribordy, MD, MPH, FAAP, Regional Medical Director

Back in 2018 we published a mildly humorous blog post highlighting medical bloopers that we have encountered as we peruse the chart notes we receive. Of course back then, EHRs were so new that most providers were still getting used to working with them. Nowadays, everyone is such an expert we rarely see charting mistakes…..

Just kidding!

Here is our long awaited sequel with upgraded oopsies – just like the EHRs we all use.

As we share these I want to mention as in the previous post – this is not to point fingers but with the understanding we all have made similar mistakes.

From the “Not Sure That’s How That Works” Department…

–…he sleeps flat with 8 pillows <…>

–She lifts boxes which way 5200 pounds all day long while working in a warehouse.

–General: Pt is awake, alert and oriented. No acute distress. Husband present. PT is ambulating in a wheelchair.

–Born as full term at 51 weeks, no major complication reported during delivery.

–Allergies: CARBOHYDRATE

–He was twin B (5 lb 11) needed chest compression for 3 days. Not intubated.

–Is a 56-year-old male – Alcohol: Currently does not drink; but did drink a sixpack of beer per day for 78 years.

–Sister states that patient carries a diagnosis of schizophrenia but patient refused to take medication. Main symptoms of her schizophrenia was shyness and not talking to others.

–Patient states she believes she has MS. She states she did some online research and wants to be tested for MS. When asked what sx she is currently having in regards to MS, Pt asked, “Can I have a phone to look up the symptoms of MS.”

–Ms. M… had a sudden loss of both eyes that occurred in December 2018.

Might Need Another Treatment Plan…

–If the injection helps, then consider radio frequency abrasion.

–He was diluted with x-rays and sent home.

–Prognosis for controlling incontinence: Hyperlipidemia

–Discussed – Unfortunately kidney has failed to have any benefit from an L4 transforaminal epidural steroid injection.

–PLAN – Hyperlipidemia, unspecified, TraMADol HCI 50 MG tablet, 1 every 4-6 hours as needed, 30 days, 0 refills.

–Methamphetamine abuse  F15.10 – The patient appears interested in taking this habit.

Kid’s Doctors Say the Darnedest Things…

–3yo daughter Callie, works as a cashier

–SOCIAL HISTORY: The patient is in the fourth grade, denies use of alcohol and tobacco.

–10 year old female here with a chief complaint of eating.

–Please let mom know Xray from last week shows moderate poop.

Captain, the Universal Translator is malfunctioning…

–Ongoing tobacco use: Advised to quit yet another gallops left left knee surgery on their printer milligrams daily.

–Reminder of value of glucose level w/level of pain & why.

–Plan: Patient with hypoplastic left heart status post Norwood procedure N salmonella shunt mother with excellent Binder for following medical home we’ll need to clarify dosages of medications.

From The MD who was an undergrad Philosophy Major…

–The symptoms occur.

And more good advice for everyone:

–She married a drug dealer which she advises not to ever marry a drug dealer.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“If it wasn’t documented, it didn’t happen.”
     -Aphorism passed on to all health care providers in their training

One of the promises of Electronic Health Records was that it would make medical information more legible, and complete.

While computer text is undoubtedly more legible than most handwritten clinical notes, it does not solve the issue of incompleteness, and may make it worse. A long progress note can be created using templates and short-cuts, but sometimes a clinician fails to record the core information of the history of present illness and the part of the physical exam relevant to that complaint. When this happens, anyone reviewing the record would come to the conclusion that the quality of care in that visit was poor and unacceptable.

For example, a patient comes to the office complaining of back pain. The progress note includes a depression/anxiety screen, smoking history, alcohol history, review of current medications, and the medical assistant’s note of the chief complaint of back pain, for the past week since moving a heavy couch. The clinician documents no further history, and the physical exam notes that the heart sounds are normal, the lungs are clear and the patient is in no acute distress. There is no recorded back or neurological exam. The assessment is back pain, and an MRI is ordered.

This electronic medical record generated note not only gives the Partnership HealthPlan of California (PHC) medical directors no details by which to judge the medical necessity of the MRI request, it reflects either poor quality care by the clinician, or poor documentation by the clinician, and possibly both.

The consequence of this: a denial of the MRI request, the need for a repeat visit to do the relevant history and physical exam, and a delay in getting appropriate care for the member.

This issue is definitely not universal. In the process of conducting utilization management reviews and investigations of potential quality of care issues, we also encounter very complete and appropriate documentation that reflects a logical collection of historical information, a thoughtful physical exam and a delineation of the differential diagnosis considered.

Sadly, we encounter many progress notes that incompletely address the reason for the patient’s visit. When we bring this to the attention to the Medical Director of the organization, they are often unaware of the issue. This is perhaps even more concerning, that health care organizations don’t closely monitor the quality of medical records and clinical decision making.

One of the best resources to offer a clinician with poor documentation practices is the UC San Diego PACE Medical Record Keeping course. Having your clinicians periodically audit each other’s charts is another way to promote attentiveness to the quality of medical recordkeeping and clinical decision making. Having a standard set of review criteria is important; Family Practice Management has an article on this topic.

Physician Assistants are required by the Medical Board to have a percentage of charts reviewed by their supervising clinician, a good opportunity to identify poor documentation practices. Although physician review of a sample of Nurse Practitioner Charts is not required by the State of California, it is also a best practice to do this on at least an annual basis, as part of a yearly performance evaluation.

One final note: excellent documentation practices help prevent medical liability lawsuits and licensure actions by California Medical Board/Nursing Board. It is better to have a system to improve documentation and decision making before such actions force the issue.

For a collection of de-identified humorous examples of actual medical records PHC has reviewed, see Dr. Jeff Ribordy’s blog.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Redemption comes to those who wait.  Forgiveness is the key.”

Tom Petty’s 1999 ballad Lonesome Sundown (part of Echo, his tenth album with The Heartbreakers) was written after completing inpatient rehabilitation, recovering from a 3-year period of heroin use. The line about redemption and forgiveness is a reflection of his need to be forgiven so he could again create new songs and genuinely share his art.

Some Partnership HealthPlan of California (PHC) members have experienced hard periods in their lives when their actions cause distress to those around them. In the health care setting, this may lead them to repeatedly missing medical appointments or have verbal outbursts with medical office staff. Sometimes, their behavior leads to disenrollment from a practice.

These patients may sometimes turn their lives around, and be ready to re-engage productively in relationships with medical providers and offices. They are often ready to seek redemption and forgiveness from the medical office that disenrolled them.
At the June PHC Physician Advisory Committee meeting, several physicians related how their practices handle these situations. Here are some highlights:

• Patients should write a letter (potentially with assistance from an advocate), requesting re-enrollment, acknowledging the reasons for their disenrollment, explaining how their life has changed and expressing a commitment to act differently.
• The office/health center should have a process for reviewing such requests, ideally involving both clinical and administrative leaders.
• Many practices require the patient to wait for at least a full year after the disenrollment to consider a request for reinstatement.
• If the request is denied, the former patient is given a written response, indicating if and when they may apply again for reinstatement.
• If the request is accepted, the patient has an orientation session outlining expectations of behavior, up-front. For PHC members, PHC needs to be notified, as well.

Tragically, Tom Petty ultimately died of an opioid-benzodiazepine overdose in October 2017, related to his attempts to treat severe pain from hip osteoarthritis, for which he was hesitant to have surgery. In the 18 years between his recovery from heroin addiction and his death, he produced 8 albums and 2 film documentaries—a pretty good redemption.

If your office doesn’t have a process for considering re-enrollment requests, please consider developing one to allow former patients who have turned their lives around to have a second (or third, or fourth) chance.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

Early data suggests that deaths due to suicide and overdose have increased since the beginning of the COVID-19 mitigation measures in the United States. Social isolation, financial insecurity, and unemployment increases the number of deaths from suicide, overdose, and illness. The factors leading to suicide disproportionately impacting communities of color. Individuals who have a history of Adverse Childhood Experiences (ACEs) are particularly at risk.

Primary care clinicians have the opportunity to screen, intervene and prevent these events. There is no way to know if someone is in trouble unless they are asked. When risk for suicide is identified, there are tools and resources that reduce the probability of suicide attempts.

One best practice is to routinely screen for depression using the PHQ-2 and PHQ-9 questions, adding some additional questions about depression risk for any patient screening positive for depression (PHQ-9 score of 10 or greater).

The National Institute on Mental Health (NIMH) developed the Ask Suicide-Screening Questions (ASQ), four questions in 20 seconds to identify people at risk of suicide. In a NIMH study, a “yes” response to one or more questions identified 97% of youth aged 10 to 21 at risk of suicide:

1. In the past few weeks, have you wished you were dead?
2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
3. In the past week, have you been having thoughts about killing yourself?
4. Have you ever tried to kill yourself?

What’s next?

If an individual responds “yes” to one or more of the four Ask Suicide-Screening Questions, they are at “imminent risk” or “potential risk” of suicide.

The next step to better understand risk-level, if any of the four questions above are answered “yes”, ask “are you having thoughts of killing yourself right now?” and if the individual says “yes,” then they are at imminent risk of suicide and need an urgent mental health evaluation to ensure immediate safety. If the individual answers “no,” then a potential risk is identified and they require a brief suicide safety assessment to determine next steps.

The Zero Suicide Model is an evidence-based practice outlining how to apply this model in a clinical setting. Practices include:

• Make a safety plan the patient can follow if thoughts of suicide appear, including calling help lines such as the National Suicide Prevention Lifeline                        (1-800-273-255).
• Discuss restricting access to things they might use to hurt themselves – especially firearms (firearms in the house are a major risk factor for completed suicide).
• Create a follow-up monitoring plan to ensure the patient receives ongoing help and support.

All three of these activities are appropriate for those who answered “yes” to any of the four ASQ questions above.

Overdose and Suicide: An overdose or self-harm event in the emergency department indicates an extreme high risk. An opioid overdose indicated an 18-fold greater risk of suicide and over 100-fold greater risk of overdose in the next year, compared to the general population. A visit for suicidal ideation led to a 30-fold increase in the risk of suicide in the next year.

ACEs and Suicide: Individuals with four or more Adverse Childhood Events (ACEs) are 37.5 times as likely to attempt suicide, when compared to individuals with no ACEs. For more information on addressing ACEs in your clinical practice, visit www.ACEsAware.org.

Screening individuals for risk of suicide saves lives! Health care professionals can help people get needed care, support and resources. We recommend a refresher training for our clinical staff on this topic, in this time of increased risk of suicide.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

The data on the effectiveness of mindfulness in reducing stress, anxiety, and cravings for controlled substances is strong. Mindfulness is also demonstrated to increase happiness.

In spite of this, many health care professionals and patients have difficulty fully embracing mindfulness as a therapy or practice, long term. Many authors have commented on this, with myriad different explanations and analyses. (For example, this essay contrasts mindfulness with psychotherapy.) Here are some underlying beliefs that may contribute:

1. Mental illness and experiencing stress are signs of personal weakness to be covered-up or suppressed, instead of understood and addressed.
2. The mind and body are separate. Those who strongly believe this cannot believe that trying to use their mind to make their body feel better or function better.
3. Mindfulness takes too much time. Individuals who believe that mindfulness is helpful may conclude that it takes too much time to practice mindfulness regularly. Does one really need to go on a two-week meditation retreat to get into a better state of mind?
4. Mindfulness equals deep breathing and meditation. Is breathing in through the nose and out through the mouth repeatedly always the best way to re-focus the mind?

The Greater Good Science Center at UC Berkeley embraces a broader conceptualization of mindfulness. Each person is encouraged to try different methods of becoming more mindful (using a broader understanding of mindfulness than its meditative Buddhist roots), finding a method that resonates especially with their personality and beliefs.

The Center performs original research to further the evidence base on different practices, which looks at the concept of micro-dosing mindfulness: spending very short periods of time several times per day to experience a sense of awe about something in your environment, and sharing this with your friends and family. This might be something beautiful, like a flower, a pet, a story or a piece of music. It might be something more intricate and complex, like a well-engineered race car, an innovative food dish, a piece of sculpture, a formal ceremony, or a novel gadget. Whatever it is, you should focus on it for a moment at the exclusion of all else, appreciating some of the intricacies and details, experience a sense of awe, and then perhaps share the details of the experience briefly with someone in your life. For example, take a picture of it with your phone and share it with a brief description of why it affected you!

This last step, the sharing, is critical for making this mindfulness practice not just a method to reduce stress but to increase happiness.  Sharing strengthens interpersonal connection, especially important in this time of physical distancing.  Interpersonal connections are necessary (but not sufficient) for a person to be happy, according to neuroscientist and author Laurie Santos.

Of course, when our friends, family, colleagues or patients share something that gave them a sense of awe, we should pause, give our attention to what is being shared, reflect back what we have heard, and allow ourselves to share some of that awe.

Robert Moore, MD MPH MBA

Chief Medical Officer

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

Last Thursday, California released the details of its previously announced “resilience roadmap,” giving requirements and recommendations for safely allowing resumption of activities based on public health risk.  This roadmap starts to give us some longer-term understanding of how the future will unfold in the months ahead. Stages 2 is fairly detailed now; stages 3 and 4 will have additional detail added later.  County health departments have been given important responsibilities in this process, ensuring sufficient community testing to allow opening up to occur, overseeing local implementation of the planning, workplace changes, and citizen communication.  We appreciate the difficult tradeoffs they are balancing in their decision-making; thank you!

The governor’s office is now shifting focus to developing strategies to address the massive budget shortfall being faced next year; their “May Revise” of the budget is due soon.  All programs that rely on state funding (education, health, public safety, transportation) are concerned about what cuts the state will use to prepare a balanced budget.

As of last week, six counties in the PHC service area (Marin, Sonoma, Napa, Yolo, Mendocino and Humboldt) now have mandates for facial coverings/masks when indoors or in crowded outdoor areas where physical distancing cannot be maintained.  Local community groups have stepped up to provide masks/facial coverings to vulnerable populations, including the homeless.  This demonstrates that a community need, combined with community spirit can ensure community-wide adherence to such requirements.

Here are a selection of updates gathered in the last 12 days, which we thought you would find helpful.  Thanks to everyone for sending suggestions and feedback!

1. Policy updates
   1. Verizon offers FCC grants to promote telehealth deployment.  Since it is a federal grant program, the paperwork and steps are rather complicated.  See the online application to get started.
   2. Congregate living environments have been particularly susceptible to COVID outbreaks across the U.S.  The CDC has posted guidance for owners/managers of these facilities to prevent spread of COVID-19.  Please pass this on to the managers of facilities where your patients live.

2. Public Health Update:  This pre-print article recalculates the estimated Ro (R-naught) of COVID-19 taking transmission of asymptomatically infected individuals into account.  Their revision increases the Ro to at least 5, with a mean likely Ro of 15.  This higher Ro helps explain the rapid spread in New York City, and the stubborn persistence of new cases and deaths in the California in spite of Public Health mitigation efforts.  The implication:  a higher level of herd immunity will ultimately be needed to eliminate outbreaks.

3. Efficient use and access to PPE.  In previous communication, we presented some PHC-generated guidelines on re-opening outpatient medical practices.  The AMA released similar guidelines.  In our discussions with local PCPs, insufficient access to sufficient masks and other PPE is a major barrier to re-opening.  Here are some new resources:
   1. CDC guidelines on optimizing efficient use of PPE.  The Centers for Disease Control and Prevention have released optimization strategies for PPE offer options for use when PPE supplies are stressed, running low, or absent.
   2. Free PPE Decontamination for Reuse.  The State of California, in cooperation with federal partners, is offering Battelle Critical Care Decontamination Systems as a solution to the N95 shortages impacting California, which will be available to all practices, free of charge.  There was some early miscommunication indicating that it was only available for hospitals, but we have confirmed that this is not true; outpatient health care offices may also use this service.

4. COVID Testing Updates
   1. Population Testing: Why is Open Testing a Goal?  The availability to test for SARS-CoV2 RNA is expanding steadily in our region, leading to rapid changes in local recommendations for testing.  While most PCPs are testing based on presence of symptoms or contacts with either cases or vulnerable populations, some external testing sites are encouraging anyone who wishes to be tested to get tested.  While on first blush this looks like an inefficient use of COVID tests, an interesting finding shows that there is some psychology to this policy.  When “asymptomatic” individuals who test positive are questioned, over half actually did have mild symptoms that they discounted at the time, suggesting that subconsciously these individuals were worried enough about these mild symptoms to seek out testing.
   2. Limits of “Rapid” RNA tests.  The first rapid COVID RNA test (Abbott) to come on the market has several important limitations.
      1. Once the specimen is collected, it must be run within 2 hours.
      2. Unlike the standard tests, no viral transport medium can be used; it can lead to false negative results.
      3. The company has not validated this test on asymptomatic individuals, and so recommends only using it for those with symptoms.  This recommendation may change in the future.
   3. Limitations of serology test interpretation.  The California COVID-19 Testing Task Force put together a succinct, easy to understand explanation of what serology tests help with and what they should NOT be used for.  The FDA has updated its policy on SARS-CoV2 antibody testing after a flood of serology tests came to market, some with poor performance and fraudulent labeling.
   4. New method of RNA testing.  Researchers are working to adapt the CRISPR gene editing methodology to identify SARS-CoV2.  Instead of amplifying, the viral sequence to the point of detection (done in PCR tests), the CRISPR method finds the viral sequence and then sends a signal, which is then detected.  The charming name for this testing methodology is SHERLOCK. If this technology is perfected, it will allow large scale rapid testing for RNA.

5. COVID disparities.  The COVID-19 outbreak initially involved cruise ship customers, international travelers and their direct contacts, and evolved to a pattern of community spread, disproportionately affecting individuals who live in crowded conditions and who continue to work as essential workers.  A steady stream of epidemiological data has showed that community spread in cities has disproportionately affected socioeconomically disadvantaged individuals.  This is reflected in analysis of hospitalizations and deaths in New York City, which showed Manhattan (with a higher median income) with less burden of disease than The Bronx and Queens, which have a much lower median income.  Evaluating race/ethnicity disparities in context is important, as there are many subconscious biases and tropes which humans are prone to attribute as causes of these disparities (thoughtfully summarized in this excellent NEJM article).

6. COVID Treatment Updates.
   1. Remdesivir:  Gilead asks Federal Government to Distribute for Compassionate Use:  Most Hospitals left out. Remdesivir is less available than previously as Gilead turned over responsibility for distribution of the drug to the Federal Government.  Remdesivir was approved under Emergency Use Authorization on 5/1/2020 for IV administration to hospitalized COVID-19 patients, based on preliminary data from the ACTT-1 study. Per the EUA factsheet, recommended adult dosing is 10 days for critically ill patients (intubated/ECMO) and 5 days for all others, with the ability to extend to 10 days if no clinical improvement. Per the distribution website, hospitals identified by the U.S. government as a recipient for donated remdesivir will be proactively contacted; to find out if your hospital has been designated to receive donated remdesivir, you can email remdesivir@amerisourcebergen.com Certain hospitals were given a supply, others were granted none.  The basis of this allocation has not been clear.
   2. Elevated PTT in serious COVID—Anticoagulate anyway!  This article found that the elevated Partial Thromboplastin Time (PTT) found in critically ill COVID patients is due to the presence of Lupus Anticoagulant, as part of an antiphospholipid syndrome.  As a result, it is an indication of a hypercoagulable state, needing anticoagulation.  Another study (added to several done before with similar findings) showed that critically ill patients with COVID had better outcomes if administered low molecular weight heparin.
   3. Pediatric Multisystem Inflammatory Syndrome (PMIS). A number have reports have been issued in the past two weeks on this topic, affecting 64 pediatric patients in New York and more in other countries with a serious condition that looks somewhat similar to Kawasaki disease:
      1. A child presenting with persistent fever, inflammation (e.g. neutrophilia, elevated C-reactive protein and lymphopenia) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder). This may include children meeting full or partial criteria for Kawasaki disease.
      2. Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal or streptococcal shock syndromes, and infections associated with myocarditis such as enterovirus.
      3. This literature is evolving quickly; any potential cases would warrant consultation with a pediatric infectious disease specialist for therapeutic advice.
   4. List of all clinical trials for treatment of COVID.  The Medical Letter has shared a comprehensive list of all drug trials being used to test    treatments of COVID.  It is worth a quick look to get a sense of the many strategies being considered.

That’s it for this week!  We at PHC continue to be proud to support and serve you as you support your community in your daily work.

Robert Moore, MD MPH MBA

Chief Medical Officer

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

See below for this week’s extensive collection of news and information on COVID-19, curated for topics of interest to primary care providers.

These summaries are being posted as blogs on phcprimarycare.org.  We have also posted a draft of our recommendations for re-opening outpatient practices on the blog.

Your team at Partnership HealthPlan is here to help and support you as you adapt to this new medical world we are all now living in!

1. Optimizing physical exams conducted by video.  Several physicians with extensive experience in providing primary care by telemedicine have posted videos sharing their best practices.  Here are some links to some of the ones that are particularly helpful.
   1. General overviews of best practices:
      1. “Bedside” manner by video (10 minutes)
      2. General physical exam (5 minutes)
   2. Provider directed patient self-exam
      1. Overview (16 minutes)
      2. Free CME from Stanford (15 minutes)
      3. Patient assisted virtual palpation (3 minutes)
   3. Best Practice on Observation (4 minutes)
   4. Specific Types of Exam 
      1. Abdominal exam (6 minutes)
      2. Neurologic exam (20 minutes)
      3. Musculoskeletal exam (6 minutes)
   5. Orthopedic exams
      1. Knee
      2. Hip and Groin; Sample exam
      3. Shoulder Exam: flexion, adduction, abduction; preparation for patients before visits
      4. Neck: range of motion, nerve root compression

2. COVID Testing
   1. Antibody tests covered by PHC and MediCal.  MediCal codes (86318, 86328, 86769) are a benefit with an effective date of April 10, 2020.  The code for the single step method test is 86318, which has a Medi-Cal rate posted.   Rates have not yet been set by the state for the other two tests.  We recommend checking the CLIA status of these tests before ordering them to conduct in your office.

B. Caution:  Antibody tests using Lateral Flow Assay have variable sensitivity.       (From UCSF ID)  Researchers in the UK (pre-print) evaluated a panel of           antibody-based COVID-19 tests – a novel Enzyme-linked immunosorbent         assay (ELISA) in the lab and 9 commercially-developed Lateral-Flow                 Assays (LFAs) to be used at the point of care. Serum of patients diagnosed       with COVID-19 served as the positive controls and serum of patients in UK       before December 2019 served as negative controls. ELISA identified                 COVID-19 IgM or IgG antibodies in 34/40 cases and 0/50 controls, yielding       a sensitivity and specificity of 85% and 100%. The sensitivity of ELISA IgG       improved to 100% when restricted to patients exhibiting symptoms for ≥10       days. No patients were IgM positive but IgG negative by ELISA. LFA had a       sensitivity of 55-70% with a specificity of 95-100%. IgG titers rose for 3             weeks post symptom onset and began to fall by 8 weeks, but remained             above the detection threshold. This small study was limited by small                 sample sizes and has not yet been peer reviewed. Bottom line: This study       suggests ELISA is best used to identify COVID-19 exposure 10 or more           days following symptoms. Despite being available at point of care,                     currently available LFAs have variable sensitivity. Whether a positive                 antibody test to COVID-19 by one of these tests correlates with immunity is       not known.

C. Persistent virus shedding associated with lower levels of SARS-CoV2 IgG:       persistent infection? A recent report showed that some patients shed viral         RNA in stool for a prolonged period after symptoms resolved and viral RNA       is no longer detectable in nasopharyngeal swabs.  Another analysis from           China of a subset with renewed detection of RNA after several negative             tests found an association with lower levels of viral-specific IgG.  This               suggests that a suboptimal immune response is associated with                         persistent or recurrent infection.  More study is needed, but this                         reinforces caution needed when interpreting positive COVID antibody             tests, especially the LFA tests, as noted above.

D. PCR/RNA tests using sputum contain more viral material than                           Nasopharyngeal swab. This pre-publication summary showcases another         option for appropriate settings, and may be collectable via self-collection.         This may generate more droplets in collection process, but saves swabs           which are often in short supply.

3. COVID Epidemiology Updates
   1. Using COVID RNA tests of sewage for population monitoring. As noted previously, SARS-CoV2 RNA has been detected in stool of many individuals with symptomatic COVID.  A recent report found that SARS-CoV2 can infect the enterocytes of the human GI tract, suggesting that virus shedding is directly from the GI tract.  Several countries have used RNA detection in sewage to detect COVID-19 infection in a community several days before the first symptomatic cases are confirmed.

    According to an article in Nature, several groups are conducting these              sewage tests in the United States.  One area of development is to look at          the RNA load in sewage to estimate community prevalence of infection.            KQED reported that ten Bay Area Counties and Shasta County are testing        sewage; a separate report indicated that Lake county has conducted tests.        In Lake county the sewage tests converted from negative to positive a few        days before the first cases were identified and confirmed.

    Once a community believes it is COVID-free for a period of time, sewage          testing may be able to confirm this, and act as an early warning of the                return of COVID to a community.  Decades ago, this methodology was used      extensively in tracking polio incidence in communities.

B. Heat and humidity of the environment may decrease transmission COVID        is spreading quickly around the world in countries with a wide variety of            climates.  Urban crowding seems to be one of the larger risk factors.  Other      respiratory viruses have less transmission in the warmer months of the              year.  This may be partly due to the thicker protective mucous in warmer            and moister climates, and partly due to more prolonged indoor exposure          to people in cooler weather.  An elegant analysis of data from multiple                countries suggests that there is some slowing of the COVID doubling                rate in more tropical climates compared to more temperate climates.                  This is a mathematical/epidemiological modelling exercise; it will be                  interesting follow further data analysis from within the United States.                  Somewhat suggestive: COVID spread was more rapid and harder to                  control in the Midwest and Northeastern states which are emerging from          winter, compared to states in the West and Southwest.

C. Pre-symptomatic infections most infectious.  Another complex                            mathematical analysis of available data published in the journal Science            compares the degree and timing of infectiousness in the course of                    different infection scenarios:  pre-symptomatic by droplet/aerosol;                      symptomatic by droplet/aerosol; by environmental contact (fomites); from          asymptomatic individuals.  The graphic below summarizes their                          conclusions:  tau represents the time since infection.  Again, this is a                  model; more data will undoubtedly refine it; it reinforces the rationale for            population wide facial covering to reduce transmission.  I speculate that            the decreased infectiousness of symptomatic individuals may be related            to greater caution taken in this phase.

D. Why are mortality spikes greater than can be accounted by reported                 COVID  deaths, in countries around the world? Last week, an analysis of           reported mortality data from around the world found that, in many                       countries,  the overall mortality rate increased sharply, but much more than       would be accounted for by COVID-reported deaths.  A few days ago, a             similar phenomenon was reported in the United States, for the last two             weeks of March, when COVID deaths accounted for only 53% of excess           deaths.  Here is the graphic:

     Interestingly, most of these excess deaths were in the Eastern US, the               percentage is notably less in Michigan and absent in Washington state.             There are multiple possible contributory explanations/factors; more                   analysis will shed more light on this.

E. COVID deaths outside the hospital (often at home), not counted in official          estimates; possibly related to the hypoxia without dyspnea described in a          prior update.

F. Strokes in young patients, related to hypercoaguable state induced by              COVID infection, which may be due to the recently documented direct              infection of endothelial cells by SARS-CoV2, with subsequent damage,            promoting thrombogenesis.  New York City found a doubling in the rate of          strokes in the past month, with half the cases in younger patients infected        with COVID.

G. Patients not going to hospital due to fear, dying of heart attacks, strokes,           other emergency medical conditions.

H. Increase in suicides.  Of note for the first possibility:  PHC now covers O2       sat monitors (HCPCS E0445) provided by DME companies.  However,           due to an international shortage, your local DME vendors may encounter           difficulty fulfilling a prescription for an oxygen saturation monitor.  PHC is           working on an alternative consignment and distribution process for O2 Sat       monitors; more to come.

4. Updates on therapeutics
   1. Tocilizumab for reducing cytokine storm. (From UCSF ID)  Two recent papers seek to uncover the mechanisms behind the development of acute respiratory distress syndrome (ARDS) in a subset of COVID-19 patients often >7 days after onset of symptoms. Blanco-Mello et al compared the transcriptional response of SARS-CoV-2 to other respiratory viruses including Influenza A in a variety of immortalized tissue culture cells, infection of primary airways cells, in vivo samples derived from SARS-CoV-2 infected ferrets, and finally from post-mortem samples collected from the lungs of humans who died with SARS-CoV-2 or normal lung biopsies. These studies, together with serum profiling in the ferret model, revealed a unique and inappropriate inflammatory response characterized by low levels of type I and type III interferons, elevated chemokines, and elevated Interleukin-6 (IL-6) expression.

    Giamarellos-Bourboulis et al compared 28 patients with COVID-19 and            ARDS to 26 patients COVID-19 without ARDS. Control groups included            patients with 2009 H1N1 Influenza A and patients with community acquired      pneumonia-associated sepsis. Some patients with COVID-19 associated-        ARDS had macrophage activation syndrome, and most had immune                  dysregulation characterized by low expression of HLA-DR on a subset of          monocytes (CD14 positive) that is triggered by monocyte hyperactivation,          excessive IL-6 release, and profound lymphopenia. This pattern is distinct        from ARDS-associated bacterial sepsis or 2009 H1N1 influenza. Together,        these studies suggest that COVID-19 associated ARDS may be                        characterized by both a reduced innate immune response coupled with an        exaggerated inflammatory cytokine response.

    A preprint report of a study of 30 patients with severe, deteriorating COVID        pneumonia treated with tocilizumab to block IL-6 eliminated the                          development of cytokine storm, compared to a matched control group.              Larger studies are in process.

B. Alpha-lipoic acid reduces systemic inflammatory response in COVID.  α-          Lipoic acid (ALA), as an antioxidant, has been confirmed to reduce                    systemic inflammatory response in patients with acute coronary syndromes,      liver transplantation patients, and kidney-pancreas combined                            transplantation  patients.  A preprint of a study suggests a benefit in                  reducing cytokine storm in critically ill patients with COVID.  Again, more            study is needed.

C. Remdesivir:  Gilead announced that their trial of Remdesivir has reached           its primary endpoint, which likely means a survival benefit has been found.       More information and detail will be coming soon.

5. Focus on inpatient care issues with COVID patients.  Given the seroprevalence data from Santa Clara (the COVID hot-spot in Northern California), it is likely that over 97% of residents of PHC counties have not yet been infected with COVID-19.  There is a strong possibility that we will see an increase in COVID hospitalizations in the future, with recruitment of community physicians to assist with their care.  All physicians therefore need to learn the essentials of caring for COVID inpatients.  Here are some highlights to help prepare.

A. Free clinical simulation of caring for patient with COVID on general hospital       floor.  This simulation takes about 15-20 minutes and hits on many                    highlights of caring for COVID inpatients that are not in the ICU.  I highly            recommend it.  The next three items are elaborations of some themes of          this simulation.  The subsequent five items relate more to critically ill                  patients in the ICU.

B. Risk factors for deterioration.  There are many models for estimating the          risk of deterioration.  Here is one called the Early WArning Score (EWAS),        using just 5 factors: age, underlying chronic disease, neutrophil to                      lymphocyte ratio, C-reactive protein, and D-dimer levels.

    Low risk is a score of 0-2, medium risk is a score of 2.5-3, high risk is a            score of 3.5 to 4.5.  The 14-day cumulative incidence of clinical                          deterioration in the low-risk group was 1.8%, which was significantly lower        than the incidence rates in the medium- (14.4%) and high-risk (40.9%)              groups.  Note the heavy weight given to elevated D-dimer level.

C. Aerosolization of COVID with different types of oxygen therapy.  The                simulation above indicates that less hazardous aerosol is released into the        room with a non-re-breather mask than with other high-flow oxygen delivery      methods.  This study casts some doubt on this popular wisdom, indicating        that the aerosolization of all oxygen delivery methods are about the same.        Bottom line:  wear a tightly-fitting, fit-tested N95 when entering the room of        a COVID patient on oxygen.

D. Heparin reduces hypoxia in hospitalized COVID patients. Since we are             seeing a variety of blood clots in patients with COVID (strokes, pulmonary         emboli, peripheral blood clots), and anti-coagulation is usually beneficial for       most hospitalized patients, it is not surprising that this study found                     improved hypoxia from use of prophylactic heparin in COVID inpatients             without active bleeding.

E. The range of survival for ventilated patients varies greatly by                              hospital/geography:  From a survival rate of 12% in New York City to a              survival rate of 94% in at San Francisco General Hospital.  This is partly            related to the effect of an overwhelmed hospital system, in New York, but          another factor is the organization of health care delivery at different                    hospitals.  SFGH’s CEO Susan Ehrlich has rigourously overseen the                implementation of lean management methods throughout their leadership        structure, which led to strong independent, self-improving teams.  I would          speculate that this is contributing to their amazing outcomes.

F. Outcomes poor for CPR in hospitalized COVID patients with cardiac arrest.      This report notes that if patients with COVID get to the stage of cardiac              arrest, CPR is unlikely to lead to positive outcomes.  Less than 1% of                COVID patients receiving CPR survived without permanent neurologic              sequelae.  This is helpful information for advance care planning                         conversation.

G. ST-segment elevation in COVID: clot vs. myocarditis?  Although the                   COVID virus infects blood vessel endothelial cells, potentially contributing         to blood clots (as noted earlier), this summary found that most patients with       ST-segment elevation on EKG are found to have no obstruction of                     coronary  arteries, suggesting that myocarditis from direct COVID infection       may be the more dominant underlying etiology, as first noted in                         Washington state’s experience.

H. Many critically ill COVID patients found to have aspergillus superinfection.        This pre-print found Aspergillus in 33% of lung specimens of intubated              COVID patients.  This might be colonization or superinfection, the latter            due to impaired immune response.  Evaluating Bronchial secretions of              COVID patients for superinfection with both bacteria and fungus seems            prudent, to not miss a treatable superinfection.

 I. Gut microbiome associated with risk of cytokine storm? Why do some              COVID patients become seriously ill, while others do not?  This analysis            speculates that the proteins produced by the gut microbiome (called                  the fecal metabolome) may affect the probability of developing cytokine            storm.  More analysis is needed to understand how this might be leveraged      for prevention or treatment.

6. What is “Crazy Paving” and what does it have to do with COVID? Crazy paving refers to the appearance of ground-glass opacity with superimposed interlobular septal thickening and intralobular septal thickening, seen on chest High Resolution CT. It is a non-specific finding that can be seen in a number of conditions. Here are two CT scan views showing this pattern, along with a picture of a mosaic paved pathway that inspired this whimsical radiological description.

Crazy paving:  not exactly a yellow brick road, but I’ll say goodbye for now.

Robert Moore, MD MPH MBA

Chief Medical Officer

(Optional items italicized)

Effective Date:  In place on re-opening or expanding clinical services

Duration: Until public health emergency lifted

Version 1.0 Date:  April 23, 2020

Disclaimer:  There are little or no controlled studies underlying these recommendations.  They are based on CDC recommendations, local health department orders, and expert consensus of PHC medical directors.  They should be considered a starting point for evaluation of office systems, and may be modified by the clinical leadership at a practice.  Any directive by a local health officer which is more stringent than these guidelines would take precedence.

Send comments or suggestions for improvements to: rmoore@partnershiphp.org

Patient Care in Office:

1. Staff and clinicians will wear face masks at all times, as will patients. This should be explained to patients before they arrive at the office.

2. Patients without their own masks will be given one on entry to the office. The mask should completely cover over the nose to below the chin and fit snugly along the sides.
3. Staff and clinicians will wear gloves for any patient contact, disposing gloves between patients and washing hands before entering and upon leaving each exam room.
4. Stethoscopes, blood pressure cuffs and other non-disposable equipment touching patients should be cleansed before and after each use.
5. When rapid, point of care PCR tests become available for office use, perform a rapid test on asymptomatic individuals prior to performing procedure that will generate significant aerosol (e.g. dental extractions, dental cleanings, office spirometry)

Virtual Visits: (all patients should be contacted by phone before coming to the office)

1. Patients with contact with a person who tested positive for COVID 19 or who are experiencing fever, chest congestion, flu-like symptoms or symptoms of milder respiratory infection will be asked not to visit the office but rather to consult with the physician via phone or video conferencing.
2. Patients who are immunosuppressed or are at higher risk for COVID 19 related complications, will be offered phone or video conferencing. If they must be seen, have a plan that minimizes their risk, such as seeing them in the first few hours of the day, or conducting a detailed history over video/phone first, before a brief office visit.
3. Develop workflows and best practices for visits to be addressed by video/phone as much as possible.  Use these guidelines to limit exposure of patients and staff to potential  infection when in person visits are needed for routine visits ( well child, women’s physicals for example) and as indicated for face to face visits for chronic disease management or other necessary exams. Consider:

a. If a person is coming in for a face to face visit for one reason, ensure all            related reasons for a face to face visit are done at the same time.

b. Methods of optimizing obtaining history and doing a partial physical exam          by virtual visit to make the physical visit short and efficient with minimum          chance of infection transmission.

c. Finding alternatives to more hazardous examinations/procedures, such as       coaching parents on application of fluoride varnish over phone or                       application of silver diamine fluoride to caries instead of tooth extraction or       filling. 

4. If patients with symptoms listed below need to be seen in the office, they will be      scheduled at a time and in a manner to prevent potential infection of other                patients. This may include

a. Examining the patient in their car.

b. If the patient may not be examined in their car, they would be scheduled at        a time and location where other patients would not be using the same room      until decontamination is possible.

c. Moving them directly to an examining room with no waiting room time               (potentially through an alternative entrance), followed by thorough                     decontamination/aeration of the exam room.

 Operational Aspects:

5. Patients will be scheduled in such a manner to maintain six foot spacing in the

            waiting area.  This may require patients to wait in their cars until called in to the

            office, or moving the patient directly to an examination room from the waiting

            room upon arrival.

6. Patients should be seen in the office alone unless they need a caregiver, or they

    are a minor needing an adult.

Staffing Aspects: 

1. Temperatures and symptom review (see below) of staff will be done each day.

2. Any staff member with symptoms potentially caused by SARS-CoV2 will be

    referred for testing as a healthcare worker with face-to-face patient contact.

3. Staff members with exposure to a person who tested positive for the virus will be

    asked to remain home under paid sick leave for 14 days, only returning after

    consultation with clinician in charge. In circumstances of significant staff 

    shortage, if rapid PCR testing is widely available, an asymptomatic exposed 

    staff member who tests negative for coronavirus may be considered for return

    to work with continuous mask use for a day or two (they would need to be

    retested every couple days to be sure they do not develop viral shedding).

4. If scribes are used by a practice, consider changes to support infection control.        Examples may include having them support virtual visits or virtual pre-visits              where the history is gathered.

Maintenance and Facilities: 

1. Hand sanitizers as well as soap and hot water for hand-washing are readily

    available throughout the office and waiting areas.

2. Cross contamination will be minimized by frequent sanitizing (wiping down) of

    surfaces, doorknobs, light handles, keyboards, phones, etc. with isopropyl

    alcohol or chlorine-based cleansers.

3. Scrubs and lab coats should be laundered daily. Neckties or other loose clothing

    that could contact patients should be avoided.

4. In the setting of an office where patients may walk in for care without a mask or

    where no screening for respiratory infections before visits can be done, adding a

    Plexiglas barrier for reception staff may need to be added.

5. Any break room should be arranged and use scheduled to allow at least 6 feet of

    distance between individuals who are eating and drinking. Discourage

    conversation while eating.

6. Shared restrooms should have surfaces decontaminated with increased

    frequency, depending on how much it is used.

7. Review decontamination procedures done by maintenance staff to ensure they

    are conducting duties in a way that protects them and thoroughly

    decontaminates the office.

8. Develop a procedure for educating staff on these infection transmission

    prevention measures and monitoring their adherence.

Symptom Review:

• Fever
• Cough
• Sore throat
• Shortness of breath
• Chills
• Severe fatigue
• Unusual headache
• Runny nose in the absence of known allergies
• Gastro-intestinal symptoms such as diarrhea or stomach cramps
• Loss of sense of smell (anosmia) or taste or suddenly all food tastes bad (dysgeusia)

Temperature Guidelines:

 Temperature of 100 degrees F or greater or with any symptoms above should be            isolated.

Definition of Higher Risk for Serious COVID infection  (CDC guidelines)

• Age over 65
• Residents of congregate living facility (skilled nursing facility, homeless shelter)
• Chronic Lung Disease, including COPD
• Chronic Lung Disease, including CHF
• Kidney failure of advanced kidney disease
• Cirrhosis or other chronic liver disease
• Diabetes
• Other condition impairing immune system
• Taking medication impairing immune system (includes most on current cancer treatment)
• Severe obesity (BMI over 40)

Definition of Exposure requiring Quarantine (recommendations vary; CDC guidelines complex)

• Direct contact with person known to be infected with COVID
• Less than 6 feet distance for at least 5 minutes with a person known to be infected with COVID who was coughing (regardless of wearing of a mask) or who was not coughing but not wearing a facial covering.
• Living in same dwelling as a person with COVID, regardless of mask use
• Recent travel from area more highly impacted by COVID than “home” area, especially if by crowded public transportation.