At the time of this writing, COVID-19 has been declared a pandemic by the World Health Organization, hospitals in the United States are scrambling to take action as new cases are occurring exponentially, viral testing abilities are scarce, many schools are closed, the public is staying home, and health care workers are being self-quarantined. Unfortunately, things have likely gotten much worse over the past few days. But what has probably not changed is what this pandemic has unveiled about the U.S. health care system.
1. There are no people like health care workers.
Health care workers are acting as a foil for politicians during this public health crisis. There is no group of people more caring, selfless, determined, and willing to make sacrifices to care for the sick and dying than the doctors, nurses, pharmacists, respiratory therapists, microbiologists, technicians, public health experts, industry representatives, and all of the associated health care professionals. No one is guided more by logic, evidence, and science, and no one is looking for accolades or attention. It is what drives the profession — during times of crisis, and during ordinary times.
2. This viral pandemic crisis has exposed just how far the bureaucratic pendulum has swung in medicine.
American bureaucratic medical red tape has become an increasing obstacle to health care providers in the United States. Road blocks occur, along every path in the health care delivery system, whether at the level of hospital policies and procedures, the electronic health record, health insurance companies, or billing and coding rules. Over-regulation is a product of the rigid, overly centralized, legal-minded, risk-averse, decision-making structure in medicine that has resulted in the loss of physician autonomy and agency.
“Red tape is an idiom that refers to excessive regulation or rigid conformity to formal rules that is considered redundant or bureaucratic and hinders or prevents action or decision-making … the term originated with the Spanish administration of Charles V, King of Spain and Holy Roman Emperor, in the early 16th century, who started to use red tape in an effort to modernize the administration … The red tape was used to bind the most important administrative dossiers that required immediate discussion”.1
As hospitals have moved quickly to adapt during the COVID-19 crisis, one of the most impressive things to watch has been the quick decision-making by hospitals. The usual multiple layers of decision-making and approvals, outside consulting, rules, and regulations suddenly don’t seem to matter as much anymore. Advice, guidance, protocols, and open communication are currently being provided quickly by the hospitals, in stark contrast to ordinary times when the approach is to hold months of meetings and legal reviews before making any plans. Suddenly, physicians and nurses are able to use their own judgements about triaging elective cases that should be cancelled, which patients really need to be evaluated by a subspecialist, and who should be able to work from home.
Heart disease is an epidemic. Obesity is an epidemic. Atrial fibrillation is an epidemic. People have been unnecessarily suffering and dying for years. What took so long to cut the red tape? Where was the same sense of urgency? After recovery from this pandemic, the medical system should be challenged to continue to keep barriers down.
3. Curbside consultation is being encouraged during a pandemic.
Why is this not encouraged during usual times? Direct informal discussions of patients can provide synchronous and efficient decision-making, as well as good patient care.2 Curbsides have fallen out of favor only because they do not generate the revenue as a formal consultation and documentation. The cost of health care could be reduced after this crisis if systems continued to encourage some degree of curbside consultation, both on the outpatient and inpatient side.
4. The era of telemedicine has arrived.
Most patients who are evaluated in an EP clinic do not need to be seen in person or examined directly by a physician, particularly if an electrocardiogram or rhythm strip could be remotely reviewed. But the arcane health care billing rules require most patients be seen and examined in order for a physician to bill for a patient encounter that is reimbursed to a reasonable extent. After years of discussions about using telemedicine, suddenly technical solutions and new billing codes have been linked to the electronic health record and made operational within days after the pandemic started. Unlocking telemedicine in America for ordinary times could be a silver lining of this pandemic.
Much will be learned during the COVID-19 pandemic. When this infectious disease is under control, it will be critical that we work together with the same sense of urgency to bulldoze barriers and slash red tape in medicine so that health care providers can more effectively tackle the pandemic of heart disease and heart rhythm disorders.
1. Red tape. Wikipedia. Available at https://en.wikipedia.org/wiki/Red_tape. Accessed March 15, 2020.
2. Knight BP. Curbside consultations – a vanishing beast. EP Lab Digest. 2018;18(3):4. Available at https://www.eplabdigest.com/articles/Curbside-Consultations-%E2%80%93-Vanishing-Beast. Accessed March 15, 2020.