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Success Story: Small Private Practice Adapts to Telemedicine During COVID-19

Based on an American Medical Association news article published May 14, 2020 and Sara Berg's interview with James Milford, a family physician and owner of Three Oaks Health in Johnson Creek, Wisconsin.

Learn how a small private practice was able to rapidly redesign physical features of the practice and implement a low-cost telemedicine approach during the COVID-19 pandemic.

What Was the Problem?

Being able to safely care for patients during COVID-19 in the primary care setting has been a global challenge. As a small private practice owner, James Milford, MD, had the advantage of autonomy to change his practice during these tumultuous times.

Developing the Intervention

Dr Milford remains focused on keeping his patients safe during the COVID-19 pandemic and beyond. With the COVID-19 landscape changing frequently, Dr. Milford implemented several new measures that allowed him to continue to provide quality care while also protecting his team and his patients.

Prioritizing patient safety

“We really have gotten back to the basics of what we went to medical school for,” Dr Milford said during a panel discussion hosted by AMA Chief Experience Officer Todd Unger.

“Right away we asked our whole team, are you on board with this, do you want to move forward with this, how can we make you feel safe so that our patients can feel safe?” he said. “There isn't a roadmap to any of this so you had to go back to the basic studies and really look at what you needed to do to keep your practice going and you had to innovate as you went along and we've done some of that.”

Dr Milford met with his son, who is his business manager, to look at how they should move forward. He emphasized, “whatever solutions we put in place are not short-term solutions. It has to be long-term solutions to put in place, something like the UV investment.”

The idea of UV light for decontamination and reuse of N95 masks came up when concerns about personal protective equipment (PPE) shortages first emerged. With this idea on his mind, Dr. Milford worked with his son to build a box to house the UVC light. Because UVC intensity is inversely proportional to distance, they decided that a box would do the trick.

While disposable filtering facepiece respirators (FFRs), like N95s, are not approved for routine decontamination, FFR decontamination and reuse may be needed during times of shortage. Guidance from the Centers for Disease Control and Prevention shows the most promise as potential methods to decontaminate FFRs.

Built in his basement, Dr. Milford lined the box with aluminum foil and added the UVC bulbs. After PPE is used, each member of the team places their mask in the box and turns the light on for sterilization. This allows for each mask to be reused several times.

“It is also asking your patients, ‘what is it that makes you feel safe?’” said Dr Milford, adding that 1 patient noted not feeling safe opening the door.

“We installed automatic doors so that they don't have to touch the doors,” he said. “We instituted different touch points and direct rooming so that patients can come directly in without going to the waiting room, and we are very verbal about that. They have that expectation ahead of time. We realized that in order to get people through our doors and to feel comfortable, we have to make them feel safe and be truthful about it.”

Implementing telehealth

Since March 11, 2020, telehealth has accounted for about 40% of the patient visits. And while in-person visits have decreased by 10%, revenue has increased compared to a year ago.

“We purchased a couple iPads and different experiments with techniques to be able to communicate,” said Dr Milford. “Luckily, we have a young staff that has allowed us to do that and we're small, so the IT part we can just figure it out.”

“We did the social distancing amongst ourselves within our office too, so unfortunately now I do telehealth in a closet,” he said. “That part is the only downside to the telehealth for me.”

Otherwise, the team was able to switch “out a visit for a telehealth visit,” said Dr Milford. “It just flowed right into the mainstream.”

“We've realized, obviously, a lot of health care can be provided through telemedicine,” he said, adding that about 50% of their patients don't need to be seen in person. While there is a lot of evidence providing guidance for telehealth and how to care for patients remotely, there is still the question of, “For a patient with hypertension, how often do you listen to the heart? For a prevention exam, does an exam really make a difference?”

“We don't have evidence to guide us on where the safety boundary is on telehealth, but we're doing our best and taking our best guess right now,” he said. “It's sort of obvious to keep them out of the clinic from the COVID standpoint, but there's going to be a long-term answer that we need regarding boundaries on physical examination.”

“As we move forward here, we're going to have the attitude of keeping people who are sick that don't need to be seen, out of the office,” said Dr Milford. “The future is ahead of us and our attitude is telehealth is going to stay.”

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