When COVID-19 struck in 2020, academic medical centers rushed to respond to the threat.
The experience of Maine Medical Center (MMC) in Portland was typical. When the hospital’s wards filled with the sickest COVID-19 patients, the center’s specialists were in high demand. But the system’s primary care physicians (PCPs) also stepped up, volunteering at the COVID-19 testing center, staffing the hospital’s Respiratory Assessment Center, taking extra shifts on inpatient service, caring for newborns to free up their pediatric colleagues, and establishing the system’s first long COVID-19 clinic.
“The question is not what did we do, but what didn’t we do?” says former MMC family medicine chair Elisabeth Wilson, now chair and professor of community and family medicine at the Dartmouth-Hitchcock Health system.
Similarly, faculty and medical students at the University of Oklahoma College of Medicine staffed testing sites, operated outpatient clinics, and rigged a decontamination center outfitted with ultraviolet light and tin foil to sterilize and reuse scarce N-95 masks at the beginning of the outbreak. Subsequently, they managed vaccine outreach and established a monoclonal antibodies infusion program.
“Only family medicine had the knowledge, skills, and operational flexibility in our health system to get things up and running,” says Rachel Franklin, MD, vice chair of family and preventive medicine at the university, who likens primary care physicians to pluripotent stem cells, able to take on any role necessary to get the job done.
“Primary care providers have really stepped up in a variety of ways to serve health care systems during COVID,” says Scott Shipman, MD, director of clinical innovations for the AAMC. “They’ve adapted to meet the needs that emerged around workforce shortages and other problems at various stages during the pandemic in pretty heroic ways.”
Pivoting to new challenges
Supporting the foundational work of PCPs in the subsequent phases of the pandemic is the objective of the AAMC’s Connected Care for COVID-19 program. The program in part encompasses initiatives that recognize the role of PCPs as critical to frontline clinicians for all things COVID, from vaccine facts and indications to managing patients with acute symptoms and long COVID-19 complications.
“PCPs are responsible for vaccinations and are the first line when patients get symptoms that they may be worried are COVID-related or when navigating treatment options,” says Shipman. “Additionally, the challenges of managing patients with long COVID fall disproportionately to PCPs. Because of the quickly shifting nature of evidence and guidance about this clinical issue, PCPs need reliable and efficient access to specialist colleagues to help when questions arise.”
AAMC’s Project CORE (Coordinating Optimal Referral Experiences) program, which involves over 40 academic medical centers, provided vital experience and infrastructure for developing COVID-19 peer management. Within the CORE model, the eConsult serves as an asynchronous tool enabling PCPs to seek guidance from specialty colleagues for COVID-19-related concerns.
When a patient presents with symptoms or questions beyond a clinician’s scope, that PCP can reach out to an appropriate specialist, such as a pulmonologist, cardiologist, or infectious disease doctor, using the patient’s electronic medical record to communicate their clinical question, rather than referring the patient for a visit with the specialist, when a visit is otherwise unnecessary. Turnaround times for the specialists’ responses average about a day, in the form of specific guidance to the PCP.
There are multiple benefits to the system.
“For specialists, the advantage is that they can handle straightforward questions electronically, increasing in-person access for more complex patients,” says Lisa Chew, MD, associate medical director for ambulatory care at the University of Washington’s Harborview Medical Center and a consultant for the program. “It’s really providing the right care at the right place at the right time for the right patient. For a PCP, it actually broadens your ability to care for a wider range of problems.”
It’s also more convenient for patients, who don’t have to take time off from work or arrange transportation to another in-person visit.
All of these benefits apply to eConsults when applied to COVID needs of PCPs and their patients.
“Before we had vaccines, eConsults allowed us to consult with specialists and facilitate care without patients having to risk exposure to COVID,” says Sara Jackson, MD, medical director in the adult medicine clinic at Harborview.
Since the COVID-19 vaccines became available, many eConsults have concerned matters like vaccine side effects and weighing the risks and benefits of giving vaccines to patients with suppressed immune systems.
“We were able to ask infectious disease doctors and allergists questions that got answered in 24 to 36 hours, which was great,” says Jackson.
Making a difference with eConsults
In one eConsult, a patient complained of the loss of taste and smell — still present eight months after her COVID-19 diagnosis. The specialist’s input gave the PCP guidance on treating the patient, an explanation of the mechanisms involved, and a level of reassurance to the PCP and the patient about the expected limited timeline for these symptoms.
PCPs are also using eConsults to seek guidance from specialists on managing symptoms after a mRNA booster shot, boosting patients who got the Johnson & Johnson (J&J) vaccine, using newly emerging COVID-19 medications, and handling post-COVID-19 symptoms like chest pain and persistent difficulty breathing.
Although there’s not much data on the outcomes of patients whose cases are managed through eConsults, research shows that they improve timely access to specialist expertise for patients and are viewed positively by both patients and providers.
As treatment protocols for long COVID-19 are developed going forward, the eConsults program is expected to become even more important in getting PCPs timely guidance on management.
“This will be a really efficient way for primary care doctors to get up-to-date information, because it will be changing,” Jackson says.
“Because COVID has been shown to have multi-system challenges for patients both in the acute and long COVID context, having a single provider who can assimilate all of the potential complexities with patients and ensure that they are getting what they need is uniquely valuable,” says Shipman, reflecting on the singular role that PCPs will play. “Primary care can bring it all together in a single medical home, which is really important for patients.”