Alexis E. Te, MD

In the current environment of coronavirus disease 2019 (COVID-19), it has become obvious that it won’t be business as usual when the economy restarts and social distancing restrictions are relaxed. Although we are beginning to flatten the curve, there will be significant challenges as we reengage patients with our clinical practices. We have the opportunity to lead and be more prepared when we redeploy to our urologic practices.

But when do we relax restrictions? Might we invite an increase in infections by loosening the constraints on self-isolation? When, exactly, do we get back to work?

COVID-19, declared a global pandemic by the World Health Organization, continues to spread across continents, infecting over 3 million people worldwide and causing over 230,000 deaths.

Many US states have mandated shelter-in-place policies, as outbreaks cluster in multiple regions across the country. Although the mandates vary from state to state, most urology offices have temporarily closed their doors and the rest have limited surgery to only the most urgent cases. This has left numbers of patients seeking assistance, and a backlog of elective procedures.

Additionally, what seems to be lost amid the rationing of services is the mental anguish of patients with cancer diagnoses and other health issues that is amplified by the isolation and loss of social support that may have made things easier to cope with. Patients have been forced to stay home, stuck with any health issues they have, which are deemed not important enough to be dealt with during the lockdown. They are, according to the headline of a recent New York Times article, “The Pandemic’s Hidden Victims: Sick or Dying, but Not From the Virus.”

The first question is, when can we begin to ramp up? This will be determined by a combination of factors including, but not limited to, local, state, and federal guidelines as well as patient confidence. An Ipsos/ABC News poll released April 3 demonstrated wide variability when people were asked when they thought they would resume their normal daily routine. Among those who say their daily routine has changed due to coronavirus, 31% believe a return to normalcy will occur by June 1. One month previously, 44% thought June 1 was the target date.

This suggests that a slowly rebounding private sector with variable confidence will be a major constraint to reopening medical practices.

Industries and financial institutions have recognized that there will be a gradual rather than a dramatic ramp-up of elective procedures recommencing in the United States. A recent Wells Fargo MedTech forecast stated that recovery of elective procedures will be “U-shaped” (gradual) versus “V-shaped” (quick), that hospitals will prioritize more urgent and life-threatening procedures, such as those for patients with cancer, over elective procedures, and that patients will prefer ambulatory surgery centers or office-based surgery over hospital surgery, due to the perceived risk of contracting COVID-19.

There will be many hospital obstacles to restarting urologic procedures, including anesthesia (with its attendant precautions and pretesting for COVID-19); a backlog of cases; the reconfiguration of operating rooms that were modified to become intensive care units; and employee constraints secondary to furloughs and layoffs. Further obstacles include vendor supply chain constraints, regulatory factors, and the potential for an event heretofore ill-prepared for––a second outbreak in the fall.

On top of all these challenges, another one is becoming a major area of concern: the posttraumatic effects of the pandemic on our heath care colleagues.

The second question is how we will get things moving again. Urologic offices have become very aware of methods designed to safely treat patients while protecting clinical staff. In part, these recommendations have been formulated in partnership with the Centers for Disease Control and Prevention (CDC).

 Naturally, they are subject to change given the rapidly evolving environment surrounding COVID-19, including diagnostics, screening, and therapeutics, among others.

The following are some recommendations for the screening and treatment of patients with suspected COVID-19 in our practice:

• Follow the CDC’s patient assessment protocol for early disease detection for patients presenting to the practice. Patients should be screened using the Criteria to Guide Evaluation and Laboratory Testing for COVID-19.

Essential visitors to the facility should also be assessed using these criteria and redirected to remain outside if there are any concerns.

• As part of the return to urologic practice, we expect to continue with telemedicine consulting to some degree. We should anticipate an extension of office hours, weekday and weekend, to ensure a minimum number of patients in the waiting room at any one time. Further, we will require temperature checks and COVID-19 questionnaires for each person to protect both patients and staff.

Current issues and guidelines to consider and keep in mind include the following:

• Most at risk are older patients, those with comorbidities, and younger patients with obesity.

• The virus is highly infectious in close quarters.

• The virus can remain on surfaces for up to 48 hours.

• Symptomatic patients carry the highest viral load for transmission.

Current prophylactic measures that may become permanent include the following:

1. Physical distancing with a recommended perimeter of 6 feet

To maintain physical distancing within the facility, require patients to sit at least 6 feet or more apart. Patients should be asked to wait in their car if that option is available. Remove magazines. Routinely disinfect the waiting room throughout the day.

• Follow the CDC’s standard precautions and transmission-based precautions, including the use of gloves, gowns, protective eyewear, and NIOSH-certified N95 respirators that have been properly fit tested.

 This applies to all health care staff interacting with a person under investigation (PUI). If there is a shortage of N95 respirators in the facility, access current CDC respirator recommendations.

3. Frequent disinfection of public and shared spaces and equipment

4. Quarantining of patients who are symptomatic and possibly of those who are asymptomatic carriers

5. Use of COVID-19 screening for active viral infection and for determining immunity

• Screening may evolve from detection of antigen to assessment of the presence of antibodies

• Consider the likelihood that presence of antibodies may cause a stop-and-go working situation for health care providers and patients reentering work or office environments

6. Recognizing that health care workers can often be the nidus of transmissions

• Limit staff exposure to suspected patients, and keep the exam room door closed. Ideally, the designated exam room should be at the back of the office, far away from other staff and patients.

• Screen health care personnel daily for symptoms, travel, and contacts that may be relevant to COVID-19.

Adopt a clinical suspicion of COVID-19 to protect patients and others. The dynamics surrounding the virus will continue to change in the days and weeks ahead. What must not change are physicians’ and care teams’ vigilance and caution. They should be exceptionally proactive in asking the right questions, documenting interactions, rigorously following protocols, and keeping abreast of emerging insights and data as the CDC makes them available.

Our biggest challenge is to ensure everyone’s safety. Until we have reliable point-of-care antibody testing, we will need to proceed slowly. In the interim, there has been a veritable explosion in telemedicine that has accelerated the virtual interaction between health care providers and patients. Among the available options are Epic’s MyChart video visits (which has had bandwidth and sign-on issues), Zoom’s waiting rooms, and virtual physical therapy.

Other modalities such as Uberdoc provide a more seamless method for connecting patients to physicians with a more efficient initial reimbursement. Remote diagnostics will also become a great source of information and revenue. For example, Stream Dx allows the remote evaluation of urinary flow rates. Other companies are working on the remote measurement of post-void residual urine volumes.

Using smartphones to measure heart rate, EKG rhythms, serum oxygen saturation, and serum glucose is already underway, with applications to test other blood parameters on the horizon. This will eventually result in decreased physical office visits as well as emergency department consultations.

Finally, this pandemic will create a new paradigm of how we provide and are compensated for the delivery of more efficient health care. Resource utilization and cost-effective care will become more evaluable, and those who operate more efficiently will be better placed than those who simply do more, in terms of quality- versus quantity-based reimbursement.

Another potential positive outcome could be how we will do business, a rethinking of revenue: for example, expense models that seem antiquated and deleterious compared with a more thoughtful group approach, and unsustainable with the low profit margins of hospitals. Some have suggested that gainsharing may prove to be a better system for physicians and hospitals, with a resulting decease in an overloaded administrative-cost tier.

These are challenging times for our patients, our staff, our peers, and ourselves. In such a unique environment, a useful approach might be to employ these 7 leadership principles for management, as described by John Quelch, a professor of business administration at Harvard Business School and dean of the University of Miami Herbert Business School: calm, confidence, communication, collaboration, community, compassion, and cash.

 is professor of urology at the Icahn School of Medicine at Mount Sinai, New York, and 

 is professor of urology at the Weill Medical College at Cornell University, New York.

COVID-19 Coronavirus Pandemic. Worldometer. Updated May 5, 2020. Accessed May 5, 2020. 

Grady D. The pandemic’s hidden victims: sick or dying, but not from the virus. New York Times. April 20, 2020. Accessed May 5, 2020. 

https://www.nytimes.com/2020/04/20/health/treatment-delays-coronavirus.html

Karson K. Fewer than half of Americans believe their daily routine will return to normal by June, as fears over coronavirus rise: POLL. ABC News. April 3, 2020. Accessed May 5, 2020. 

https://abcnews.go.com/Politics/fewer-half-americans-daily-routine-return-normal-june/story?id=69940187

Warner JJP. Return to post-pandemic in orthopedics as a potential model for factors which may affect other surgical specialties and non-surgical specialties. VuMedi. Accessed May 5, 2020. 

Prepare your practice for COVID-19. CDC. Updated March 31, 2020. Accessed May 5, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/preparedness-resources.html

Evaluating and testing persons for coronavirus disease 2019 (COVID-19). CDC. Updated April 27, 2020. Accessed May 5, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html

Infection control basics. CDC. Updated January 5, 2016. Accessed May 5, 2020. 

https://www.cdc.gov/infectioncontrol/basics/index.html

8. Respiratory fit testing. Occupational Safety and Health Administration. January 2012. Accessed May 5, 2020. 

https://www.osha.gov/video/respiratory_protection/fittesting.html

Clinical questions about COVID-19: questions and answers. CDC. Updated April 16, 2020. Accessed May 5, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html

 Quelch JA. 7 leadership principles for managing in the time of coronavirus. Harvard Business School. March 26, 2020. Accessed May 5, 2020. 

https://hbswk.hbs.edu/item/7-leadership-principles-for-managing-in-the-time-of-coronavirus

Articles

"In the current environment of coronavirus disease 2019 (COVID-19), it has become obvious that it won’t be business as usual when the economy restarts and social distancing restrictions are relaxed," write Steven A. Kaplan, MD, and Alexis E. Te, MD.

How to restart your practice when the COVID-19 red light turns green

The majority of practicing urologists, urology residents, and medical students with interest in the field utilize at least one of the apps provided by the American Urological Association. Over the past few years, the AUA has developed a number of apps that provide clinical guidance and preparation for exams.

This article illustrates the content of the six apps that are available from AUA (figure 1). The apps are free to AUA members unless otherwise specified.

This award-winning app, designed by leaders in urology, functions as an interactive guide that prepares urology graduates for their oral board exams. It is structured into about 60 interactive cases pertaining to 30 common urologic topics, inspired by the AUA clinical guidelines and knowledge from the AUA Core Curriculum. The app can be purchased online and a discount is provided to AUA active members.

This app (figure 2) provides up-to-date, evidence-based guidelines and best practice statements. It makes guidelines easily accessible in daily clinical practice whether you’re in the office or the operating room.

AUA Guidelines at a Glance for Primary Care Professionals

This app is a summary of the AUA guidelines for primary care physicians. Covered topics include management of hematuria, erectile dysfunction, BPH, and many others. These guidelines can assist the general practitioner in acquiring the appropriate workup for basic urologic diseases prior to referral to urology. (Not available for iOS 11.)

This trivia app (figure 3) inspires friendly competition by providing multiple-choice questions to test users’ knowledge of urology.

The AUA created this app to offer medical students a structured module of essential topics in urology. Since some medical schools do not offer a formal urology rotation, this app is beneficial for medical students interested in the field and those who want to improve their urologic knowledge.

With this app (figure 4), the AUA provides users with access to the comprehensive Core Curriculum, as well as other scientific resources to facilitate quality education, including videos, webcasts, textbooks, and abstracts from prior AUA annual meetings. The app interface allows users to bookmark key topics for later review.

 is a urology resident at Weill Cornell Medicine/New York-Presbyterian, and 

 is professor of urology, Weill Medical College of Cornell University, Weill Cornell Medicine/New York-Presbyterian, New York.

This article illustrates the content of the six apps that are available from AUA.

App review: AUA apps offer clinical guidance and more

One in three Americans is at risk for kidney disease, but early detection is often hampered by the inefficiency and inconvenience of the testing process. Healthy.io has pioneered a home testing service that facilitates diagnosis of potentially reversible renal dysfunction, which could help curtail the exorbitant economic burden of complications from chronic kidney disease.

Step 1: The patient obtains a kit with a color board and follows the instructions provided by the app.

Dip.io is an FDA-approved, home-based urinalysis test. It allows smartphones to function as a medical diagnostic tool through the corresponding Dip.io app. Introduced in 2018, Dip.io has already been commercialized in European countries and the United Kingdom. It has also been introduced and studied in the U.S. A study involving the National Kidney Foundation and Geisinger Health has suggested that the product allows kidney patients to actively participate in and adhere to their medical care. Dip.io smartphone urinalysis kits can also help improve albuminuria screening, as well as improve management of chronic kidney disease.

Step 2: After dipping the stick in urine, the patient inserts it into the color board.

Dip.io is modeled after the urinalysis dipstick, which is able to measure 10 different parameters. The parameters are analyzed with a semi-quantitative method and include leukocytes, nitrates, glucose, ketones, protein, blood, pH, urobilinogen, bilirubin, and specific gravity. Furthermore, the kit provides a semi-quantitative analysis of microalbumin (10-150 mg/L), creatinine (10-300 mg/dL), and albumin-to-creatinine ratio (mg/g).

Step 3: The color board is scanned with the smartphone camera and submitted for analysis.

"The app provides detailed instructions as well as a “virtual nurse chatbot” to guide the patient through the steps"

The app provides detailed instructions as well as a “virtual nurse chatbot” to guide the patient through the steps. The kit comes with disposable test strips that can be accurately interpreted by the Dip app once the patient scans the dipstick against the color board. The app provides test results immediately to both patients and their clinician through an electronic platform (figures). Urinalysis based on smartphone technology has been suggested to be equivalent to lab-based devices.

Steps 4 and 5: The results are made available to the patient and the provider electronically.

Healthy.io kits can be purchased by health care organizations, but not yet by end consumers in the U.S. In the future, the availability of kits across pharmacies, as is the case in the UK, will help further improve access to preventive care and management of chronic kidney disease.

is a urology resident at Weill Cornell Medicine/New York-Presbyterian, and 

is professor of urology, Weill Medical College of Cornell University, Weill Cornell Medicine/New York-Presbyterian, New York. 

of Healthy.io for providing information on the Dip.io app.

Spyridon P. Basourakos, MD, and Alexis E. Te, MD, review the Dip.io app.

App review: Dip.io brings urinalysis to your smartphone

UpToDate is one of the most trusted medical reference tools with evidence-based clinical information for daily practice. UpToDate, a Wolters Kluwer brand, initially started as a web-based nephrology resource in 1992 and has since been broadened to encompass multiple specialties, including urology. In recent years, UpToDate has become more readily accessible with the development of a mobile app for smartphones and tablets.

After downloading the UpToDate app, providers will be prompted to sign in with appropriate credentials, obtained through personal or institutional subscriptions, to obtain access.

The home screen of the UpToDate app has a search box at the top and a menu of other features, such as My UpToDate, Calculators, Contents, Drug Interactions, and Settings (figure 1).

As users enter queries into the search box, the app automatically provides a list of relevant topics related to the search term(s). Once a topic is selected, the app subcategorizes the content into Adult, Pediatric, and Patient Education sections. Patient education materials enhance patient-provider rapport by involving patients in the management of their medical conditions.

"Content can also be bookmarked for ease of future access"

Content can also be bookmarked for ease of future access. For instance, when one inputs “UTI” into the search box, multiple UpToDate articles related to urinary tract infection appear (figure 2) and can be filtered based on the categories described above. For each topic, there is a basic outline that includes introduction, clinical manifestations, diagnosis, and treatment with access to pictures, tables, and algorithms (figure 3).

The top of the page contains information about the authors, editors, and disclosures. Furthermore, the dates of the last literature review and the last update to a given topic are provided 

 Hyperlinks to other relevant topics are provided in each article 

This tab tracks search history and bookmarks, which allows the user to easily revisit and organize favorite topics.

This section comprises a list of topics organized by medical specialty and also contains “Practice Changing UpDates” and “What’s New” tabs, include recent updates in practice guidelines, FDA approvals, and groundbreaking medical advances.

The UpToDate app facilitates the acquisition of clinically relevant numerical data by providing calculators for commonly used formulas. Calculators are organized either alphabetically or by specialty.

This tab is a recent addition to the app. It offers access to a database with drug-drug interactions, which improves patient safety in daily practice. This feature is offered in collaboration with 

, an online electronic drug reference solution.

UpToDate has been accredited by Accreditation Council for Graduate Medical Education. Providers can earn CME credits as they review clinical topics while logged into UpToDate. Credit can be redeemed at no extra cost and without additional testing.

UpToDate Advanced is a new feature of the UpToDate website released in early 2018. It allows the physician to receive patient-tailored recommendations through algorithms. Physicians input their patients’ symptoms and history into an interactive algorithm that can guide medical decisions. In addition, a lab interpretation feature helps physicians better understand unusual or challenging test results by providing differential diagnoses. Although only available on the UpToDate website thus far, it would be a valuable asset to the mobile app.

 is a urology resident at Weill Cornell Medicine/New York-Presbyterian Hospital, and 

 is professor of urology, Weill Medical College of Cornell University, Weill Cornell Medicine/New York-Presbyterian Hospital, New York.

In the first installment in a new series, Spyridon Basourakos, MD, and Alexis E. Te, MD, review the UpToDate app.

Alexis E. Te, MD

Articles

How to restart your practice when the COVID-19 red light turns green

App review: AUA apps offer clinical guidance and more

App review: Dip.io brings urinalysis to your smartphone

App review: UpToDate earns high marks for accessibility