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Today I spoke to Dr. Naresh Gunaratnam from Huron Gastroenterology in Michigan. He’s also on the executive committee of Digestive Health Physicians Association (DHPA) that has been leading efforts with the $2T stimulus package. It’s because of DHPA’s phenomenal efforts that physician practices and ASCs may soon be able to apply for SBA loans and grants.
Watch this “home-made” interview to gain insights on:
˃ How Huron Gastroenterology is dealing with COVID-19
˃ How two clinicians in the practice contracted the virus (a patient showed up at the hospital with digestive symptoms)
˃ What steps are they taking clinically and business-wise
˃ Challenges and opportunties with telemedicine
˃ What telemedicine tools are they using and for what kinds of patients
˃ What to expect in the coming days with the stimulus package and DHPA’s role
The Transcribed Interview:
Praveen Suthrum: Thank you Naresh for taking the time today. I broadly have four questions covering from you know, how the COVID 19 crisis which has affected every single practice across the country, how it is affecting you and Huron Gastroenterology and the steps you are taking in trying to control this crisis and finally what you’re doing at DHPA and what DHPA is doing. So, if it’s okay with you I wanted to get started with the first question.
Dr. Naresh Gunaratnam: Sure
Praveen Suthrum: So, you know pretty much everybody, every business, every medical specialty has been affected by COVID-19. The last two weeks have really flipped the lid of all kinds of businesses. How has it affected you at Huron Gastroenterology both from a clinical standpoint as well as a business standpoint?
Dr. Naresh Gunaratnam: Within two weeks we went from one extreme to the other. We were having active conversations about recruitment and growth and actively engaging and recruiting new doctors to handle the work that was a lot. And then within a day it became full stop, we needed to shut everything down. We made a recommendation early on and our board met, and we basically made a decision that we just needed to stop everything. So, we were ones that made a decision to stop before the CMS guidelines about endoscopy. We just felt that if we get one patient who is COVID positive that entered our hospital, our ASC or office, it could be catastrophic. Because then, that person would have exposed our staff, other patients and trying to track that patient down and trying to stop this, we thought would be too difficult. We made a difficult decision to stop all ASC procedures and then stop all office patients. We then needed to scramble and figure out how to do telemedicine which we can get into a little bit later on.
Praveen Suthrum: Okay. But you had told me earlier that couple of your colleagues did get infected and how did that happen and how did you deal with it?
Dr. Naresh Gunaratnam: Yeah, I mean both of my colleagues who were rounding in the hospital they were… our first patient in the hospital who was somebody who had gone… who had traveled abroad and then came with non-respiratory symptoms historically respiratory symptoms with cough and fevers so forth were felt associated with COVID but in our case we had a patient who came in with GI symptoms and so, no one was suspecting that this was a COVID patient. So, my colleague went in and saw the patient as you would any other GI patient with diarrhea and then three days into her stay, the ship that she was travelling in has called all passengers and said “Oh by the way a lot of the passengers who are traveling on the ship are COVID positive” so, then she alerted us and got herself tested and found that she was tested positive. By that time unfortunately she had been in the hospital for three-four days not being suspected to have it. My colleague who was taking care of her so then, she was quarantined and in the last week we had a second colleague who again was rounding in the hospital who was an incredibly fit person who runs marathon and so forth and three four days into his rounding week became short of breath and now he’s isolated. So far this is obviously impacting our work force because we’re on the front lines.
Praveen Suthrum: Do you have enough PPE’s available? Enough equipment that you need?
Dr. Naresh Gunaratnam: No. We’re scrambling. Every one of my partners and I, we have an N-95 mask but we’re holding it dear such that we don’t have to reuse it. So, we treasure that like it’s our family heirloom and we try to hold on to it. And we’re cleaning it as well as we can. The utilization of PPE is now being modified in real time. Initially it was like well, you don’t need anything, and you just put a surgical mask on if you go into a person you don’t suspect has COVID and then you can put on your N-95 mask that you do know as now we know that it’s very hard to figure out who has and who doesn’t so, it’s almost a universal precaution. We’re just assuming everybody has I and we are trying to put on you know, our head covering, N-95 mask, face shields when we’re doing procedures, and gowns in procedures, but the trouble is that when you’re in a hospital everything from the keyboard to every door knob you touch and you’re constantly touching everything. And it’s very hard to really feel like you’re completely protected. My colleagues who were infected, they were very cautious you know, they were doing all the things we’re supposed to do and yet, I think the viral load is so high and so prevalent in surfaces and not just surfaces you know, in people around you that I’m almost resigned to the fact that I’ll get infected and I just hope that I can come out on the other side.
Praveen Suthrum: Yeah. Wish you all the best with that.
Dr. Naresh Gunaratnam: Yeah.
Praveen Suthrum: So, what kind of a business impact has this had for your group and your surgery center?
Dr. Naresh Gunaratnam: Well you know, it’s dramatic. We went from being economically doing very well with our ASC’s we had five rooms running with 16-17 cases a day five maybe six days a week to five/six cases a day and those were people that were urgent, the cases we’re doing are people we have high suspicion has a cancer. Anything short of that we’re not doing. Same is true for the office side. We’re trying to do telemedicine, but you know, from never having done telemedicine to 24 hours a day doing all telemedicine you can just imagine the logistical challenge, all the inefficiencies that we kind of have to work through. So, we’re working through everything from drop calls, to our patients not knowing how to use technology, to how you bill for it and going through all the codes and so forth, so it has been quite challenging.
Praveen Suthrum: What kind of tools are you using for telemedicine?
Dr. Naresh Gunaratnam: We’re using Zoom for our patients. However, some of the more technologically advanced procedures or technologies, our end user which is our geriatric patient doesn’t know how to download and run the operations so we may start a call… attempted call using Zoom or these other technologies. Sometimes, I just break and use FaceTime with patient who has a phone that can accommodate FaceTime otherwise let me just call. So, then you get into the dilemma that if you call is it a telephone call or is it a failed telehealth call. We’ve defaulted to the fact that if you made a good-faith effort to do telehealth and then you have to switch to a phone because the patient is a Medicare patient and just doesn’t know how to engage technology we’re billing that as telehealth call and the guidance has been that we should be okay doing that because this is a crisis and hopefully CMS will give us a break as long as we had good faith to do telehealth.
Praveen Suthrum: Yeah. And I think that is what the notice from CMS also said you know; they expect physicians will do it in good faith I think they would be okay with that. What kind of cases are you seeing are these IBD cases? Or all the cases are through telemedicine now?
Dr. Naresh Gunaratnam: Well yeah. We’re really seeing everything from abdominal to nausea to constipation and it’s intriguing and if there’s anything good about this it is the fact that we’ll be able to scale up telemedicine is probably one of the good things because it’s frankly very convenient for the patient and very convenient for us and I think most of gastroenterology is history and counseling and so forth. And I know… it’ll break the heart of my med school teachers who taught us physical exam but I can’t remember the last time a physical exam affected my decision making in the office. In the hospital it may be different because somebody may have an acute abdomen and so forth but, in the office setting people are coming with nausea, vomiting, you know chronic abdominal pain, constipation, reflux, fatty liver and frankly the physical exam is really not making me change what I do, what I assess. So, I think the good thing I that most of GI can be delivered through telehealth which I think would be a paradigm shift for us.
Praveen Suthrum: Okay. But then where you do need to see the response of the patient through a physical exam or you’re checking different systems, do you ask them to do it? Do you navigate that at all?
Dr. Naresh Gunaratnam: Yeah. You know, interestingly I think you can do most of it without a physical exam because I think… for instance if someone has an inflammatory bowel disease and we’re asking questions… you know, did your stool frequency decrease? Did the blood in your stool decrease? Did your pain get better? So forth and there is nothing to feel or touch because of that. I think, it’s rare that a patient comes in and says you know I have an abdominal mass or pain in the right lower quadrant. I mean people with acute pain usually show up in the hospital I mean, the pain is so severe that they come in through emergency. People who show up in the office rarely show up with acute pain… usually they have had this pain for three months and here are the tests we’ve done, and they still can’t figure out and that’s when we get involved. So, I think the majority of what we can do, can be provided via telehealth. um: Okay. But then where you do need to see the response of the patient through a physical exam or you’re checking different systems, do you ask them to do it? Do you navigate that at all?
Praveen Suthrum: Do you have any advice for GI doctors who might watch this or administrators of GI practices who’d be watching this?
Dr. Naresh Gunaratnam: Well I think as in any crisis, we’re trying to stay calm, and hoping that in a month or two, we will be able to come out of this. I think the most exciting thing is that this new bill if you know, 48 hours old and we’re trying to wait through this and the good news is that there is going to be support for the staff as well as ASC loss productivity. So, I think we need to go through the law very carefully and basically see how we can use these laws and subsidies given by the government it to keep our business running. And the good thing is that there are forgivable loans that will go towards our staff and it looks like there’s going to be some for the lost cases that we got from the ASC. So, in the next 24-48 hours we’re going to see how to best apply the law because there are some timing issues to optimize getting the loans, what parts of it should be grants what should be loans, do you furlough patient employees, when do you furlough, when do you not furlough, do you bring them back. So, these are the questions that we need to kind of work through. But I’m optimistic we can get through this and I’m hoping that this whole experience is going to make us leaner and as we’ve spoken, some ways that we deliver care like the telehealth will be a paradigm shift for how we go about doing business going forward.
Praveen Suthrum: Thank you so much Naresh and I wish you well and you colleagues too and stay safe.
Dr. Naresh Gunaratnam:  Thank you.


By Praveen Suthrum, President & Co-Founder, NextServices. 

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