Governor Gretchen Whitmer has issued several Executive Orders (EOs) in response to COVID-19 (2019 novel coronavirus). The stated goal of the EOs is to “mitigate the spread of COVID-19 and to provide essential protections to vulnerable Michiganders and this state’s health care system and other critical infrastructure.” Willful violations of the EOs are misdemeanors.
While several of the EOs impact all Michigan residents generally, three EOs have a direct impact on medical practices. Below is an overview of EOs 2020-7, 2020-17, and 2020-21 to help you understand actions to be taken to ensure your medical practice is in compliance.
This EO imposes limited and temporary restrictions on the entry of individuals into health care facilities, residential care facilities, congregate care facilities, and juvenile justice facilities through April 5, 2020 at 5:00 pm. The Michigan Department of Health and Human Services has confirmed that “any place that offers health care services is considered a health care facility and is subject to Executive Order 2020-07.” Therefore, physician-owned and operated medical practices must comply with this EO.
Pursuant to the EO, the following persons are prohibited from entering the above-mentioned facilities including medical practices:
- Persons who are not necessary for the provision of medical care, the support of activities of daily living, or the exercise of power of attorney or court-appointed guardianship for an individual under the facility’s care;
- Persons who are not a parent, foster parent, or guardian of an individual who is 21 years of age or under and who is under the facility’s care;
- Persons who are not visiting an individual under the facility’s care that is in serious or critical condition or in hospice care; and
- Persons who are not visiting under exigent circumstances or for the purpose of performing official governmental functions.
The EO requires all health care facilities, including medical practices, to screen all individuals each time before they enter the facility. This applies to all permitted visitors and clinical and non-clinical staff. These individuals must be evaluated for symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat; and contact in the last 14 days with someone with a confirmed diagnosis of COVID-19. If an individual does not meet such screening criteria, he or she cannot enter the practice.
The State has issued frequently asked question guidance on Executive Order 2020-7. A frequently asked question regarding the meaning of contact for the purposes of health care workers who are treating COVID-19+ patients generated the following response:
“Contact for the purposes of health care exposures is defined as follows: a) being within approximately 6 feet (2 meters), of a person with COVID-19 for a prolonged period of time (such as caring for or visiting the patient; or sitting within 6 feet of the patient in a healthcare waiting area or room); or b) having unprotected direct contact with infectious secretions or excretions of the patient (e.g., being coughed on, touching used tissues with a bare hand).”
The EO does not address the evaluation of patients seeking to enter a medical practice or other health care facility for treatment and services. It is recommended that all medical practices adhere to the Centers for Disease Control and Prevention (CDC) recommendations for infection prevention and control which include patient screening protocols. The CDC handout, Get Your Clinic Ready for Coronavirus Disease 2019 (COVID-19), offers step-by-step guidance on how to proceed.
EO 2020-17 imposes temporary restrictions on non-essential medical and dental procedures and is operational for as long as the state of emergency declared in Executive 2020-4 is in effect. Pursuant to the EO, all covered facilities (hospitals, freestanding surgical outpatient facilities, dental facilities, and all state-operated outpatient facilities) are required to implement a plan to temporarily postpone all non-essential procedures. A “non-essential procedure” is defined as “a medical or dental procedure that is not necessary to address a medical emergency or to preserve the health and safety of a patient, as determined by a licensed medical provider.”
Additionally, the covered facilities noted above and medical centers or offices that perform elective surgeries or cosmetic plastic surgeries are required to minimally postpone joint replacement, bariatric surgery, and cosmetic surgery. Exceptions can be made for emergency or trauma-related surgery where postponement would significantly impact the health, safety, and welfare of the patient. A plan for a covered facility that performs medical procedures should exclude from postponement: surgeries related to advanced cardiovascular disease (including coronary artery disease, heart failure, and arrhythmias) that would prolong life; oncological testing, treatment, and related procedures; pregnancy-related visits andprocedures; labor and delivery; organ transplantation; and procedures related to dialysis.
The American College of Surgeons recently posted COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures which may be helpful to triage operations during the period in which the EO is in effect.
Although this EO does not explicitly state that it applies to physician practices and clinics, all physician medical practices, urgent care centers and clinics should consider whether non-urgent procedures should be rescheduled or, if appropriate, switched from in-person to telemedicine. The purpose of such planning is to minimize patient and health care workers potential exposure to COVID-19, as well as to reduce the demand on personal protection equipment which is in short supply. Physicians may want to check whether their national specialty societies have issued recommendations on such matters.
This EO requires Michigan residents to stay in their place of residence to the maximum extent feasible. A summary of the Governor’s “Stay Home, Stay Safe,” EO includes a list of permitted and prohibited activities.
Under the EO, only persons whose jobs are necessary to sustain or protect life or to conduct minimum basic operations may leave their residences to go to work at the employer’s premises. And, only businesses and operations that employ critical infrastructure workers may continue in-person operations, subject to certain conditions. Clinical health care workers are included as critical infrastructure workers (“necessary to sustain or protect life”). If a medical practice chooses to remain open, the medical practice must determine which clinical health care workers are to continue to report to work, and whether any non-clinical staff is required to work on site to strictly conduct minimum basic operations, which are limited to the performance of functions such as processing transactions (e.g., payroll, employee benefits, etc.), security (e.g., the reception counter, etc.), or to facilitate the ability of other workers to work remotely. If such non-clinical staff is necessary, they must be so designated by the medical practice. These designations initially can be made orally and must be confirmed in writing beginning April 1, 2020. A designation can be written on paper or in an email and should identify the employee by name and the basis for the designation (e.g., processing transactions). Clinical staff do not need to be designated as critical infrastructure workers, but it may be helpful for medical practices to confirm their status in writing if they do not have hospital-issued identification cards.
Medical practices that remain open should limit their in-person patient encounters to those essential to maintaining the life and health of patients, including those encounters not subject to postponement under EO 2020-17. Additionally, medical practices should consider whether medical visits can be conducted via telemedicine. Medical practices that remain open for in-person appointments must comply with visitor restrictions and screening requirements pursuant to EO 2020-7, as well as adopt “social distancing practices and other mitigation measures to protect workers and patrons. Those practices and measures include, but are not limited to:
- Restricting the number of workers present on premises to no more than is strictly necessary to perform the business’s or operation’s critical infrastructure functions.
- Promoting remote work to the fullest extent possible.
- Keeping workers and patrons who are on premises at least six feet from one another to the maximum extent possible, including for customers who are standing in line.
- Increasing standards of facility cleaning and disinfection to limit worker and patron exposure to COVID-19, as well as adopting protocols to clean and disinfect in the event of a positive COVID-19 case in the workplace.
- Adopting policies to prevent workers from entering the premises if they display respiratory symptoms or have had contact with a person who is known or suspected to have COVID-19.
- Any other social distancing practices and mitigation measures recommended by the Centers for Disease Control.”
- Physician medical practices should limit their in-person patient visits to essential services and those not subject to postponement under EO 2020-17.
- Staffing must be limited to necessary clinical and non-clinical staff.
- The requirements of EOs 2020-7, 2020-17 and 2020-21 must be followed.
- If patient encounters do not require in-person visits, physicians can consider telemedicine encounters.
- Even if the office is closed to patients, physician medical practices are permitted to conduct minimum basic operations which require designated workers to be present in-person at the office, subject to the requirements of EO 2020-21. All other workers who can work remotely would need to do so if authorized by the practice to do so.
- Adhere to the Centers for Disease Control and Prevention (CDC) recommendations for infection prevention and control.
- Check with national specialty associations for further guidance on nonessential versus essential encounters.
Learn more about Michigan’s Executive Orders and related frequently asked questions. You may also call the state’s COVID-19 Hotline at 1-888-535-6136 between 8 am - 5 pm daily. Questions for MSMS by can be directed to Stacey Hettiger and Sarah Waun.