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Leveraging Clinical Decision Support Tools to Support Care for Uninsured and Needy Immigrants

January 21, 2014
by Mark Hagland
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Robert Moon, M.D. discusses the use of evidence-based clinical decision support tools in caring for the uninsured and underinsured

Robert Moon, M.D., is medical director at the Korean Community Services Health Center in Buena Park, a near suburb of Los Angeles, in Orange County, California. He and his colleagues at KCSHC serve about 75 patients a week, the majority of whom are Korean immigrants, but whose population also includes Latino and Vietnamese patients, as well as uninsured and underinsured patients of all races. These patients are mostly uninsured, and a small percentage are also homeless. Dr. Moon and his colleagues make use of UpToDate® Support from the Minneapolis-based Wolters Kluwer Health, an evidence-based clinical decision support tool provided at the point of care, to support the care of these fragile populations. Dr. Moon is a board-certified internist and geriatrician. He spoke recently with HCI Editor-in-Chief Mark Hagland about his clinic’s work. Below are excerpts from that interview.

How many physicians and staff work at the clinic?

We have three physicians here, including myself, and we all work part-time. Unfortunately, I have to do a lot of administrative staff; but we have about three or four employees, and in this clinic and a previous clinic, we couldn’t survive without volunteers—volunteer nurses, volunteer front desk, about four or five of those.

Robert Moon, M.D.

How do you use UpToDate?

Well, for the past three or four years, I’ve been involved mission work and this community clinic work. And UpToDate is clinical decision support that is especially focused on providing support in caring for uninsured or how-insurance people.

I actually use most of UpToDate’s capabilities for the majority of the medical conditions I see. Being able to get the background, history, and what to expect in a patient who shows signs of any number of diseases, and then being able to identify the tools and aids that can help guide my treatment, is invaluable. The key in our context is diagnosing and delivering care in an environment of extremely limited resources. So, for example, when I look up pneumonia, I’m already familiar with what medications they use in hospitals and clinics. But it will particularly help me to find older medications that are generic or are less expensive.

Is it built into your EMR?

No, I use the internet-access version. And one of the other things is, when I care for patients at missions for the poor or through our mobile clinic, I use my mobile phone, and can just download periodically all the latest information on my smartphone.

What kinds of clinical decision support do you need in the environments in which you practice?

It’s mostly looking up guidelines on the kinds of resources I’m working with. For example, Target and WalMart each have a formulary of medications that only cost $4. They’re all older medications that are still good ones. So for example, a magazine historically used for seizures or epilepsy can be used to treat nerve pain. It can be an effective substitute.

Are almost all of your patients uninsured?

I would say that 70 percent of the patients I see are uninsured, and 30 percent are on MSI—Medical Services Initiative—it used to be called Medical Services for the Indigent, provided by the state here in California. And the formulary is very, very limited.

So you’re always having to balance providing effective care for your patients with extremely limited resources?

Yes. And the web service gives us a lot of guidance, but all patients have their individual elements. So it really helps a lot in providing care to access clinical decision support services on the Internet.

You do have some kind of EMR?

That’s correct. It’s called MedAZ.

You’re dealing with a somewhat transient population, right?

Yes, that’s a fair assumption.

What are some of the challenges involved in delivering care to this kind of population? I bet there’s a lack of continuity of care for many of these patients, right?

Yes, that’s right. And in terms of lack of resources, it’s not only a lack of medications, but it’s a lack of access to specialists, such as gastroenterologists or urologists. That’s when I rely heavily on this web service or online textbooks. So medications and specialty services.

Is it possible to do any kind of care management for these patients over time?

There is some. We’re connected to an office with case managers. Korean Community Services has case managers. At  lot of times, they’re focused on the community, and for any patient who’s on this MSI insurance, they try to do whatever is possible for those patients.

Based on language difficulties and culture issues, are there challenges in terms of medication and doctors’ orders adherence?

Absolutely. There is a cultural component, and an education component.

Can  you give me an example of a patient who has benefited from this?