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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?

There was a 60-year-old Caucasian gentleman. He was told he had high blood sugar at health fair eight years ago. He had a cough, and he wasn’t typically the type to see doctors; he didn’t normally follow doctors’ orders. And as with so many patients in our community, these people only come to us when they experience symptoms from disease. And this man had worked in a shipping yard, and had been exposed to asbestos. And he had had seizures. But the history was unreliable. And I had to take all of these things into account; it wasn’t like I could order fancy tests. And he could only kidney function and blood sugar tests. I did find out he was diabetic, and probably had asbestosis from asbestos exposure. A lot of the clinical exam was suggestive of that; however, I couldn’t get a chest x-ray or CT exam. Finally, I did encourage him to call his family just so he could an x-ray. But he also had signs of depression. And in managing diabetes, I had to take into consideration that there was depression going on.

So in treating the diabetes and depression, I had to make sure that none of these medications would interact. And one of the medications for pain and one for depression, had a slight chance of increasing seizures. And often, it’s very difficult, because there’s no solid medical history. And it was very unclear whether he had had seizure problems in an ongoing way, or had he just gotten drunk, or just hit his head? But I just had to make sure that treating one condition wouldn’t endanger another condition. And the CDS really absolutely was of help; it provided a lot of assistance. These informatics, when you punch in a drug and get information on what it interacts with, situations you should avoid using it in, considerations, and when a drug is metabolized by the kidney or liver, those are always considerations.

If you have a patient who with good insurance would naturally be referred to a specialist, what are your options in your clinic?

A huge element of what I do is education. And I tell patients, if they have certain red flags, they should just go to the ER. So a lot of it is what to expect from their disease. But if shortness of breath occurs, I advise them to go to the ER for treatment.

Do you have any advice or lessons learned for other physicians, clinicians, or staff, in community clinics, based on this?

I would just say that the whole patient has to be taken into consideration, including the educational level, or e3ven if they’re suffering from depression. If the patient isn’t going to understand the reasons for you treating a disease that’s actually symptomatic… A person might have high blood pressure or high blood sugars, they may actually still feel fine. And why would they want to treat their high blood pressure? So as much patient education as you can give them, is very important. And providing the patient with education, and explaining to them why we’re treating them; and you also have to let them know why they should go to the ER.




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