The nation’s federally qualified health centers, or FQHCs, are organizations whose leaders are constantly working as hard as possible to stretch very limited financial and human resources in order to serve the healthcare needs of many of the most vulnerable residents in communities across the U.S.
North County Health Services, a 13-clinic FQHC organization based in San Marcos, California, serves more than 70,000 patients spread across the North County region of San Diego County. Like other FQHCs, it is as stretched as any in terms of its ability to ensure optimal care for its patients. And it is in that context that its leaders, including Patrick Tellez, M.D., the organization’s chief medical officer, and Denise Gomez, M.D., its clinical director of adult medicine, have been collaborating with the San Diego-based AristaMD, a company that provides an eConsult services platform (which the company also refers to as a referral intelligence platform) that has made it possible for NCHS’ patients to successfully obtain medical specialist expertise at a level previously unattainable.
Essentially, what Drs. Tellez and Gomez and their colleagues have achieved is the following: making use of the AristaMD eConsult services platform, the primary care physicians at NCHS can share their clinic notes with specialists participating in the AristaMD, who can remotely provide the NCHS primary care physicians with specialty consults, sharing specialist expertise with them and ensuring that they can better care for their patients. Leveraging technology in this way supports the need for underserved patients to benefit from specialist expertise, given that most specialists in California either refuse to accept MediCal (the state’s version of Medicaid) or patients altogether, or generally fail to see them in a timely way if they do accept MediCal patients. And of course, patients who are completely without insurance normally have even fewer practical options. The use of this contracted service represents a major leap forward in access to specialist expertise for both groups of patients.
Recently, Drs. Tellez and Gomez spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this initiative. Below are excerpts from that interview.
Tell me about your initiative around improving your patients’ ability to receive specialist advisement or care.
Patrick Tellez, M.D.: Being that we have a robust service in primary care to serve the underserved, the majority of our patients who have insurance are insured under MediCal, which is Medicaid in California. That’s about 74 percent of our patients; that enrollment has grown substantially since the ACA. The challenge that we face is that, in California, reimbursement to private-sector physicians, is the third-lowest in the country. So that limits access to specialty care. And our population is one with a lot of deferred medical issues, even though they’re not very old. And they deserve specialty medical care, so the access issue has been a challenge. So we would make 2,500 or more referrals to specialty care in a given month, and only a small percentage would ever get seen. Access issues—the inconvenience of having to drive 30 miles, and also long wait periods. And people lack transport. And there’s the affordability if there are any out-of-pocket charges.
Patrick Tellez, M.D.
So we needed to address that issue. I was introduced to AristaMD, and engaged them to produce a pilot. My hypothesis was that many of the referrals might involve a level of care that, with specialty guidance, could be provided in a primary care setting. We wanted to test that hypothesis, and we got funding that NCHS got from HRSA, which oversees all the FQHCs. So we took some funding we got as a reward for our clinical quality, and funneled into a pilot with AristaMD that would seek to define the applicability of electronic consulting, which we define as provider-to-provider consulting on patients, in a secure, asynchronous communication environment, and which allows a primary care provider to document specialty care recommendations as to care that can be provided by primary care, and that can be documented.
It's an electronic portal. We send information to a secure portal. It’s an electronic consultation (written). We would take information from our own EHR, and transfer it to a portal that the consultants use. They review the material, and make a recommendation based on criteria that are established as evidence-based workups of individuals. And then the primary care will be able to take that information and bring it into the care plan.
Denise Gomez, M.D.: I work with the system directly, so I do consultations. There are two parts to it. One is the guidelines that AristaMD has entered. So if you choose a specialty like rheumatology and have a certain system set, it will give you guidelines for even before you do a consultation. So it will help guide you before even doing a consultation. So if it’s a mid-level, and they’re not sure how to write up a thyroid nodule. So if you have a question about a diagnosis, you can do the electronic consultation with the endocrinologist specialist; so you’re asking a question with concerns, you give a history with notes and labs, and the endocrinologist would send back their recommendations. And those might include, the patient needs a biopsy, needs to see an ENT doctor; or the patient may have a benign nodule, in which case the endocrinologist recommends medication and a follow-up. And if you just have a question, you can just ask the endocrinologist the question.
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