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San Diego MDs Leverage Technology, Services to Serve Vulnerable Patients’ Needs

November 4, 2016
by Mark Hagland
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At one San Diego-area FQHC, leveraging technology and contracted services is helping underserved patients

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.

You’re getting around all the practical issues that might have thwarted a specialist visit, then?

Gomez: Yes, that’s one part. But also, working with HMOs, you need authorizations for specialty care. We do 2,500 specialty referrals a month, and there’s a huge amount of work around that—you’re not having to do authorization, having the person contact the patient, and getting the results, that can be the most difficult part. So that whole process is bypassed. And I can tell you, in North County, for a MediCal patient to see a neurologist is five to six months, and at least six to eight weeks for most specialties.

Denise Gomez, M.D.

How many cases have been pursued through this, so far?

Tellez: It’s well over 100 so far since May.

How has it worked out for you, as PCPs?

Gomez: We started in the clinic I work in, in Oceanside, our second-largest. We have four medical doctors and eight allied health professionals, and when we started this project in our clinic, they really liked it a lot, because not only did it help our mid-level providers in giving them guidance on how to work patients up before a referral; they also got guidance within 24 hours. Most of the ones have been dermatology, so you can send them a photo along with the history… Orthopedics, the patient was able to get some workup before seeing a neurologist. And our providers have been very, very enthusiastic about this. And we’ve rolled it out to almost every clinic now; our last clinic is just coming on board now.

And the specialists participating in the network have been helpful and cooperative?

Gomez: Oh yes, the consults have been very, very thorough. As a primary care provider, you look for guidance, and for the teaching about the disease state; and the specialists have really been good about providing that. The specialists are part of AristaMD’s network. The specialists could be located anywhere in the country, and when they sign up, they do have to agree to sign up within 24 hours, and the response time is much quicker than that. And what they send back is part of the medical record, and it’s an official consult, and becomes a part of the electronic health record.

Do you see the potential for this to be replicable elsewhere?

Tellez: The FQHCs in California collectively see over 4 million patients—both rural and urban—but the access challenges are the same, and I think the opportunities could be tremendous. There are two reasons. One, from the patient’s perspective, they get quicker access to specialty-guided care. Two, 65 percent of the consults result in specialty-guided care being provided in the primary care setting. So it’s not 100 percent—we’re still making those referrals 35 percent of the time that are to be seen in person, as appropriate. But if you think about the cost savings of that much efficiency to the state, it opens up an avenue for solving a reimbursement problem and expanding the access to care.

Is there anything you’d like to add?

Tellez: I think the exciting thing is that FQHCs are in a position to do something hands-on about the specialty care access issue that perhaps even enriches their own practice experience. And I know that the next level beyond this—I’m anxious to explore creating a virtual multispecialty medical group in a secure Internet space that operates even closer to real-time, perhaps through secure, text-based e-consults at some point in time, as I know Kaiser is doing here in California.

Gomez: I think if you look at the way that medicine has evolved over time, it used to be that you could call up your colleague on the phone, and really enhance your patient’s care in that way; this harks back to that model. This really enhances not only the patient care, but also enhances primary care physician’s learning. Especially the practice experience is enhanced just by having that kind of specific consultation with your colleague via e-consults.

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KLAS: EHR Integration, Enterprise Scalability Key Challenges Facing Telehealth Vendors

December 11, 2018
by Heather Landi, Associate Editor
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Healthcare organizations report high satisfaction with their telehealth virtual care platforms (VCPs), however there are significant differences in how broad the various platforms are and in the quality of the vendors’ service. What’s more, integration with electronic health record (EHR) systems is a key challenge facing every telehealth vendor, according to a KLAS report.

In its report, “Telehealth Virtual Care Platforms 2019: Which Telehealth Vendors Have the Scalability Customers Need?,” KLAS evaluates some of the top telehealth companies including American Well, MDLive and Epic, and analyzes what capabilities will set vendors apart as more healthcare organizations adopt virtual health technology solutions.

Most virtual care platform vendors receive positive performance ratings, but the depth and breadth of their capabilities vary, and this can impact scalability for organizations looking to grow, according to KLAS. No two vendors are alike in their capabilities, offering different combinations of functionality and experience.

Of the companies KLAS evaluated, the most common type of visit varied—most of American Well’s visits were on-demand urgent care, while the majority of Epic’s visits were associated with virtual clinic visits.

A key factor of scalability is the ability to support multiple visit types, KLAS researchers note. While multiple vendors offer support for all three visit types (on-demand or urgent care, virtual clinic visits and telespecialty consultations) no single vendor has a large proportion of customers using all three (only 12 respondents across all vendors said they were doing so).

American Well, a market share and mindshare leader, and MDLIVE, two of the vendors used most frequently for multiple visit types, receive generally positive—but lower than average—performance scores. Vendors more specialized in specific visit types or component layers (e.g., Vidyo and Zipnosis) have high scores but narrower expectations from customers.

No one vendor meets all needs equally well, but several are reaching for “all-purpose” status with internal development and/or recent acquisitions (American Well acquired Avizia; InTouch acquired TruClinic), according to the report.

KLAS’ analysis also uncovered a general trend of poor integration. In most cases, the addition of a virtual care platform also means the introduction of a second EHR into the clinician workflow.

“Although integration between EMRs is generally understood to be important for care quality, patient safety, efficiency, and productivity, few interviewed VCP customers have full bidirectional transfer in place. Most say that they are too early in their virtual care programs to pursue integration or that it simply costs too much,” KLAS researchers wrote.

Only American Well, Epic, and MDLIVE have more than half of interviewed customers currently on an integrated path, KLAS found. Epic has placed virtual care capabilities directly into their top-rated MyChart patient portal, which many patients already use. Epic integration means clinicians are able to stay within their existing workflow environment as well.

Many provider organizations are in the early phases of their virtual care programs where showing an ROI is an important milestone and one that organizations want to achieve as soon as possible, KLAS notes. “A key promise from vendors is that their technology and accumulated expertise will result in a fast start and continuous acceleration. When this comes at significant cost or progress is slower than expected, provider organizations can experience disappointment,” the KLAS researchers wrote.

When it comes to getting their money’s worth and achieving desired outcomes, Epic and InTouch are rated highest among fully rated vendors, and swyMed and Vidyo perform well among their smaller groups of respondents, KLAS researchers note.

“For each vendor, the current value proposition is somewhat narrow but well understood: Epic’s use is limited to existing patients of Epic EMR customers; InTouch is used primarily for consults; swyMed is used by respondents primarily for mobile, first responder needs; Vidyo delivers video-conferencing tools,

which are typically combined with other VCP solutions. SnapMD is seen as a low-cost option, but some customers say the impact has been limited. Commentary from VSee customers suggests a similar experience,” KLAS researchers wrote in the report.

Many healthcare organizations are early on in their virtual care journeys, and their ability to achieve desired results depends on guidance from vendors. According to KLAS’ analysis, swyMed and InTouch receive the most praise for taking initiative in proactively guiding customers and also in quickly responding to support problems.

While respondents praise American Well’s platform scalability, some customers blame the vendor’s “exponentialgrowth for staffing shortages that have led to implementation holdups and backlogged service requests. Some SnapMD customers say hard-to-beat pricing comes with a support model that is spare in terms of providing tailored guidance, according to the KLAS report.

Most vendors offer two additional options that can help accelerate customers’ expansion and growth—supplemental services, including added-cost advisory and outsourced services, and tools that automate patient-facing tasks that traditionally require additional staff. I

KLAS found that few customers mentioned these options in top-of-mind conversations. “Respondents who spoke of their vendor’s supplemental services most often referred to marketing support or strategic planning services from vendors American Well, MDLIVE, or Zipnosis. Those who referred to task automation report patient-self-service capabilities around check-in, scheduling, surveys, and/or patient flow from InTouch Health (TruClinic), Epic, MDLIVE, or Zipnosis,” the KLAS researchers wrote.



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Study: Neonatal Telehealth Reduces Hospital Transfers, Saves Money

December 11, 2018
by Heather Landi, Associate Editor
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Neonatal video-assisted resuscitation reduces transfers from hospitals without newborn intensive care units and provides significant cost savings, according to study published in the November issue of Health Affairs.

The study authors, led by Jordan Albritton of Intermountain Healthcare, examined a newborn telehealth program implemented at eight Intermountain Healthcare community hospitals in November 2014–December 2015 and the impact on the transfer of newborns from those eight hospitals to level 3 newborn intensive care units.

Studies show that 10 percent of newborns require assistance breathing at birth, and 1 percent require extensive resuscitation. At Intermountain Healthcare, approximately 1–2 percent of all babies born in suburban and rural hospitals are transferred to newborn intensive care units (NICUs) for higher-level care, according to the study.

In response to the need to improve outcomes for complex newborn patients, an innovative telehealth program was established at Intermountain Healthcare in 2013 to provide synchronous, video-assisted resuscitation (VAR), bringing a neonatologist to the bedside. As a result, access to specialized neonatal services in rural and suburban settings is no longer limited to telephone calls or the arrival of a neonatal transport team, the study authors wrote.

While telehealth can facilitate video connections between neonatologists at tertiary care centers and providers at smaller hospitals, there is little empirical evidence about the benefits of telehealth programs for neonatal resuscitation, according to the study authors.

Although Intermountain Healthcare began using telehealth technologies in 2013, the current VAR program was implemented in the period November 2014–December 2015. Today, neonatologists from four level 3 NICUs provide VAR support for nineteen referring hospitals.

As part of the study, the researchers evaluated eight hospitals that contained either well-baby (level 1) or special care (level 2) nurseries staffed by physicians, advanced practice clinicians, nurses, respiratory therapists, and other health care professionals. T

The study found that video-assisted resuscitation was associated with a reduction of 0.70 transfers per facility-month and a 29.4 percent reduction in a newborn’s odds of being transferred. Annually, this resulted in 67.2 fewer transfers and an estimated cost savings of $1.2 million per year.

The study authors conclude that reducing transfers keeps families closer to home, increases community hospital revenue, and reduces risk associated with transfers.

“This program helps keep newborns in level 1 or 2 nurseries, which in turn allows families to stay closer to home, improves social support, and increases the revenue of community hospitals while reducing costs and risks associated with transfers,” the study authors wrote. “Payers should consider reimbursement for pediatric subspecialty telehealth consults for neonates in level 1 and 2 nurseries. Through improvements in care quality and cost savings, this service would likely pay for itself many times over.

However, the authors also note that lack of reimbursement for telehealth services limits widespread implementation.

“Policy changes are necessary to align payment incentives and promote the use of telehealth services,” the study authors wrote.

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Can Telehealth Slow the Traffic Between Nursing Homes, Emergency Departments?

December 6, 2018
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The RUSH Act seeks to reduce the 1.3 million transfers from skilled nursing facilities to emergency rooms each year

There are 1.3 million transfers from skilled nursing facilities (SNFs) to emergency rooms each year, and CMS estimates that two-thirds of those are avoidable. The result is as much as $40 billion in unnecessary spending. Could telehealth be part of the solution?

That question led Timothy Peck, M.D., formerly chief resident in the Emergency Department at Beth Israel Deaconess/Harvard, to co-found a startup company, Call9, and become an advocate for legislation, the RUSH (Reducing Unnecessary Senior Hospitalizations) Act of 2018, to support reimbursement for connecting emergency physicians and SNFs.

Peck has spent considerable time studying the issue. “I didn’t know much about nursing homes when I started,” he said.  “I went and lived in one for three months. I wound up sleeping on a cot in a conference room.”

Peck was trying to understand nursing home finances and operations and why the patients are being transferred. They usually have things like urinary tract infections or pneumonia, which could be treated in the outpatient setting, but the SNFs aren’t equipped with the right tools to be able to treat these patients. Those patients come in without their families and 43 percent have dementia, he said. “Most become delirious upon transfer. We don’t have much information about them so we order every test under the rainbow, driving up the bill unnecessarily. We put them in hallways. They get bedsores. We inevitably admit these patients for an average of $15,000 to $20,000 per admission.”

The two-thirds of transfers that are avoidable represent about $40 billion in unnecessary spending for something that harms patients,” he said. “We are spending money on hurting patients.”

Peck zeroed in on three operational issues:

• First, on average, nurse to patient ratios in nursing homes are 1 to 36. If one patient becomes acutely ill and spikes a fever, that nurse does not have time to take care of that patient when they have 35 other patients to take care of. Also, most nursing home nurses are trained to handle chronic care, not emergency or acute care. It is a mismatch of skills, not a people problem in any way, he said.  

• Second, diagnostic equipment is sparse, and EKGs and lab tests take 24 hours to 48 hours to come back. That doesn’t work well for acute care.

• Third, physicians are not present in nursing homes. “When I was living in that nursing home and walking the halls weekends and nights, I never once saw another physician. Long-term care patients are seen once a month by their primary care doctors.”

Peck described the Call9 service: They embed 24x7 a paramedic or EMT or a nurse with emergency experience in the SNF. They go to the patient’s bedside and connect to a remote emergency physician who is available 24x7 and working from home. They can see a patient in nursing home A with a paramedic by the bedside and then jump to nursing home B and see a patient there with a first responder with them. “It makes the physician a scalable resource,” Peck said. “Believe it or not, they are our least expensive resource because they get scaled.”

Call9 has full integration with the three most commonly used EHRs in the SNF world. The solution also deploys a suite of mobile diagnostics and can return lab test results in a few minutes. It offers real-time telemetry and real-time ultrasound.

After treating a few thousand Medicare Advantage patients, he said the model has shown that it can save payers more than $8 million per nursing home per year. That allowed Call9 to get involved with Medicare shared savings value-based contracts with several payers nationally. But he notes that 60 percent of patients in nursing homes are Medicare patients. “We took that data to CMS and showed it to them,” Peck said. “The Ways and Means Committee in the House of Representatives got ahold of the data and got excited and started writing the Rush Act.”  He stressed that Call9 is not the only organization creating a program like this. There are others working on similar solutions.

Peck said CMS is interested in using telehealth in this way, he said. “But they don’t have any way to change payment mechanisms in a quick manner. They would have to ask CMMI to run demos, which takes years. But Congress could pass new legislation.” He described the RUSH Act as creating a value-based shared savings arrangement with Medicare where 50 percent of the savings goes back to Medicare, and 37.5 percent goes to a company like Call9 or a physician group or medical staffing group that administers the program and 12.5 percent goes to the nursing home, aligning all stakeholders, he said. “The bill has been introduced by a bipartisan group, because it is a nonpartisan issue.” With time running out in this session, he said, the bill still has strong support among Democrats set to take over House leadership in 2019.

Besides bipartisan sponsors in Congress, the bill also has support from patient advocacy groups such as the Alzheimer’s Association, Michael J. Fox Foundation for Parkinson’s Research, American Heart Association, the National Alliance on Mental Illness, and the American Telemedicine Association. “They are saying that the patients need it; the taxpayers benefit; why are we not doing this?” Peck said.

As someone who has seen family members and friends make that repeated, disruptive round trip from nursing home to emergency room, I concur.  



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