It was great recently to interview leaders from North County Health Services (http://www.nchs-health.org/), a 13-clinic federally qualified health center (FQHC) organization based in San Marcos, California, which serves more than 70,000 patients spread across the North County region of San Diego County. I spoke last month with Patrick Tellez, M.D., the organization’s chief medical officer, and Denise Gomez, M.D., its clinical director of adult medicine.
As Drs. Tellez and Gomez shared with me, they and their colleagues have been leveraging information technology to overcome a common but very large and difficult obstacle facing FQHCs and other community-based clinics that serve indigent patients: the intense difficulty getting those patients specialist referrals, and then getting them to those specialists. At North County, as at most FQHCs, most patients are either on Medicaid (which in California goes by the name MediCal), or are uninsured. And not only are most specialists unwilling to see Medicaid and/or uninsured patients; even when specialists accept referrals from primary care physicians (PCPs) to see those patients, the patients often don’t show up, as they are plagued with problems such as lack of transportation, unstable living situations, and other challenges.
Given the difficulty of connecting their patients directly to specialists, Drs. Gomez and Tellez hit upon an ingenious solution: they partnered with the folks at the San Diego-based AristaMD, collaborating with them to test and market a platform that brings primary care physicians and specialists together. Essentially, using that platform NCHS’s primary care physicians 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.
Listening to Drs. Gomez and Tellez describe the challenges they face, and the path they’ve taken to address those challenges, what is absolutely clear is that, rather than trying to proverbially “boil the ocean,” they instead decided to tackle one discrete yet important issue facing their organization—how to improve care for their patients by regularly accessing specialty consults. They’ve been both idealistic and realistic at the same time: they are getting their patients what they directly need, which is the knowledge of specialists, while recognizing that consistently getting them face-time with specialists would be largely unrealistic.
Patrick Tellez, M.D.
This is an example of where leveraging information technology in a very precise way can really be impactful. “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,” Dr. Tellez explained in our interview. “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.”
And here’s the key element in all this. As Dr. Tellez described it, “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.”
And Dr. Gomez explained this in further depth, when she said in the interview that the portal “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.”
Denise Gomez, M.D.
What’s more, she noted, “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.”
What I find so refreshing and encouraging here is the smart, sensitive realism of Drs. Tellez and Gomez and their colleagues at North County. Rather than trying to rectify a complex set of practices in the medical world that are implicitly discriminatory towards indigent patients, they came up with a concept, worked with a solutions provider to make it a reality, and implemented it seamlessly into their care delivery processes, with a resulting win for their patients. The harsh reality is that getting specialists to see MediCal and uninsured patients in any numbers, they instead put control of the process into the hands of the primary care physicians in their clinics who are dedicated to their care. What’s more, they are also implicitly broadening the medical knowledge of those PCPs, as they take the online and telephonic specialist consults they are able to obtain, and implement their findings in their direct care of their patients.
This is just one example of how really smart, innovative physicians and other clinicians are leveraging information technology, along with, in this case, the contracted services of specialists, to make a real difference in the lives of their patients. And I believe we’ll see many more examples like this going forward, as the U.S. healthcare system transforms itself over the next several years. Because sometimes, even relatively small-scale innovations can have major impacts on people and communities.