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.
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.
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.
