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 March 30, 2020: For this installment of our field reports from the front lines of the crisis, we have Dr. Eric Lee, medical director in clinical informatics at AltaMed and Ray Lowe, CIO at the same company. AltaMed is a federally qualified health clinic that has a variety of community health centers across Orange County, primarily serving underprivileged groups with a range of health services. It’s one thing for larger medical firms with ample funding, preexisting IT integration, and specialist staff to talk about scaling in this crisis, but completely another for providers on the margins. Ray and Dr. Lee talk about where AltaMed was in terms of their capacity for Telehealth, RPM, and integration with Epic’s MyChart before the crisis, and which of these services they have had to double down on since. We hear about how the team has searched for funding to help them speed up in the implementation of these IT systems, and who came through to support them in the end. Ray and Dr. Lee touch on some other special considerations today too, such as how many of the communities they serve are non-English speaking, meaning things like interpreters and language factor into their IT scaling process. Our guests also share some proud moments in how they are managing and they speak about implementing Epic in the last year alone despite having to wear multiple hats. Tune in for some well-needed perspectives from a provider on the fringes.

Key Points From This Episode:

  • Background into AltaMed and the large underprivileged communities they serve in LA.
  • Reprioritizing/reassigning in different areas of health care provision to cope with COVID-19.
  • Funding restrictions impacting federally qualified health clinics and community health centers.
  • How AltaMed has coped with scaling Telehealth and other IT with newfound reimbursements.
  • Dr. Lee and Ray’s search for which technologies integrate well with Epic.
  • A decline in visits to AltaMed clinics since COVID-19 and how Telehealth can help.
  • Considerations in implementing Epic around language diversity in the OC.
  • Looking for the right provider to integrate with Epic’s MyChart.
  • Ray’s wish for an earlier focus on Telehealth over RPM to prepare for COVID-19.
  • Wearing different hats and how Ray and Dr. Lee couldn’t have done things differently.
  • Proud moments in the impressive IT scaling that AltaMed has achieved after COVID-19.

This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

 Welcome to this week in Health IT News, where we take a look at the news that will impact health it. This is another field report where we talk to leaders from health systems on the front lines. My name is Bill Russell Healthcare cio, coach and creator of this week in Health. It a set of podcast videos and collaboration events dedicated to developing the next generation of health leaders.

As you know, we've been producing a lot of shows over the last three weeks and series. Healthcare has stepped up to sponsor and support this week in Health It, and I want to thank them for, uh, giving this the opportunity to, to capture and share the experience, stories, and wisdom of the industry during this crisis.

If your system would like to participate in the field reports, it's really easy. Just shoot me an email at Bill at this week in health Now on to today's show. Alright, today's conversation is with Dr. Eric Lee, medical director, uh, clinical informatics, and Ray Lowe, CIO for Ulta Med Health Services.

Good afternoon gentlemen. Thanks. Uh, thanks for taking the time to meet with me today. Oh, thanks for having us on, bill. Appreciate it. Thank you, bill. Um, I'm looking forward to the conversation. I think everyone thinks that I only wanna talk to large health systems and whatnot in metropolitan areas, although you guys are in a metropolitan area, but I like the different perspectives.

You guys are, uh, you know, federally qualified health clinic and, and community health center. So this will be an interesting conversation. Uh, for me, just perspective, uh, just give us an idea of. Uh, the area and what ED does for, uh, for the markets that you serve. Sure. So Ed, um, we are the largest, uh, qualified healthcare center.

In, uh, California, and we serve about 250,000 wives in the greater Los Angeles, orange County area. We primarily serve the multi-ethnic Latino market, the underserved communities. Uh, many of our patients are actually 400% low poverty level and, um, the best communities that we serve. Wow. So, uh, yeah, and you're looking at Orange County and la So you guys, um.

Uh, give us, give me an idea of what kind of service are you guys are still, uh, mostly ambulatory or predominantly am ambulatory. I mean, background. So we got about 40, over 40 different locations, um, in both LA and orange counties. Um, we provide ambulatory care with, uh, regards to pediatrics, um, family practice, internal medicine, and women's health and OB services.

We also have a PACE program and a dental program. So our pace, um, we have eight pace centers in LA County and, um, they provide care to, uh, 55. Those that are 55 years older or older have one significant life impairment and are Medi-Cal. Those are the three main criteria for, uh. To be part of that program.

And the main goal of that program is to keep patients living independently, um, outside of nursing homes, uh, for as long as possible, you know, to put it in really simple terms. Wow. So the goals of all of these different types of clinics and programs will vary, um, significantly over time. And, and with Covid, it's been a different emphasis in focusing on what, with regards to the PACE program.

What our dental clinics can do and cannot do, and then how we approach primary care. So it's been a different strategy for those areas. Yeah, I was just, I was just thinking about that. I mean, you're doing dental, I would imagine dental has slowed down except for. Emergency care? Is that pretty accurate? It has, uh, significantly.

Um, and it, so we're limited to mostly like emergent kind of cases. Um, we are still doing telephone visits for them to help out with, um, health education or, uh, dental education. And, uh, so that's been there, there has been some telephonic outreach. Interesting. So Teledentistry and those kind of things? Yeah.

Alright, so you're gonna, you're gonna have a different, uh, different problem set. I've heard, I've heard from other health systems that are telling me that essentially the, um, the, the primary care clinics and those kind of things have all but gone completely telehealth. Is that, is that how you guys are, are, are approaching that?

Well, it's been, um, it's been a little bit different for us and I think, um, some of it stems from. What you get reimbursed for for remote patient monitoring and telehealth? Um, I think it's been the most restrictive set of guidelines has been impacting the federal qualified health centers and community health centers in general.

So it started with, you know, your big pay, your commercial payers and CMS granting reimbursements for Medicare. And just recently, this past calendar year, moved to Medi-Cal, but the. Allowances does not stretch to that of federally qualified health centers. So we've had, um, I guess we, we've been trying to make, uh, spaghetti sauce out of, uh, using ketchup packets and trying to figure out how to deal with this crisis.

Um, for us with the 1135 waiver from, um, the Department of Health Services and, uh, the California Primary Care Association. Granting us equal reimbursement for telephonic visits. That's been our primary strategy in getting that enabled and, and quickly pivoting and getting a, a rapid build into epic for handling telephone visits in three days and piloting that and getting that out, um, has been our main focus to date.

We are now focusing on, on the video, uh, visit portion. So, so Ray, did you have a, some of that infrastructure built out or if you had to figure out how to put a bunch of this stuff in place?

Yes. So, um, you, we've done a lot of technology uplift at ALT in the last two years. You know, when we basically have to take, um, a normal, you know, 50 to a hundred people, that we'd be telecommuting and scaling that up into the hundreds and even thousands overnight. Was, uh, no small feat. So we did a lot of uplift leveraging, uh, a lot of Cisco work we've done on firewalls and security in order to do the distance working.

We put together a templated approach in terms of how we're doing our drive-through clinics. That was some realtime work as well. And, um, we also looked at how do we go ahead and do our collaboration. Uh, we're using WebEx versus Zoom in terms of inside of our organization. That's great. So for, but from a telehealth standpoint, did you have.

Uh, did you have a pretty established telehealth program and you just scaled it up, or did you have to to do some other things? That's a great question. So, you know, we've, Dr. Lee and I were joined at the hip in terms of defining the digital transformation strategy. So we actually have gone through and looked at what integrates well through Epic, uh, primarily through MyChart.

You know, there's American, well, there's video and there's Cisco Extended care. So, uh, we're actually right on the cusp of actually putting those in place before the Covid 19 crisis happened. So it actually is making us accelerate a lot quicker. I'll refer to Dr. Lee as to what we're looking at doing, uh, in the next few days.

Great. Uh, Dr. Lee, do you want to expound on where you guys are gonna be going? Um, I, I think we haven't, um. Exactly. Come to an agreement on the vendor yet. So, uh, you know, we don't wanna, we don't want to favor one vendor over the other, but, um, I think we're pretty close to making a decision. And then, um, and it, you know, it's, I think there's some discussions about how many concurrent licenses we'll be allowing for, or con con concurrent sessions we'll be having in our, in all of our clinics.

And, um, so I think that's the main thing to work out. But I think we have, you know, all of this other stuff has been. I mean, thankfully, you know, Ray and I have been working on this for months in terms of, uh, getting the strategy in place, doing the shopping, figuring out how we were gonna deal with this even before the relaxation of these requirements, because I.

For what we wanted to do. We were not gonna get reimbursed at all for any, any of these telehealth visits whatsoever. And now we have to accelerate because we can get reimbursements. And so, you know, what we found in our clinics to date is that some of our clinics have maybe half the volume, the visit volume that they typically have.

Um. I think we, with the institution of our telephone visit program, we've been converting and trying to minimize or decrease risk for a lot of those in-person face-to-face visits that don't necessarily have to happen if we can handle them over a telephone. So what we're finding is maybe it's been about 30 to 40% in person, and then we've added, um, about 30 to 40% with telephone visits.

So we're, we're up to about 70% of what our previous visit volumes were before this Covid 19 crisis started. And we're hoping to add video to be able to bridge that gap and be able to bring us up to as quickly as possible to, you know, what we were having before this crisis started. Yeah. You know, it's interesting I think, um.

The, the difference you're serving a a, uh, uh, you know, the, the markets that don't have a lot of money, it's not a good payer mix. Uh, it's a lot of Medicaid, it's a lot of, and all Medicaid. I think people are sitting back going, well, why aren't they moving faster? Well, you really do have to make sure you're gonna get paid for things.

'cause it's not like there's this huge net there that you're, you know, we can just start. Doing whatever we want and the money's gonna be there. I mean, some of the larger health systems in your community, uh, might be running real fast at certain things, but they have a huge, um, you know, endowment and other things that they, they know they can fall back on.

Uh, for that, you guys really do have to make sure that, I mean, you are serving the community, but you have to make sure that at each stage you're not getting out over your skis or get ahead of yourself 'cause you guys don't have a ton of margin for error. With regard to this. Absolutely. Yeah, that's correct.

Yeah. And they, uh, and they added complexity on it because we serve, again, the primarily Latino community is, um, we need to make sure that it's all Spanish enabled as well. And we're talking Spanish, we're talking, you know, about a, uh, fifth grade level of Spanish in terms of the interpretation. Uh, interpreter language is required.

You know, the other thing we're looking at on the telehealth is what is the near term? And what's kinda the longer term answer we're looking at that will actually go through MyChart application. So we can actually serve the Televisit through, uh, you know, the Epic portal. Yeah, I was, I was, I just completed an interview with, uh, Boston Children's and one of the things they did is a call just like this, there's three of us on it.

The interpreter's on the patient's on, and the clinician's on. So that's, I mean, and I said, well, you know, did you do this? It was like, no, we're just doing a Zoom call just like this, . It's like we just put the three people on. We're having a conversation, we're documenting it over here in, in the EHR. And we're, uh, that's, that's how they're doing it.

And I, there are comple, I, I mean I served in the same markets. I served in Orange County. So, uh, I don't think people recognize the number of languages that exist within Orange County. Uh, you know, a third of our visits to our, uh, ed, uh, were Hispanic, but, um, a good, uh, you know, 15 to 20% were different Asian populations that didn't speak English.

So it's not, it's not like you, oh, you just need to speak Spanish. There's, there's other populations you're serving as well. Oh yeah, there's, there's Vietnamese, the gal, Mandarin. All those, uh, you know, are very rich in the oc, so. Absolutely. So, uh, what do you wish you had sort of done earlier or could you have done anything earlier to be more prepared for where you're at today?

Hmm. So I think I would say, um. Dr. Lee and I, we, we were looking at the right player and the integration, um, with Epic through MyChart. So honestly, I really wish we had gone faster, uh, through that. You know, as we looked at the digital transformation in healthcare, we not only looked at the talent opportunity.

But we also look at the remote patient monitoring. So we're looking at, are we gonna go after CH hf, COPD, are we gonna go on our pregnancy journey? How does it fit? How does it fit into our existing service lines that we support? And, um, uh, with Covid 19, we have a much more focus, right, to deliver the tele, and then, and we can relax what we're doing around the RRP m.

So we're looking at the whole ecosystem. So from my point of view is you, we probably should have moved faster on the side. Like they were trying to figure out which was the best based on quality outcomes, you know, and in terms of delivering the transformation of the organization. That's my view. Dr. Lee, what are your thoughts?

Yeah, I mean, bill, I, I don't know if we could have done that much more differently, to be honest with you. We just went live with Epic Foundation on 8 1 20 19, and we did that. We signed the contract with Epic on 8 16 20 18. So in 50 weeks time, you know, we went live with Epic Big Bang implementation. We had to stabilize, um.

and all along Ray and I, you know, were wearing multiple hats because we're not like the, like some of the bigger, larger, well endowed organizations that have a chief digital officer, a chief, you know, technical officer, or a chief, uh, you know, innovation officer. We, we wear all of those hats and, and, uh, so therefore, in our infinite spare time, we had to plan our telehealth kind of strategy and remote patient monitoring strategies.

And so I, I honestly, you know, Ray, I don't know, I mean, in looking back, bill, I, I really don't think we could have done it any differently. I'm just glad we did all this planning all along so that we are, you know, if, if only we had another month or two is probably the only thing I would say. It's, yeah, it's really time.

If you had a little bit more time, but, um, exactly. But yeah, imagine, imagine trying to do what you're doing today if, if this had happened three years ago. That would've been, uh, you know, you have, you're on foundation, your MyChart is out there. You've already trained, uh, a group, I assume a group of the physicians on telehealth.

Mm-Hmm. . And so you just had to expand all those programs, which is, uh, which is, which is great. Um, what, what are you most proud that you guys have been able to accomplish?

Yeah, I'll, I'll start. I think from a technology perspective, um. Really being able to mobilize and, and change the workforce. Uh, you know, we, we've put over 50 call center agents out remote. You know, we've pushed over, pushed over 500 corporate employees be to be remote as well. Uh, you know, we are, we're doing a lot of video, which didn't exist in the, uh, in the past there from a technical perspective, you know, we.

Performed and completed that in about a week. And I'm also really proud that we set up our first drive through clinic on day seven of the crisis. And we have six of those open across, um, Los Angeles and Orange County. Uh, you know, I, I can go on and on, I mean, procurement, sizing, et cetera. But, um, we are very fortunate to have been prepared.

That's awesome. Yeah, I think, um, I, I, I couldn't be prouder of our organization. I think we have really strong leadership throughout. Um, and the way we all came, GA came together so quickly and set up our core meeting and. Meet on a regular basis, um, once, twice, three times a day if necessary, to just make sure we're all aware of what's going on.

And aware of the active issues, I think has been something that I, you know, I'm, I'm proud to, um, to be a part of. Um, and then from a provider perspective, I'm for us to pivot so quickly. I couldn't say enough about our Epic team about having to build a new telephone visit type and encounter, um, . In three days and get it trained, um, with, you know, with our providers out there and, um, get it trained and operational.

Um, and inside of a week really is just something that's truly amazing. 'cause normally, you know, we, we know that everyone's accelerating their programs and, and how they're converting this, but normally this would've taken a couple of months at least. Yeah. You know, that's fantastic and I, I appreciate, um, you know, that you've been able to do this in this tough work environment that you're in.

I see the Little mermaid behind you and the stars and all those things. Um, it's ama I, I'm doing these interviews and everybody has a different place that they're doing these interviews in. And it looks like you're in your kids' room. Yeah. Yeah. That's my kids', uh, playroom. So, you know, they, they, I'm sorry, all artwork that they've had in the, in the before and Ray's got, Ray's got the dog going in the background.

So we're, we're getting the full experience of the gonna tell Yeah. The work from home. Yeah. She never had their dog bark working from home. Right. Exactly. Well, gentlemen, thank you. Uh, thank you very, very much for your time. I really appreciate you taking the time to, uh, spend a few minutes with me. Thanks, bill.

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