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:
Field Report: AltaMed (FQHC) with Ray Lowe and Eric Lee, MD
Episode 215: Transcript - March 30, 2020
This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.
[0:00:04.5] DM: Welcome to This Week in Health IT news where we look at the news which will impact health IT. This is another field report where we talk to leaders in 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 podcasts, 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 Sirius Healthcare has stepped up to sponsor and support This Week in Health IT and I want to thank them for giving us the opportunity 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 firstname.lastname@example.org. Now, on to today’s show.
[0:00:55.0] BR: All right, today’s conversation is with Dr. Eric Lee, medical director, clinical informatics and Ray Lowe, CIO for AltaMed Health Services. Good afternoon gentlemen, thanks for taking the time to meet with me today.
[0:01:09.2] RL: Thanks for having us on Bill.
[0:01:10.1] EL: Thank you Bill.
[0:01:11.4] BR: I’m looking forward to the conversation. I think everyone thinks that I only want to talk to large health systems and what not in metropolitan areas although you guys are in the metropolitan area but I like the different perspectives, you guys are federally qualified health clinic and community health center. This will be an interesting conversation for me just different perspective.
Just to level set, give us an idea of the area and what AltaMed does for the markets that you serve?
[0:01:41.2] RL: Sure, AltaMed, we are the largest federally qualified healthcare center in California and we severed out 250,000 lives in the greater Los Angeles, Orange County area. We primarily serve the multi ethnic Latino market, the underserved community. Many of our patients are actually 400% below poverty level and that’s communities that we serve.
[0:02:09.5] BR: Wow. You’re looking at Orange County in LA so you guys – give me an idea of what kind of service, you guys are still mostly ambulatory or predominantly ambulatory. I mean, give me a little background on it.
[0:02:30.4] EL: We got about 40, over 40 different locations in both LA and Orange Counties. We provide ambulatory care with regards to pediatrics, family practice, internal medicine and women’s health and OB services. We also have a pace program and a dental program. Our pace, we have eight pace centers in LA county and they provide care to those that are 55 years old or older, have one significant life impairment, and are [inaudible 0:03:33] Those are the three main criteria to be part of that program. The main goal of that program is to keep patients living independently outside of nursing homes for as long as possible to put it in really simple terms.
The goals of all of these different types of clinics and programs will vary significantly over time and with COVID, it’s been a different emphasis and focusing on, with regards to the pace program, what our dental clinics can do and cannot do and then how we approach primary care. It’s been a different strategy for each of those areas.
[0:03:37.0] BR: Yeah, 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?
[0:03:44.9] EL: It has, significantly. We’re limited to mostly like emergent kind of cases. We are still doing telephone visits for them to help out with health education or dental education and so that’s been – there has been some telephonic outreach.
[0:04:03.6] BR: Interesting, so teledentistry and those kind of things? You’re going to have a different problem set. I mean, I’ve heard from other health systems that are telling me that essentially, the primary care clinics and those kind of things have all but gone completely telehealth, is that how you guys are approaching that?
[0:04:26.1] EL: Well, it’s been a little bit different for us and I think some of it stems from what you get reimbursed for, for remote patient monitoring and telehealth. 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.
It started with your big pay – your commercial payers and CMS, granting reimbursements from Medicare and just recently this past calendar year moved to medical but the medical allowances does not stretch to that of federally qualified health centers. We’ve had I guess, we’ve been trying to make spaghetti sauce out of using ketchup packets and trying to figure out how to deal with this crisis.
For us, with the 1135 waiver from the Department of Health Services and the California Primary Care Association, granting us some equal reimbursement for telephonic visits, that’s been our primary strategy in getting that enabled and quickly pivoting and getting a rapid build into Epic for handling telephone visits in three days and piloting that and getting that out has been our main focus to date but we are now focusing on the video portion.
[0:05:52.3] BR: Ray, did you have some of that infrastructure build out or have you had to figure out how to put a bunch of this stuff in place?
[0:06:02.6] RL: That is a yes. There’s been a lot of technology updates at AltaMed in the last two years. When we basically had to take a normal 50 to a hundred people that we are telecommunicating with and scaling that up into the hundreds and maybe even thousands overnight was no small feat.
We did a lot of uplift leveraging, a lot of Cisco work, we’ve done our firewalls, security in order to do the distance working. We’ve put together a [inaudible 0:06:33] approach in terms of how we’re doing our drive through clinics, that was some real time work as well and we also looked at how do we go ahead and do our collaboration, using WebX versus Zoom in terms of our organization.
[0:06:45.1] BR: That’s great. From a telehealth standpoint, did you have a pretty established telehealth program and you just scaled it up or did you have to do some other things?
[0:06:56.4] RL: That’s a great question, we, Dr. Lee and I, we’re joined at the hip in terms of defining the digital transformation strategy. We actually have gone through and looked at what integrates well to Epic, primarily to my chart, there’s American Well, there’s video and there’s Cisco Extended Gear.
We were actually right on the cusp of actually putting those in place before the COVID-19 crisis happened so it is actually making us accelerate a lot quicker. I’ll refer to Dr. Lee as to what we’re looking at doing in the next few days.
[0:07:26.6] BR: Great. Dr. Lee, do you want to expound on where you guys are going to be going?
[0:07:34.1] EL: I think we haven’t exactly come to an agreement on the vendor yet so you know, we don’t want to favor one vendor over the other but I think we’re pretty close to making a decision and then you know, I think there’s some discussions about how many concurrent licenses we’ll be allowing for concurrent sessions we’ll be having in all of our clinics and so I think that’s the main thing to work out but I think we have all of this other stuff has been – thankfully, Ray and I have been working on this for months in terms of getting the strategy in place.
Doing the shopping, figuring out how we’re going to deal with this, even before the relaxation of these requirements because for what we wanted to do, we were not going to get reimbursed at all for any of these telehealth visits whatsoever. Now we have to accelerate because we can get reimbursements and so 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.
I think 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 that we’ve added, about 30 to 40% with telephone visits.
We are up to about 70% of what our previous visit volumes were before this COVID-19 crisis started. I am hoping to add video to be able to bridge that gap and be able to bring us up to as quickly as possible to what we were having before this crisis started.
[0:09:22.1] BR: Yeah you know it is interesting I think the difference – you are serving the markets that don’t have a lot of money, it is not a good payer mix. It is a lot of Medicaid, it is a lot of – people are sitting back on, “Well why aren’t they moving faster?” Well, you really do have to make sure you are going to get paid for things because there is not like there is this huge net there that we can just start doing whatever we want and the money is going to be there.
I mean some of the larger health systems in your community might be running real fast at certain things but they have a huge endowment and other things that they know they can fall back on 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 are not getting out of your skis or get ahead of yourself but you guys don’t have a ton of margin for error with regard to this.
[0:10:19.0] RL: Absolutely.
[0:10:20.1] EL: That is correct. Yeah and the other complexity on it because we serve primarily at the Latino community is we need to make sure that it is all Spanish enabled as well and when we’re talking in Spanish, we are talking about a 5th grade level of Spanish in terms of interpretation, interpret of language required. You know the other thing we are looking on in Telehealth is what is the nearer term and what is the longer term answer we are looking at that will actually go to MyChart applications. So we can actually serve the tele-visit through the Epic portal.
[0:10:53.8] BR: Yeah I had just completed an interview with Boston Children’s and one of the things they did is a call just like this. There is three of us on it. The interpreter is on, the patient is on and the clinician is on. So that’s – I mean and I said, “Well you know did you do this?” and he’s like, “No, we are just doing a Zoom call just like this.” It’s like we just put the three people on, we are having a conversation, we are documenting it over here in the EHR,” and that is how they are doing it.
And there are complaints – I mean I serve in the same markets. I served in Orange County. So I don’t think people recognize the number of languages that exist within Orange County. You know a third of our visits to our EB were Hispanic but a good 15 to 20% were different Asian populations that didn’t speak English. So it is not like you just need to speak Spanish, there is other populations you are serving as well.
[0:11:46.6] RL: Yeah, there is Vietnamese, Negala, Mandarin, all of those are very rich in the OC.
[0:11:52.7] BR: Absolutely. So what do you wish you had sort of done earlier or could you done anything earlier to be more prepared for whatever you’re at today?
[0:12:05.2] RL: So I think I would say Dr. Lee and I, we are looking at the right player and the integration with Epic through My chart. So honestly I really wish we had gone faster through that and as we look at the digital transformation in healthcare, we not only looked at the Tele opportunity but we also looked at the remote patient monitoring. So we are looking at are we going to go after CHF, COPD, are we going to go on our pregnancy journey, how does that fit?
How does that fit into our existing service line that we support and with COVID-19, we have a much more focus like to deliver the tele and then we can relax and we’re doing it around the RPM’s where we can get the whole ecosystem. So from my point of view as we probably should have moved faster on the tele side but then we are trying to figure out which was the best based on quality outcomes. You know in terms of delivering the transformation of the relation. That is my view, Dr. Lee what are your thoughts?
[0:13:09.5] EL: Yeah I mean Bill 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 in 8-1-2019. When we did that, we signed the contract with Epic on 8-16-2018. So in 50 weeks’ time we went live with Epic. A big bang implementation. We had to stabilize and all along Ray and I were wearing multiple hats because we are not like some of the bigger, larger well in doubt organizations that have a chief digital officer or a chief technical officer or a chief innovation officer.
We wear all of those hats and so therefore in our infinite spare time, we had to plan our Telehealth kind of strategy and our remote patient monitoring strategies and so I honestly Ray, I don’t know. I mean looking back Bill, I really don’t think we could have done it any differently. I am just glad we did all of these planning all along. So that we are if only we had another month or two is probably the only thing I would say.
[0:14:13.9] BR: Right, yeah it is really time if you had a little bit more time but yeah, imagine trying to do what you are doing today if this had happened three years ago. That would have been, you have your own foundation, your MyChart is out there, you have already trained I assume a group of the physicians on Telehealth and so you just had to expand all of those programs, which is great. What are you most proud that you guys have been able to accomplish?
[0:14:45.1] RL: Yeah, I’ll start. I think from a technology perspective, really being able to mobilize and change the workforce. We have put over 50 call center agents out remote. We pushed over 500 corporate employees to be remote as well. We are doing a lot of video, which didn’t exists in the past from a technical perspective. You know we really performed and completed that in about a week. I am also proud that we set up our first [inaudible 0:15:22] clinic on day seven of the crisis.
And we have six of those open across on Los Angeles and Orange County. You know I can go on and on, on the procurement, sizing, etcetera but we are very fortunate to have been prepared.
[0:15:36.8] BR: That’s awesome.
[0:15:38.4] EL: Yeah, I think I couldn’t be prouder of our organization. I think we have really strong leadership throughout and the way we all came together so quickly and set up our core meeting and meet in a regular basis, once, twice, three times a day if necessary to just make sure we are all aware of what is going on and aware of the active issues, I think has been something that I am proud to be a part of and then from a provider perspective and for us to pivot so quickly.
I couldn’t say enough about out Epic team about having to build a new telephone visit type and encounter in three days and get it trained with our providers out there and get it trained and operational inside of a week really is just something that is truly amazing because normally you know, we know that everyone is accelerating their programs and how they’re converting this but normally this would have taken a couple of months at least.
[0:16:45.6] BR: You know that is fantastic and I appreciate that you have been able to do this in this tough work environment that you are in. I see the Little Mermaid behind you and the stars and all of these things. It’s amazing I am doing this interviews and everybody has a different place that they are doing these interviews in and it looks like you are in your kids room.
[0:17:04.8] EL: Yeah, so my kids put them so you know, they had that work that they’ve had and then packed them before.
[0:17:12.7] BR: Yeah and Ray’s got the dog going on the background. So we are getting the full experience of the tele.
[0:17:20.4] RL: Yeah work from home. Yeah you shouldn’t have your dog bark but what can I say we’re working from home right?
[0:17:24.7] BR: Exactly, well gentleman thank you very much for your time. I really appreciate you taking the time to spend a few minutes with me.
[0:17:32.9] EL: Thanks Bill.
[0:17:34.4] RL: You got it.
[END OF INTERVIEW]
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