New HIE hook-up, telemedicine transform care at L.A. clinic
For decades, Chinatown Service Center of Los Angeles, a federally qualified health center community clinic, relied on the ubiquitous faxing of patients’ medical records from local hospitals and physician offices, as well as patients bringing their most recent doctor visits’ paperwork outside of CSC to their appointments.
Though CSC had digitized its own patient records at its four FQHCs in the last decade, faxing remained the only way to share data with other local practices and hospitals to get the most current patient-encounter data to inform care. Caregivers would wait to receive requested faxed paper records over days, weeks and even months.
CSC physicians and clinical teams depended heavily on the faxing of patient records to better understand what procedures and tests already were performed. The goal was – and still is – preventing costly duplicate healthcare expenses and taking better, more informed care of patients.
LANES, the Los Angeles Network for Enhanced Services, is a non-profit, community-based organization that operates a health information exchange that enables LA County provider participants to access and collaboratively share medical records of local patients. Practically overnight, the LANES platform eliminated faxing at CSC altogether, and connected CSC electronically to community providers also using the HIE.
“In early March of this year, the LANES team brought to us a fast and secure digital way to access our most up-to-date patient records from a central place,” said Dr. Felix Aguilar, Chief Medical Officer at CSC. “The HIE technology was both HIPAA- and ePHI privacy-compliant. Initially, we had many concerns about the adequacy of the HIE’s security controls, such as how to prevent unauthorized access to patient records or detect and prevent data breaches – all of which could adversely affect patient care and operations.”
However, CSC's fears immediately were addressed. CSC records are encrypted and shared only with other authorized users who see CSC patients, and, in turn, CSC only is able to access patient records when care is established with CSC.
MEETING THE CHALLENGE
Today, CSC's staff members regularly look up any of their patients in LANES to find out in minutes what was ordered or not, if that person had visited a hospital or a specialty practice in L.A. County. In the past, that capability would have been impossible.
The lack of timely and accurate medical information kept CSC in the dark. Adding fuel to the fire was the fact that most patients were unclear about the instruction they had received from a non-CSC provider. With LANES, CSC staff now are able to clarify treatment orders, results and next treatment steps with patients.
"Fast access to patient records during the COVID-19 pandemic has become more precious, medically necessary and urgent."
Dr. Felix Aguilar, Chinatown Service Center of Los Angeles
“The LANES technology extracts, aggregates, normalizes and categorizes relevant medical record data collected from different EHR systems such as eClinicalWorks, Cerner and Epic, to name a few,” Aguilar explained.
“LANES’ data repository comprises lab results, radiology diagnostics, procedures, transcription notes, allergies, immunizations, vitals, prescriptions and ADT information. A patient’s health information is presented to users as data types categorized in an organized fashion.”
The categories make it simpler for users to look at one view of a person’s health holistically. The HIE eliminated the massive time barrier of wading through hundreds of faxed pages, including searching, for instance, for only three pages at a doctor’s request to inform a current diagnosis.
“Interestingly, at the same time that we were implementing the LANES HIE in March, which coincided with the start of the COVID-19 outbreak, California Gov. Gavin Newsom issued the first statewide stay-at-home order to curb the spread of the novel coronavirus,” Aguilar recalled.
“Ever since, our community health center clinics have been on the front lines managing both prevention and diagnosis. We’ve strived to limit exposure of the coronavirus to our patients.”
By the end of March, CSC’s entire way of interacting with patients had changed and transformed radically over three weeks. CSC’s four community clinics swiftly prioritized telemedicine training and changed practice workflows to incorporate the LANES platform. Telehealth consultations are CSC’s new normal.
“I must give a shout-out to our IT team members who’ve worked tirelessly for weekends and overtime setting up new software to handle the new Medi-Cal billable coding for telemedicine and new equipment such as microphones and webcams, adding bandwidth and creating standard telemedicine protocols,” Aguilar noted. “Each of our four clinics’ front-office staff helped educate and acclimate patients quickly to the virtual visits.”
CSC clinic staff converted 80% of acute in-person visits to smartphone or video-conferencing services such as Zoom and the CURAGO e-scheduling platform. Patients quickly accepted the new e-visit approach.
“To date, about 5% of our approximately 12,000 CSC patients – the majority of whom are immigrants and reside in downtown and east of L.A. County – have been diagnosed with COVID-19,” he reported.
Since implementing the LANES workflows in March, within a matter of weeks CSC reduced staff and patient time transitioning to telehealth visits by 30%. The clinics improved timely access approximately 75% to retrieve hospital emergency room and hospitalization records at participating hospitals in L.A. County.
Another telehealth benefit to HIE participation is the newfound ability to reconcile medications. Before the COVID-19 outbreak, patients usually brought medication bottles or a list of prescribed drugs to their appointments.
However, if a patient was unable to visit in person, but still needed care, clinical support-staff faced an impediment to performing medication reconciliation. LANES combines and provides visibility of all prescribed medications, so CSC providers can discuss the drugs with patients during telemedicine appointments.
“On the public health side, telemedicine is brand new,” Aguilar said. “The COVID-19 pandemic forced CSC’s transition to telehealth. The actual technology implementation was made possible on March 19 with Medi-Cal expanding the services and reimbursement to help our patients and staff comply with California’s stay-at-home order.
“I’m thankful that Congress passed an emergency-spending package that included $100 million to support community health centers in their COVID-19 response,” he added. “My clinic leaders believe this is a good start, but the funds shall not go far.”
ADVICE FOR OTHERS
Aguilar has a lot of advice for peers in the industry considering HIEs and telemedicine.
“Implement the technology as fast as possible in order to improve and inform patient care, and especially in the advent of a public health emergency,” he advised. “Fast access to patient records during the COVID-19 pandemic has become more precious, medically necessary and urgent. Community HIE participation is the new way that providers must accept and implement into their routine practice. You wouldn’t drive today without a GPS, so why would you consider practicing medicine any other way?”
Augment patient education, he suggested. CSC can better explain, educate and inform patients on the course of previously ordered procedures and treatments – whether administered in the hospital ER or a specialty practice visit.
“One of my patients shared her experience leaving a local hospital visit with little provider interaction and comprehension in understanding her diverticulitis symptoms along with the prescribed treatment,” Aguilar remembered.
“In less than a minute, I was able to pull her medical record within the regional HIE, review the hospital provider’s finding, and explain in real time the infected pouch in her colon. I also shared illustrations of the condition. Now that I know the patient’s diagnosis, I can better inform and monitor her continuing treatment.”
Another piece of advice from Aguilar: Physicians need to embrace a new mindset adopting new technologies.
“Waiting for results to diagnose a patient accurately for a month or longer is usual practice in healthcare,” he said. “A patient came to me with a directive from an ER physician to see me, her primary care physician. She was told by the ER doctor, actually in passing, to inform her primary care physician that she had a cyst in her thyroid.
“I ordered her record from the hospital ER to see the size of the cyst,” he said. “I waited and decided to proceed with an ultrasound, and, at about the same time I received the image results, I received the patient’s faxed diagnostic results.”
From the time she was seen to the time of the ultrasound took about a month and a half. Medical providers need results sooner than later to take care of patients promptly. Healthcare today is working with a horse-and-buggy mindset of, “Well, we’ll fax the information to you someday,” Aguilar said.
“We’re in the middle of a pandemic, and medical professionals do not have the luxury of time,” he added. “We must act now on the patient’s behalf, and HIE technology gives us the means to carry out actionable, informed care in real time.”