HIMSS Davies Award. Case Study #2. Joe Humphry MD, FACP, CPEHR Cori Takesue PsyD. December 13, 2017

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1 HIMSS Davies Award Case Study #2 LCHC Telehealth Joe Humphry MD, FACP, CPEHR Cori Takesue PsyD December 13, 2017

2 501(c)3 Non profit Organization Federally Qualified Health Center (FQHC) Provides services to approximately to 60% of the island s population LCHC provides holistic, INTEGRATED medical, dental, and behavioral health services. Total number of employees is approximately 40, most are fulltime and hired from the local community. Clinical professionals include 2 full time Family Nurse Practitioners, the Medical Director.25 FTE clinical, 2 full time Psychologists and the dental team. LCHC will see over 2000 unduplicated patients in 2017 and approximately 7,500 visits.

3 3,100 people Plantation history The Pineapple Island Diverse mostly Asian/Hawaiian/ Pacific Islander population Over 40% of residents Filipino 30 miles of paved road Amazing hikes, gorgeous beaches, fresh air Current primary economic driver is the hotel/hospitality industry

4 Telehealth improving access and improving care VTC ZOOM Store and forward 1. Tele ophthalmology 2. Tele dermatology 3. Tele ultrasound Remote monitoring Integration with Health Information Technology

5 Behavioral Health Integration with Primary Care Background: 80% of mild to moderate BH conditions are managed in the primary care setting; rural communities lack the resources to effectively manage the range of cases in the community Objectives: Improve screening, detection, and management of patients with BH conditions SBIRT (Screening, Brief Intervention, Referral and Treatment): Implementation health center wide, across all services Vertical integration with psychiatry for consultation, medication management and education Timely access to psychiatrist for crisis management and brief interventions

6 ZOOM VTC Vertical Integration Psychiatry consultation with either primary care (PC) provider or psychologist sitting in and developing a common care plan with PC follow up as needed ZOOM VTC BH team meetings with psychiatrist, care coordination and selected educational topics Brief telephone consultation within 24 hours for urgent consultation or medication management LCHC provides the technology (ZOOM license) and scheduling by the PC provider or psychologist

7 Stress Questionnaire Beyond Depression Screening Survey implemented in CDMP s survey portal allowing the patient to complete the survey on line, or the patient works with the Medical Assistant (MA)/Dental Assistant(DA)/Community Health Worker (CHW)/BH provider to complete the survey Automatically scored in CDMP and the Depression score is exported to BridgeIT for UDS depression screening reporting; UDS reporting is completed using BridgeIT MAs, DAs, and CHWs are trained for brief intervention for tobacco and alcohol use Stress questionnaire is completed annually or sooner if provider feels it is appropriate; tracked in ecw with a electronic copy of the full stress questionnaire stored as a document in ecw

8 Workflow for stress questionnaire Stress questionnaire completed by patient with or w/o assistance from MA/DA/CHW/BH provider and filed in EHR DOCS Positive for ETOH or tobacco YES Brief intervention and inform provider NO NO Positive for Anxiety/depression YES Managed by primary care NO Report to Primary care provided who assesses severity YES Psychology/psychiatry referral

9 Access and Quality: Increased access to psychiatrist for diagnosis and medication management resulting in better care particularly for the serious mentally ill and the expanded and supervised use of psychotropic medication

10 LCHC/UHDOP model for others, HJMPH

11 ZOOM: Synchronous Telehealth Hub and spoke with the hub at the site of origin (i.e., primary care site) LCHC provides the technology for telehealth Agnostic related to communication device Available in all exam rooms and throughout the health center, as well as patient s home with use of Tablets Access to psychiatric telehealth consultations Used for behavioral health team meetings and educational sessions Used with consultants new to telehealth consultation for pre op and post op care and other medical specialties LCHC does not have a telehealth coordinator; process is managed by the clinical and administrative staff

12 Tele ophthalmology: JVN/CDMP Oldest of the LCHC telehealth programs; started in 2009 MAs are trained imagers and schedule and take the images LCHC has optometrist services twice a month; patients with diabetes who have visual problems are seen by the optometrist; those requiring only annual retinal exam have the option of teleophthalmology Using CDMP, image is stored in the cloud and available to optometrist reader who generates a standard report returning the report via CDMP

13 CDMP Clinical data Exam report 7 image acquisition by imager (MA) EHR and provider Reader (Optometrist) reads and reports

14 31 retinal images in the this year; 71 total LCHC eye exams

15 Tele dermatology Initiated in 2013: store and forward technology using DirectDerm secure information system Obtain photos and complete clinical information form on secure web page Dermatologist is licensed in Hawaii and credentialed with health plans 39 derm consults completed since January 2014

16 Tele ultrasound Prenatal and Abdominal GE Volusan 8 Ultrasound Ultrasound tech is on island for scheduled and unscheduled studies Image transfer technology Studycast Support ( OB readers at Kapiolani Women s and Children's Hospital (Oahu) using StudyCast Cloud Abdominal reader at Maui Diagnostic Imaging using PACS transfer to the groups server 8 12 studies per month

17 Case study: Common duct stone Patient is a 72 year old female who presented with episodic severe abdominal pain and a history of possible ulcers; she was initially seen and treated with a PPI (ulcer medication); she returned a week later with relapsing abdominal pain lasting several hours with periods of minimal pain Physical Exam showed epigastric and RUQ pain Urgent US was ordered indicating a common duct stone and appropriate labs drawn indicating acute obstruction of the common duct Patient was referred to Queens Medical Center via commercial air transportation and subsequently had GB surgery and has had an uneventful recovery

18 Remote monitoring and diabetes and prediabetes management Remote monitoring added in 2017 for patients on insulin using the recently released One Touch Vario Flex meter interface with CDMP Hypertension occurs in approximately 60% of patients with diabetes and the addition of remote monitoring for diabetes encourages treating the whole patient rather than focusing on hypertension. Addition of Community Health Workers to implement remote monitoring and offer home and community based chronic disease follow up CHWs with tablets are able to provide data collection for patients without a smart phone or other device.

19 CDMP blood glucose graphs and charts

20 CDMP Survey tools including scoring

21 ABC Diabetes Pilot and Future Plans Partnered with ABC Diabetes ( to provide 5 educational sessions for 4 patients in conjunction with LCHC CHW and Providers who attended the sessions CDMP provided clinically relevant information to the Certified Diabetes Educator and the survey tools to assess the patient (Diabetes Distress, Diabetes Knowledge Assessment, Diabetes Self Care Profile) CDMP Care Plan LCHC recently contracted with an APRN/CDE and Dietitian to join our team through ZOOM VTC both to train CHW and staff and to provide direct to patient diabetes education; the Dietitian is also assisting with development of the WIC program recently awarded to LCHC

22 CDMP care plan and patient dashboard

23 Challenges in diabetes prevention in a rural community Defining our population Limited resources for program development and implementation; focus on the population with greatest benefit Small population with a challenge for group programs; options in management: Developing a program for our total population that is culturally diverse including 25% of patients being foreign born Defining and measuring true outcome for the patient and focus on the patient and not the prediabetes

24 LCHC Prediabetes Population

25 CDMP history and development Developed by consortium lead by the Joslin Diabetes Center including VA (Boston VA), Military (Walter Reed), Indian Health Service and University of Hawaii/Tripler Army Primarily DOD funding (50+ million dollars) initially to develop teleophthalmology and subsequently the Comprehensive Diabetes Management Program that evolved into the Chronic Disease Management Program Designed to complement the EHR and interface with the EHR and designed based on the Chronic Care Model Primarily used in research and more recently with the CMS CPC+ track 2 available through SaturnCare (

26 Impact of Telehealth and HIT for our patients LCHC has focused on affordable and accessible quality of care for our patient through the use of telehealth and HIT Access is essential for high quality care; the tele ultrasound and teleophthalmology will never show a ROI and the cost of the equipment requires grant funding Travel costs and telehealth savings are significant; however, savings are primarily realized by the patient and not the providers; however, Medicaid (and a few other insurances) benefit as the health plan does not have to pay for patients to travel to other islands Increased appropriate utilizations for timely consultations, US and retinal imaging and remote monitoring, i.e., timely data transfer

27 Cost Saving through Telehealth Ultrasound 2017 LCHC had 110 image studies saving off island referrals (Plane and ground transportation cost at $250) results in $28,000 savings. Tele ophthalmology 31 images for patients not requiring a complete eye exam. (Cost of dilated eye exam $200 and retinal imaging $50) results in $4,650. Tele derm 12 consults per year (Plane and ground transportation cost at $250) results in $3000 Cost savings are realized by Medicaid Managed Care Health Plans who cover transportation costs or by the patients Costs do not include missed work, hotel accommodations due to limited flight schedule, family members who may need to travel with the patient or meals.

28 Challenges and Barriers Rapid growth: 2013 UDS 1,190 unduplicated patient will increase to close to 2,000 in The number of patients with hypertension increased by 43% in 2016 Further refining the efficiency and effectiveness of our CHW community based care (i.e., caseload for CHW, data acquisition and management, care team coordination, etc.) Conflicting HIT priorities: UDS quality metrics and management, MU reporting, Million Heart recruitment and reporting, grant reporting and writing, etc. Staff training: Staff has increased from 14 in 2013 to over 40 currently

29 Challenges and Barriers (Continued) Vertical integration to improve care: University of Hawaii, VA, Queens Medical Center, Kaiser all consume significant time and effort, especially during contract/collaboration discussions Lack of support from vendors: eclinicalworks, Life Scan, CVS Pharmacy extremely difficult to work with and achieve cooperation Health Plans and Prior Authorization requirements: BP Cuffs (Medicaid Managed Care only) and One Touch Verio Flex Meters Future payment models and rural health: Metrics for measuring quality and impact with small numbers; staffing, cost savings not returned to the Health Center; changing technology and scalability

30 Pau! The staff of Lana i Community Health Center