Mobile App-Based Access to
Better Care in Venice Family Clinic’s
Street Medicine Program
Margarita Loeza, MDChief Medical
Information Officer
Coley King, DODirector of Homeless
Services
Laura Garcia &
Wendy CervantesEMR Trainers
Jason Hua Chief Information
Officer
Learning Objectives
● Share how Venice Family Clinic is providing care to the homeless population with the use of a mobile-app EHR
● Demonstrate how the use of the mobile-app helps
VFC address fragmented care, lack of data, and inaccessible, in-clinic care
● Learn how VFC implemented mobile-app technology
Disclaimer
● We are clients of the product presented today.
● We do not have any relevant financial relationships to
disclose.
● All views expressed are our own and do not represent the views of the companies or specifics brands in
this presentation.
Questions for the Audience
Mentimeter
1. What is your profession?
2. Do you currently use a mobile-based
EHR in your practice?
Venice Family Clinic
• To provide quality primary health care to people in need.
Mission:
• To improve the health of people and communities through accessible, quality care.
Vision:
At VFC We Serve
28,000 low-income, uninsured men, women and children each year
• 15% are homeless
• 4000+ patients are experiencing homelessness
Services are provided at 12 locations across the Westside of Los Angeles in SPA-5
$
Homeless People have a High Mortality Rate
• US Life Expectancy: 78 years
• Diabetic: 70 years
• Chronic homelessness: 48 years
Tri-morbidity
• Addiction, mental illness, major medical illness
Health Care Costs
• Camden Coalition “hot spotter” study showed 1% of patients account for 1/3 of medical costs
• Estimated annual cost per homeless person on the street: $30,000 -$50,000
• In supportive housing: about half
FQHC Mandates: Title 42 §254b
• Addressing disparities in healthcare
Disproportionate Barriers
• Real barriers: transportation, cost, etc.
• Perceived barriers: cost, negative experiences, etc.
Why focus on people experiencing homelessness?
Locations Served
• Clinic
• Shelter
• Satellite
• Street (Multidisciplinary)
• Began in the mid-80s
• Trauma-informed care
• And medically trauma
informed care
• Showers, clothing,
food, and transportation
vouchers
Primary Care
Mental Health
Substance Abuse
Treatment
Health Insurance Enrollment
Case Management
DentalHIV/Hepatitis C Program
Overview of Homeless Program
The Annenberg Access Center
• David Solomon, MD
• Coley King, DO
• Valerie Aguilar, PA
• Nancy Pierre Paul, NP
• Ernesto Ortiz, PA
• Gilmore Chung, MD
Safe Place for Youth
• Carrie Kowalski, PA
The Cold Weather Shelter
• Gilmore Chung, MD
• Margarita Loeza, MD
St. Joseph’s Homeless Service Center
• Dr. Coley King, DO
Connect Days
• Malibu
• National Health Center Week
VFC Satellite/Outreach Sites
IMHT
• Christina Cady, PA
• Dr. Coley King
HMST
• Valerie Aguilar, PA
• Dr. Coley King
FSP/St. Joes
• La Chune Price, PA
Westside E6/SPA 5
• Carrie Kowalski, PA
Metro LA E6/SPA 4
• La Chune Price, PA
• Ebony Funches, NP
Santa Monica C3
• Ernesto Ortiz, PA
• Dr. Coley King
St. Joseph’s C3
• Dr. Coley King
Malibu/Briskin
• Dr. Coley King
• Ryan Wesley, Psychiatrist
Palisades/Briskin
• Nancy Pierre-Paul, NP
• Samantha Stewart, Psychiatrist
Currently 9 teams,
each with different funding:
Registry/Housing-Based: Person-Person Defense
Outreach-Based: Zone Defense
Hybrid: Malibu/Briskin
VFC's Street Medicine Teams
A Vet’s Story
Limitations in Outreach
Medical notes are hand-
written
Unknown if patient seen is
new or established VFC patient
Duplicate patient charts
created
Patients seen without secure access to their medical chart• Vital medical
history unknown
Unable to confidently
give immunizations
No vaccine history
Duplicate lab orders and vaccines
Duplicate medications
given out
Limitations in Outreach (continued)
• No phone
• No portal access
Unable to call or contact patients
in outreach
• Can’t see future appointments
• Or book a follow up
Difficulties with scheduling
clinic appointments
• Paper requisition lost
• Don’t know previous results
• Can’t give patients their resultsOrdering lab work
• No ERX
• Proper handling of physical pharmacy dispensing requires a paper logProviding Medication
• Multi-step logons required
• Need hotspot service for internet access, connection to VPN, multi-factor authentication, Citrix, EMR
• Time-consuming process
• Need to re-start process if one logon times out
Multiple connectivity issues if using remote
EMR
Before: Paper-based Documentation
• Illegible handwriting• Risk of losing or damaging
completed notes• Delays in accurately
transcribing note into the EMR
• Unable to objectively monitor wound, rashes, without photos (etc).
• Delays in medical care• Scanning paper is required
Challenges with paper notes:
Before: Paper-based Documentation
• Front Desk – Registration form
• Medical Records – Scanning paper notes
• Transcribers - Data entry in templates
• Care Coordinators – Generating referrals and diagnostics orders
• Providers - Closing encounters
• Billing - submitting E&M codes
Long processing time due to multiple hand-offs
• Lacking critical information in electronic chart
Data lag
• Revenue loss
Billing lag
Fragmented Care due to Incomplete Information
52 y/o homeless male presents to the cold wet weather shelter with a cough for 7 days. Incomplete history obtained from patient by medical student and attending from existing VFC patient. Patient was HIV+
• Prescription of OTC medication for a cold given
• Access to patient's chart would have aided provider in prescribing correct medication
Mobile App Integration
Mobile extension of EHR in Outreach
• clinical data from phone to EHR
Dictation-based software:
• Demographics
• Medical notes
• Lab results
• Scanned Images
Access to patient chart:
• Messaging feature:
• communication between care team members
• Photo uploads to patient chart
HIPAA-compliant:
Now: Dictation-based Documentation
• Outreach encounters are
dictated directly into phone
• Transcription edited directly
from phone and uploaded
into the EHR
o Better continuity of care
o No information is lost
for follow-up care
• Faster access to medical
information by VFC staff
From Field to EHR
A Team Effort
• Real-time access to completed transcription and photos in EHR
• Clinic staff still transcribe note into EHR templates
• Faster and more accurate transcriptions
• Encounters closed within days
• Dictating E&M code
• Dictate location of visit• Prompt billing submission
• Efficient use of provider time
Benefits:
Secure Image Uploads
• Upload images directly into EMR• Create a patient profile or picture
ID for chart• Document wounds, and rashes
over time• Copy Registration/consent forms• Copy hard copies of medical
records, and lab results• Capture Insurance card
Use the camera on your device to
• Photos an be saved in different folders of chart
• Do not stay on your device
Categories
Other applications: In-clinic use
Today's Jobs (schedule)
On-the-go chart review
Replaces use of shared physical camera
PAQ sign-off
• Signing your labs
• Covering for providers on vacation
• Address urgent labs
Mobile app: sign in, jobs, messaging
Chart: Facesheet and Documents & Images
Other Applications uses:
• power outages• network issues• inaccessible workstations
Back-up of EMR:
Group messaging among clinical staff
• caller ID blocking when returning phone calls
On call
Alternative to multi-step logon when accessing EHR remotely
Piloting of Mobile-App
• two outreach providers
Mobile-app launched in Summer 2018
• CMIO, CIO, Physician champion, EMR Trainer Team & Mobile EHR Support Team, and Staff
Team consisted of:
• Receiving and Implementing Feedback
• Sufficient time for Training and Troubleshooting
PDSA
• 1-on-1 Trainings for providers
• Workflow Design and redesign
EMR trainers
Piloting of Mobile-App
• Password resets• Managing Cloud portal
Back-end support by Mobile EHR support team
• Dictation cheat sheets• Swim chart on visio
Documenting Workflows
• Currently training new providers 1-on-1
• Followed by in-person support during provider go-live
Go live staggered
Cheat sheet and Swim chart
Improvements with the app:
Better care
• Access to vaccine record, lab results, previous notes
• Increase patient and provider satisfaction
• Providers encouraged to finish note on-the-go
• Medical info is more accessible and complete
Closing Encounters
• Faster turn-around
• 6 vs 3.5 business day
Patient Records
• Decrease number of duplicate patients
• Paper charts were not lost
Comparison two months before and after go-live
The future
Training all staff
• All outreach providers to use mobile app
• Coordinators to use the portal
• Nursing to use camera function
ePrescribing via app
Appointments
• Scheduling/viewing future appointments on app
VFC staff managing the portal in house
• Creating referrals to specialty care
• Making appointments
• Creating charts in real time
• Running insurance
Quadruple Aim
● Better patient outcomes
○ Immediate access to
history; improved
medical decision-making
● Improved Clinician
Experience
○ Providing quality care
○ Less time charting
Quadruple Aim
● Lower Costs
○ Reduce duplicate lab
and vaccine orders
○ Avoid duplicate patient
encounters
○ Faster billing submission, reduced loss of revenue
● Improved Patient Experiences
○ Avoids repetition of medical
information already in EHR
○ Improved Follow-up care in
outreach and in-clinic
Thank you!
