Got an ailment? Take a picture; send it to a specialist

Aug. 1, 2012, 11:40 a.m.

Patricia Martinez, who has diabetes, gets a retinal screening at South Central Family Health Center in South Los Angeles. (José Martinez/OnCentral)

Imagine you've got a strange rash on your skin – you don't know where it came from or how to treat it. You're also uninsured.

Maybe your only option is to go to your local community health clinic and speak to a physician there – but she's not a dermatologist, so she's unsure what to say about the rash. What she can do, though, is take some photos of the rash and electronically send them off-site to a licensed dermatologist. The dermatologist will look at the photos and tell your provider his or her diagnosis and prescription. Your provider, in turn, relays that information to you.

All for $55.

That's called telemedicine, and Nina Vaccaro, the executive director of the Southside Coalition of Community Health Clinics, says it's particularly useful in a community like South Los Angeles, a place with little access to the medical expertise in the surrounding areas.

"It's using innovation to increase access to health care services that are either impacted or not accessible based on geography or a lack of access to someone with a particular expertise or specialty," she said.

Vaccaro explained that people typically think of telemedicine being used in rural communities, where patients would need to travel hundreds of miles to get to the closest specialist. But it's also an ideal way to expand care to southside residents, many of whom are without insurance.

Telemedicine is nothing new, and Vaccaro says that in South L.A. in particular, there are still a few hiccups to work out. One of them is bandwidth – live video feeds and the uploading of high-resolution photos require a fast, reliable Internet connection, something some of the clinics in the coalition are still struggling to acquire.

The other is billing: Vaccaro says billing for telemedicine "is not quite where it needs to be" in terms of ease, clarity and coverage, although a lot of policy work over the past five years has worked toward making telemedicine a standard component of health coverage plans. At this point, Vaccaro says that's more of an urban problem, since insurers have recognized that covering telemedicine for rural folks makes a lot more intuitive sense.

"There are wonderful opportunities if we can get that infrastructure where we need it to be," said Vaccaro.

Cheaper than an in-person consultation

Vaccaro pointed to two manifestations of telemedicine in particular.

"There's the traditional way, where you've got someone in front of a camera or monitor on one end and someone in some other remote place," she said. That's the live video feed method, and not the one clinics in the Southside Coalition tend to use.

"Or there's things like 'store and forward'," said Vaccaro. "What it is, essentially, is when you're capturing an image or sound and you're uploading it into a secure portal via the Internet. You're sending it off to a specialist or whoever you're asking for expertise. They're looking at the images, they're listening to the sounds and they're able to provide you with a consultation."

Those consultations are cheaper than an in-person visit would be. Vaccaro said tele-dermatology consultations run about $55, which is the Medicaid rate, while retinal screenings – in which medical staffers take photos of a (usually diabetic) patient's eye and send it to a specialist who looks for signs of oncoming blindness – cost about $15.

That cost, she added, is usually covered either by a grant or the patient, if she or he can afford it.

South Central Family Health Center is in the Southside Coalition and uses telemedicine, primarily for retinal screenings. Dr. Felix Aguilar, the clinic's chief medical officer, said "it's changed the way we do some really important stuff."

"In the old days – five years ago, maybe less – we used to send patients with diabetes who were uninsured to the county. Ninety percent of them never got their eye exams because the waits were too long," he said. "It took too long to get in, people forgot their appointments. All kinds of stuff like that."

Now, because of telemedicine, Aguilar said his clinic knows exactly who needs treatment.

"People went blind waiting for exams in the past," he said. "Now we only need to send 10 percent of our patients to additional treatment. That then allows us to be more deliberate with those patients and then follow up. In the past we just sent everybody."

St. John's Well Child and Family Center, also in the coalition, uses telemedicine a bit more broadly than its fellow member clinics: In addition to retinal screenings, they use it for tele-dermatology and are even gearing up to start a tele-psychiatry program.

"It's Skype, essentially," said Jim Mangia, the president and CEO of St. John's. It's not actually Skype, he added, but it works pretty much the same way.

"What this does is it allows us to provide some level of specialty care and specialty access to patients who wouldn't otherwise have those services," he said. "So for our diabetic patients, for example, the retinal screenings can allow us to intervene to prevent blindness."

Mangia said telemedicine "significantly reduces cost," "dramatically improves access," has a very quick turnaround and can be a boon to clinics who don't have enough space but still want to provide some sort of specialty medical care.

St. John's is in the process of building a specialty clinic, and some of the services there will be provided via telemedicine, he added, noting that won't replace flesh-and-blood specialists and doctors.

"It's not like you can exclusively run a specialty care practice through telemedicine," he said. "But it's a very important addition to increase access and specialty care."

Telemedicine in action

Juan Delgado, a medical assistant at South Central Family Health, carries out many of the clinic's retinal screenings, which happen every weekday except Thursday. The camera machine he uses, which cost $15,000, is fully automated.

"We just type in their names, date of birth and ethnicity," he said. "Then we push start and it does it all by itself."

The grant funding the clinic received to do these retinal screenings via telemedicine specifies that they're only to be done for diabetic patients; so every person Delgado sees for these appointments has diabetes. His goal, he said, is to prevent vision loss.

The process is this: He'll dilate a patient's pupils, which usually takes about 20 minutes. Then he'll set them in front of the camera machine so it can photograph the patient's eyes, which usually lasts about five minutes. He'll upload the photos to a secure Internet system that sends them to a specialist in Berkeley, who will examine the photos on the same day and tell Delgado or one of his colleagues if the patient should be referred for further treatment.

If an uninsured patient needs to be referred, Delgado says he or she is usually sent to the county. Patients on Medi-Cal will talk to a clinic counselor, who has a list of specialists they can see.

Red flags on the retinal screenings, said Delgado, include spots of blood, which means veins are popping, which signals a person's diabetes is out of control.

"Yellow spots also aren't good," he said. "And the worst possible sign is a big blob of blood. If you see blood, they have to be referred right away."

Delgado's colleague, Crystal Gonzalez, is a disease management coordinator and says patients who don't need to be referred come back for yearly screenings. South Central Family Health Center has another clinic in Huntington Park, but Gonzalez says that clinic doesn't do nearly as many screenings as the one where she and Delgado work. Luckily, she said, their equipment makes that pretty manageable.

"We don't really have to do much," she said. "We just enter patient information and the camera does it all on its own."

A recent study found that community clinics are as good as if not better than regular private medical practices. As far as the Southside Coalition, said Vaccaro, telemedicine really embodies one of the reasons why that's true.

"I think the use of innovation in care delivery really is one of the key factors that puts community clinics out there," she said. "As innovators, they are leaders and they are working on addressing quality care and improving access to care delivery. Telemedicine is just one of those components they're using to drive that access for their patients."

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