Telemedicine Connections Between Community Health Centers and Florida Title V Services: A Model for Serving Uninsured Children with Special Health Care Needs in Underserved Communities

Lynda Honberg: Thank you, Phyllis. Jerry.

Dr. Jerry Williamson: Yeah, I’m going to have to stand up because I’ve got a map for you to see and if I can get this on, I’m still trying to think about what Lynda was saying. Twenty-five years in health care, I guess I must have been a child prodigy or something. I’m not sure exactly what--how--I mean, oh, I wrote that. I’m Jerry Williamson. I’m a pediatrician, and I am very, very happy to be partnering with these folks in this particular program because it’s--Lise described the fact that we can now enroll more children. When I heard about the program, to me, lightning went off. There was so many other considerations and possibilities and opportunities which I’m going to address in just a few minutes. If we can--yeah. What I would like to do to begin with is give you a little bit of a flavor of Immokalee.

You’ve heard the name Immokalee. Let me tell you a little bit about our community and about our community health centers, some of the barriers that we face, and then I’d like to kind of segue into some of the telemedicine barriers and talk about some of the opportunities. And as you may be able to see, this is Naples over here in south Florida, okay? And as you come going to the east side, there is Immokalee there. Immokalee is roughly about 20,000 people during the off-season. During the peak season when we have our migrant workers that come in and the farm workers increase in number, we can double. We can go to 40,000 people.

Now that’s a fair number of people because that usually coincides as well with the people that are coming to visit Naples and Fort Myers and to visit the snow birds that come down for the season, so it really at that point jams emergency rooms and a variety of other health centers because of that. But if you look at this, you can see here’s the Naples, and here is Immokalee, and what I want to bring out as well is if you look at where we can refer kids in Immokalee to, basically we’re talking about St. Petersburg which is All Children’s Hospital. That’s about 150 miles. Then we can south. We can go to Miami, and that’s another 150 miles, so there’s really very little, and then where Lise is up in Gainesville as you can see that’s much further north, Tallahassee and Jacksonville.

There’s really not very much in the near vicinity of Immokalee to send kids for specialty care. Next slide please. This is the demographics of our community. As I said, we’re about 20,000. It is truly a rural community. People that have worked there and people that had visited Immokalee have called it a third-world country, and in many ways it really does reflect that kind of a community. This is basically the breakdown in terms of population, and as you can see, we have a very, very large Hispanic population which probably reflects most of the community health centers in the state. Next. And the barriers to health care. Well, as a rural community, I can tell you that poverty is probably number one, and the poverty brings with it a whole variety of things. These people live in very, very substandard housing.

There’s no way you can call to remind somebody to come back for a visit because they don’t have telephones. This is a community where the ability to be able to purchase and eat a nutritionally proper diet is very, very difficult as well. In terms of transportation, most of our patients don’t have a form of transportation. As a matter of fact, our facility about ten years ago went out and purchased a bus, and we actually have two buses that go right through the community, and people know exactly when the bus stops and where it stops, and we pick up people and bring them to our community health center. And it’s interesting because now the bus driver’s making some additional stops at some of the food stores and other places as well. But if that’s their form of transportation to get what they need, that’s fine with us as well. The multiple languages.

The multiple languages goes along with the cultural diversity in our community. We have people that speak Spanish, but that’s not adequate enough in terms of translation because we have people from rural Guatemala that speak a language called Kanjobal, and Kanjobal is an oral but not a written language. So it becomes even more difficult to translate that onto paper. We have a large Haitian population, and they speak Creole, so we really have to have available to us translators as well in each of these languages. So our Kanjobal translator does not speak English but speaks Spanish, so he translates Kanjobal to Spanish. Then we have somebody else who gets the Spanish to English, and then it comes to English to our health care provider, and those of you that have had 25 years in health care might remember the game telephone where you kind of stand in lineup and say something to one person and 20 people later, you try to figure out what was said originally.

We go through this as well. Education. We truly--the patients that we see have very, very limited education. Most of them actually can’t read or write, so we have translated into their various languages information that they might need and help them with their disease processes; however, it’s difficult because they can’t necessarily read and write, so we have those barriers as well. In terms of specialty care as I was showing you, the Naples community is a very, very rich community. You got to remember Collier County, of the 67 counties in Florida, is the largest in terms of size, most of it being rural. But there are some very, very nice, non-rural areas such as Naples and Marco Island, so the people that need specialty care that have to go from Immokalee to Naples, the Naples providers are very, very reluctant to see our patients.

They’re reluctant to see our patients principally because they have no means of payment. So it’s very, very difficult for us to get patients from Immokalee for their specialty care in Naples. It’s difficult to get them to Fort Myers for the same reason. The closest hospital is about 35 miles away, so when we’re closed in the evening, the way patients get their care is they basically call 911. And it may be a 911 call because a child has a fever, and then they’re taken to the emergency room 35 miles away. So it’s very, very difficult to provide this care. Next slide. These are some of the barriers that I see to what we can do in terms of telemedicine.

When we received this equipment, it was really truly a very exciting time for me because I saw this and a whole variety of opportunities came to mind. The geographic limitations in relation to telemedicine. You cannot now cross state lines, so any physician in the state of Florida that would want a consultation for a patient, they have to stay in the state. Once they go out of the state, the physician who is getting the consultation outside of the state is practicing where the patient is, which is in Florida, without a medical license. So that is just one example of multiple regulatory problems that are going to have to change. And I’m certain that they will, but it’s going to take some time. Reimbursement. We’ve alluded to the issue of reimbursement. It is very, very difficult to go ahead and have physicians agree to see patients in consultation through telemedicine if they know they’re not going to be reimbursed.

It’s very difficult to take them away from their patients, their patients that are paying patients, to go ahead and do this, so somehow we have to figure out--in our patient population, 50 percent of our kids have Medicaid, and if we can get the state to go ahead and agree to go ahead and pay for these services through Medicaid, then I think we’re going to be one step ahead. There are now 23 states in the union where Medicaid is paying for telehealth services, so Florida is not one of them. I can assure you that. And then, of course, we have the Joint Commission, and, again, our facility, interestingly enough, we were one of the first community health centers in the United States to be joint commissioned, and our second survey was even better because we had a 99. They gave us accommodation with that.

So JACO is a problem as well because what JACO says is that if you have a telehealth consultation with another physician, if that physician is directing services meaning he’s prescribing medication or doing something as such, the community health center, we, have to credential as physician doing primary care credentialing. So that’s just another headache, another thing that we have to do and have enough staff to be able to do all that, and that comes out of my office, the credentialing piece. Next. So the opportunities that I saw when Lise came and talked to me was, this is terrific. We can go ahead and provide clinical services for our patients. We can’t get our patients into specialty care in Naples or in Fort Myers or anywhere else, so I can get my patients into various partnerships, Children’s Hospital in St. Pete, without the patient ever leaving my facility, or to Gainesville or to Miami or to wherever I want to go because now I don’t need these folks and necessarily see them because I can go ahead and do it this way. So this would be a huge, huge help.

Educationally this is another big, big issue for us. We have students. We have students from one of the medical schools in Miami. We have dental students because we have a huge dental program, and our dental students come from the University of Florida in Gainesville. This would be a marvelous way to be able to tap into grand rounds for our medical students, to be able to tap into grand round for our physicians and our nurse practitioners. It’s even equally good to be able to tack into nursing programs. We have nurses. We have support staff that would love to participate in those kind of programs, so it’s really exciting to be able to do it with that as well. So what we’ve done is we now have multiple partners.

I managed to go ahead and get the Children’s Hospital in the St. Pete to become a partner. We right now can do teledermatology because we also use the Tandberg, and we have the hand-held camera, but that is what we’re limited to. Children’s in St. Pete is going to provide us with a stethoscope that attaches. It’s a marvelous piece of equipment as well as an otoscope, so we can look in ears, and this will help us to be able to take care of these kinds of problems and do it with the camera. The resolution is phenomenal. The other part of this that I want to see our providers doing is using this to help and teach parents.

It’s marvelous to tell a parent, “Okay, your child has a small perforation of the eardrum.” They don’t have any idea what you’re saying regardless of the language that you’re using, so all you need to do is hook up the machine and just put it up on the screen and you just tap a button and it gives you a fixed image. You can now look at a tympanic membrane almost the size of this screen and be able to see great resolution with it, so I’m really excited about teaching parents about what we can with that. Next. That’s--yeah. Let me finish and tell you as an example one case before we had our telemedicine that I thought would have been perfect for this kind of equipment. I was called down to see a child by or who was being seen by a nurse practitioner, and this was a two-month-old child that had came in with a swollen eye.

Well when I saw the child, my first thought was because this was truly--I’m sorry I don’t have a picture of it. This was either an intraorbital, meaning an inside the eye, tumor, or this child has a large bloody-type tumor, something called a hemangioma on the lid. Couldn’t really tell for sure what it was. Little bit concerned about the inside of the eye. Parents were from Guatemala. They did not speak English. They spoke Kanjobal. The parents had no idea what was going on. The child saw a pediatrician somewhere at two weeks of age and end up with some eye drops. That’s all they knew. The child had no immunizations, no other health care. So I managed to get a consultation for this child in Miami. The father did not have money for gas. The father was borrowing a car. The reason he was borrowing a car is because he didn’t even have a license to drive, so we gave him gas money.

He went down to Miami, and when he got there, the door was apparently closed. So then he came back, and we went ahead and told him he needed to ring the bell which he didn’t do. So the next day we gave him additional gas money. Not only gas money, we had to go ahead and give him money to--oh, what, we needed money. We went ahead and purchased a car seat for the child so that the child would be driving to Miami safely. Well, that was day two. They turned out to be a hemangioma. The child ended up having surgery. It was completed, but then the parents had to take this child back four different times because they wanted to see the child in follow-up. That’s 150, 140 miles each way times four. This could have been done with a camera at our facility.

So there is some marvelous ways that you can use this equipment. I am, as I said, I’m very excited about it, and I just want to see this happen, and I’m sure it will, but I really do appreciate these folks making it happen for us. Thank you. Are you going to print it?

Unidentified Speaker: I’m going to use that microphone.