Ryan Health is a federally qualified health center based in Manhattan that has been providing comprehensive and affordable primary and specialty care to New York’s diverse and underserved communities since 1967.

Ryan Health has seven primary care centers, seven school-based health centers, two community outreach centers at transitional housing sites and one mobile health center, all located throughout Manhattan. As an FQHC, 75% of patients are enrolled in Medicaid or Medicare. Another 7% are uninsured.

THE PROBLEM

Prior to 2020 and the COVID-19 pandemic, there were federal and state policies in place that discouraged FQHCs like Ryan Health from adopting telehealth services due to payment restrictions.

"For that reason, Ryan Health had very limited telehealth services in behavioral health and care management prior to April 2020," said Farooq Ajmal, CIO at Ryan Health. "With the onset of COVID-19, not only the CDC and state health authorities, but our chief medical officer as well as infection control officer suggested limiting the patients physically coming to our centers.

"At the time, there were discussions at the federal and state level to amend the rules on a temporary basis to allow healthcare providers, including FQHCs, to act as a distant site for Medicare and Medicaid beneficiaries, thus allowing the providers to be reimbursed for telehealth services from the healthcare facility as well as from home," he continued.

Based on Ryan Health's efforts to deliver care as safely as possible and the changes in telehealth reimbursement, the organization's IT department started to explore the available telehealth platforms.

"Our first choice was to have a secure integrated solution with our EHR," Ajmal said. "Ryan Health did not immediately have the infrastructure in place to accommodate telehealth services from the centers or from providers’ homes. Besides the telehealth platform, we lacked webcams and laptops for providers.

"Ryan Health started to procure those devices, but due to supply chain issues that were emerging, there was a shortage of equipment in the market," he recalled. "Ryan Health was making these investments from our own capital budget, although later in the year Ryan Health received several grants that covered those costs and allowed new investments on infrastructure."

Prior to March 2020, only a few providers or employees were connecting remotely. For that reason, Ryan Health's firewall and VPN technologies were not capable of supporting 400-600 simultaneous remote connections.

"I strongly advise that choosing integrated solutions is always better than selecting disparate best-in-class solutions."

Farooq Ajmal, Ryan Health

Ryan Health invested a lot of its own capital and subsequently the grant funding to strengthen the infrastructure to support the enhanced need. This also brought other challenges such as cybersecurity concerns, which also were addressed.

"Ryan Health uses healow telehealth systems from eClinicalWorks as well as technology from Doximity as our telehealth solutions," Ajmal reported. "These solutions not only addressed the concerns with COVID-19, but allowed expanded access to patient populations. Telehealth has become an integral tool in delivering healthcare since the onset of the pandemic – many patients rely upon it as it overcomes some of the barriers to care, such as finding childcare, getting time off work and transportation."

PROPOSAL

In the early days of the COVID-19 pandemic, there was a panic in Ryan Health's patient population. People wanted to see their doctor to figure out if they were infected and what they should do. Patients wanted to hear from their provider, who they trust.

Ryan Health had to come up with a solution to continue providing care to patients without jeopardizing their health and spreading COVID-19.

"As a CIO, my main concern was that the solution should integrate with our existing technology system, be scalable, and be easily adopted by our providers," Ajmal explained. "Ryan Health uses eClinicalWorks as our EHR. We contacted eCW and started to explore their integrated telehealth solution. Their solution was readily available, was cost effective and could be deployed right away.

"Ryan Health started to test that solution and prepared training documents for deployment," he continued. "Very early in the process, we found some limitations with the eCW solution, including requirements that the patient must have an eCW patient portal enabled and have the eCW healow app installed on their smartphone."

Given the patient population, those requirements were limiting factors in serving the entire patient population. The system also did not work well for the behavioral health providers, because they often provided group therapy. The telehealth systems were limited in their ability to have more than 2-4 participants.

"Ryan Health deployed Microsoft Teams and Lifesize as a telehealth solution for behavioral health group therapy," he noted. "We are still using these platforms on a limited basis, but Doximity and eCW healow platforms have been expanded for more participants.

"We started to explore several other commonly used solutions in the market," he said. "Since a lot of providers were part of the Doximity network, Doximity released a telehealth solution that was agnostic to the mobile device used by the patient. The provider can connect with the patient via a video call or audio-only directly from their desktop or phone."

It also allowed for anonymizing the originating phone number so the patient can ensure the call is coming from Ryan Health and to protect the privacy of the provider. The Doximity platform met the organization's requirements, was available at no cost, and was HIPAA-compliant. It also allowed non-providers to use the platform to assist the provider with pre- and post-visit patient preparations.

"Ryan Health standardized on eCW telehealth, as well as Doximity as our two approved telehealth solutions," Ajmal said. "The initial testing and documentation were completed in April 2020 for the eCW telehealth solution, and it was deployed to all providers. These platforms were adopted quickly by both our providers and patients. Doximity was deployed a few months later in July 2020.

"During the height of the pandemic, 80% of our visits were conducted through telehealth for both medical and behavioral health services," he continued. "We realized that telehealth services are suitable for follow-up visits where more information exchange or coaching is required, instead of taking vitals or conducting tests."

As the pandemic subsided and vaccines became available, Ryan Health started to go back to in-person visits. Gradually it came back to pre-pandemic volume, with 80% of visits in person and 20% via telehealth.

"We do advocate for telehealth payment parity for FQHCs so that telehealth services will be fully reimbursed after the public health emergency," Ajmal noted. "Telehealth provides a great tool especially in FQHC space as it allows us to serve patients who were otherwise not getting proper healthcare service due to social determinants of health such as lack of transportation or time out from work."

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MEETING THE CHALLENGE

To further enhance the telehealth capability, Ryan Health also explored remote patient monitoring systems. Its remote patient monitoring project was unsuccessful due to the infrastructure and staffing needed to support the patient devices. It now is exploring working with a vendor that provides integrated remote patient monitoring services.

Ryan Health also expanded its work with vendors that provide chronic care management that sends the clinical data back into the EHR. Ryan Health currently is working with ChartSpan for these services.

RESULTS

Prior to March 2020, Ryan Health did not have a telehealth system. All visits were in-person visits. After the telehealth systems were deployed in April and July of 2020, Ryan Health was providing 80% of services through telehealth.

Besides dental services that were suspended as per CDC and the New York Department of Health, the FQHC was providing all other services and maintained its patient volume and visit counts above 80% of pre-pandemic levels.

Ryan Health also procured and implemented an online scheduling system toward the end of 2020 just as the COVID-19 vaccines were becoming available. Ryan Health used the online scheduling system exclusively for scheduling the COVID-19 vaccine appointments.

"Due to tremendous demand and short supply of vaccines, it was not possible to manage that demand through our call center," Ajmal said. "In addition, like many organizations, we had staff shortages due to COVID infections.

"The technology deployed in 2020 and its successful adoption allowed Ryan Health to maintain its financial sustainability, as well as continue our mission of providing healthcare for the community," he continued. "Due to the great work that Ryan Health was doing during the pandemic, we were chosen as a preferred provider by the federal and state departments of health for vaccination administration, outreach and population health."

Finally, this sudden paradigm shift in care delivery allowed the organization to re-examine its processes and allowed it to think outside of the box.

"Ryan Health Clinical Informatics Committee has been trying for several years to standardize workflows," Ajmal noted. "The disruption caused by COVID-19 allowed all Ryan Health staff to be more open to change, which allowed us to standardize most workflows.

"One example was that we were using both the thick client as well as the web client to access our EHR," he continued. "eClinicalWorks stopped enhancing the thick client and significantly enhanced the capability of the web client. Regardless, most people were used to the look and feel of the thick client, which is less robust than the web client."

The transition to remote work and telemedicine forced the workforce to start using the web client to access the EHR.

ADVICE FOR OTHERS

"Healthcare transformation still is in its early stages and there is a lot more to go until we reach a fully integrated healthcare system nationally that empowers the patient," Ajmal said. "For this reason, each healthcare provider is unique in how it uses its technology and workflows to deliver care. Even if two organizations are using 90% of the same technology, their build and workflows can be significantly different.

"I strongly advise that choosing integrated solutions is always better than selecting disparate best-in-class solutions," he continued. "Most EHRs are still very restrictive and do not work well with other systems, although there are many vendor-agnostic solutions on the market."

Ajmal thinks part of Ryan Health's success was a robust governance framework at the core of which is the clinical informatics committee.

"The committee has representation from most areas of the organization and this committee was instrumental in providing the oversight to select the correct solutions and workflows," he said. "I also think that the buy-in and agility of our clinical staff made this a success.

"I am a strong believer in Peter Drucker’s famous words, 'If you can’t measure it, you can’t manage it,'" he continued. "We built reports and dashboards around most of the new technology usage, including the usage of different telehealth solutions. This allowed us to figure out which solutions are working, which ones need further optimization, and which ones need to be eliminated."

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