Chronic disease tracking using a refill protocol

A few years before we joined the TransforMed National Demonstration Project, my office was having a lot of problems dealing with prescription refills. The volume of requests was tremendous. We were fielding 50 to100 requests per physician per day. We had the feeling that we were not doing a very good job with turnaround time on these requests. We had negative feedback from nursing, pharmacists and, worst of all, patients.

We decided to study the problem. For a solid week, we tracked the process each refill request went through from the time it was received in the office via fax, phone or in-person patient request to the time the authorization or denial was sent back to the pharmacy or the patient. What we found was surprising: the turnaround time was an average of 48 hours, but with a range of 30 minutes to 5 days. This variance arose from absences of staff and physicians, as well as day-to-day variations in how busy we were. But it did not seem to be caused by variations in fax traffic or whether prior authorizations or patient instructions were needed.

From our study, we were able to craft a plan to reduce this time. Our goal was to reduce the turnaround time to 2 hours per prescription on average. In mapping each process (made very easy by our EMR system, Centricity), we tried to identify every time the request would sit in a "parking lot" or queue where it was waiting for the next person to act upon it. Our goal was to reduce the number of parking lots. We realized that for certain classes of medications, mainly maintenance medications, the physicians used pretty much the same criteria to refill them every time: When was the patient's last appointment? When and what were their last labs? We decided to collect these criteria into a protocol that the nurses could follow immediately when the request arrives and the physicians could review and sign later.

Within 2 months of implementing this policy, we had reduced our turnaround time to less than 2 hours. This in turn greatly reduced our rate of call-backs from patients and pharmacies and consequently reduced our total phone call volume.

The protocol also served as an excellent way to track and schedule patients appropriately for their chronic disease follow-ups. The physicians make a point to prescribe medications in refill amounts to coincide with the allowed amounts on the protocol. At first, patients complained about having to come in "so often" for appointments, which let us know that they had not been coming in as often as they should have before we had the protocol in place.

The entire process is streamlined now and we all are happier: patients, pharmacies, nurses and physicians. It is also educational for the nursing staff; they have a much better understanding of medications, what they are for and how they are used now.

Posted at 12:59PM Nov 11, 2009 by Melissa Gerdes, M.D.  |  Comments[0]

Our implementation of virtual office visits

The first components of the medical home we implemented were a web site and virtual office visits. We chose MedFusion (http://www.medfusion.net) as our vendor because TransforMed paid for installation and the first two years of maintenance. The template for the website was structured and easy. My office manager fortunately had the skills to build the site. She spent 3 hours in training with the vendor and 12 hours building the site. Each provider spent 2 hours training.

For the virtual office visits portion of the site, we first had to establish the problems and topics for which we would offer virtual visits. MedFusion offered more than 200 types of virtual visit, with the type based on the patient's reason for the visit. The web software is set up to ask the patient to specify the reason for the visit and then ask a series of questions pertinent to that reason. That way it collects answers the treating physician can review later. Among the visit types offered were chest pain, abdominal pain and others we did not think could be dealt with safely without a face-to-face visit and exam, so the other providers and I started by reviewing titles for safety. We came up with a list of approximately 15 visit topics we thought would be safe and finalized the list by surveying the patients.

Here is the survey:

Dear Patient:

The Whitehouse Clinic will soon be offering "E-visits," This is a secure e-mail portal where you may receive care directly from your physician. You will be given a site address and password and will be able to select from a variety of problems, answer specific questions about your problem then receive advice or treatment from your physician. No visit to the office is required. We are interested in knowing some of your thoughts on this service before we proceed. Please take a moment to answer these questions so we can provide you with the best service.

1) For which of the following types of problems do you think you may use an e-visit? (Please circle your choices)

Cold/allergies
Constipation
Dental problem
Depression follow-up
Diabetes
High blood pressure
High cholesterol
Medication monitoring
Obesity/weight loss advice
Osteoporosis
Problems with sex drive
Sleep problems
Warts
Would never use an e-visit

2) Almost no insurance companies in our area currently pay physicians for this type of service (though insurance companies in other areas of the country are paying). Knowing this, how much would you be willing to pay for the convenience of an e-visit?

$50
$40
$30
$20
$10
None

Please provide any additional comment or thoughts regarding this service:

Thank you for your time.

We used the results of this survey to construct our program. We offer a dozen visit types (all of the above except "warts") and charge $20 per visit. The visits are very easy for patients to navigate and complete. They incorporate branching logic, so the questions asked are determined partly by the patient's answers to earlier questions. We found that the histories produced by this process are often more complete than those we would take in a face-to-face office visit. The physician can elect to "no charge" the patient if she simply provides advice or recommends that the patient come in for a face-to-face visit based upon the answers collected.

Utilization for the first 12 months was spotty:

As you can see, utilization started out rather low (our practice of 2.0 FTE family physicians treats 5,000 patients). It has continued to be low, and this service does not generate much revenue. In fact, annual maintenance fees for the website and virtual office visit service are $2280, so it hasn't even come close to breaking even. If TransforMed hadn't paid the set-up fee of $2,000, the financial picture would be worse.

We found that certain types of patients tend to use these visits: shift workers, cash-pay patients, and busy people. Sinus problems account for 90 percent of the visits. Next are depression and anxiety medication follow-ups. Some patients use the hypertension template for monitoring their blood pressure numbers.

Given the low initial response, we decided to promote this service heavily by specifically scheduling virtual visits with appointment cards. We have posted advertisements in all our exam rooms and lobby.  I also wrote an article in the local paper about the service, and we ran some ads. Despite all these efforts, this service is not highly utilized and not profitable. I think the main reason is that our office also provides open access scheduling and our capacity to see patients in the office is well matched with our panel size. Nevertheless, as patients become more comfortable with conducting their medical business on-line, utilization may increase.

Posted at 04:00PM Oct 30, 2009 by Bob Edsall  |  Comments[0]

Team spirit between visits

The medical home is all about continuous and coordinated care. One thing that means is maintaining continuity between our typical 15 minute visits. In fact, for people with chronic diseases like diabetes, hypertension, and asthma, this is where most of the care and for that matter, most of the illness resides. We all know that what we do as doctors 2-4 times per year in our 15 minute office visits does not impact these folks with chronic diseases very much. What they are doing, eating, drinking and watching during the time they are not in the office has much more impact than what we do in the office. The question becomes, how can we use our offices, despite being locked in fee-for-service arrangements, to assist our patients with their out-of-office, "life" care?

In our practice, through lessons learned in TransforMed, we have made between-visit care the domain of the nursing staff. This makes sense, since they are not bound by any fee-for-service arrangement; they are paid hourly. We incorporate the nurses in our visits from the very beginning, as important members of the care team. The patients get to know their nurse and hopefully become as comfortable with him or her as they are with their doctor.

At the beginning of each visit, the nurse checks in the patient following a protocol that begins with ascertaining the chief complaint, obtaining vital signs and creating a prioritized list of issues. The nurse then initiates a conversation regarding preventative care and advises the patient which studies are due. If the patient doesn't want to do a test, the nurse notes down the reasons. Next are immunization recommendations, followed by the most important question: "What is the goal of your visit?" We get the most valuable information in the answer to this question. The entire nursing process only takes 2-3 minutes per visit, but it helps build the patient's sense that the nurse is an important member of the care team. It also sets up the patient's expectations nicely to match with that of the physicians. We find that the visits go more smoothly with less disappointment and fewer "Oh, by the way..." moments as the doctor is exiting the room.

Between visits, our nurses return phone calls to answer patient questions, refill medications using a physician-approved protocol and inform patients of their lab and test results. (I'll have more to say about the refill protocol in a later entry.)  They get to know the patients, their family support systems, which home health agency they use, which pharmacies they use, etc. This background information is  valuable in making care personal and efficient. The patients are able to get more individualized care with a team, not just a doctor, taking care of their needs whenever they arise.

The nurses also do recall projects between visits, letting patients know when they are due for visits and other services and helping them schedule appointments into their busy lives. Since the nurses take ownership of this between-visit care, they can really see how the whole picture comes together and have more understanding of how people cope with their illnesses 24 hours a day, 7 days a week. At the same time, the patients come to feel that their care is truly continuous and coordinated, not just episodic and visit based. Everybody ends up with more team spirit.

Posted at 04:31PM Oct 20, 2009 by Melissa Gerdes, M.D.  |  Comments[1]

Real practice redesign

In many ways, family medicine is in decline. Physicians are working faster, seeing more patients, and getting paid less. There is more "hassle" with paperwork and insurance companies. The expense of running a practice is increasing. Patients have trouble getting timely access to care. Family physicians are retiring early and not being replaced as fewer and fewer medical school graduates train in primary care fields. Despite the doom and gloom, though family medicine does see a bright spot on the horizon: practice redesign.

The impetus for redesign comes from the 2004 Future of Family Medicine report. This report was read by many, accepted by some and embraced by a few. It was those few who started pilots and experiments in the transformative process. My clinic was lucky enough to be selected for AAFP's TransforMed National Demonstration Project. As part of the project, we worked for two years, from 2006 to 2008, to redesign. Why? Perhaps the best answer is a little something I found in a fortune cookie as we embarked on the study:

Even if you're on the right track, you'll get run over if you just sit there.
-- Will Rogers, US humorist & showman (1879 - 1935)

So, the first question is, are we on the right track? I think we are. It is amazing to think of all the things that have changed in the world since family medicine was conceived over 30 years ago. We have more specialists, more technology, better communications, and more time demands. It follows that in order to survive, family medicine will need to evolve. Initially, family doctors treated acute illnesses. Next, chronic diseases and the pharmaceutical explosion were added. Finally, preventative care was added. However, family medicine still functions for the most part on the same 15 minute point-of -service visit. Redesign efforts center around new models to accomplish all these tasks.

Next, are we sitting or moving? Moving, I think, but maybe too slowly. Change is always very slow, and pushing change is difficult without a major crisis. We are not quite at crisis point, but the signs that it is coming are there. To change is to take risks, something that many family medicine practices do not feel they have the reserves for. The redesign pilots embrace the change that is necessary.  Fortunately, many of them are now getting some funding.

Finally, which way do we go? The current redesign and medical home pilots are hopefully giving us a road map to follow. We must be cautious as we follow, however. We should learn from the mistakes of the early pilots and try not to repeat them. We should grasp for the low-hanging fruit and try components that have succeeded in the early trials.

Here are some "mover" sites for perusal:

• Taking Care of the Uninsured: A Path to Reform

• Bruce Hamory's presentation on the redesign of the Geisinger Health System

• CMS pilot programs

• The TransforMed web site

In this blog, I hope to be able to give you a sense of what we have done in redesigning our practice, why we've done it, and how it works. I hope to be able to offer you help in your own redesign efforts. And if you have good redesign ideas, I hope you'll share them. Nobody has all the answers yet. The best we can do is help each other keep on the right track and keep moving in the right direction.

Posted at 01:48PM Oct 02, 2009 by Melissa Gerdes, M.D.  |  Comments[0]