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Friday, May 7, 2010

Group visits

A number of practices in the TransforMed National Demonstration Project (NDP) implemented group visits.  Several practices did diabetes visits, and some did prenatal visits. The practices agreed that group visits greatly improved care outcomes and peer-to-peer support and learning for patients. They did, however, find group visits time-consuming. One practice estimated spending 60 staff hours in preparation for a 2 hour diabetes visit – probably far above the average, but something to think about.

Several years ago, before the NDP, I had experimented with group visits.  I was disturbed by how many of my female patients weighed over 200 pounds.  These were women under 6 feet, so none of them should have weighed that much.  From an EHR search of my 3000+ patients (of whom 75 percent are women), I found that 600 of them weighed over 200 pounds and 200 of them weighed over 300 pounds!  This fact was very distressing.  I felt that my 15 minute face-to-face encounters were not doing the job.  And, to be honest, counseling during occasional 15-minute visits alone is not the best way to help a patient lose weight and learn to eat better.

My office manager and I visited several exercise facilities in the area and were able to secure discount coupons for patients who attended our planned weight-loss group visits. We obtained dietary information handouts from a dietitian friend and BMI calculators from a pharmaceutical rep.  (For the record, my office manager and I spent about 10-12 hours combined to prepare, not 60!)  I then solicited patients for interest based upon office visit content.  I soon had a list of 12 interested patients. We scheduled the visit for a Friday afternoon when the clinic was usually closed.  Three of the 12 who had signed up actually came.  For the second group visit, I charged a “holding fee” of $10, and five of 10 signed up showed up.

I conducted the group as the only provider.  We calculated caloric requirements for weight loss for each person and reviewed general dietary principles, deciding as a group to follow a low-carbohydrate diet. Beginning weights were recorded, and two of the members formed a “walking group,” planning to walk together daily. The group had one follow-up visit, with modest weight losses of 3-4 pounds per member over 1 week.  The group decided they did not want to continue to meet and thought they could maintain the program on their own. I did not bill insurance companies, since weight loss counseling is a “never-covered” service.

The patients paid $10 for a 1 hour group visit.  In retrospect, this was a very low fee, and perhaps we would have had more participation if the fee had been higher.  We did not find this format to be any more successful in helping with weight loss than normal visits.  Most weight loss groups do work by accountability and money committed but charge much higher fees and have more intensive programming.

I have no current plans to schedule more group visits, although I might if I were to measure some clinical outcome that told me that individual visits weren't doing the job in helping patients live with asthma, diabetes, or some other chronic condition.

Though my experiment was not very successful, NDP practices collectively have a wealth of experience with group visits, and I'll benefit from that if I do decide to try again. Diabetes has been the most popular disease state around which to construct a group visit.  Peer education in patients with diabetes is powerful in encouraging adherence to lifestyle changes and therefore in promoting improved control of diabetes.  Group visits can work for a variety of different patient types, however.  Moreover, physicians can get paid for their work in a group visit as long as the visit incorporates one-on-one time with each patient and documentation supports the level of E&M code billed. 

The group visit set-up can provide a change in the daily routine of visit after visit.  The practice works more as a team, pulling in other staff members to do teaching and evaluation.  Many practices in the NDP networked with community providers, bringing in dietitians, dentists, or pharmacists as guest lecturers. If you think you might want to try a group visit, it's easy to learn more. The TransforMed web site provides a list of resources on group visits, the AAFP offers advice on implementing group visits, and Family Practice Management has published several relevant articles and tools, which you'll find in the "Access to care and information" section of the FPM's collection of Patient-Centered Medical Home Resources.

Monday, April 19, 2010

Why a registry?

What is a registry?  Many practices will be asking themselves this question as they move toward becoming patient-centered medical homes or just work to improve the care they deliver.  In its simplest form, a registry is a list of patients who share certain characteristics – all patients with diabetes, for example – with information on their status. To continue the example, a practice with a diabetes registry should be able to consult it to see quickly which patients are up-to-date on eye exams or have reached their LDL goals.  Most registries today are capable of tracking multiple clinical data points across many patients.  The AAFP offers a number of resources concerning registries, and Googling “chronic disease registry” will give you a plethora of additional examples and advice.

Why would a practice want to start a registry? Reasons vary. One practice may decide it wants to send reminder letters to all patients with diabetes who have not had a documented eye exam in the past year.  Another may want to incorporate reminders for eye exams into quarterly diabetes office visits.  One practice in the National Demonstration Project (NDP) used the CINA product to print a complete sheet of services due at each visit for each patient.  They used the sheet as a template to guide the visit and then gave the sheet to the patient to take home as a visit summary.  The practice was able to customize their registry to pull only the clinical information they were interested in knowing.

Registries come in different types with different functionalities.  The simplest ones, but by no means the easiest to use, are freestanding databases that require manual entry of all data; the work of keeping the registry up-to-date can make these challenging to implement. Probably the easiest ones to use are parts of EHRs and mine data directly from the EHR.  More complicated (and usually more functional) ones interface with the EMR, scheduling software, billing software and/or other databases and mine data from them.  The data identifies patients or groups who are due services related to their diagnosis codes.

Registries are only as good as the data entered or imported into them.  Most will import only structured data – data stored with each separate data point (e.g., A1C level) in the same "box" in each record.  Free text data, which many physicians are more comfortable entering, is not stored as discrete data points and therefore will not import easily into a tool like a registry.  Before you implement any sort of registry, make sure as much of the relevant data as possible is entered into your EHR as structured data.  Several of the NDP practices delayed starting registries because the technology was not really ready.  Many systems required the physician or staff to “double enter” data in the EMR and then again in the registry.  To read more about the implementation process in the NDP, see the two final TransforMed reports from the project evaluators: "Preliminary Answers to Policy-Relevant Questions" and the "More Preliminary Answers" follow-up report. 

What about practices that don't have electronic records? Registries can be done in Excel or even on paper.  Practices that saw the benefit of managing a disease state through their patient population jumped into doing this before computerizing. Typically, the practice chooses what clinical data it wants to track, then writes it down in an easily identifiable location in each patient’s chart.  Data points are collected into another file that is searched and acted upon periodically.  For example, say a practice wants to track influenza immunization rates in patients with diabetes.  Each patient with diabetes could have a yellow sticker on their chart.  When the nurse pulls a chart with a yellow sticker, she knows to go to the immunization flow sheet (the same in each chart) and look for the immunization.  (Examples of flow sheets are available in the FPM Toolbox).  If the influenza immunization has not been given, she gives it by standing order for the clinic.  If it has not been given, is contraindicated, or the patient refuses, she notes that. Then, an index card with the patient’s name and yes or no to influenza and the date is filed in a box.  At the end of the flu season, the practice can calculate compliance rates and decide how they want to handle immunizations the next year.  They could take the registry one step further and pull all the charts that have yellow stickers but do not have a card in the file and recall those patients. 

Building a registry, whether electronically or manually, takes time. If you're interested in starting, first decide on what data you will track and what your practice will do with the data. Start simple as in the examples above. Try to track too much data, and you'll be at it forever. It is nearly impossible to track all parameters available to a primary care practice. Then devise a way to structure the data you need at the point of data entry. When enough time has passed for you to have a reasonably complete data set, put the data to use. Generally, the output of a registry  is one or more reports that require some work to be useful. The practice decides who will work the list and how (e.g., by recalling patients overdue for services). Finally, don’t forget to take time to review the process and software for problems and ways to improve the next time. 

Friday, April 2, 2010

The importance of physician leadership

In most family medicine practices today, the physician is the boss.  This de facto leadership is given to the physician by his or her patients and staff.  How the physician executes this role is critical to facilitating practice redesign.  The importance of physician leadership was clearly demonstrated in the report of early lessons learned from the TransforMed National Demonstration Project (NDP). Physicians in the project learned that they had to closely examine their own attitudes and actions, transforming themselves into the leaders their practices needed before transforming the practices. That self-transformation often involved transferring some of their power to others. After all, since physicians are given the role of boss whether they want it or not, they have the power to give away pieces of that role.  This empowerment of others is critical in achieving practice changes and limiting physician burnout.

Changing the way a practice operates – implementing new workflows and processes – takes a project champion.  This champion is often the physician but could be any member of the staff.  The champion pulls together meetings and keeps the change process going. Delegation of power is critical in such situations.  It behooves the physician to evaluate others for leadership strengths and support their use of these strengths. The results can be gratifying.

Our practice had struggled for several years to improve our mammogram compliance rates.  We were able to improve to a point by reminding patients during their visits and scheduling mammogram appointments for them, but we could not push the rate above 50 percent.  We empowered a nurse in our office to design ways to improve our compliance rate.  The nurse, who had a special interest in breast health, distributed buttons to staff members so everyone would remind patients of the importance of having their test, thus enlisting the team.  Educational materials were placed in the lobby and examination rooms, thus broadly engaging the patients.  The nurses called patients to schedule their mammogram appointments.  A mobile unit visits the clinic twice monthly. Our compliance rate improved to 70 percent without physicians having to do anything.  That nurse was our project champion and was able to make the necessary interventions to improve our numbers.

Regardless of who the champion is, the underlying attitude of the physician leadership toward a project could make or break the implementation. This effects of this attitude can be very subtle. Physicians who are negative, angry, or overworked will transfer their negativity to other employees and lower morale and productivity.  Physicians need to realize that their behavior is being observed and mirrored all the time.  This can be a lot of pressure on physicians, but is an inevitable part of the job. 

The Fred Factor, by Mark Sanborn, gives an excellent account of the kind of behavior you would want to model for your staff.  Sanborn describes a postman named Fred, who has what most would consider a fairly mundane job.  But to Fred, nothing is mundane about his daily work. He tries to make others feel special, going the extra mile to serve them.  Doing special things for others makes Fred feel special himself. I try to "be a Fred" as much as possible. It is very simple and does not take much effort. Many would call this "leading by example." I also try to point out "Fred" behavior to others whenever I see it.

One day, my lab tech became aware of a scheduling conflict an elderly patient had between an appointment with a specialist and her hair appointment.  This patient was in for a simple blood draw, which would take the tech a few minutes.  However, the tech personally called the specialist’s office and the hair salon and rescheduled the patient’s appointments so they would not conflict.  The tech certainly did not have to do this; rescheduling was not a part of her job.  She did it because she is a Fred working in a Fred-supporting environment that I'm proud to take some credit for. When I witness staff members doing “Fred” things, I make a point to recognize them at a staff meeting or sometimes give a small token of appreciation, like a gift card. In this way, we can “spread the Fred.”

Leading through empowerment and modeling often require “personal transformation” on the part of the physician, as detailed in the "Initial Lessons Learned" section of the NDP report I mentioned above.  Practice facilitators often spent a large part of their time leading physicians on this deep personal journey during the NDP.  It is difficult for physicians to take a hard look at how their attitude and actions are affecting the others around them and then to have the courage to change for the better.  However, this process was demonstrated to be critical to the transformation of practices to medical homes.  More information is available in Family Practice Management, on Delta Exchange and on the Transformed web site.

Thursday, February 18, 2010

What is your practice's service philosophy?

This question is worth answering for your practice.  It should be a part of your vision and mission statements.  After all, each practice is essentially a business delivering services and sometimes products to customers.  Having – and practicing – a service philosophy is crucial to doing well.

We deliver quality, safety, and value very well in family medicine, so it is focusing on service that makes a practice special in patients' eyes. This focus comes naturally to many practices, I suppose. Physicians and staff who know their patients well and care about them will naturally tend to deliver personalized service. Other practices can probably use some work. We are a new practice, relatively speaking, with physician tenures being 10, 7, and 4 years.  The TransforMed National Demonstration Project taught us that this was an area we could work on some.

To deliver excellent service to patients, one first has to understand how the patients define excellent service.  This can be very difficult in a family medicine practice as there are so many different ages, genders, and types of patients. We ask our patients.  Nurses and physicians ask informally during visits and try to create a culture in which patients to be honest about what they think.  We survey patients.  Our favorite question on the survey is "what would make your experience better?"  We really want to know the answer to this question, because we believe we can always improve on service.  The best answers are sometimes deceptively simple, like when one patient told us the visit was great, but that we needed better magazine choices in the lobby.  That is simple to fix.  We thought more deeply about this answer, though: Were our patients waiting too long if they had time to think about our choice of magazines?

Experience as a physician and patient helped me to develop a service philosophy. Wait times are a huge dissatisfier to patients.  We focused on reducing our wait times by measuring cycle times. This can be done very easily by handing the patient a clipboard and asking him or her to record the start time for each part of the visit: check-in, nurse, physician, ancillary testing, physician return, check-out, etc.  Many practice management systems will do this automatically. Patients will keep us honest, though, as the timing probably matters most to them. Studying the results of such surveys can help identify bottlenecks to patient flow in the office. Efforts can then be focused on reducing bottlenecks.

For instance, we found that the cycle times for one physician were much longer than for the other two physicians in the practice. We began by having a frank discussion about what we were doing differently. We considered simply making the one physician's appointment times longer, but ultimately addressed the problem by pairing ourselves with nurses who would help with staying on time, streamlining and standardizing our check-in process.

Reading also helped me to develop a service philosophy. I highly recommend the book  If Disney Ran your Hospital: 9 1/2 Things You Would Do Differently, by Fred Lee. You might think that family medicine and Disney are an odd mix. We treat sick people, not people who are going on vacation. However, that is no reason not to try to give them the best experience possible. Consuming medical services is generally not a very satisfying experience for the average patient. But what if instead of making it less "unsatisfying," we worked to make it outstanding?  We can learn a lot from the way Disney does things to help us in medicine. I have my nurse ask each patient: "What is the goal of your visit today?" Answers range from serious to facetious. One patient with a cough may want to make sure it is not cancer, while another simply wants to be well enough to visit their grandchild this weekend.  Knowing the patient's goal helps us tailor the care and deliver that "outstanding" experience.

Wednesday, December 9, 2009

The advent of the 'QuickSick' visit

One day in early 2004, I was trying to schedule myself a dental appointment. Scheduling the appointment had been on my to-do list for a week. It was difficult to make enough time for this simple call. Finally, I actually had two minutes to sit down for lunch at 12:58 one busy day in the office. I called the dentist. They were, of course, also at lunch. Their answering service could not schedule my appointment. Since their office hours were the same as mine, but their lunch hour was twice as long as mine, I was thinking I needed a new dentist. Then it suddenly dawned on me: My patients were having this same experience when they called my office for an appointment. We needed to do something about this.

Immediately, we got an informal meeting together with staff. We decided that my nurse and I would stagger our lunch with the other physicians and their nurses, so that our office would never “close” during the middle of the day. While we were open, we would never roll phones to the answering service, which could neither schedule visits nor answer questions. We have done this ever since.

At the time, we were having a horrible time accommodating the predictable swell in demand for acute sick visits during the winter cold and flu season. We were not quite ready to hire another partner, but wanted to be able to handle this seasonal variation in demand somehow. Eventually, after consulting management literature and not finding a good solution, we came up with what we've trademarked as the QuickSick visit.

Basically, a QuickSick is a focused office visit dealing with the essentials of a single, upper respiratory problem; it's billed as a 99213. The visit can take as little as 5 minutes. We built a template in our EMR (Centricity) that includes a check-box history, which the nurse completes along with obtaining vital signs. Next is a check-box physical, which the physician completes after reviewing and adding to the history. Finally, the system produces a printable bill and an assessment and plan form complete with quicktexts and check-box advice for documentation. After all, I pretty much tell patients with strep throat to care for themselves in exactly the same way every time.

When a patient calls with a problem that might be appropriate for a QuickSick, the receptionist follows a set script for arranging the appointment.

QuickSickTM scheduling: sample script
October 12, 2005, updated 1/2/08

Patient calls, requesting same-day/next-day appt.

  1. Get name, age (no one over 65 yrs of age), established patient.
  2. Get symptoms; must be upper respiratory (e.g., congestion, eye, sore throat, cough, fever)
  3. Ask if they would like a QuickSickTM visit – a 5-minute visit designed with their busy schedule in mind – to take care of this illness only.
  4. If, so, schedule in designated QS spots same-day or next day
  5. Remind them that they need to be on time, since as many as 12 ill people may be seen over the noon (or applicable) hour and we want everyone to be able to be back to work on time. Remind them to bring their insurance information/payment method.

On arrival for a QuickSick, the patient is given a copy of an explanatory letter. We have received tremendous positive feedback on this service. Patients now call and ask for a QuickSick visit by name. My partners all use them. We were even written up in the New York Times a few years back for the concept.

We all love the concept of these visits. We typically allot 3 per 15 minute time slot around the noon hour. I do mine between noon and 1, while my partners take 11 to noon and 1 to 2, respectively, and we all do them at 4:30. This matches up beautifully with patient needs. Working patients can run in and out in 30 minutes or less. Children who become ill during the day at school can always be seen the same day. Most days we do not book all of these visits (we could see 15 of them in a day, theoretically), but as long as we book at least 5 (and we always do that), we are not losing any spaces.

We feel this type of visit offers the busy “consumer-minded” patient an alternative to retail and acute clinics. They are still seen in their medical home, in the context of their whole person and with their medical history. This comes in handy for more complex cases, like the time a QuickSick patient with strep throat also happened to be in new-onset atrial fibrillation with a rapid ventricular response. She was easily transported by ambulance to the hospital, and I went right along with the rest of my QuickSicks.

The QuickSicks also ended up being an excellent infection control measure, quite by accident. With so many flexible appointment slots open per day, the “sick” patients tend to cluster together in the waiting room. The rest of the day, the waiting room is full of “non-sick” patients.

Wednesday, November 11, 2009

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.

Friday, October 30, 2009

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)

Dental problem
Depression follow-up
High blood pressure
High cholesterol
Medication monitoring
Obesity/weight loss advice
Problems with sex drive
Sleep problems
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?


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:

 Number of Visits
 January 2007
 2 $ 30
 February 8 $180
 March 4 $ 80
 April 16 $320
 May 9 $180
 June 6 $120
 July 0 $   0
 August 0 $   0
 September 0 $   0
 October 2 $ 40
 November 7 $140
 December 9 $180
 Totals 63 $1,270


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.

Tuesday, October 20, 2009

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.

Friday, October 2, 2009

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:

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.

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About the Author

Melissa Gerdes, MD, is a family physician practicing at Methodist Family Health Center – South Arlington in Arlington, Texas, and former president of the Texas Academy of Family Physicians.

Note: This blog is no longer updated; this is archived content.

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Real-Life Practice Transformation is a Family Practice Management (FPM) blog. However, the views expressed here are those of the individual authors. They do not necessarily reflect the opinion of FPM or the AAFP. The FPM blogs are not intended to provide medical, financial or legal advice. For more information see Terms of Use.