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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.

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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.