It takes work to design an office with patients at the center
Physician-managers tackle challenges of shifting workflow patterns, retraining staff and getting other physicians on board with change
From the May ACP Internist, copyright © 2008 by the American College of Physicians.
By Bonnie Darves
When asked about the effort required to equip Physicians Health Alliance for greater patient engagement and more proactive diabetes care, John Guzek, FACP, sighs in the manner of someone who’s just done some very heavy lifting, and then laughs.
“We used a multi-step process, but what was amazing was how we had to start reconstructing the process before we could actually start reconstructing the process,” recalled Dr. Guzek, chair of quality improvement for the 55-physician Scranton, Pa., multispecialty group.
“We had a bunch of problems that made it difficult to assess how well or poorly we were doing” with diabetes care, he continued. The electronic health record (EHR) program didn’t generate useful reports, and wasn’t much help in PHA’s attempt to create a diabetes registry.
Like Dr. Guzek, many physicians find that one of the biggest hurdles to implementing patient-centered care is not the patient but the office. Problems range from shifting workflow patterns to learning new systems to getting physicians on board with change. Dr. Guzek and two other practices shared how they overcame these obstacles and ultimately created a better system for both patients and physicians.
Worth the trouble
At PHA, the data-gathering exercise turned out to be a bit of a Pandora’s box. “We had 3,500 patients who supposedly had diabetes, but 900 weren’t on any diabetes medication. And we found a couple hundred patients who were on diabetes medication, but who didn’t have diabetes listed among their problems,” Dr. Guzek said. “It was a real eye-opener.”
As was the physicians' resistance factor. “It was an adventure, just trying to get the physicians to cooperate. We had a bunch of physicians who had come from independent practices and were used to doing their own thing,” he said. Yet, when the physicians and staff met to identify process changes to improve and standardize care, 80 suggestions emerged.
Once PHA got over these initial hurdles, the practice’s process-improvement wasn’t exactly a slam-dunk. But it was moving forward.
The group now uses patient-specific diabetic profiles that show patients’ (and physicians’) progress toward meeting targets, and generates a to-do list for patients to better manage their disease.
For example, PHA modified its EHR system to color-code “danger-zone” vital signs and generate pop-up prompts for physicians during the visit if new lab results are available.
If a patient’s blood pressure is too high a pop-up might ask if the physician wants to add medications. When patients on insulin check blood sugars more than once daily, prompts remind clinical assistants to upload the patient’s home glucose meters so that physicians can adjust insulin based on pattern recognition and graphed data.
Similarly, nursing staff now receive reminders for needed checks. If the patient is due for a urinalysis or foot exam, the nurse receives a prompt to collect the sample or ask the patient to remove her socks and shoes, which saves time for the physician.
“The new system slowed things down at first, but now it’s easier—we don’t have to look in several places [for the information] before the patient comes in.”
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“The new system slowed things down at first, but now it’s easier—we don’t have to look in several places [for the information] before the patient comes in,” said Melissa White, a medical assistant who has been with PHA for six years. “It’s all in one place. And the patients definitely pick up on that—that we don’t have to ask them a lot of questions.”
As an added benefit, Ms. White noted, the patients have become more compliant about getting their tests done. “We’re not chasing them down anymore,” she said.
Low-tech interventions
On the low-tech end of the scale, internist Saleem Memon, MD, has modified his practice using outside resources to improve heart failure management and enlist patients in the effort. His two-physician practice, Grays Harbor Internal Medicine in Aberdeen, Wash., has implemented an education and self-management program developed by the oxygen therapy provider Lincare. The company sends educators to patients’ homes to instruct them on important self-care, such as blood pressure and heart rate monitoring, and weight changes and diet. Patients receive a log to complete daily and share with the practice.
The simple log book bridges communication between Dr. Memon and his patients and provides key chart data efficiently, freeing up physicians and nurses to handle other patients’ needs. “I look through the log book and if I see variations—in weight, for example—I ask what happened, and I have the patient to provide the information. Then I ask what they would do next time,” Dr. Memon said, and provides explicit instructions for adjusting medications accordingly. “The log gives us information, but more importantly, it makes the patients feel cared for when we show an interest in their numbers.”
Looking over the log book means that Dr. Memon spends an extra five minutes or so on patient visits than he used to. But the change has saved time in other areas. Log use—more than half of Dr. Memon’s 50 heart failure patients are on the program—has vastly improved patient adherence to treatment and significantly reduced hospitalizations, Dr. Memon notes, making his schedule more efficient.
“One patient with ejection fraction of 30% used to end up in the hospital two or three times a year,” he explains, “but that’s only happened once in the last two years.”
Similar gains have occurred with other patients, and all those on the program are faring better, at least psychologically. “They really do think that they are controlling their disease more actively now,” Dr. Memon said. “They really like this program.”
Time investment pays
Bob Mead, MD, president of Bellin Medical Group in Green Bay, Wis., makes no bones about the challenges internists face when reconfiguring their practices for supported self-management.
Bellin uses patient-directed goal setting and associated action plans, in tandem with frequent post-visit staff telephone check-ins with patients to gauge goal progress—both time-consuming activities that required staff and physicians. Staff engaged in role playing before rolling out the new model.
Bellin also swapped the usual order of business with regard to laboratory testing, so that patients’ labs are done and results in before they arrive for their visit. (Some patients are so engaged now that they request their lab results before they come in, Dr. Mead noted.)
Those substantial modifications made for some “interesting times” among staff during the adjustment phase, Dr. Mead said.
Staff members were sometimes uncertain about who had done what with which patient or chart, resulting in overlap and the occasional omission at first. Physicians also found adjusting their workflow more difficult than expected, and had to add more time in the exam room for the goal-setting session.
“Any time you make a major change, you need to have frequent meetings to see what needs to be modified and to give each other feedback,” Dr. Mead said, “to ensure that the changes you’re making stick.” Those meetings needn’t be long, he added.
One such meeting, for example, led to Bellin’s development of a diabetes flow sheet that enables care-team members to log and track vital lab and screening data—including, among others, average glucose levels and checking frequency, weight and smoking status, blood pressure, kidney function, foot and eye exam status, and education and dietician consults.
The good news, Dr. Mead said, is that the front-end time investment has paid off. “Having the labs ahead of time and the charts prepared the night before has saved staff a lot of time on the back end. There are far fewer phone calls now,” to patients or from them, he said.
“Reorganizing the visit and getting patients more involved is saving us time,” he adds, as well as boosting morale as the “ownership changes … from the physician to the patient.”
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