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Self-Directed Practices - First Year Milestone Report

Meet the Self-Directed Practices of the NDP...

The point is so cliché that it almost bears no mention: change, even when it's for the good, is hard.  And for the last year, the facilitated practices of the NDP have lived this adage with stories of struggle and success.  How do you implement Advanced Access in a practice that is already booked 3 months out? How do you determine ways to become more efficient when you don't even have to time to eat lunch? How do you empower staff who may not want to be empowered?

None of the above challenges are easy to tackle, even with the help of a skilled and knowledgeable facilitator.  Imagine trying to accomplish such tasks with no outside help at all, completely "self-directed" in the pursuit of progress.  This is the scenario faced by most of the nearly 94,000 Family Medicine practices in the US today...including the 15 self-directed practices of TransforMED's National Demonstration Project (NDP). 

Thirty-six practices were originally chosen for the NDP from a field of more than 300 complete applications.  Next, following the "best practices" of research, the 36 were randomized to two groups: the facilitated practices and the self-directed (control) practices.  Over the two-year project, the facilitated group receives discounted technology, access to consultants, and the focused support and assistance of a skilled facilitator. 

The self-directed group represents the vast majority of Family Medicine practices who are trying to make changes and implement technology without outside assistance.  One of the goals of the NDP is to ascertain the extent, if any, to which is facilitation necessary to implement change. 

Earlier this summer, physicians and office managers from 12 self-directed practices gathered together at the Minary Conference Center in Squam Lake, NH for a weekend retreat of learning, sharing and reflection.  The self-directed practices themselves organized the retreat, developed the agenda, sought external funding, and served as the retreat speakers and learners.  Topics ranged from the practical and pragmatic (Advanced Access, electronic medical records, practice finances) to the philosophical, such as a critical review of the Future of Family Medicine report and its implications and meaning for each individual Family Medicine physician.  The following report highlights a few of the presentations and discussions as witnessed at the retreat. 

Electronic Health Records

Every practice attending the retreat had an EHR in place.  The two practices that had recently implemented their EHRs (within the past 2 years) recounted the difficulty of the transition, from the arduous selection process to the sometimes drastic changes in work flow.  All practices agreed that the greatest ongoing struggle was finding enough time to master their EHR and really "make it work for them" while still trying to see enough patients.  Other enormous time-eaters included training new staff on the system, helping non-computer-users adapt, and dealing with constant "glitches" and upgrades. 

“The group agreed that the time commitment seemed to peak at the Striver level, where the EHR seemed to be adding rather than reducing work. 

Physicians urged each other to push through this difficult phase and make it to the "next level"...”

Despite the challenges, the practices acknowledged the enormity and importance of taking this step, as many of the New Model components depend on having an electronic infrastructure in place.  Dr. Bill Harrington of Sommerville Family Practice (Midlothian, VA) presented statistics on the overall efficiency and cost of EHRs.  He remembered an article that noted the different levels of EHR users: Viewers, Basic Users, Strivers, Arrivers, and System Changers.  The group agreed that the time commitment seemed to peak at the Striver level, where the EHR seemed to be adding rather than reducing work.  Physicians urged each other to push through this difficult phase and make it to the "next level", where the EHR seemed to actually enhance workflow and efficiency and improve quality of care. 

The group shared tips on maximizing the EHR.  Although they are time consuming to create, the group agreed that templates customized for each physician's style is a feasible way to marry the concepts of a personal medical home and standardization across the practice. 

Instant Medical History/Patient Portal/Email Communication

The next step after a practice goes electronic is to educate and include the patients.  Many self-directed practices have already done this, with Instant Medical History(IMH), patient portal, and/or email communication.  Dr. Harrington praised the ability to do simple email communication with patients via his EHR (not a reimbursed, encrypted e-visit). He says such communication saves daily phone time with patients – he saves at least 30 minutes and his staff up to an hour each day.   Dr. Harrington also spoke highly of the IMH program – patients sit in his practice and complete the detailed history.  Dr. Harrington said that surprisingly, the computer opens up lines of communication that might not otherwise exist.  For example, the physician can say to the patient, "The computer seems to think you may have an eating disorder, what do you think?"

Dr. David Loxterkamp from Seaport Family Practice (Belfast, Maine) had positive reports from the recent addition of a web patient portal at his practice.  He said a big part of preparation was patient education, and the most effective way of promoting the service was during the patient visit, when the provider could literally walk the patients through the sign-up step.  He listed the potential benefits of a patient portal as accessibility, portability, and transparency.  He cautioned that these could also be potential problems; i.e. , with patients now seeing their chart and doctor's notes, the chart completion needs to be timely and accurate.  Dr. Loxterkamp advises others to write out medical acronyms into plain English for the patients. 

Finally, the practices discussed e-visits, both how to do get them started and how often they are currently being used. No practice reported receiving insurance reimbursements for e-visits resulting in a mixed approach on how to deal with this – some charged cash for such visits whereas others just offered them for free. Although some physicians were frustrated by incomplete templates or the inability to integrate with the EHR, the largest deterrent seemed to come from patients: many seemed reluctant to use e-visits which could be a result of lack of knowledge or comfort using this new technology or could reflect a preference to see the doctor in person.  

Advanced Access (Open Access)

Almost every SD practice is practicing some form of Advanced Access scheduling (also known as Open Access, or Same Day Scheduling).   The extent to which a practice can keep their schedule "open" depends on the age of the practice, patient volume, number of providers, types of patients, and even stage of EHR implementation.  Dr. Ed Schwager of Carondelet Health Network (Tucson, AZ) said it took a complete paradigm shift at his busy, 6-provider practice. He suggested the following steps when first implementing same day appointment scheduling:

1. Educate staff.  Dr. Schwager says there was a great deal of initial uncertainty among staff.  Some even laughed at the idea of telling patients to call the day they wanted to come. 

2. Educate patients.  Patients were very skeptical; they just couldn't believe they didn't have to wait 4 months for an appointment.  It took significant time for patients to grasp the notion of calling the "same day ".

3. Educate physicians – Dr. Schwager says this step was perhaps the most important!

a.  Change the perception that the only "good" doctors are ones with long waiting lists of patients who will wait forever to come in. 

b.  Take that leap of faith that the patients WILL come… that you won't go broke using Advanced Access scheduling.  Dr. Schwager says, "you need to have the ‘If you have it, they will come' mentality. "

Dr. Schwager added that Advnced Access has worked so well, the practice's no-show rate has dropped to 3% and the day is completely booked by 8:30am. 

As the self-directed practices discussed the challenges and benefits of the "imperfect science" of Advanced Access, a common question arose: "How to best deal with patients who WANT to schedule ahead of time?" Many of the practices with an older population noted that those patients preferred to have an established time and date for their follow-up appointments. 

Most self-directed practices have adopted some of flexible, hybrid approach of same day and pre-booked scheduling in an effort to best fit their patient population.  As Dr. Kim Leatham of Virginia-Mason Winslow Clinic (Bainbridge Island, WA) pointed out, "Part of providing patient-centered care is seeing the patient when they want to be seen. "

Care Teams: "Care is a Team Sport"

“Dr. Leatham recommends evaluating every clinical care process and asking yourself, "From the patient perspective, does your office CARE? (Check, Activate, Reinforce, Engineer)?"”

Dr. Leatham also spoke of providing comprehensive, patient-centered care by using and involving more of her staff.  She described a day-long brainstorming retreat that resulted in the establishment of care team "flow stations." The three physicians team up with three MA's and share an RN and pharmacist in order to create highly functioning "microsystems" within the practice.  Currently, the care team focus is diabetes and depression.  The RN does the education and coaching with the patient, the pharmacist checks over the medication, and the physician comes in the last 5-10 minutes and oversees the entire encounter.  With proper documentation, the visits are coded as 99214s and the patients report being very satisfied with their care.  The Virginia-Mason office manager reported that staff seems more satisfied as well, as even the MA's are taking on greater roles.  Dr. Leatham recommends evaluating every clinical care process and asking yourself, "From the patient perspective, does your office CARE? (Check, Activate, Reinforce, Engineer)?"

Chronic Disease Management/Group Visits

Dr. Robin Kollman of the Kollman Clinic (Dover, OH) and Dr. Lou Kazal of Dartmouth-Hitchcock Family Medicine (Lebanon, NH) spoke about the changing role of the Family Medicine physician as THE coordinator of care in chronic disease management (CDM).  Dr. Kollman distributed CDM literature ( and seemed to echo the sentiments of many when he said, "CDM is not something that we older docs were trained to do in medical school; only recently has it come to forefront and we have to realize we're not just treating single patients, but populations of patients. "

Dr. Kazal explained that group visits is one way his practice is treating its diabetic population.  Before even starting group visits, he worked actively to "raise consciousness" in the practice about the importance of standardization in CDM.  The practice developed standards of care and standing orders for certain things (e.g., HBA1C), trained staff to expand their repertoire of skills, and put up "data walls" in each pad for ongoing documentation and reminders.  Dr. Kazal recommends the website as a great tool to find information on rethinking the way your practice tackles CDM. 

“Dr. Kazal says the group visits are an ongoing project, but the feedback from patients is overwhelmingly positive – so positive, in fact, that Dr. Kazal says the practice is doing group visits for enhanced patient care, not access reasons.”

Once the practice was ready for group visits, a significant amount of planning and fine-tuning went into the project.  For example, it took several visits to figure out the best way for Dr. Kazal to do a diabetic foot check while the guest speaker was lecturing (he circulates the room checking feet, only speaking when necessary, the patients know the drill).  Dr. Kazal says the group visits are an ongoing project, but the feedback from patients is overwhelmingly positive – so positive, in fact, that Dr. Kazal says the practice is doing group visits for enhanced patient care, not access reasons.  Both Drs. Kazal and Kollman noted that successful CDM requires adopting another paradigm within the practice: truly embracing teamwork and enabling staff to take on more responsibility in the patient care. 

Ancillary Services/Community Involvement

In a true entrepreneurial spirit, the Romeo Medical Clinic (Turlock, CA) offers a host of ancillary services which, by design, "subsidize" the type of Family Medicine that Dr. Mike Romeo and his partners want to practice.  For example, the practice offers "Camp California Fitness, a healthy lifestyle camp for adolescent females; "Healthy U," a service that sells corporate health program to local businesses; and an aesthetic medicine program (Botox, etc.) on-site at the practice.  Dr. Romeo says that these ancillary, "fee-for-service" (no insurance) programs allow him and his partners to spend more time with their patients because they do not feel the productivity/financial crunch to see as many patients as possible. 

Dr. Romeo adds that the ancillary services do well because the practice marketed itself like any new business (went door to door, handed out flyers, etc.) and because the practice makes a point to stay very involved in community life, "just like the old-style family docs. "

Since prevention and wellness is a huge thrust of the practice, the physicians and often staff are present at any community wellness or fitness event, including a Family Fitness Day hosted by the practice.  The physicians decided not to take on hospital work so they could serve as team physicians for all the high school and community sports. 

Dr. Romeo's mention of Botox led to spirited discussions on the benefits and pitfalls of offering such services.  Dr. Cynthia Kizer of Olio Road Family Care (Fishers, IN), one of the few physician at the retreat still doing OB, said she currently doesn't do aesthetic medicine, but her female patients constantly ask her about it.  Other physicians cited similar scenarios, and many said they may consider such services in the future, because 1) their patients ask for it, and say they prefer it from their Family Medicine doctor, and 2) the financial advantage might decrease the pressure to see so many patients a day. 

What does transformation look like?

The presentations and discussions on the nuts-and-bolts of practicing Family Medicine in a changing world were balanced out by thoughtful and reflective discussions on what it means to work in Family Medicine, the direction of Family Medicine in the 21st century, and what a truly transformed Family Medicine practice looks like. Thoughts were varied and vigorous, poignant and passionate, and much talk centered on the Future of Family Medicine reports and the work of Dr. Barbara Starfield, whose research has demonstrated that continuity of care with a primary care provider actually does make a difference in the overall health status of a nation. (See the end of this article for more links.)

While the depth of such discussions are beyond the scope of this article, one overarching thought held true: the heart of Family Medicine is the value it puts on the relationships with patients.  Family Medicine is a whole-person relationship… two people coming together, physician and patient… and the sum is greater than the parts. 

Dr. Loxterkamp summed it up in this way: "Once the relationship is there, the trust… there is the potential for numerous transformations to occur daily, perhaps in a very small way.  It comes down to one doctor, one patient… fundamentally, the human relationship.  THAT is the core of Family Medicine.  That is why it matters. " Dr. Kip Bidwell of Henry County Family Physicians (Napoleon, OH) added to the statement, reminding each participant why they are there: "It's one doctor ENJOYING taking care of one patient.  We can't forget the joy in that relationship.  It's why we do what we do.  "

Next Steps

The retreat participants returned home to their busy practices, home to another year of change and its subsequent challenges and successes.  The NDP self-directed practices will be highlighted in future newsletter and website stories so that others can learn from their experiences as true representatives of today's pioneers in Family Medicine. 

Web sites referenced in this article:

» Instant Medical History



» Dr. Barbara Starfield's bio
   at Johns Hopkins Bloomberg School of Public health



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