Preliminary Answers to Policy-Relevant Questions
From the Early Analyses of the Independent Evaluation Team of the National Demonstration Project of TransforMED
by The Center for
Research in Family Medicine and Primary Care
Elizabeth E. Stewart, PhD (NDP Qualitative Analyst)
Carlos R. Jaén, MD, PhD
Paul A. Nutting, MD, MSPH
Benjamin F. Crabtreee, PhD
William F. Miller, MD, MA
Kurt C. Stange, MD, PhD
NOTE: This information was derived exclusively from analysis to date of the experiences of the NDP practices by members of the independent evaluation team. There is also strong evidence (see interim Report to the Board) that the NDP practices were exceptional, and not a random sample of family practices in the US. As the evaluation team we are releasing these findings in the hope to illuminate current policy questions based on our observations. Formal data collection and analyses continue and final analyses will not be available until early 2010.
Q. Is it easier for practices to provide chronic disease management if they have a self-populating disease registry integrated within the EMR?
A. Yes, we were beginning to see evidence of this by the end of the two-year demonstration project. Some of the practices themselves reported a real difference in how they are providing care, and the data indicate many were starting to take a more proactive, population-based approach to their patient panel rather than just reacting to whatever walked through the door that day.
Implementing such a product is NOT a plug-and-play action; practices are dependent on the EMR companies for upgrades or rely on complicated workarounds to make one piece of technology talk to another. But when the physicians finally have the registry in place, particularly one that also gives point-of-care reminders, most are both delighted and humbled with the results (quotes from NDP physicians below):
- "I thought I was doing a good job with my diabetics... this was a real eye opener!"
- "The registry has completely changed the way I approach the patient visit."
- "The registry has been a win-win situation... I can't believe we used to practice medicine without it."
- "Vaccines are just flying off the shelves now. We are finally doing preventive medicine the way it should be done."
Some practices will go to great lengths to develop a registry, even doing double-data entry or using workarounds and outside resources to track certain populations. But the majority of practices, particularly independent practices without an IT department, will need self-populating registries as part of the EMR. The technology aspect needs to be more seamless, because the real work for the practice comes in developing effective workflow procedures that make review of the data and follow-up actions a regular part of patient care.
Finally, it should be noted that just having a registry in place – just the technology piece - does not guarantee effective population management. We have seen examples of this. This is because within the medical home concept, all the pieces are interdependent and interconnected, and the ability to use the registry effectively depends on many other pieces of the puzzle, especially the level of leadership, teamwork and communication within the practice. On the other hand, if a practice has those fundamentals in place, and then implements the registry, they more often seem to have the ability to really USE the registry to proactively manage their chronically ill patients. For the most part, these are the doctors who say the registry has changed the way they practice medicine.
Q. What has been the experience of rural practices trying to implement an EMR and related technology? Can they do it? Are they successful?
A. Our data demonstrate that the small and/or rural practices are actually the MOST successful at implementing technology. At the end of the demonstration project, only 2 practices out of the 31 remaining had not implemented an EMR, and those two practices belonged to large systems. Every rural, small, and independent practice had successfully implemented an EMR at the end of the NDP. Furthermore, it appears at this point that the small and/or rural practices were more likely to implement additional health information technology such as patient portals and disease registries. Below, some data points on the 31 remaining practices:
EMR: Every rural practice in the project successfully implemented EMR. Every small practice (≤ 4 physicians) successfully implemented an EMR. Many of these rural and small independent practices had an EMR in place prior to the start of the NDP.
Registry & Patient Portal: More than half of the practices (17) implemented a portal, a registry, or both over the past three years. Of those, 82% (14) were either small, rural, or both.
- Small practice breakdown: 76% (13 out of 17) are small, privately owned practices.
- Rural practice breakdown: 41% (7 out of 17) are rural practices. Of those 7 rural practices, all but one are small and privately owned.
Small and/or rural practices may be better positioned to adopt technology because they are usually very nimble and self-sufficient. Also, the adoption of technology has usually been their own decision, not thrust upon them, so it is viewed as a personal investment. Because the private practices do not have the support system of a large system, the adoption of technology is viewed almost as a survival skill. It represents a critical way to stay connected to the outside world, especially in a rural environment.
These practices often develop very innovative ways to adopt the technology and use it to increase efficiency and promote better patient care. The personal investment in the technology is evident as they invite the patients to participate when appropriate such as patient portals. Thus far, most practices have not seen a return on investment in a strictly financial sense, but they say they are very optimistic about the savings in staff time (e.g., the portal - emailing labs back instead of calling) and the expectation of better quality care (e.g. – the disease registry).
Consider the case of one solo, privately owned rural practice in the demonstration project. The practice started with an EMR but nothing else. In less than three years, the practice had implemented a bi-directional lab interface; e-prescribing; a patient portal that allowed patients to view their labs and parts of their chart and conduct HIPPA-compliant email communications with the nursing staff; and two registry systems, one which allowed detailed point-of-care reminders on all patients and the other which ran registry reports on the five most common chronic conditions. This practice received some assistance from the TransforMED project team and some assistance from a state insurance quality improvement program. In this case, the modest assistance yielded tremendous results in the practice's ability to accelerate their use of technology.
Q. What are the primary challenges facing medical practices as they implement EMR and other forms of HIT?
A. There are many challenges, among them three stand out.
FINANCIAL: Some practices – especially private practices – may need financial assistance in purchasing EMR and related technology. While the practices of the TransforMED demonstration project were able to make massive changes with little or no financial assistance, these are exemplar, highly motivated practices. For the many practices operating on a very thin margin, tens of thousands of dollars for an EMR is simply not an option. And purchasing the EMR is simply the first step – like all technology, it is difficult and disruptive to implement, and requires regular maintenance, repairs and upgrades.
OPERATIONAL: Simply buying a practice an EMR and plunking it into place is a recipe for disaster. The EMR changes nearly all aspects of the practice workflow and for nearly every individual in the practice. Many physicians in the TransforMED project reported it took a minimum of two years to really "cross the hump" with the EMR and even longer to start learning and using all the available features. Our data show that practices can use assistance in the following areas:
- Teamwork & Communication: the EMR often changes the roles of clinicians and staff and changes the way they communicate with each other. Without a strong foundation of understanding of new roles, things will get missed and the EMR will create more work, not less.
- Redesign in workflow and even office physical layout: the EMR is like a new member of the practice. Exam rooms may need to redesigned to accommodate a place to put the computer, physicians and MA's need to figure out who will enter what data in the computer, etc.
- Patient Engagement & Communication: the EMR and related HIT can represent an opportunity to engage the patient further in the care, but only if physicians have the time, space, training and encouragement to do so. Without this, the EMR is often seen as an intrusion and detriment to the patient encounter.
LACK OF INTEROPERABILITY: Lack of interoperability, both within and outside the practice, is a major challenge and source of frustration. There are hundreds of different EMRs and none of them are designed to 'talk' to one another so seamless transfer of data from one physician to another is limited if not impossible. Nearly all the practices in this demonstration project cite examples of how their quest for a paperless office can actually result in more work because so many outside sources of information (e.g., a specialist) still use paper or an incompatible EMR, meaning the practice must adopt the extra steps of scanning the document and file correctly within their EMR system. Furthermore, technology within each practice may not 'talk' to one another either. One practice in this project tried unsuccessfully for two years to integrate a stand-alone disease registry with their EMR, which was not cooperative because the company hoped to create their own registry someday. This is an example of the many external factors outside the practice's control which can be major stumbling blocks to transformative change.
Q. Is implementing HIT enough to transform a PC practice into a medical home? What other components are needed and why? How are these components connected?
A. Implementing HIT alone is clearly not sufficient to transform a practice to a PCMH. The PCMH represents an innovative and exciting national conversation that melds core primary care principles, relationship-centered patient care, reimbursement reform, new information technology, and the chronic care model. No single component is sufficient to achieve a medical home.
While HIT can play a critical role in the medical home, and may support development and maintenance of the other PCMH components, technology alone is clearly not sufficient for the practice transformation. There are examples of practices in the NDP that have all the right HIT "pieces" in place but they are not a medical home – not by our independent observations nor by their patients' reports.
Q. What type of support/resources, if any, do practices need as they attempt to make transformative changes? Do they just need more money?
A. FINANCIAL: The NDP practices did not receive direct financial support and were able to make tremendous progress in implementing the NDP model components. However, the NDP practices were highly motivated and many had already implemented many model components before starting the NDP. Going forward, some practices may need financial and other kinds of support. Purchasing an EMR and related HIT is costly in both equipment and time spent for training and implementation. Most other changes cost in terms of staff and physician time – e.g., an hour spent in staff meeting instead of seeing patients. Most (if not all) of the practices in the demonstration project declared positive benefits from such meetings including improved efficiencies and enhanced fiscal oversight. However, getting practices who are used to a daily treadmill of seeing patients to intentionally stop and meet/discuss/reflect could be a challenge without some kind of financial support or incentive.
FACILITATION: Not all practices will want or need facilitation, but our data clearly show that for some practices, facilitation was crucial in helping them build the foundation of a high-performing, high-functional practice with the adaptive capacity to take on the many successive changes required in the NDP. Some practices will require external assistance and support as they attempt transformative changes. Our data indicate this assistance is very different from simply consulting where practices are told to follow a protocol or complete a checklist. The type of assistance required in some practices involves working to strengthen the leadership and relationship infrastructure of the practice
"Most organizations will benefit more from evaluating and working on themselves, you know, learning how to do things for themselves, rather than having a consultant come in and say 'do this do that.' It is MUCH more beneficial to have to figure things out for yourself, figure out how to do things better as a team... team management is so critical. In medical school you learn how to be an isolated king, what we really need to learn is how to manage and work with other people." (National Demonstration Project physician)
PEER-TO-PEER LEARNING & SUPPORT: One of the important features of the NDP was the ability for physicians and practice staff to connect and share their experiences as they went through the change process. It was apparent that experts and consultants were useful but only up to a point. The practices learned the most from each other – they just needed an external agent (TransforMED) to bring them together, whether face-to-face or virtually. The physicians say the shared information and learning was invaluable, but even more powerful was the simple act of connecting to others on the same journey.
"Getting together and learning from each other was so valuable... way better than going to a conference and listening to an 'expert'... We are all over-achievers. We looked for resources and change and couldn't find any so we decided to teach each other! We weren't the experts telling you what to do. We were only the experts in what we had tried and knew worked or didn't work." (NDP physician)
"Talking to the other practices, invaluable! The synergy, the energy of the other practices, there's strength in numbers. When you go to a learning collaborative and you drink the water and feel the electricity, you never the same." (NDP physician)
Q. What happens to physician satisfaction as PC practices make transformative changes? How do the doctors on the ground floor feel about all this? What motivates them?
A. Our qualitative data speaks very strongly in favor of increased physician satisfaction in the medical home model. There are multiple examples of physicians on the brink of burn-out who found a renewal of energy and purpose within the medical home model with the patient at the center. A few key pieces that helped:
- Patient-centered changes (e.g., same day scheduling) that resulted in immediate positive feedback from patients
- Increased delegation and shared responsibility; emphasis on teamwork
- Improved communications within the practice
- Professional stimulation and connection to peers
- Finding a sweet spot where technology and increased efficiency allowed for more quality time with patients, more relationship-building
The demonstration project physicians themselves can probably tell their stories best:
"TransforMED's largest boost to our practice was the development of the tools on the human side. The concept of "team" has hit home with their help, and its evolution into full function continues. This has made the world of difference in the satisfaction of both providers and patients. Understanding how to make this part of the practice work well completed a loop to allow integration of all parts."
"I am excited to think of what it will be like if hopes about the new skills and chemistry come to reality. Tools for making change are being installed and it is key that we now have a greater grasp on what to do with the tools and how to use them. We now see where we are going, and before we were just drifting."
"I love my job. I look forward to working with my staff each day. It is a real pleasure seeing a nurse or MA, a receptionist, or an office manager stretch herself and grow. I treasure my interactions with each and every patient. It is a privilege to be a part of a patient's life story, to be part of his or her family. It is a challenge to continue to improve not just my knowledge, but the processes that help me use that knowledge in a systematic way to help my patients."
"That's what I fell in love with in the first place... the relationship centrality, the ability to see the big picture about this patient. Now that we finally have the infrastructure with the EMR, we can actually coordinate that comprehensive care, keep track of everything. The technology gives us tools to make our primary job easier... focus on the patient, what's best for them, what they want and need."
Q. With so many changes at the practice level, is there still value in the physician-patient relationship?
A. The relationship is at the heart of family medicine and primary care. As many of the physicians said in their quotes, one of the greatest strengths of the medical home is the fact that the patient is at the center, and all the changes are designed to ultimately enhance the time the physician spends with the patient and bear witness to the importance of the physician-patient relationship.
The relationship piece is possibly more valuable than ever, as the role of patients will need to change as well inside the medical home model. Patients will need to become more engaged, activated, participants in their care – not passive, subordinate consumers. In order to fully engage patients, it is helpful for a strong physician-patient relationship to be in place. One physician describes it as such:
"Many of the decisions that we made for the patient in our head, they may not agree with; it really is more of a partnership and the portal helps with that... We're no longer afraid of our patients and their judgments, they see their charts, they see our errors, now they all know we are human and we can move forward from that as true partners.... This is so exciting!"
Q. What do we know about patient satisfaction in a primary care practice making transformative changes? How long before we might see outcomes?
A. We have not yet completed analysis of the patient outcome surveys (POS). Note that patients rated their practice on 13 factors: patient-centered practice experience, coordination of care, community knowledge, comprehensive care, cultural responsiveness, empathic care, knowledge of the family, openness to patient's concern, patient enablement, personal physician preference, ease of access to care, comprehensive care/patient advocacy, ability to get a same day appointment.
Some initial general findings suggest that:
- The POS does appear to differentiate among practices that patients perceive more as medical homes than others.
- The POS appears to be responsive to changes in the practice over time
- The stress of rapid change may decrease 'patient satisfaction as measured by our factors' in some practices, before they later improve
- Facilitated practices may see less decrement in 'patient satisfaction' than self-directed practices.
Q. What do we know about changes in patient's health (quality outcomes) in a primary care practice making transformative changes? How long before we might see outcomes?
A. The chart audit time frame was extended to 28 months from the beginning of the NDP in order to capture more of the expected delay in changes in quality outcomes. We are still in the process of gathering medical record data and have not taken 'early peeks' at the data we have in hand.
Our experience with previous work of this type suggests a definite delay between implementation in practice change and reflection of those changes in medical record data.