Family Care Network in Bellingham, Washington, is a physician-owned practice with multiple locations in communities throughout northwest Washington state. Over the last several years, they have used the three-question framework—“How will this change benefit the care team? How will it improve patient care? What resources are needed to support the change?”—to select various change efforts, including telephone care treatment protocols, an online patient portal and web messaging system, numerous ancillary programs, and value-based contracts with payers to help support innovation efforts with new payment mechanisms. Every project has deliberately sought to achieve three goals—easing the physicians' work burden, measurably improving patient care quality or access, and attaching revenue to support the service.
A physician leader found that he was frequently interrupted with phone calls from patients on anticoagulation therapy who needed their international normalized ratio (INR) lab results so they could decide whether their anticoagulation therapy needed to be adjusted. His time with patients in the office was disrupted by these calls, and if he tried to review the information and call patients back later, he often failed to connect with the patient in a timely manner, which delayed proper management of the patients' condition. It did not seem right to ask each patient to come back for another visit to discuss INR results and medication adjustment, and patients also did not want to make two visits to adjust their therapy.
The team wanted to design a better way to monitor patients on anticoagulation therapy that did not inconvenience the patient and would make the practice team's lives better. The team thought that the physician might not be needed at all if he had previously specified the treatment level and duration for the patient's diagnosis. The team also wanted to create a single visit in which the INR test could be performed as a point-of-care test in the office, where the clinical record would be available to both the clinician and patient at the same time. This would allow the results to be reviewed jointly, and if necessary, a change of therapy to meet the physician-prescribed goals could be discussed and agreed to, with all questions answered. This vision led to the selection of an in-office warfarin testing system and establishment of an in-office testing procedure with regular unknown sample quality testing, as well as the development by the practice physicians of a common protocol to adjust warfarin therapy. A nurse clinician was paid to undergo training so she could see patients and conduct the warfarin testing, counsel patients and follow the physician-created dose adjustment protocols in coordination with the patient's physician. The results were dramatic. Phone call interruptions disappeared. Patients were pleased with the added convenience and the doctors and staff no longer worried about the patients they could not reach by phone who needed their medication adjusted. In addition, because consistent patient education was being provided by the same nurse clinician, the percent of patients at their therapeutic anticoagulation goal was improved.
Success leads to culture change
After the initial success with the anticoagulation project, the attitude of the practice physicians towards practice improvement projects started to change, and new projects were suggested. Unhappiness with the after-hours on-call experience led to the establishment of a shared office open in the evenings, on weekends, and on holidays. This dedicated “after-hours” office enabled physicians to see patients with unanticipated and unscheduled needs. Several doctors in the group stepped up to provide this service, and extra physicians and mid-level practitioners were hired. The shared medical record made it easy to ensure that each patient's personal physician was made aware of any after-hours office visits so a follow-up appointment with the patient's primary physician could be arranged. Patients greatly appreciated the extra access to care, and revenue for these extra visits was a positive for the practice.
A learning experience: EHR implementation leads to team-based care
Not all of the practice's change management initiatives have been successful. The team studied and selected an Electronic Health Record (EHR) system that was supposed to improve record-keeping, facilitate quality management, and enable the care team to provide patients with information when and where it was needed. They also believed it would pay for itself by eliminating expenses for transcription and the servicing of paper charts. However, the practice did not adequately appreciate the profound effect of using the computer on the physician–patient relationship and the extra burden it would place on the team and patients.
The team tried many approaches to easing the burden of capturing the patient's information during patient visits, including dictation, using templates for common visit types, and using “smart phrases” that would add blocks of text by using verbal or keyboard cues. Despite these interventions, the practice realized that they had made more work for the clinicians during the patient visit, moving their attention from the patient to the computer.
Consequently, the practice chose another project to address the problem that had evolved from what had previously been viewed as a solution. The practice now uses two nurse assistants who work with patients and remain with them for the entire visit (see the team documentation module). The nurse assistant takes care of traditional rooming duties and acts as a scribe during the physician portion of the visit. She stays in the room after the physician portion of the visit is complete to arrange any needed tests, answer questions, and print out a summary of the visit for the patient. The physician reviews the note, makes any needed alterations or additions, and signs the note. This second intervention achieved the goal of easing the work burden, and the increased office efficiency allowed two extra visits per day that pay for the increase in nursing staff.
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