More and more of clinical work was becoming administrative and falling to the physician to complete, resulting in less face-to-face time with patients. These factors, plus others, were leading to physician frustrations, burnout, and less joy in clinical work.
Developing the Intervention
While most residents in the country are exposed to some of the least functional models of ambulatory care, the family medicine residents at the University of Colorado are trained in one of the most functional models. How did this come to pass?
In late 2014, University of Colorado health system leadership announced that they wanted to make primary care one of the pillars of the organization. The Chairs and Vice Chairs of the primary care specialties were asked to develop a vision for their training programs. Realizing that their new family physicians would spend most of their careers in the ambulatory environment, the leaders decided that primary care residents should be trained in the optimal practice environment.
The goals of the care model redesign were to increase support for patients and physicians to ensure that the best possible care is given at each visit, decrease the burden of the EHR and reduce the amount of work that is pushed to the physician, and, as a result, reduce burnout. They also intended to improve access by improving efficiency.
The model hinges on training early. As interns, physicians were partnered one-to-one with a medical assistant (MA). Before the resident entered the exam room, the MA completed expanded rooming tasks, such as agenda-setting, medication reconciliation, and updating the patient's past medical, family, and social history.
During their second year of training, residents were each paired with two MAs, who provided additional support, such as beginning to record the history of present illness (HPI) information into structured templates during rooming and closing care gaps per protocol. For example, MAs screened each patient for depression using the Patient Health Questionnaire-2 (PHQ2) tool, and if positive, moved on to the PHQ9. For patients on opioid medications, the MAs accessed the statewide prescription drug monitoring program database. All MAs were “delegates,” which means they could routinely pull this information before the physician saw the patient. If the patient hadn't signed an opioid agreement form, that form was pulled out and ready. If a patient needed a work excuse for the visit, the MA prepared the letter.
By the third year of residency, the model was expanded to add the support of the MA in the room. After a structured warm handoff, where the MA reported to the physician any medications refilled, care gaps closed, and agenda items clarified (including any hidden agenda item the MA may have uncovered), the MA and the physician entered the room together. The MA logged into the computer while the physician pulled up a stool and to sit knee-to-knee with the patient, making eye contact and giving the patient full, undivided attention. While the physician obtained further HPI and performed the exam, the MA entered this information into the electronic health record (EHR) in real time. When the physician verbalized the care plan, the MA entered the orders and typed the instructions into the after-visit summary.
Near the close of the physician component of the visit, the MA logged out and the physician logged in to sign the orders while still in the room. The note was then completed by the physician outside the room. All work for the first patient was completed before the physician moved on to the next patient. Meanwhile, the MA stayed behind to review the next steps with the patient.
Medical students were also exposed to the APEX model, accompanying the MA during rooming and then independently expanding on the HPI. The student, MA, and supervising physician returned to the room together, where the student presented the patient, the physician examined the patient, and the MA recorded the visit.
There were some challenges along the way. One rate-limiting step early on was finding and training MAs. The residency clinic went from 11 MAs to 25 MAs in the new model and faced competition in hiring. Initially, training was done on the job; now, the University of Colorado has an established MA training academy to prepare the MAs for their new responsibilities.
Another challenge was the change itself. For some physicians, it was more comfortable to continue to work in a familiar, if inefficient, mode, rather than go through the upheaval of making a change. Practice transformation specialists were available to work with such physicians and encourage them by suggesting, “Just twice this session try closing the note before moving on, and see how it goes.” In clinics where the faculty were full-time, the transition to the new model was faster.
With the APEX model, there is no duplication of communication, as happens in other models where the physician must leave the room, find the MA, and repeat the patient instructions.
Between-visit care was also enhanced with the APEX model. All inbox messages were directed first to the MAs who addressed as much as possible, calling the patient for more information as needed, pending any orders that might result, and drafting patient-requested letters before sending to the physician for further direction.
The residents are not the only physicians benefiting from this model; APEX is being rolled out to all of the family medicine faculty practices. After one year in the APEX model, faculty burnout dropped from 53% to 22%, quality metrics improved, and access expanded. For example, the rates of colorectal screening, mammography and blood pressure at goal have all shown improvement.
The higher levels of staffing and teamwork have improved clinic capacity. Prior to APEX, 60% of patients required 40-minute visit slots; now only 25% of patients require these longer visits, thus freeing up additional capacity for new and returning patients. New patient appointments have nearly doubled. Revenue has also improved, as faculty are seeing an average of 3 more patients each day.
Dr Corey Lyon, Associate Vice Chair for Clinical Affairs, Department of Family Medicine, describes the joy in practice with the APEX model by quoting a patient who reported, “I have never in my 66 years felt so well-cared for.” MAs have commented that “It's challenging but exciting at the same time”, “We're having fun at work and the work is done at the end of the day”, and “This new model gives me purpose.” And physicians indicate, “I don't have to do it all. Patient interactions feel more connected and the patients are attentive”, “I'm done with all my notes by 5:30 or 6 p.m. That's never happened before”, and “It's been a game-changer; it allows me to stay in practice and be happy.”