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Highly productive physicians were reporting spending more time with the computer than with the patient. With low engagement scores from imbalanced workloads and increased demands, Intermountain saw lost revenue, lower patient access, poor patient experience, and physician burnout. Primary care providers were ready for a change.
A core group of family physicians and internists formed through a grassroots effort to design a new Working Smarter staffing model—based on the team-based care work of Bellin Health in Green Bay, Wisconsin, and the University of Colorado—that shifts clerical work to care team members to create in-room support for physicians. First, a literature search identified thought leaders in team-based care and offered ideas for the future intervention. One of the thought leaders identified was Bellin Health, so later Dr Jill Faatz attended the Bellin Health Team-Based Care Training Camp to acquire new knowledge that she then shared with her colleagues.1,2 Eventually, the concept was shared with nursing leaders, care managers, advance practice provider leaders, and others for feedback.
“One of the best things for me about being involved in the pilot was to be able to peel away from the computer and look my patients in the eye. The communication with my patients is much better and feels so much more natural.”—Jason Howell, MD, family medicine physician, Intermountain Healthcare
“One of the best things for me about being involved in the pilot was to be able to peel away from the computer and look my patients in the eye. The communication with my patients is much better and feels so much more natural.”
The model requires a ratio of 5 clinical team members for every 2 physicians, and expanding the medical assistants' (MA) role. These clinical team members rotate; typically, 4 MAs room for the 2 providers while the fifth supports the team by working the message log, organizing and checking charts, completing prior authorizations, answering phone calls, etc. Expanded MA duties include:
Care management population health duties, such as colon and breast cancer screening, and other activities to close care gaps that are national benchmarking metrics
Traditional MA work
Clinical team members took scribing classes to prepare for their new duties. Importantly, they were empowered and encouraged by the team to take on these new duties. The Working Smarter model was piloted for 6 months.
Several barriers were identified during implementation. For example, the learning curve was steep for MAs asked to learn new workflows and expanded duties, and in-room documentation proved particularly challenging. It was difficult for the practice to maintain a fully staffed team of MAs who were being asked to perform difficult duties.
The new workflow was also an adjustment for the providers. Peter Leavitt, MD, family physician, noted, “Shifting gears and letting go of some of the charting and ordering was a challenge after having done it for my entire career. Allowing clinical team members to work at the top of their license so that I can use my time on patient care and population health for my panel was a skill I needed to learn—but it works.”
Despite initial difficulty learning the model, the MAs reported finding new meaning in their work and higher job satisfaction. Providers and the practice also benefited from the application of the Working Smarter model. After 6 months, the shift in clerical work from physicians to appropriate team members improved productivity. Changes in efficiency observed include:
Burnout was reduced and continued to improve each month following implementation. On a scale of one to five, with five being “I rarely experience burnout from my work,” physician burnout improved by 50%, from a two to a four. Clinical team member burnout went from a score of 2.2 to 3.7 over the course of the 6-month study period.
“I felt my work-life balance was much better and my work felt more meaningful, even as my patient panel size grew quickly.”—Jason Howell, MD, family medicine physician, Intermountain Healthcare
“I felt my work-life balance was much better and my work felt more meaningful, even as my patient panel size grew quickly.”
The Working Smarter pilot supports the following conclusions:
The traditional provider-centered family medicine staffing model predates the EHR and population health management and should be redesigned as a team-based care model suited to current healthcare demands.
Physicians' skills should be reserved for evaluating patients, medical decision-making, and establishing a patient-doctor relationship.
A versatile team can be created to offload other clerical duties, support documentation, manage care gaps, and further support top quality patient care.
Intermountain Healthcare is a team of nearly 40 000 caregivers who serve the health care needs of people across the Intermountain West, primarily in Utah, southern Idaho, and southern Nevada.
Intermountain Healthcare is an integrated, not-for-profit health system. There are about 200 family physicians and 50 family medicine clinics in the system in remote rural as well as urban settings. The intervention described here was piloted at the Heber Valley Clinic, a semi-rural clinic that sees all ages and serves a diverse population.
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