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More 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. What is the value of self-populating disease registries in chronic disease management?

A. There are three parts to this answer.

1. Most NDP practices say there is tremendous value in such registries. Some of the practices that implemented them report a real difference in their daily routine; i.e., rather than just reacting to whatever walked through the door that day, they now have data to help plan a population-based, proactive approach. Practices say the registries with point of care reminders help them to promote needed, preventive care services to patients who come in for acute reasons. And finally, disease registries provide opportunities to more fully engage both medical assistants in team-based patient care through the development of standing orders based on registry results.

2. The NDP practices with registries say they found great value in such registries, but report that this value is greatly enhanced or diminished by the presence or absence of the self-populating feature. Our data show that while most NDP practices were eager to implement registries, fewer are willing or able to do "double data entry" with stand-alone registries that do not integrate within their EHR(Electronic Health Record). Finding the time in a busy day to enter patient data in the registry after already entering it in an EHR is a tremendous challenge. As one NDP doctor stated:

"Getting staff to enter everything twice... that's just not going to happen. If my MA has patient phone calls to answer or stuff to put in a registry and 10 minutes before she goes home – which one is she going to do?"

3. Our data on disease registries of any type are somewhat limited because the practices as a whole did not begin steps toward registry implementation until the second year of the NDP and often near the end or after the project was complete. There appear to be at least two primary reasons for the delay.

Scenario 1: the practice wasn't ready – it needed to work on teamwork and communication before embarking on such an extensive project and sometimes the physician leaders experienced a paradigm shift in their notion of patient care. They changed their view from a "patient by patient" view to a "patient within a population" view.

Scenario 2: the technology wasn't ready - EHR companies promised registries with long-awaited upgrades or non-EHR registries promised seamless integration that didn't always happen. As the technology continues to improve, it is important to note that many practices will still need to work through the first scenario. Even with increased availability of self-populating registries, implementation is not plug-and-play.

Q. What has been the experience of small practices (4 or fewer physicians) trying to implement an EHR and related technology? Can they do it? Are they successful?

A. EMR: The small, private practices* of the NDP were enormously successful in EHR implementation – every single one either had an EHR prior to the project or added one during the project. The only small practices without EHRs are part of larger systems that control the implementation process as opposed to the practice.

Patient Portal: Of the 14 practices who eventually offered patient portals, 12 (86%) were small, private practices. They had both the desire and autonomy to integrate such a portal as soon as their EHR vendor offered it and their financial situation allowed it. The larger practices, almost always part of larger health systems, also desired a portal, but they had to rely on the development process, timeline, and priorities of the system and its IT department.

Disease Registry: Of the 15 practices who implemented a disease registry, 10 (66%) were small, private practices. It is a similar scenario to the patient portals: the small private practices were limited by finances and time, but had the autonomy to choose the upgrade as soon as it became available. The larger practices, almost always part of systems, were dependent on the decisions of their system and IT department. The priorities of the practices themselves and the priorities of the system were often not in alignment, particularly in regard to HIT projects.

*Typically we refer to small practices as those with 4 or fewer physicians; they may include additional clinicians as mid-levels.

Q. What type of assistance do FM practices need most as they implement an EHR? What is involved beyond purchasing the technology? Do they just need money or do they need other kinds of help?

A. Family medicine practices in the NDP, especially those that are small and/or privately owned, demonstrated through the NDP their ability to successfully implement an EHR and related HIT. Their experience reveals what types of assistance might be helpful to other practices moving in this direction:

1. Some practices may need money and financing to implement an EHR and related technology. Small, private practices reported concerns about the upfront cost of the EHR, the ongoing cost of maintaining the technology, and the loss of productivity during implementation. However, just giving practices money to buy an EHR is not the sufficient.

2. Some practices may need assistance in choosing an EHR and related technology. Selecting an EHR could be a frightening decision for small practices. Some practices expressed feelings of confusion, frustration and being overwhelmed at the array of EHR choices.

3. Some practices may need assistance in the ongoing implementation of the EHR. Nearly every NDP practice reported that implementing the EHR was more complicated and took longer than anticipated. EHR implementation changes almost every process within the practice: patient flow, clinical documentation, communication in the exam room, lab follow-up, etc.

Implementing the technology is merely the first in a series of changes required for a practice to fully utilize EHR and related technology. Some practices in the NDP needed assistance in developing strong communication, leadership and relationship patterns so they were better equipped to respond to the stream of new challenges presented by the EHR. It is important to note that the challenges don't end once the EHR is in place. Some practices were observed to be constantly updating the technology with vendor upgrades, attempting to integrate new technology, mastering new skills and techniques within the EHR, determining ways to empower staff and engage patients by use of technology (e.g, electronic standing orders or a patient portal, respectively). These actions don't happen by accident in a busy practice; they are the results of intentional efforts by a practice with strong communication, leadership and relationship patterns.

"Everyone cross-trains in the office. We have spent a lot of time training the MAs to take on more responsibility. CINA [a disease registry] and its directions and standing orders have really helped empower them. Now they don't have to wait for me to tell them – it's right there in the computer, we have agreed what to do ahead of time, they feel confident doing it... it really works." (NDP physician)

Q.Can small practices, particularly small rural practices, implement an effective technology strategy with appropriate support?

A. Yes, small practices were able to implement the major components of the NDP model (see above).

Yes, many practices benefited substantially from a range of support while attempting to implement and use NDP model components.

Two NDP physicians from small practices describe what happened in their practice:

"TransforMED helped create our care team; before, we didn't have that vision. Now communication between physician and clinical assistant is fantastic, it's so much more fun to come to work. We are hiring better people, and although we are paying a lot more, they are doing a lot more... so work is a lot more enjoyable now! Time and energy is now pointed on patient-centered care rather than employee problems."

"I think my practice is beginning to realize now they are part of something extraordinary. Our conversations at the retreat were was so worth it and now we're building on that. They realize they're not just working, they are pioneers.... We've always been patient-centered, but TransforMED educated us and confirmed for us what we know to be true. It kept on course, got us there faster. Over time what we did in 2 years may have taken me 5 or 6 years. What would've happened in that time, who knows? They helped us stay on track and moved us along faster. But the key is, you are never really there, you have to be constantly moving forward."

Q. What is the concurrent issue of quality of life for primary care physicians when they have implemented the concepts of the patient centered model of care in their practice?

A. The evaluation for National Demonstration Project was not designed to systematically measure the quality of life for primary care physicians we do not have data to explicitly answer this question. However, interviews and transcripts from learning sessions yielded testimonies from physicians that support the notion of positive change in the professional lives as part of the NDP journey.

Delegation: The delegation of some aspects of care to empowered staff (i.e., "doing only what a physician brain needs to do") can reduce the responsibility, stress and even emotional drain on the physicians. As one NDP physician described, "This concept of team care... I talk it up to everyone. Training my staff to help with histories and physicals is one the best things I've ever done. I get to actually talk to my patients now." This delegation can also mean shared leadership among physicians so there is an actual sharing in projects in ideas and a real disbursement of responsibility. Another physician explains, "We transformed the office ultimately with shared leadership among providers, it's no longer all on me... This concept of the shared load has been incredibly effective."

Positive Patient Response: Some changes, such as same day scheduling or doing procedures in-house, resulted in immediate positive reaction from patients, which in turn reaped immediate positive rewards for physicians. While same day scheduling is a moving target, under constant refinement for most practices, there is almost unanimous agreement from the physicians that patients are happier when they can get an appointment on the same day they call in with an acute problem. One NDP physician described it as such, "The patients are just so happy to be there when it works for them, it makes my job so much easier!" Email is another good example – not necessarily an e-visit, but just a simple email communication to stay connected. One NDP physician explains, "How long does it take me to email a patient back and say 'Good job!' about his blood sugars or exercise? Not long at all. But how much does that go toward building our relationship? More than you would ever think. They appreciate it SO MUCH."

Physician-Patient Relationship: Some physicians report that a series of small changes, as listed above, can result in a cumulative effect of enhancing the patient-physician relationship. When physicians don't feel as rushed because they're trying to do everything, when they aren't so worried they will forget some preventive care steps, when the patient isn't furious because they waited 3 weeks for an appointment... the focus in the exam room is back on the relationship. Several NDP physicians stated in many different ways: "This is the reason I went into family medicine."

Connecting to other Physicians: Although not explicitly part of patient-centered care model, one significant finding of the NDP has been the importance of physicians being able to connect and network with other physicians in a psychologically safe environment such as a learning collaborative. The physicians express feelings of isolation in being change agents; they need the stimulation and positive energy of shared ideas and brainstorming. As an example, the self-directed practices self-organized their own collaborative midway through the NDP, and the resulting feeling of connection was so profound that it carried them through the entire next year of the project until the final learning session with all practices invited. The learning collaboratives were equally important for the facilitated physicians, as one said, "My husband says these sessions are like my medicine... I need them." The electronic list-serve and conference calls have also been helpful in keeping the practices connected; however, the virtual methods seem to work best in tandem with the powerful synergy of face-to-face meetings.

Q. What do we know about patient engagement and empowerment in a primary care practice making transformative changes? How long before we might see outcomes?

A. We have not yet completed analysis with the Patient Outcomes Survey (POS), a survey which allowed patients to rate 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, and ability to get a same day appointment. Our initial analysis of the POS points to a positive effect of facilitation in buffering the potentially negative repercussions of abrupt and rapid change. Furthermore, facilitated practices may see less decrement in these patient satisfaction measures than practices without facilitation.

For the NDP, it is possible that longer observations will detect benefits at the patient level. At the end of two year, the practices themselves declared "two years is not enough" and "we are just getting started."

It should be noted that many of the practices spent the first part of the NDP project immersed in practice-level changes which demanded full attention (e.g., technology, team building, access). For some practices, an explicit focus on the patient experience did not come until later.

In addition, it bears repeating that all parts of the transformation model are intertwined, interdependent, and connected, so changing one or two pieces is unlikely to have a meaningful impact at the practice level, much less the patient level. Again, like the experience of the big systems, transformation is not a piecemeal, incremental process – it requires fundamental redesign and re-imagination, replacing old thoughts and processes with new ones.

You may also be interested in the evaluation team's Preliminary Answers Part 1