At Mayo Red Cedar Medical Center patients have their laboratory tests done a few days before their appointments and are able to discuss results and engage in shared decision making at the time of the visit. This system eliminates an hour or more per day of post-appointment results reporting. David Eitrheim, MD, reported e-mail, July 9, Patients like to discuss the results of their lab work at the time of their office visit. In many practices, patients cannot reliably see their own primary care physician the same day a need arises.
In addition, most patients are not receiving all recommended prevention and chronic illness care. Improving access and increasing adherence to clinical guidelines requires building additional capacity into the practice. Many sites accomplished capacity building by transforming the roles of medical assistants, licensed practical nurses, registered nurses, and health coaches so that they assume partial responsibility for elements of care. When a patient is taken to an examination room rooming , the process has been expanded from 3 minutes to 8 minutes and now includes medication review, agenda setting, form completion, and closing care gaps.
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For example, the medical assistant reviews health-monitoring reminders, gives immunizations, and proactively books appointments for mammograms and DXA dual-energy x-ray absorptiometry scans for osteoporosis. A medical assistant training curriculum is available at http: These problems include streptococcal throat infections, conjunctivitis, ear infections, head lice, sexually transmitted diseases, uncomplicated urinary tract infections, and warfarin management. At Clinica Family Health Services 27 nonprofessional health coaches provide patient education and counseling to help patients with chronic conditions set goals and formulate action plans.
Group Health Cooperative GHC couples centralized population management with team-based panel management. Centrally, GHC sends birthday letters to patients reminding them of overdue preventive services. Medical assistants on clinical teams are responsible for outreach to patients who do not respond and address remaining care gaps during the rooming process.
We observed that team development must often overcome an anti—team culture. Institutional policies only the doctor can perform order entry , regulatory constraints only the physician can sign paperwork for hearing aid batteries, meals delivery, or durable medical equipment , technology limitations electronic health record work flows are designed around physician data entry , and payment policies that only reimburse physician activity constrain teams in their efforts to share the care. An extended care team of a social worker, nutritionist, and pharmacist may be affordable only in practices with external funding or global budgeting.
Physicians across our study sites reported spending about 2 hours per day on visit note documentation, and some physicians reported spending up to an additional hour per day on computerized order entry. At the Cleveland Clinic Strongsville, primary care physicians work with 2 medical assistants or 1 medical assistant and 1 registered nurse. The nurse or medical assistant first completes an expanded rooming protocol, then returns with the physician to record notes while the physician talks with and examines the patient.
After 1 year in the new model, average daily visits increased from 21 to 28, thereby improving access and continuity. Quality metrics, as well as patient, staff, and physician satisfaction scores, improved. Kevin Hopkins, MD, the family physician leading the innovation noted in conversation, December 6, The MAs and nurses are more fully engaged in patient care than they have ever been and they enjoy their work….
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They have increased knowledge about medical care in general and about their individual patients in particular. I am far more satisfied. I leave work an hour earlier every day and have a very fulfilling relationship with my team…. Managing calls, e-mails, and faxes regarding prescription renewals consumes many health care resources. By separating prescription renewal from chronic illness appointment adherence, and by providing to month prescriptions for stable medications, practices can avoid repeating the same work multiple times throughout the year.
At Allina-Cambridge in the Minneapolis area, medications are renewed for a full year at the annual comprehensive care visit, thus avoiding unnecessary interval handling of stable prescriptions. For example, a 3-month supply with 4 refills covers the patient until the next annual visit. Prescriptions initiated at interval appointments will have refills remaining. These prescriptions are resynchronized with all other chronic prescriptions once a year. Amy Haupert, MD, explained personal communication, July 10, Tasks previously entrusted to receptionists, pharmacists, nurses, and transcriptionists have been transferred to the physician with many electronic health record implementations.
In addition, replacing asynchronous electronic messaging with verbal messaging reduces the volume of in-box messages. Fairview Clinic in Minneapolis has decreased the in-box work from 90 minutes to only a few minutes per day for many physicians. All messages are first directed to the medical assistant or nurse, who filters out normal laboratory results, prescription renewals, or requests that can be managed by protocol, passing through to the physician only messages that require physician-level attention.
Whenever possible, electronic messaging is replaced by more time-efficient verbal messaging between nurse and physician. We can answer questions on the fly rather than waiting to get back to the computer and pinging messages back and forth. If nurses and medical assistants cannot quickly run a problem by the physician, the problem loops around the office via time-consuming asynchronous e-messaging, creating more work and delays for patients. In addition, the lack of meeting time precludes development of improved work flows.
Co-location can make minute-to-minute communication more efficient. Team meetings provide protected time to improve processes and strengthen trust and reliance among the team. Previously this physician took 2 to 3 hours of work home each night; with co-location that facilitates efficient verbal communication and the expanded role for medical assistants, he routinely leaves the office with all of his work completed. At the Cleveland Clinic, the physician and clinical staff meet weekly to review data and refine their work flows.
Dr Hopkins explained in conversation, December 6, We set aside 1 hour every Friday morning to go over the week: We do some education as to why do we do microalbumins on diabetic,s etc. Learning why we do certain things gains buy-in.
Source and Analysis of the Stories
Medical care involves a large number of recurrent tasks: These work flows can be efficient, rapid, and promote patient safety, or they can be complex and fraught with hazards. Without careful planning, new work flows developed in response to changing regulations or technology can push much of the work onto the physician. Adopting a systems approach to practice redesign can improve efficiency and reduce waste. ThedaCare-Oshkosh in central Wisconsin saw its performance on clinical and operational metrics move from last to first place in its clinic organization.
The group attributes this to systematic work flow planning using Lean techniques, which include identification and elimination of waste through value stream mapping and process standardization. We identify wait times, do a root cause analysis, develop countermeasures and then quickly reassess with data. The current practice model in primary care is unsustainable. We question why young people would devote 11 years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training.
Likewise, we question whether patients benefit when their physicians spend most of their work effort on such tasks. We set out in search of joy in practice. What we found were pockets of professional satisfaction. Our observations suggest that these 23 innovative sites are pointing the way to a better model.
No single practice has solved every issue; each practice still struggles to overcome its own unique set of constraints.
In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices
There were unifying themes among our sites. Practices that build stable, well-trained teams which work together every day and meet regularly to improve their work can create efficient work flows and rewarding practice environments. Teamwork is facilitated by proximity of workstations and frequent forums for interaction. Thoughtful physical layout with co-location of staff and line of sight enhances communication.
Face-to-face verbal communication is often more effective, efficient, and enjoyable than circulating asynchronous electronic messaging. Despite these unifying themes, we found contrasting approaches to several common issues in primary care among our study sites, including the details of delegating responsibility, scheduling, and documentation.
Physicians can share the care with a team in 2 distinct ways. In the first model physicians are involved with every patient visit but entrust responsibility for many visit-based tasks medication reconciliation, order entry, after-visit summary, visit note documentation, self-management support to other team members.
These practices prioritize access, continuity, and relationship with the same physician, maximally leveraging the skills of the physician. In the second model physicians perform most visit-based tasks, but they are involved with only a subset of patient visits, while directing the patient to other team members for discrete episodes of care: These practices prioritize continuity with the larger care team.
One approach, exemplified by GHC, decreases the number of visits per day and reduces physician panel size. The volume of work associated with record keeping and order entry has increased during the past decade with the introduction of electronic health records, quality-monitoring initiatives, and increasingly complex billing regulations.
Tasks that took a few seconds in the pre—electronic health record world can take several minutes in the electronic world. Visit notes have become lengthy documents, formatted on a billing template, complicating rather than facilitating the cognitive work of finding key information. Scribing is a powerful tool to reduce the burden of record keeping and order entry and to free the physician to focus more fully on direct patient care and relationship building.
The observations described here could lead to a series of hypotheses for future research Supplemental Appendix 3, at http: For example, do physician burnout scores diminish when a practice initiates standing orders that empower team members to assume new responsibilities? Does patient and non-physician staff satisfaction change when such standing orders are instituted? To add context to such quantitative studies, physicians, nonphysician staff, and patients can be interviewed individually or in focus groups to gain greater understanding of the impact of team-empowering standing orders.
Similar research questions can be asked about scribing and about each of the innovations listed in Table 2. Furthermore, although staff satisfaction and the patient experience fell outside the scope of the project, some managers and staff reported that professional satisfaction was increased for medical assistants and nurses with each of these innovations—another area for future study. The core work of primary care remains meaningful and rewarding, but this work has been crowded out by increasingly complex regulatory, technological, and administrative requirements.
Primary care physicians across the country now spend much of their time on large volumes of clerical work, including visit note documentation, order entry, prescription processing, and clearing the in-box. As a result, primary care physicians experience low levels of professional satisfaction 1 and underutilize the training that society has invested in them.
We believe a shift from a physician-centric model of work distribution and responsibility to a shared-care model, with a higher level of clinical support staff per physician and frequent forums for communication, can result in high-functioning teams, improved professional satisfaction, and greater joy in practice. We are also thankful to Richard Baron, Daniel Wolfson and Timothy Lynch for their thoughtful review of the manuscript.
All authors participated in the site visits. Sinsky, and Bodenheimer prepared the initial and revised manuscripts. In the ninety case histories described herein not only do we acquire a vast knowledge of the conditions to which the human eye can fall prey, but we learn the great pains that a fine ophthalmologist and surgeon and his colleagues must go to in order to "fix" their patients' eyes. A man of skill and compassion with a readiness to continue learning throughout his long career, Dr. Barber leads us through the amazing stories of patients, from the most highly placed, to the most humble, all treated with equal respect.
And as each problem is solved, Dr. Barber tells us what he has learned from the case, not only about the eye but about the patient.. Some of the stories are amusing, some are appalling. And some are heartwarming such as that of a man who had been blind for twenty years until Dr. Barber repaired his eyes so that he was able to see his grandchild for the first time. Barber kept copious notes in order to be able to summon the information needed to pack the details from forty years of practice into a single volume.
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In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices
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