Dorothy Hung

Leveraging Electronic Health Records to Develop Measurements for Processes of Care

OBJECTIVES To assess the reliability of data in electronic health records (EHRs) for measuring processes of care among primary care physicians (PCPs) and examine the relationship between these measures and clinical outcomes. DATA SOURCES/STUDY SETTING EHR data from 15,370 patients with diabetes, 49,561 with hypertension, in a group practice serving four Northern California counties. STUDY DESIGN/METHODS Exploratory factor analysis (EFA) and multilevel analyses of the relationships between processes of care variables and factor scales with control of hemoglobin A1c, blood pressure (BP), and low density lipoprotein (LDL) among patients with diabetes and BP among patients with hypertension. PRINCIPAL FINDINGS Volume of e-messages, number of days to the third-next-available appointment, and team communication emerged as reliable factors of PCP processes of care in EFA (Cronbachs alpha=0.73, 0.62, and 0.91). Volume of e-messages was associated with higher odds of LDL control (≤100) (OR=1.13, p<.05) among patients with diabetes. Frequent in-person visits were associated with better BP (OR=1.02, p<.01) and LDL control (OR=1.01, p<.01) among patients with diabetes, and better BP control (OR=1.04, p<.01) among patients with hypertension. CONCLUSIONS The EHR offers process of care measures which can augment patient-reported measures of patient-centeredness. Two of them are significantly associated with clinical outcomes. Future research should examine their association with additional outcomes.

Recognition as a Patient-Centered Medical Home: Fundamental or Incidental?

PURPOSE Little is known about reasons why a medical group would seek recognition as a patient-centered medical home (PCMH). We examined the motivations for seeking recognition in one group and assessed why the group allowed recognition to lapse 3 years later. METHODS As part of a larger mixed methods case study, we conducted 38 key informant interviews with executives, clinicians, and front-line staff. Interviews were conducted according to a guide that evolved during the project and were audio-recorded and fully transcribed. Transcripts were analyzed and thematically coded. RESULTS PCMH principles were consistent with the organization’s culture and mission, which valued innovation and putting patients first. Motivations for implementing specific PCMH components varied; some components were seen as part of the organization’s patient-centered culture, whereas others helped the practice compete in its local market. Informants consistently reported that National Committee for Quality Assurance recognition arose incidentally because of a 1-time incentive from a local group of large employers and because the organization decided to allocate some organizational resources to respond to the complex reporting requirements for about one-half of its clinics. CONCLUSIONS Becoming patient centered and seeking recognition as such ran along separate but parallel tracks within this organization. As the Affordable Care Act continues to focus attention on primary care redesign, this apparent disconnect should be borne in mind.

Implementing a Lean Management System in Primary Care: Facilitators and Barriers From the Front Lines.

Background: Although Lean management techniques are increasingly used in health care to improve quality and reduce costs, lessons about how to successfully implement this approach on the front lines of care delivery are not well documented. In this study, we highlight key facilitators and barriers to implementing Lean among frontline primary care providers. Methods: This case study took place at a large, ambulatory care delivery system serving nearly 1 million patients. In-depth interviews were conducted with primary care physicians, staff, and administrators to identify key factors impacting Lean redesigns in primary care. Results: Overall, staff engagement and performance management, sensitivity to the professional values and culture of medicine, and perceived adequacy of organizational resources were critical when introducing Lean changes. Specific drivers of change included empowerment of staff at all levels, visual display of performance metrics, and a culture of innovation and collaboration. Barriers included physician resistance to standardized work, difficulty transferring management responsibilities to non-physician staff, and time and staffing required for participating in improvement efforts. Conclusion: Although Lean offers a new approach to delivering care, the implementation process itself is both complex and crucial to success. Understanding early facilitators and barriers can maximize Leans, potential to improve health care delivery.

Experiences of primary care physicians and staff following lean workflow redesign

BackgroundIn response to growing pressures on primary care, leaders have introduced a wide range of workforce and practice innovations, including team redesigns that delegate some physician tasks to nonphysicians. One important question is how such innovations affect care team members, particularly in view of growing dissatisfaction and burnout among healthcare professionals. We examine the work experiences of primary care physicians and staff after implementing Lean-based workflow redesigns. This included co-locating physician and medical assistant dyads, delegating significant responsibilities to nonphysician staff, and mandating greater coordination and communication among all care team members.MethodsThe redesigns were implemented and scaled in three phases across 46 primary care departments in a large ambulatory care delivery system. We fielded 1164 baseline and 1333 follow-up surveys to physicians and other nonphysician staff (average 73% response rate) to assess workforce engagement (e.g., job satisfaction, motivation), perceptions of the work environment, and job-related burnout. We conducted multivariate regressions to detect changes in experiences after the redesign, adjusting for respondent characteristics and clustering of within-clinic responses.ResultsWe found that both physicians and nonphysician staff reported higher levels of engagement and teamwork after implementing redesigns. However, they also experienced higher levels of burnout and perceptions of the workplace as stressful. Trends were the same for both occupational groups, but the increased reports of stress were greater among physicians. Additionally, members of all clinics, except for the pilot site that developed the new workflows, reported higher burnout, while perceptions of workplace stress increased in all clinics after the redesign.ConclusionsOur findings partially align with expectations of work redesign as a route to improving physician and staff experiences in delivering care. Although teamwork and engagement increased, the redesigns in our study were not enough to moderate long-standing challenges facing primary care. Yet higher levels of empowerment and engagement, as observed in the pilot clinic, may be particularly effective in facilitating improvements while combating fatigue. To help practices cope with increasing burdens, interventions must directly benefit healthcare professionals without overtaxing an already overstretched workforce.

Effect of Organizational Culture on Patient Access, Care Continuity, and Experience of Primary Care.

This study examined relationships between organizational culture and patient-centered outcomes in primary care. Generalized least squares regression was used to analyze patient access, care continuity, and reported experiences of care among 357 physicians in 41 primary care departments. Compared with a “Group-oriented” culture, a “Rational” culture type was associated with longer appointment wait times, and both “Hierarchical” and “Developmental” culture types were associated with less care continuity, but better patient experiences with care. Understanding the unique effects of organizational culture can enhance the delivery of more patient-centered care.

Framework for research on implementation of process redesigns

Background: Complex system interventions benefit from close attention to factors affecting implementation and resultant outcomes. This article describes a framework for examining these factors in process redesign (PR) and for assessing PR outcomes. Methods: Using literature scans and expert comment on draft frameworks based on the Consolidated Framework for Implementation Research, a team of researchers developed the PR framework for the Agency for Healthcare Research and Quality. As a case study, an independent team of researchers in a large care system subsequently applied the PR framework to implementation of Lean-based primary care redesigns. Results: The PR framework adds 2 domains to the Consolidated Framework for Implementation Research, focused on relevant measures of implementation and outcomes, as well as some new constructs to the Consolidated Framework for Implementation Research. Using the PR framework to guide a study of primary care PR, researchers found that the health care reform environment encouraged staff recognition of need for redesign, but physicians worried about key redesign issues, including colocation with care team partners and the competencies of the individuals assigned to manage new workflows. Team member acceptance of the redesign was also influenced by other features of the implementation process and contextual features, including the decision style of the local clinic. Conclusions: The PR framework helped guide the qualitative study and aided researchers in informing their leadership about critical issues affecting PR implementation.

Why do we observe a limited impact of primary care access measures on clinical quality indicators

The study assessed the effects of enhanced primary care access and continuity on clinical quality in a large, multipayer, multispecialty ambulatory care organization with fee-for-service provider incentives. The difference-in-differences estimates indicate that access to own primary care physician is a statistically significant predictor of improved clinical quality, although the effect size is small such that clinical significance may be negligible. Reduced time for own primary care physician appointment and increased enrollment in electronic personal health record are positive predictors of chronic disease management processes and preventive screening but are inconsistently associated with clinical outcomes. Challenges in identifying relationships between access and quality outcomes in a real-world setting are also discussed.

CA7-05: Transforming Primary Care in 3 NCQA-Certified PCMHs

Background/Aims Hopes are high for revitalizing primary care through transformation to a Patient- Centered Medical Home (PCMH) model. This model has been implemented in some capitated integrated delivery systems, but the transferability of PCMH to practices with a mixture of fee-for- service (FFS) and capitation contracts is uncertain. This study documents and analyzes how a transformation into a PCMH was achieved in a largely FFS multispecialty group practice in Northern California which has 30 clinics in three geographically distinct divisions. Division A was certified by NCQA at level 3 PCMH, Divisions B and C at level 2 PCMH. Methods Multi-method case study includes qualitative data from semi-structured key informant interviews and quantitative data from medical records and administrative sources in 2005–2010. Key informants were purposefully sampled to capture experiences in all divisions and included executives, frontline physicians, nurse, health educators and medical assistants. We report on the interviews that were audio recorded, transcribed and analyzed thematically. We also present some initial quantitative findings on the association between the levels of NCQA PCMH certification and measures of process and outcomes of care. Results Thirty-three key informant interviews have been completed to date. Four emerging themes are: quality improvement efforts and responses to local market pressures pre-dated the national focus on PCMH; successful implementation of some PCMH components occurred in a top-down fashion with physician champions; dominant business line (FFS) presents disincentive for some PCMH components; and organizational culture differences may affect how well certain initiatives are taken up and sustained. EHR data reveal that the level 3 PCMH division had the shortest wait time to a 3rd next available appointment for a longer visit (i.e., improved access), the highest proportion of patients with diabetes having their HbA1c measured every 6 months (improved process) and the highest proportion of patients with diabetes with their blood pressure under control (130/80) (improved outcomes). Discussion We conclude that implementation of many PCMH components pre-dated the national focus on PCMH. Successfully implemented elements had organizational champions in practice cultures supportive of innovations. Some clinical process and outcome performance are consistent with the level of NCQA certification.

Ready for Change? The Role of Physician and Staff Engagement, Burnout, and Workplace Attributes

We examined factors associated with change readiness among 343 primary care physicians and 590 nonphysician staff undergoing “Lean”-based process improvements. Baseline levels of engagement were associated with greater readiness for change across all measured domains. Job-related burnout correlated with greater need for change, but lower self-efficacy and perceived support, whereas a personal sense of accomplishment was associated with higher efficacy to implement changes. At a department level, teamwork, participation in decision making, and change history were associated with higher engagement and lower burnout among physicians and staff; conversely, a busy or stressful department correlated with lower engagement and higher burnout.

Medical Assistants as Flow Managers in Primary Care: Challenges and Recommendations.

EXECUTIVE SUMMARY As healthcare organizations look for ways to reduce costs and improve quality, many rely increasingly on allied healthcare professionals and, in particular, medical assistants (MAs) to supplement the work of physicians and other health professionals. MAs usually work in primary care, where they often play important roles on healthcare teams. Drawing on an empirical study of a large, multispecialty delivery system engaged in reconfiguration of primary care, we found that using MAs as flow managers required overcoming several challenges. These included entrenched social and occupational hierarchies between physicians and MAs, a lack of adequate training and mentorship, and difficulty attracting and retaining talented MAs. We offer several recommendations for healthcare organizations interested in using MAs as flow managers in their practices.