Practice Innovation Pays Off

Past the Learning Curve, Big Benefits Become Clear

By Bonnie Darves
Bonnie Darves is a writer for Physicians Practice

For today’s typical time-crunched and resource-slim medical practice, embarking on redesign initiatives that seek to change both processes and culture is no small undertaking. Practices that do take the plunge, embracing organizational and operational change in the interest of improving patient care, often gain substantial benefits.

The concept, in a formalized way, has been around for a few years. The Boston-based Institute for Healthcare Improvement (IHI) launched the Idealized Design of the Clinical Office Practice (IDCOP) initiative in 1999, according to the group’s Web site, “to significantly improve the performance of clinical office practices through dramatic and sustained system-level changes.”

And how have practices done at sustaining change since this initiative began? Very well, according to the following examples of two physician organizations that are experiencing big payoffs for their IDCOP-inspired innovation initiatives.

Streamlining with technology
Charles Burger, M.D., happily takes on the naysayers who contend that small physician practices can’t enjoy the same benefits and economies of scale from technology investments that a large medical group might reap. Burger, part of the two-physician primary care practice Norumbega Medical Specialists in Bangor, Maine, has been on the cutting edge of technology integration for more than a decade.

The practice, which has an active panel of approximately 5,000 patients and is affiliated with Eastern Maine Healthcare, began using electronic medical records (EMRs), exam-room computer terminals and patient-physician e-mail in the early 1990s — years before such technology-based tools began emerging in mainstream medical practice. Burger has also been a forerunner in the use of nonclinical staff for patient-care tasks typically performed by physicians and nurses, such as wellness-visit care and medical-history updating. The practice uses telephone triaging to avoid unnecessary visits for such issues as uncomplicated urinary tract infections or minor upper respiratory symptoms. Telephone follow-up is built into the care process.

“We have a good system in place for monitoring quality, and all of our training is very performance-based,” Burger said. In the typical practice, physicians spend approximately two-thirds of their time gathering information and only one-third analyzing it. “That’s not a very efficient use” of a highly trained professional’s time, he added.

At Norumbega, the patient is asked to input some of the medical history information on the computer, and the medical assistant gathers the remaining data. By the time the physician enters the exam room, most of the work is done. “All we do is check [data] and ask a few more questions. Our function, then, is to sit down with the patient and say, ‘Here are your symptoms, and here is your data. Let’s think about these things together,’” Burger said. That way, patients are directly involved in the decision-making process to the extent that they wish to be involved. At the end of the visit, patients receive a copy of the encounter notes.

Most recently, the practice has implemented evidence-based computer tools and processes that have significantly standardized the care patients receive. The primary tool, called Problem-Knowledge Coupler (PKC) (see sidebar), elicits the patient symptom information, links it to current medical knowledge and presents appropriate care strategies.

Burger’s group first implemented the PKC program a few years ago to develop an approach for treating migraines. It has since implemented PKCs for more than 100 common problems. “If we see 500 patients with headaches, they will all have the same things done. And all of the information is stored in a relational database, so when we decide to do outcome studies, the data is there,” said Burger.

New efficiencies, satisfaction
One might think it would take a mountain to move a large integrated delivery system’s medical groups from paper-intensive, overburdened and chronically behind to nimble practices that provide streamlined care and consistently earn high marks from patients. It took a commitment to innovation and a willingness to stay the course, admitted Greg Long, M.D., medical director of the 100-physician organization.

Today, ThedaCare, a Wisconsin-based organization with 22 outpatient sites, is able to book most patient appointments within two days since it embraced the advanced-access model developed by the IDCOP initiative. “Our system-wide goal is to reach two days or less [to next-available appointment] for our part-time providers, and one day or less for our full-time providers, and we’re getting close to that,” Long said.

Other major undertakings — using non-physician personnel to perform a variety of care-related tasks formerly done by ThedaCare doctors and reviewing medical records before patients’ appointments to identify needs that can be addressed in a single visit — have yielded similarly impressive gains. In 2003, the organization’s doctors were seeing 25 to 30 patients a day, down from 28 to 35 a few years ago, which translates into far more one-on-one time with patients. Patient-visit cycle times have also dropped substantially, in part because of ThedaCare’s implementation of electronic medical records.

“All of these process changes tend to be patient-centric. Before, the processes put in place were more for the benefit of the business,” Long said, adding that both patients and the staff have far higher satisfaction levels now.

Long admitted that implementing broad-scale process change is no small feat, even when there is commitment to innovation. The advanced-access model has proved more difficult to establish in some clinic sites than in others, and some physicians are still wrestling with the extra documentation tasks the EMR system requires. “Getting these kinds of results in a four-doctor clinic is one thing. Trying to spread it throughout a large organization is more difficult,” Long said. “The learning curve has been steep,” at times.

Based on its success with implementation of ICDOP principles, ThedaCare has continued its push for process improvement. Last year, the organization has embarked on a self-styled version of Toyota’s “lean-manufacturing” model of production efficiency, in which the goal is to eradicate unnecessary steps and eliminate waste. The model involves mapping out a process from start to finish to identify all value-added and nonvalue-added steps.

ThedaCare first tried out the lean-manufacturing model in accounts receivable (A/R) and discovered that fully two-thirds of the steps that might occur between the time a claim is generated and the time it gets to the payor were either unnecessary or didn’t add value. “In A/R, we went from 45 steps down to 11,” Long said, adding that the process “dissection” yielded several surprising findings. For example, ThedaCare discovered that in some situations claims documents were still being routed physically through couriers.

A new ThedaCare pilot involves using the same approach to identify nonvalue-added steps in the acute-care delivery process. As part of the pilot, physicians and other personnel are mapping out all the steps that occur between the time the patient calls for an appointment until the time the physician-patient interaction is completed. “The objective is to figure out what the nonvalue-added steps are and get rid of them so that we can make the whole process more efficient for the patient,” said Long. “What we’re trying to determine is how many handoffs it take[s] until the patient gets what he needs.”

Although the pilot is still in its early stages, ThedaCare physicians and management team are optimistic that it will result in further improvements and more streamlined care. “We’re pretty excited about it,” added Long.

Back to top