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Technophile's response
Paths using practice archetypes may lead in the wrong direction
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Susan T Andrews, Murfreesboro, TN, USA MD Family Practice Partners
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Participation in the research network PPRNet has brought our practice immense satisfaction as well as dramatically improved the health of our patients. Our practice recognizes itself as a member of the technophile group. One of the most important factors in our improvement is having accurate data reflecting our level of care. This gives us motivation and helps us direct our efforts at improvement. As Chris Feifer points out, we set up our practice workflow and EHR to minimize effort while maximizing ease of adhering to practice guidelines for both health maintenance and chronic disease management. Although we are solidly in the Technophile group, we’re increasing our use of techniques of the Motivated Team. Our nurses have expanded duties. They have become providers alongside our doctors using standing orders to update overdue immunizations, labs and tests, coming up with ideas for improvement, motivating our patients, and soon, helping with group visits. As part of the AAFP TransforMED demonstration project, we’ve also become a much more effective team, having daily huddles before seeing patients and running effective weekly meetings of subgroups of the practice. PPRNet through its site visits and annual meetings has taught us how to assess what we need to improve, change processes to improve care, and then reevaluate our results to see if they were effective. Although this particular study is over, the techniques have become a part of our practice culture. We continue to analyze our reports quarterly, choose indicators to work on, and change processes. Our next step is to offer group visits for patients with diabetes. This fits under the area of Care Enterprise. Over time, each group may adopt more techniques of the other groups so that we may become less identifiable. As an effort to obtain evidence-based CME for a presentation on EHRs, I’ve found literature supporting the fact that systematic use of an EHR can bring definite improvement in adherence to practice guidelines, but that having an EHR alone does not improve care. The practitioner needs to mine the data, and then needs to make use of features of the EHR as well as modify work processes to improve care. Chris Feifer outlined the techniques we used well. The PPRNet model has much to offer practices that wish to focus on quality. 1. Kensaku Kawamoto, et al: Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. American Journal of Medical Quality, Vol. 22, No. 1, 34-41 (2007). 2. Ornstein SM, Nietert PJ, Jenkins RG, Wessell AM, Feifer C, Corley ST: Improving Diabetes Care through a Multi-component Quality Improvement Model in a Practice-Based Research Network. American Journal of Medical Quality, 2007, 22(1): 34-41 Website: http://ajm.sagepub.com/cgi/content/abstract/22/1/34 This article reports the impact of a multi-component quality improvement intervention on adherence diabetes care guidelines. Significant improvements occurred for 12 of 13 measures showing that intervention can have robust effects on care. The providers all used the same EHR and received feedback on the indicators quarterly. 3. Ornstein SM, Jenkins RG, Nietert PJ, Feifer C, Roylance LF, Nemeth L, Corley S, Dickerson L, Bradford WD, Litvin, C: Multi-Method Quality Improvement Intervention to Improve Cardiovascular Care: A Cluster Randomized Trial, Annals of Internal Medicine, 2004; 141(7):523-532 http://www.annals.org/cgi/content/full/141/7/523 Improved performance on cardiovascular indicators were documented using intervention techniques that included EHR use. 4. Orzano, A. John MD, MPH, et al: Improving Outcomes for High-Risk Diabetics Using Information Systems. Journal of the American Board of Family Medicine. 20(3):245-251, May/June 2007. http://www.jabfm.org/cgi/content/full/20/3/245 Conclusions: Use of relatively simple systems to identify and track patient information can improve diabetic care outcomes. Practices making investments in an EHR must recognize that this technology alone is not sufficient for achieving desirable clinical outcomes. Researchers must explore the interrelationships of organizational factors necessary for successful information use. 5. Nagykaldi, Zsolt PhD; Mold, James W. MD, MPH. The Role of Health Information Technology in the Translation of Research into Practice: An Oklahoma Physicians Resource/Research Network (OKPRN) Study. Journal of the American Board of Family Medicine. 20(2):188-195, March/April 2007. http://www.jabfm.org/cgi/content/full/20/2/188 This study documents how the implementation of a clinical reminder system in an EHR improved adherence to practice guidelines. 6. Devine, Emily Beth, et al: Characterization of prescribing errors in an internal medicine clinic. American Journal of Health-System Pharmacy. 64(10):1062-1070, May 15, 2007. Implementation of an electronic prescribing system with drug interaction and allergy checking may decrease the frequency of serious errors. 7. Sistine A. Barretto, et al: Linking Guidelines to Electronic Health Record Design for Improved Chronic Disease Management: Evidence Based Guidelines and EHR references. AMIA Annual Symposium Procedures. 2003; 2003: 66–70. Rousseau N, MCColl E, Newton J, Grimshaw J, Eccles M. Practice based longitudinal, qualitative interview study of computerised evidence based guidelines in primary care. BMJ. 2003 3268 Feb; This report shows problems with awkward efforts of using computer to improve adherence to guidelines. American Journal of Medical Quality, Vol. 18, No. 4, 150-154 (2003) 8. Jeffrey East, MD, MPH: Impact of a Diabetes Electronic Management System on Patient Care in a Community Clinic; Published online February 23, 2007 Diabetes Care 30:1137-1142, 2007 This supports the use of an electronic registry for improving diabetes care. 9. Davis Bu, MD, MA et al.: Benefits of Information Technology–Enabled Diabetes Management. BMJ 2005;330:765 (2 April), All IT techniques used in the study improved care and reduced expenditures. Competing interests: None declared |
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David G Litaker, Cleveland, Ohio Senior Researcher, Louis Stokes Cleveland VAMC
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Feifer and colleagues seek to identify recurring themes in the use of specific strategies that represent practice “archetypes” for improvement within a group of high-performing practices participating in a national demonstration project (1). One of the key messages of this paper is a hopeful one: that there exist many potential practice strategies to achieve high performance. An assertion worth questioning, however, is that the archetypes identified are appropriate as guides for other practices to follow on the “path to improvement”. Others have suggested, for example, that reconfiguring practices to conform to an “ideal” may have the unintended consequence of reducing or eliminating variation in work processes (and outcomes) that are appropriate to local circumstances (2,3). Indeed, important elements missing from the practice characteristics obtained from multiple sources of qualitative and quantitative data in this study are those relating to context, or the setting in which the practice is embedded. It is easy to envision a practice conforming to the “Technophile” archetype described in this paper that fails miserably in attaining high performance goals in certain organizational contexts or socioeconomic settings. A second practice characteristic largely unaddressed in this study is readiness to change - a dynamic and evolving quality. Factors such as how practice staff view their options for change, the extent to which motivation to act toward a specific goal is shared, the allocation of power, patterns and types of communication, and features of the “web of relationships” have been suggested as important in positioning practices to adopt and implement evidence-based practice or initiatives to improve care (4,5). Perhaps practice archetypes exist and can be useful in characterizing or classifying high-performing practices. Their use as paths to improvement, however, ignores the vast and, as yet, poorly understood complexity of primary care. Using them as guides without first considering practice context, readiness to change and interpersonal dynamics may lead some practices toward unintended and potentially counterproductive destinations. References: 1. Feifer C, Ornstein SM. Strategies for increasing adherence to clinical guidelines and improving patient outcomes in small primary care practices. Jt Comm J Qual Saf. 2004;30(8):432-41. 2. Flocke SA, Litaker D. Physican practice patterns and variation in the delivery of preventive services. J Gen Int Med. 2007;22:191-6. 3. Crabtree BF, Miller WL, Tallia AF, et. al. Delivery of clinical preventive services in family medicine offices. Ann Fam Med. 2005;3(5):430 -5. 4. Cohen D, McDaniel R, Crabtree BF, et. al A practice change model for quality improvement in primary care practice. J Healthc Manag. 2004;49(3):150-70. 5. Thomas P, While A. Increasing research capacity and changing the culture of primary care towards reflective inquiring practice: the experience of the West London Research Network (WeLReN). J Interprofessional Care. 2001;15(2):133-139. Competing interests: None declared |
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