Quality, Satisfaction, and Financial Efficiency Associated With Elements of Primary Care Practice Transformation: Preliminary Findings

Julie Day; Debra L. Scammon; Jaewhan Kim; Annie Sheets-Mervis; Rachel Day; Andrada Tomoaia-Cotisel; Norman J. Waitzman; Michael K. Magill

doi:10.1370/afm.1475

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Figure 1
Relevant samples for Care by Design implementation elements obtained from patient chart audits.

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Table 1

Characteristics of the Community Clinics

Clinic	Year Opened	Total Clinicians, No.	Primary Care Clinicians, No.^a	Visits per Year (Fiscal Year 2011), No.	Characteristics
1	1985	22	12	48,244	Multispecialty, multilingual, metropolitan, evening/weekend urgent care
2	1999	7	5	20,155	Rural family practice with pediatrics
3	2001	6	5	14,449	Rural affluent, multispecialty and primary care
4	1988	8	4	27,247	Suburban, family practice, and pediatrics
5	1976	16	8	41,128	Suburban, multispecialty, full primary care center with obstetrics-gynecology and pediatrics
6	1989	6^b	5	13,133	Exclusively primary care in a bedroom community
7	2003	10	6	11,574	Suburban, family-oriented community practice
8	1996	14	14	17,502	Urban, high-volume, mental illness, residency training site
9	1989	5	5	16,763	Urban, residency training site
10	2007	4	4	9,288	Suburban, primary care

↵a Includes family medicine, internal medicine, and internal medicine/pediatrics clinicians because measures of chronic and preventive care services used to assess clinical quality applied only to adults.
↵b One clinician was a pediatrician.

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Table 2

Care by Design Implementation Data Elements and Sources

Data Element or Outcome	Source	Level at Which Collected	Level at Which Reported	Sample	Time Period
Data Element
Appropriate access
Same-day appointments	Report	Appointment	Clinician	All patient appointments scheduled	Quarter
Seen by primary care clinician at last visit	Chart audit	Patient	Clinician	Patient sample A	Month
Response to messages (first contact)	Report	Team	Message pool team	All patients	Week
Call abandonment rate (call center)	Report	Queue level averaged to get center number	Center	All patients	Month
Calls answered within standard (call center)	Report	Queue level averaged to get center number	Center	All patients	Month
Percent of patients signed up for MyChart^a	Report	Patient assigned to primary care clinician ever	Clinician	All patients assigned to primary care clinician	Ever
Care team
Use of X-files^b by MA	Chart audit	Patient	Clinician	Patient sample A	Month
Clinician uses physical template	Chart audit	Patient	Clinician	Patient sample A	Month
Response to BPAs	Chart audit	Patient	Clinician	Patient sample A	Month
Standardized stocking of examination rooms /plan	Observation	Examination room	Clinician	N/A	Day of observation
Huddles and schedule reviews	Interview	Clinician	Clinician	N/A	Day of observation
Efficient visit (<10-min wait throughout visit)	Observation	Patient	Clinician	All visits observed	Day of observation
Blood draws done in room	Observation or interview	Clinician	Clinician	All visits observed	Day of observation
Continuity of MA throughout patient visit	Observation	Patient	Clinician	All visits observed	Day of observation
MA engagement in visit (use of X-files, BPAs, scribe, orders, AVS, referrals, follow-up appointment)	Observation or Interview	Clinician	Clinician	All visits observed	Day of observation
Documentation of patient communication needs	Chart audit	Patient	Clinician	Patient sample A	Month
Presence of advance directives	Chart audit	Patient	Clinician	Patient sample A	Month
PHQ-2 or -9	Chart audit	Patient	Clinician	Patient sample A	Month
List of community resources for common needs	Observation	Center	Clinician	N/A	Day of observation
Efficient communication among team members	Observation	Team	Clinician	N/A	Day of observation
Planned care
Use of registries	Observation or interview	Clinician	Clinician	N/A	Day of observation
Labs done prior to visit	Chart audit	Patient	Clinician	Patient sample C	Month
AVS given to patient	Report	Patient	Clinician	All patients seen	Month
Medication reconciliation at last visit	Chart audit	Patient	Clinician	Patient sample A	Month
Procedure/consult notes available at follow-up visit	Chart audit	Patient	Clinician	Patient sample B	Month
Care plan documented for high-risk/important conditions	Chart audit	Patient	Clinician	Patient sample C	Month
Track progress on care plan and action steps	Chart audit	Patient	Clinician	Patient sample C	Month
Contact patient postdischarge	Chart audit	Patient	Clinician	Patient sample D	Month
Outcome
Clinician satisfaction	Report (AMGA)	Clinician	Center	N/A	Annual
Patient satisfaction	Report (Press Ganey)	Patient	Clinician	All patients with e-mail	Quarter
Quality data	Report	Patient	Clinician	Varied	Aggregate of 12 or 13 months ending June 2011
Productivity	Report	Clinician	Clinician	N/A	Annual
Financials	Report	Center	Center	N/A	Annual

AMGA = American Medical Group Association; AVS = After-Visit Summary; BPA = Best Practice Alert; CBD = Care by Design; EHR =electronic health record; MA = medical assistant; PHQ = Patient Health Questionnaire; N/A = not applicable.
↵a Patient portal in the EHR.
↵b Patient history template in the EHR.

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Table 3

Summary Statistics on Care by Design Implementation, Patient Satisfaction, Clinician Satisfaction, and Financial Data in 2011

Variable	Score, Mean (SD)
CBD implementation^a
Same-day access	2.22 (0.94)
Primary care clinician continuity	2.62 (0.81)
Response to messages	0.99 (0.46)
Abandonment rate	3.00 (0.47)
TSF (% of calls answered within standard)	2.00 (0.94)
Patients signed up for MyChart^b	1.89 (1.14)
Use X-file^c	2.53 (1.16)
Physical template	1.97 (1.20)
Best Practice Alerts	0.78 (0.59)
Standardized examination rooms	3.28 (0.74)
Efficient visit	2.71 (0.73)
Huddles	2.29 (1.46)
Blood drawn in room	2.98 (1.56)
Continuity of MA in visit	3.27 (0.61)
MA engagement in visit	2.38 (0.62)
Documentation of patient communication needs	1.92 (1.27)
Presence of advance directives	0.08 (0.13)
Depression screening	0.24 (0.24)
List of community resources	2.53 (1.35)
Efficient communication among team	3.75 (0.29)
Registries	0.37 (0.77)
Labs done prior to visit	2.03 (0.64)
After-Visit Summary given	0.77 (0.70)
Medication reconciliation	2.55 (0.58)
Procedure/consult notes available at follow-up visit	3.57 (0.44)
Care plan documented	0.12 (0.17)
Progress on care plan documented	0.34 (0.24)
Contact patients after hospital discharge	0.03 (0.07)
Overall scores
Planned care	1.08 (0.21)
Care team	2.41 (0.36)
Access	2.12 (0.30)
Implementation	1.94 (0.20)
Quality measures
Patients prescribed antiplatelet therapy	0.78 (0.05)
Patients prescribed drug therapy for LDL-C	0.87 (0.03)
Patients with prior MI who were prescribed β-blocker	0.72 (0.06)
Lipid profile	0.63 (0.08)
CAD patients with LDL-C <100 mg/dL	0.65 (0.06)
Patients who have LVSD and/or diabetes and were prescribed ACE inhibitor/ARB	0.86 (0.06)
HbA_1c testing	0.78 (0.05)
HbA_1c <9%	0.59 (0.05)
Blood pressure <140/80 mm Hg	0.56 (0.05)
LDL-C testing	0.70 (0.04)
Diabetic patients with LDL-C <100 mg/dL	0.36 (0.06)
Urine protein testing	0.86 (0.02)
Eye examination	0.14 (0.07)
Foot examination	0.48 (0.10)
Patients who had LVF assessment ever	0.63 (0.13)
Patients who were provided HF education in past year	0.08 (0.06)
Patients with AF who were prescribed warfarin	0.91 (0.08)
Breast cancer screening	0.46 (0.08)
Colon cancer screening	0.46 (0.08)
Patients aged ≥50 y who received influenza vaccination during Sep-Feb	0.35 (0.04)
Pneumonia vaccination	0.77 (0.05)
Patient satisfaction^d
Wait time in clinic	0.49 (0.10)
Friendliness/courtesy of the clinician	0.83 (0.05)
Explanations the clinician gave you about your problem or condition	0.79 (0.05)
Information the clinician gave you about medications	0.77 (0.03)
Follow-up instructions	0.75 (0.03)
Amount of time the clinician spent with you	0.75 (0.05)
Likelihood to recommend	0.80 (0.04)
Overall satisfaction	0.71 (0.05)
Clinician satisfaction^d
Morale of your group	0.16 (0.18)
Quality of care dimension (questions 14–18)	0.39 (0.14)
Quality of care you are able to provide	0.45 (0.23)
Time spent working dimension (questions 20–24)	0.16 (0.14)
Time you work	0.13 (0.14)
Time you spend with patient	0.16 (0.11)
Volume of patient load is reasonable	0.17 (0.18)
Patient interaction dimension (questions 26–29)	0.35 (0.10)
Relationship with patients	0.79 (0.14)
Continuity of care you are able to provide	0.38 (0.26)
Relationships with staff dimension (questions 40–43)	0.27 (0.14)
Nonphysicians in my practice carry out clinical instructions	0.18 (0.14)
Not enough support staff	0.19 (0.16)
Using EHR has improved my practice	0.61 (0.21)
Overall satisfaction with practice	0.27 (0.22)
Financial/productivity, $^e
Net revenue/visit	147.27 (10.53)
Clinician cost/visit	64.04 (20.18)
Clinician cost/WRVU	45.39 (14.35)
Staff cost/visit	64.51 (11.14)
Net revenue/WRVU	104.17 (4.61)
Staff cost/WRVU	45.86 (8.11)
Staff cost/clinician FTE	240,965.50 (52,506.46)
WRVU/clinician FTE	5,525.50 (1,526.03)
Visits/clinician FTE	3,856.80 (974.90)

ACE=angiotensin-converting enzyme; AF=atrial fibrillation; ARB = angiotensin receptor blocker; CAD = coronary artery disease; CBD = Care by Design; EHR = electronic health record; FTE = full-time equivalent; HbA_1c=hemoglobin A_1c; HF = heart failure; LDL-C = low-density lipoprotein cholesterol; LVF = left ventricular function; LVSD = left ventricular systolic dysfunction; MA = medical assistant; MI = myocardial infarction; TSF = telephone service factor; WRVU = work relative value units.
Notes: Denominators for the quality measures varied by measure and ranged from 233 to 20,143. Completed patient satisfaction questionnaires were returned by 2,051 unique patients in 2011 on the basis of visit date. The clinician satisfaction questionnaire was completed by 51 unique clinicians in 2011.
↵a Implementation scores range from 0 to 4, with higher scores indicating greater degree of implementation.
↵b A patient portal in the EHR.
↵c A patient history template in the EHR.
↵d Patient and clinician satisfaction scores range from 0 to 1, with higher scores indicating greater satisfaction.
↵e Dollars in 2011.

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Table 4

Summary of Significant Correlations (P ≤.05) Between Care by Design Elements and Outcome

CBD Element	Quality Measures	Patient Satisfaction	Clinician Satisfaction	Productivity and Cost
Appropriate access
Same-day appointment	Pneumovax vaccination (−0.66)	–	–	Clinician cost/WRVU (0.74) Staff cost/clinician FTE (−0.87) WRVU/clinician (−0.83) Visits/clinician (−0.89)
Primary care clinician continuity	Influenza vaccination (0.68)	Likelihood to recommend (0.72)	–	–
Response to messages	Diabetes patient BP <140/80 mm Hg (−0.64)	Wait time at clinic (−0.75) Friendliness/courtesy of clinician (−0.68) Likelihood to recommend (−0.64)		–
Abandonment rate	ACE inhibitor/ARB (−0.70)	–	Continuity of patient care able to provide (−0.64)	Clinician cost/WRVU (−0.66)
Calls answered within standard	Patients with AF prescribed warfarin therapy (−0.66)	Mammogram (0.70)	Time you spend working (−0.84)	Staff cost/clinician FTE (0.78) Visits/clinician FTE (0.69)
Patients signed up for MyChart^a	Warfarin (−0.71) Eye examination (−0.80)	–	–	–
Care teams
X-files^b	–	Explanation of care (−0.70) Instructions clinician gave (−0.68) Likelihood to recommend (−0.77)	–	–
Physical template	HbA_1c test (−0.63) Influenza vaccination (−0.63)	–	–	Staff cost/clinician (−0.82) Visits/clinician (−0.69)
Best Practice Alerts	LDL-C treatment (−0.65)	–	–	–
Standard examination room	HbA_1c <9% (−0.70)	–	Not enough support staff (0.79)	Staff cost/WRVU (0.64) WRVU/clinician (−0.75) Visits/clinician (−0.73)
Efficient visit	Lipid profile (−0.75) CAD patient LDL-C <100 mg/dL (−0.64) Diabetes patient LDL-C test (−0.72)	Wait time at clinic (0.79)	Time you spend (−0.71)	–
Huddles	LV assessment (0.78)	_	–	–
Blood draw in room	–	Overall satisfaction (0.68) Wait time at clinic (0.66)	Your relationship with patients (0.71)	Net revenue (−0.68) Staff cost/clinician (−0.76) Clinician cost/WRVU (0.73) WRVU/clinician (−0.65)
Continuity of the MA	–	Friendliness/courtesy of clinician (0.82)	–	–
MA engagement	BP <140/80 mm Hg (0.63) Breast cancer screening (0.64)	–	–	–
Documented patient communication needs	–	–	–	Staff cost/WRVU (0.64) WRVU/clinician (−0.74)
Presence of advance directives	Diabetes patient LDL-C <100 mg/dL (0.72) HbA_1c <9% (0.70) Urine protein (0.81)	Friendliness/ courtesy of clinician (−0.69) Information clinician gave (−0.69) Amount of time clinician spent (−0.75) Likelihood to recommend (−0.79)	–	–
Depression screen	–	Amount of time clinician spent (−0.62)	–	–
List of common resources	Diabetes patient LDL-C <100 mg/dL (−0.66) Colon cancer screening (−0.71) Influenza vaccination (−0.69)	–	Morale of group (0.88)	–
Efficient communication	Antiplatelet therapy (−0.68)	–	Volume of patient load reasonable (−0.70) Not enough support staff (−0.73) Quality of care able to give (−0.59)	–
Planned care
Registries	–	–	Volume of patient load reasonable (−0.70) Continuity of care you are able to provide (−0.77)	Clinician cost/visit (−0.81) Clinician cost/WRVU (−0.76)
Labs done prior to visit	–	–	Morale of group (−0.67)	–
After-Visit Summary given	β-blocker (0.64) Diabetic patient LDL-C <100 mg/dL (0.67) LV assessment (0.67) Patient heart failure education (0.67)	–	–	Net revenue (0.64)
Medicine reconciliation	Patient heart failure education (0.79)	–	EHR improved my practice (−0.79)	Staff cost/visit (0.71) Staff cost/WRVU (0.74)
Procedure/consults notes available	Warfarin (−0.72)	–	–	–
Care plan documented	Warfarin (−0.77)	–	Time you spent working (−0.70) Continuity of care you are able to provide (−0.69)	–
Progress on care plan	Warfarin (−0.77)	–	–	–
Contact patients postdischarge	HbA_1c <9% (0.68) Diabetic patient LDL-C test (0.68) Diabetic patient LDL-C <100 mg/dL (0.68) Urine protein (0.70) Pneumovax (0.70)	Overall satisfaction (−0.70)	Quality of care able to give (−0.71)	Staff cost/clinician (0.68)
Composite scores
Appropriate access	Warfarin (−0.64)	Explanation of care (0.67) Instructions clinician gave (0.72) Likelihood to recommend (0.76)	–	–
Care teams	–	Overall satisfaction (0.67)	Time you spend working (0.68) Your relationship with patient (0.72)	Staff cost/clinician (−0.94) Visits/clinician (−0.70)

ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; BP =blood pressure; CAD = coronary artery disease; CBD=Care by Design; EHR=electronic health record; LV = left ventricle; LDL-C = low-density lipoprotein cholesterol; MA = medical assistant; HbA_1c=hemoglobin A_1c; WRVU = work relative value unit.
Note: Values in parentheses are correlation coefficients.
↵a A patient portal in the EHR.
↵b A patient history template in the EHR.

Additional Files

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Supplemental Appendixes 1-3

Supplemental Appendix 1. Contextual Factors Relevant for Understanding and Transporting Findings From This Study; Supplemental Appendix 2. CBD Implementation Assessment Tool; Supplemental Appendix 3. CBD Implementation Correlation Outcomes

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Supplemental data: Appendix 1 - PDF file, 3 pages, 217 KB
Supplemental data: Appendix 2 - PDF file, 16 pages, 369 KB
Supplemental data: Appendix 3 - PDF file, 10 pages, 414 KB