Different Paths to High-Quality Care: Three Archetypes of Top-Performing Practice Sites

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