 Snapshot
SummaryThe Marshfield Clinic has long used information systems to facilitate care process redesign for patients with chronic illnesses, and the organization expanded its efforts after becoming a participant in the Centers for Medicare & Medicaid Services Physician Group Practice Demonstration Project. As a result of these expanded efforts, Marshfield Clinic has enhanced quality and access to care; reduced hospitalizations, adverse events, and clinical and administrative costs; and earned performance bonuses in both years of the demonstration project.
See Description of Innovative Activity, Results, and Adoption Considerations sections for updated information and outcomes (updated June 2009).
Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including appointment waiting times, adverse events, hospitalizations, and costs.
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begin doxmlDeveloping OrganizationsMarshfield Clinic The Marshfield Clinic is located in Marshfield, WI.
end doDate First Implemented2004
begin ppPatient Population
Geographic Location > Region; Vulnerable Populations > Medically or socially complex end pp |
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Problem AddressedHealth care organizations that have information systems, including electronic medical records (EMRs), often fail to take advantage of their capabilities, as they are not adequately integrated into care management processes and workflow. This problem is particularly significant for physician practices, which often do not take full advantage of such systems even when they have spent significant sums of money to purchase them. For example, a National Center for Health Statistics study found that, although 34.8 percent of office-based physicians reported using EMRs in 2008, an evaluation of the actual functions used suggests that only 20 percent are using the electronic systems in a meaningful way.1
Description of the Innovative ActivityThe Marshfield Clinic has redesigned patient care and workflow processes for chronically ill patients to take advantage of the organization's full-function EMR and wireless tablet personal computer (PCs) technologies. These redesigned processes guide the care of all chronically ill patients, although they were motivated in part by the Centers for Medicare & Medicaid Services (CMS) Medicare Physician Group Practice Demonstration Project (see Context section for more information on this program). Key elements of the program are described below:
- Revamped EMR, tablet PCs, and other information technologies: The clinic first implemented an EMR in 1985, and over time the practice has promoted adoption of the full functionality of the system. The clinic began using wireless tablet PCs for electronic prescribing and dictation in 2003; expansion of the system's use allowed the clinic to completely eliminate paper charts by the end of 2007, as all information is now readily available in electronic format to physicians at any time at any care site.
- Leveraging the systems to redesign chronic care processes: Marshfield has developed a comprehensive package of initiatives that leverage the electronic technologies to redesign care for chronically ill patients, including the following:
- Preventive services for diabetes, other chronic diseases: The EMR generates a preventive services list on the dashboard of each electronic patient record. This box compares the patient's clinical profile with evidence-based clinical practice guidelines formed from a number of sources including the American Diabetes Association and input from endocrinologists at Marshfield and highlights (in red) gaps in care related to preventive services, immunizations, routine screening, and diabetes care needs; eventually, this functionality will be expanded to cover additional disease states. The system prompts the physician to provide or schedule needed preventive services during the patient visit. In contrast to disease-specific programs and care registries, this list allows physicians to proactively plan and coordinate needed preventive, screening, treatment, monitoring, and education across a spectrum of diseases for each individual patient.
- Flagging of high-priority patients: A "hierarchical recovery list" includes high-risk patients with multiple chronic conditions that are in need of immediate attention. High-risk patients with serious gaps in care (e.g., diabetes patients who have not made appointments for annual eye and foot examinations and whose hemoglobin A1c level is above goal) appear at the top of the list; physicians and staff use this list to work with the patient to provide or schedule needed care immediately.
- Anticoagulation care management system: All patients who take warfarin are managed under a single set of protocols. Under this nurse-managed, physician-directed telephonic management program, nurses place outbound calls to patients to discuss their anticoagulation management and check on their general health. As needed, registered nurses adjust dosing based on written protocols and enter updates into the EMR.
- Electronic prescribing to enhance safety: Physicians use tablet PCs for electronic prescribing, with prescriptions printed by computer, thus reducing the potential for medication errors.
- 24-hour nurse line: Patients have access to a 24-hour telephone number staffed by registered nurses. Nurses listen to the patient's concerns, refer to the EMR for background data and care plan, offer advice, and triage patients for physician appointments using physician-approved guidelines. An automated e-mail system notifies physicians whose patients have called the nurseline and provides a hyperlink to the patient's medical record.
- Timely, actionable feedback and other programs to facilitate quality improvement: Through the EMR, Marshfield provides timely performance feedback designed to spur quality improvement. Through use of interactive "quality dashboards," Marshfield offers providers actionable information, including registries of patients with a particular condition, any needed tests or services for those patients, upcoming appointments, etc. The system also provides unblinded data showing performance for the system as a whole and by individual department and practitioner, thus allowing clinicians to seek out the best performers to learn what they are doing to achieve such good performance. The overall goal is to get clinicians to think about managing the health of their entire patient population, not just individual patients. Other quality improvement efforts facilitated by the EMR include continuing medical education, online provision of care guidelines, and coaching by quality improvement medical directors and clinical nurse specialists.
References/Related ArticlesMcCarthy D. Case study: improving quality and efficiency in response to pay-for-performance incentives under the Medicare Physician Group Practice Demonstration. The Commonwealth Fund. March 12, 2007. Available at: http://www.commonwealthfund.org/innovations/innovations_show.htm?doc_id=468900
Trisolini M, Pope G, Kautter J, et al. Medicare physician group practices: innovations in quality and efficiency. The Commonwealth Fund and RTI International. December 2006; 12-14. Available at: http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=428880
Institute of Medicine (IOM). Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
Lohr S. The evidence gap: health care that puts a computer on the team. New York Times. December 27, 2008.
This profile is adapted from an Improvement Report by the Institute for Healthcare Improvement, available online at: http://www.ihi.org/IHI/Topics/OfficePractices/Access/ImprovementStories/
Contact the InnovatorTheodore A. Praxel, MD, MMM, FACP
Medical Director
Quality Improvement and Care Management
Marshfield Clinic
1000 North Oak Avenue
Marshfield, WI 54449
(715) 389-3188
E-mail: praxel.theodore@marshfieldclinic.org
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ResultsThe EMR-facilitated care redesign has enhanced access to care and reduced adverse events, hospital admissions, and clinical and administrative costs. As a result, Marshfield Clinic has earned performance bonuses in the first 2 years of the CMS demonstration program.
- Quicker access to needed care: Timeliness of appointment scheduling has improved, as measured by decreased time to the third-next available appointment, an accessibility metric used by many physician groups.2
- Reduction in adverse events and hospital admissions: Better adherence to practice guidelines for diabetes care enabled a reduction in the all-cause admission rate for diabetes patients from 355 to 311 per 1,000 patients, meaning that 770 hospitalizations were avoided. A randomized controlled trial of the anticoagulation program showed that it was superior to usual care, reducing adverse events and hospitalizations and increasing the amount of time patients spend in the appropriate therapeutic range.3
- Cost savings: Fewer hospitalizations and adverse events yield significant cost savings. The anticoagulation program, for example, saves Medicare an estimated $11.67 million for 5,000 patients, along with $2.5 million in savings for patients.3 On the administrative side, the clinic is expected to save $4 million annually as a result of not needing space for paper records and labor to physically pull paper records.
- Enhanced revenues under pay-for-performance due to strong cost, quality performance: During the first year of the demonstration project, the Marshfield Clinic was 1 of 2 participating sites (out of 10 total) to earn a performance bonus by reducing expenditures as compared to a comparison group in the same region; in addition, the clinic met 9 of the 10 performance goals related to diabetes care set forth in the program (missing the 10th goal by only a very small margin). In year 2, Marshfield Clinic was 1 of 4 participating sites to earn a performance bonus, and it exceeded all 27 quality-related goals for diabetes, congestive heart failure, and coronary artery disease.
Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including appointment waiting times, adverse events, hospitalizations, and costs.
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Context of the InnovationThe Marshfield Clinic is a multispecialty group practice with more than 750 physicians and 6,000 staff serving more than 360,000 patients at 41 ambulatory care sites located in 35 Wisconsin communities. The clinic was 1 of 10 sites in the United States selected by CMS to take part in the Physician Group Practice Demonstration project. Clinic leaders decided to participate in the program because it gave the organization the opportunity to advance their existing and planned electronic initiatives. The 3-year project, now extended to 5 years, began in 2005. The goal of the project is to improve quality while reducing costs by preventing avoidable illnesses and hospitalizations through strategies such as improving access to care, providing thorough preventive care, offering prompt follow up care, and improving patient education and self-management. Project participation involves collecting and measuring performance on 32 quality measures drawn from CMS’s Doctor’s Office Quality project, focusing on measures from five condition modules: coronary artery disease, diabetes, heart failure, hypertension, and preventive care. A participating group may earn a bonus of up to 80 percent of any Medicare cost savings that it achieves in excess of 2 percent of target expenditures; a group is not penalized if it does not meet its target.
Planning and Development ProcessBecause Marshfield Clinic had already adopted an EMR, there was not a great deal of upfront planning and development required for the program. However, planned enhancements and use of the system were accelerated as a result of participation in the Physician Group Practice demonstration project. For example, the clinic reprioritized the deployment of tablet computers to primary care areas because most patient contacts occur in those areas. Marshfield Clinic physicians work with information technology staff on an ongoing basis to upgrade the systems and processes related to chronic care.
Resources Used and Skills Needed
- Staffing: The project required 2 full-time equivalents (FTEs) of clinical nurse specialists ($173,232), 0.8 FTE quality improvement and care management medical directors ($166,803), 6.4 registered nurses ($387,314), and 1 FTE of health service coordinator ($27,081), for a total staff cost of $754,435.
- Costs: The primary costs of the program involve ongoing information technology investments, which comprise approximately 3.5 percent of the clinic's annual revenues. As noted, however, the program has resulted in significant administrative and clinical cost savings. The true additional information service costs are not known.
begin fsxmlFunding SourcesMarshfield Clinic All project-related staff and funding are provided by the Marshfield Clinic, which entered into the Physician Group Practice demonstration project knowing that the clinic was at financial risk for the investments made in process improvement.
end fsTools and Other ResourcesMedicare Physician Group Practice Demonstration Design: Quality and Efficiency Pay-for-Performance. Available at: http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/PGP_Demo_Design.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software.)
The CMS Doctor’s Office Quality measures can be found on page 9 in the following document: http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/Quality_Specs_Report.pdf
The AHRQ Resource Page on System Design can be found at: http://www.ahrq.gov/qual/systemdesign.htm.
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Getting Started with This Innovation
- Integrate EMR into process redesign: The EMR should not be considered a "silver bullet" that will automatically improve quality and reduce costs. In fact, implementing an EMR without a concomitant process redesign will result in little more than the creation of an "electronic filing cabinet."
- Identify goals and projects to leverage EMR: Identify and implement concrete goals and programs that leverage the EMR's capabilities.
- Integrate EMR into workflow: To the extent possible, ensure that staff and physicians can incorporate use of the EMR into their established daily routine.
Sustaining This Innovation
- Facilitate culture change: Successfully implementing and leveraging an EMR requires more than just a technological change. Rather, an ongoing cultural change needs to occur within the organization to promote team-based care and practice redesign. To facilitate this type of cultural change, leaders need to build relationships, communicate frequently, and invite staff at all levels of the organization to participate in planning and decisionmaking. Although this approach may appear to slow things down in the short run, it will speed up the achievement of results over the long term, as staff will engage in and take ownership over the change process (rather than seeing it as something imposed from above).
- Provide timely, actionable feedback: When using the EMR to facilitate improvement, provide actionable data to clinicians on a timely basis, including detailed information on needed tests and treatments and unblinded performance data that allows clinicians to seek out and learn from the best performers.
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3 Hillman M. Testimony before the Subcommittee on Health of the House Committee on Ways and Means, Hearing on Promoting Disease Management in Medicare. Washington, DC: U.S. House of Representatives; April 16, 2002. |
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Original publication: December 12, 2008.
Last updated: October 28, 2009.
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