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Service Delivery Innovation Profile

E-Mail and Telephone Contact Replaces Most Patient Visits in Primary Care Practice, Leads to More Engaged Patients and Time Savings for Physicians


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Snapshot

Summary

Based on the belief that more than one-half of primary care office visits are unnecessary, GreenField Health relies heavily on e-mail and telephone communications for the majority of patient contacts, which, in turn, frees up staff to see patients who need in-person care on a timely basis. This approach appears to more fully engage patients in their care and decisionmaking, enable better care management, and save physician and staff time.

Evidence Rating (What is this?)

Suggestive: Anecdotal information suggests that these activities improve the quality and efficiency of care.
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Developing Organizations

GreenField Health
GreenField Health is located in Portland, OR.end do

Date First Implemented

2001

Problem Addressed

Although the environment for medical care has changed dramatically in recent years with the development of new clinical knowledge and information technologies, the structure of primary care has remained largely the same, with face-to-face office visits serving as the primary method of delivering services and little patient–clinician contact taking place outside of that visit. The net result is a large number of unnecessary visits, long waits for those who truly need inperson care, and missed opportunities for providing effective care and education between visits.
  • Many unnecessary visits: An estimated 50 percent of ambulatory care visits are unnecessary due to a mindset that equates physician visits with medical care.1
  • Few available appointments for those who need them: Patients who need care are not always able to get an appointment, because physicians are so busy conducting visits that may not be necessary.
  • Little time for ongoing management: The typical time-limited office visits provides only episodic care designed to treat specific symptoms or problems of the moment; this is especially true for patients with chronic diseases. The net result is that physicians are often unable to provide ongoing care management (e.g., preventive and screening services, education on self-management) that can help to prevent problems from occurring in the future.

What They Did

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Description of the Innovative Activity

GreenField Health has fundamentally redefined the relationship between patient and provider by setting up a system that provides ongoing, continuous (rather than episodic) care, with heavy reliance on e-mail and telephone communications as a replacement for inperson office visits when practical. Freed-up office time has been used to enhance access to inperson visits for those who truly need it. Among the features that make this medical practice design unusual are the following:
  • As-needed contact by e-mail, online, or telephone: Patients can contact their providers at any time by e-mail, telephone, or through an online system. Approximately 80 percent of care is done by e-mail or telephone. Laboratory results are also sent to patients in a timely manner via e-mail and/or telephone.
  • Enhanced access to inperson care: The time freed up through electronic and telephone contact enables the clinic to provide walk-in and same-day appointments to any patient who needs one. Any patient can see a physician within 24 hours of requesting an appointment.
  • Personal medical assistant: Each patient is matched with a health coordinator who serves as an advocate and care coordinator for that patient, including interacting with consulting physicians, hospitals, laboratories, and other ancillary services. Health coordinators are trained as medical assistants and serve as the point of contact for referrals, ordering tests, and other services.
  • Indepth patient education: Online educational materials and group visits for patients with the same diagnosis or risk factor (e.g., weight management) provide an opportunity for indepth education that more fully engages patients in their own care and decisionmaking processes. Many educational documents are sent electronically to patients, and GreenField Health has educational videos on their Web site. Patients also receive a monthly electronic newsletter with large amounts of information about prevention and chronic disease management.
  • Clinical information system as support: GreenField Health's clinical information system connects and integrates information from both within and outside the practice. All members of the care team, including the patient, have access to the same medical information and participate in making care decisions. The system includes the following components: an electronic health record that integrates knowledge management through automated clinical guidelines; a practice management system; customized encounter forms; disease registries; secure messaging (e-mail) and connectivity; secure Internet portal for patients; online clinical information; practice decision support; patient decision support; electronic diagnostic technology; scanning; network faxing; interfaces with laboratory, radiology, and hospital systems; medical group intranet; patient e-newsletter; and telecommunication systems.

Context of the Innovation

GreenField Health, established in 2001, is a medical group practice with an integrated research and development component. An independent clinic with two sites and nine physicians, this medical practice operates in a predominantly fee-for-service environment and manages a patient population that is approximately 5 percent Medicaid and 15 percent Medicare, with the remaining patients privately insured. It pursued this initiative as a part of its stated mission to actively explore the use of information technology (IT) and system design to understand how to improve care. GreenField Health functions not only as a primary care practice but also as a research laboratory for primary care service delivery innovations and a resource for organizations interested in improving practice management and redesign.

Did It Work?

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Results

Anecdotal reports indicate that the program has helped patients become more engaged, resulted in cost efficiencies for the practice, and improved followup care:
  • More patient engagement: Based on anecdotal observation of patient interactions by phone, e-mail, and in person, patients at the practice are highly engaged in their care and decisionmaking.
  • More reliable care and followup: The practice's ability to provide evidence-based care has been enhanced. For example, 95 percent of adult patients have had a cardiac risk assessment, consistent with National Cholesterol Education Program/Adult Treatment Panel III recommendations. Other performance indicators have not been collected on a standardized basis and are not presently available.
  • Cost efficiencies: According to one insurer, GreenField Health is 20 percent more cost efficient than normal in terms of total cost of care. This is due in part to the reliance on e-mail and phone encounters to replace many of the office visits that occur in a typical practice. At GreenField, the average patient experiences nearly five e-mail contacts and five phone contacts per year compared with fewer than two inperson visits.

Evidence Rating (What is this?)

Suggestive: Anecdotal information suggests that these activities improve the quality and efficiency of care.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Weekly team meetings and training sessions: These 1-hour team meetings are used for discussion on pertinent clinical and managerial issues and to review ongoing quality improvement projects.
  • Partnerships with IT companies: The practice has a strong working relationship with several IT companies that help guide the development and integration of technological solutions to care management problems.

Resources Used and Skills Needed

  • Staffing: The program requires 1 medical assistant for every 500 patients. In addition to serving as advisers to patients, medical assistants do most of the administrative work, including answering telephones, scheduling appointments, and greeting and checking in patients.
  • Costs: Cost information is not available.
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Funding Sources

GreenField Health
Funding sources include income from consulting services, grants from IT partner companies, insurer reimbursement (some Oregon insurers pay for e-mail or telephonic consultations, but this practice is not universal and may be less common in other regions), and an annual patient fee to support electronic care and research and development.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Set a clear goal to transform the practice of primary care.
  • Be creative in developing and testing new approaches.
  • Integrate electronic systems at the beginning of the process rather than converting data and systems later.
  • Begin with one custom-designed IT component as an initial step, and add additional components over time so as not to overwhelm the staff.

Sustaining This Innovation

  • Maintain, test, and update IT equipment, software, and security measures.
  • Orient staff when they are hired, and continue training as an ongoing process.
  • Integrate new knowledge and tools to enhance diagnosis and treatment over time.

Additional Considerations

  • Relationship-based care requires the ability to connect with patients without the need for an inperson visit; developing this capability through e-mail and the telephone requires the development of sophisticated systems for providing followup care to patients.
  • E-mail is a robust platform for communication between physicians and patients.

More Information

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Contact the Innovator

David Shute, MD
Medical Director
GreenField Health
9450 SW Barnes Road Suite 100
Portland, OR 97225
Phone: (503) 292-9560
E-mail: David.Shute@GreenFieldHealth.com

Kristin Walker (Exec Assistant)
E-mail: Kristin.Walker@GreenFieldHealth.com

Innovator Disclosures

Dr. Shute has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Kilo CM. Transforming care: medical practice design and information technology. Health Aff (Millwood). 2005;24(5):1296-301. [PubMed]

Kilo CM, Leavitt M. Medical practice transformation with information technology. Chicago, Illinois: Health Information Management and Systems Society and the Institute for Healthcare Improvement; 2005.

GreenField Health Web site. Available at: http://www.greenfieldhealth.com/Portal/default.aspx

Kilo CM. April 25, 2006 presentation at Primary Care at the Crossroads: New Models for the 21st Century. Available at: http://www.familymedicine.medschool.ucsf.edu/pdf/cepc/0406_pres/KiloPPTSlides.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Footnotes

1 Kilo CM. Transforming care: medical practice design and information technology. Health Aff (Millwood). 2005;24(5):1296-301. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 26, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 23, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.