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Service Delivery Innovation Profile

Multispecialty Practice Uses Electronic Templates to Provide Customized Support at Every Visit, Contributing to Improved Patient Behaviors and Outcomes


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Snapshot

Summary

Nurses in a multispecialty group practice use templates within a secure electronic medical record at virtually every visit to assess patients’ weight-related health risks, create a customized exercise “prescription,” and evaluate and address smoking status. The resulting information is summarized in a personalized document designed to support the patient in making needed behavioral changes. During the visit, the nurse and physician explain this document to the patient, reinforce its key messages, and make referrals to relevant support programs offered by the practice and in the community. The program has contributed to a leveling off in the prevalence of overweight/obesity, above-average quit rates in smokers, better blood glucose control in those with diabetes, and fewer racial disparities in the care of some chronic conditions.

Evidence Rating (What is this?)

Suggestive: The evidence consists primarily of post-implementation data and trends among subsets of clinic patients in average body mass index (BMI), the proportion of patients with a BMI above 25, quit rates among smokers, blood glucose control, and racial disparities in chronic disease outcomes. Although the results cannot be tied directly to the LESS initiative, program leaders believe the program has played a contributing role.
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Developing Organizations

Southeast Texas Medical Associates
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Date First Implemented

1999
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Patient Population

The program serves all patients who come to the multispecialty clinic; the clinic cares for low-income Medicare, Medicare Advantage, and Medicaid enrollees. Roughly one-third of patients are African American, with the bulk of the remainder being white.end pp

Problem Addressed

Unhealthy behaviors such as poor eating habits, sedentary lifestyles, and smoking contribute to overweight/obesity and other health-related problems, as well as high mortality rates. Although physicians can play a valuable role in encouraging and supporting patients in making health-related lifestyle changes that can prevent and/or mitigate the impact of such problems, many fail to do so on a consistent basis during time-pressed office visits.
  • Unhealthy behaviors, leading to health problems and high mortality: Smoking, physical inactivity, poor diet, and problem drinking are common and lead to a variety of health problems and to increased risk of death, as outlined below:
    • Significant, growing prevalence of overweight/obesity: Poor health-related behaviors have contributed to a growing obesity epidemic. More than one-fourth (25.6 percent) of adults are obese,1 a figure that has increased markedly over the last several decades. The same phenomenon has occurred among children and adolescents.2
    • Severe health consequences, increased risk of death: Overweight and obesity put children and adults at current and future risk of serious health problems, including cardiovascular disease, type 2 diabetes, and mental health conditions such as anxiety and depression.3 Smoking, physical inactivity, poor diet, and problem drinking can lead to or exacerbate a variety of chronic diseases and acute health episodes; collectively, they account for approximately 37 percent of deaths (and 70 percent of preventable deaths) in the United States.4
  • Lack of clinician support: Behavior modification can be difficult, but individuals who succeed in modifying unhealthy behaviors cite physician recommendations and support as important motivators.5 However, physicians often fail to provide such counseling and support, often because they forget or do not have the resources or time to do so. For example, one study found that only 40 percent of physicians assessed the physical activity status of patients.6 Another study found that only 42 percent of obese adults were advised by their physician to lose weight.7

What They Did

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Description of the Innovative Activity

Through the LESS initiative (“Lose weight, Exercise, and Stop Smoking and/or avoid Second-hand Smoke”), nurses in a multispecialty group practice use templates within a secure electronic medical record (EMR) at virtually every visit to assess patients’ weight-related health risks, create a customized exercise “prescription,” and evaluate smoking status. The resulting information is summarized in a personalized document designed to educate and support the patient in making desired changes. The nurse and physician explain the document to the patient, reinforce its key messages, and make referrals to relevant support programs offered by the practice and in the community. Key program elements are outlined below:
  • Three-part, template-driven assessment at almost every visit: The nurse takes the patient's vital signs (standard metrics along with body fat, pulse oximetry for those with pulmonary conditions, and blood glucose for those with or at risk for diabetes) and enters them into the EMR. The nurse then completes a three-part assessment using electronic templates embedded in the system. This 30-second process takes place at every patient visit except those that occur less than 2 months after the last visit (in which case the nurse briefly updates any new information). The process works as follows:
    • Weight management assessment: The nurse clicks on a button within the EMR to bring up the weight management assessment template, which automatically calculates BMI, basal metabolic rate (the amount of energy expended by the body at rest), daily protein needs, weight classification (e.g., normal, overweight, obese, morbidly obese), risk profile based on weight, and desired weight change to eliminate weight as a health risk factor. The desired weight change does not focus on achieving an ideal body weight, but rather on achieving a realistic weight loss that will produce a positive impact on the patient’s health and meaningfully reduce his or her risk factors.
    • Written, customized exercise “prescription”: Based on the weight management assessment and nurse-inputted information on the patient’s current exercise regimen (obtained by asking the patient), this template creates a personalized prescription for achieving “good” aerobic conditioning. The prescription emphasizes the need for 10,000 steps a day and provides a personal target heart rate. For patients with diabetes and/or congestive heart failure (as documented in the EMR or medical history portion of the visit), separate templates create a customized regimen based on the patient’s disease-related capacity limitations and complications. As with the weight management assessment, the prescribed regimen focuses on practical ways for the patient to engage in realistic amounts of physical activity based on his/her current situation.
    • Smoking assessment and followup: Through a separate template, the nurse inquires as to whether the patient currently uses any type of tobacco (including chewing tobacco) or has recently quit doing so (and if so, how long ago). The nurse also inquires as to whether the patient faces routine exposure to secondhand smoke in the home or office. The practice is currently modifying the template to address whether an individual faces routine exposure to thirdhand (or tertiary) tobacco by being around an individual who smells heavily of tobacco (but does not smoke in the patient’s presence). Based on the information provided, the template creates customized information on cessation strategies for the patient or a family member who smokes, including counseling, support groups, and medications. For anyone who currently smokes, the template creates an electronic “tickler file” that alerts the care coordination department to follow up with the patient a month later to see how his or her efforts to quit are progressing.
  • Nurse review of personalized, written plan: The nurse prints a 12- to 15-page personalized document that has the patient’s name and relevant patient-specific data on every page. The document highlights key points and issues related to the three-part assessment, including explaining weight- and smoking-related risks, the customized exercise plan, and other desirable health-related changes, such as improving one's diet. The nurse spends several minutes explaining the purpose and content of the document to the patient, emphasizing that it offers customized information based on the patient’s individual situation. The nurse reminds the patient to bring the document to the next visit so as to evaluate progress against established goals.
  • Physician reinforcement: As part of their regular interactions with patients during the examination, the doctor confirms that the patient has received and understands the document, answers questions, and generally reinforces the most important behavior changes the patient needs to make, such as exercising more, eating a more healthful diet, and quitting smoking.
  • Support services: During their interactions with patients, nurses and physicians use the information generated by the LESS templates to identify and provide, arrange for, or make referrals to needed support services that can assist patients in making the desired behavior changes, including the following:
    • Gym memberships: Seniors who are members of a local Medicare Advantage plan are advised of their ability to secure a free membership at a local gym, including twice-a-week training sessions.
    • Disease management templates and programs: Nurse and physicians may refer patients to any of several disease management programs offered within the multispecialty practice, many of which also use disease-specific templates within the EMR to assist patients in better managing their conditions. Programs currently target diabetes, congestive heart failure, hypertension, and high cholesterol.
    • Smoking cessation support: Nurses and physicians may provide brief cessation counseling during the visit and/or advise patients about clinic- or community-based smoking cessation support programs, including more extensive counseling and pharmacologic treatment.

Context of the Innovation

Founded by two physicians in 1995, Southeast Texas Medical Associates, LLP, is a multispecialty group practice with 23 physicians and 12 nurse practitioners working in 5 clinic locations in southeast Texas. The practice serves more than 500 patients a day (roughly 170,000 a year), using a secure EMR since early 1999. The impetus for the LESS initiative came from practice leaders in mid-1999, as they realized that the EMR had to that point done little more than electronically document encounters. Feeling it could do much more, they decided to leverage the power of electronics and computation in managing patients. The concept was based on Peter Senge’s The Fifth Discipline, which emphasizes the need for systemic solutions to complex problems. Practice leaders began by developing various disease-specific tools within the EMR related to managing diabetes, hypertension, high cholesterol, and congestive heart failure. Over time, they began to recognize that the same set of behavior changes—losing weight, exercising more, and quitting tobacco use—could improve the health of virtually all clinic patients. Consequently, they began working on a program to leverage the EMR so as to create a systemic, consistent approach to supporting patients in making these desirable lifestyle changes.

Did It Work?

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Results

The program has contributed to a leveling off in the prevalence of overweight/obesity, above-average quit rates among smokers, better blood glucose control in those with diabetes, and fewer racial disparities in the care of some chronic conditions.
  • No increase in overweight/obesity: An analysis of more than 32,000 patients seen by the clinic at least 6 times in the past 10 years found that average BMI has remained stable (rising only slightly, from 28.15 to 28.56). Similarly, the percentage of these patients with a BMI above 25 (the cutoff for being considered overweight) also remained stable, rising by only 0.49 percentage points (from 63.13 to 63.52 percent). This stabilization suggests the program has had a positive impact on weight management because it occurred as these individuals got older (BMI often increases with age), and during a time when rates of overweight/obesity rose for the nation as a whole. Although the LESS initiative cannot be considered solely responsible for this stabilization, program leaders believe it has been a major contributor due to its systematic, consistent focus on weight management and related behaviors at virtually every visit.
  • Above-average quit rates: In the past 10 years, the LESS initiative has helped at least 2,767 patients quit smoking. In addition, at least 15 percent of the 3,209 smokers who have visited the practice at least twice in the last 2 years have quit permanently. (Actual quit rates are likely higher, as documentation of those who quit does not always occur.) This rate is well above the 7-percent or lower average quit rate among smokers who want to stop smoking but receive little or no assistance in doing so.8,9
  • Better blood glucose control: Median hemoglobin A1c levels in patients with diabetes dropped from 7.78 percent in 2000 to 6.50 percent in 2008. Multiple initiatives (including disease management tools, a self-management education program, and an endocrinologist joining the practice) likely account for this decline, with the LESS initiative playing a supporting role.
  • Fewer disparities in chronic care: The practice has virtually eliminated disparities in diabetes outcomes, with similar percentages of African-American and white diabetes patients having their blood glucose levels under control. The practice has made some (but less substantial) progress in reducing racial disparities in managing hypertension and high cholesterol. The LESS initiative has played a supporting role in reducing these disparities, primarily through its systematic emphasis on addressing health-related behaviors for every patient (regardless of race) at virtually every visit.

Evidence Rating (What is this?)

Suggestive: The evidence consists primarily of post-implementation data and trends among subsets of clinic patients in average body mass index (BMI), the proportion of patients with a BMI above 25, quit rates among smokers, blood glucose control, and racial disparities in chronic disease outcomes. Although the results cannot be tied directly to the LESS initiative, program leaders believe the program has played a contributing role.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Creating electronic templates and tools: With support from a college intern with programming experience, the practice’s chief executive officer (CEO) worked on a part-time basis over several months to develop the relevant templates for the program. As part of this process, the CEO and intern researched the literature to identify proven approaches to educating patients on weight management, exercise, and smoking cessation. For example, the CEO transformed the American Medical Association’s 200+ page adult weight management program into an electronic, template-based format that emphasizes the risks associated with excessive weight and makes recommendations related to diet, exercise, and treatment. A similar approach was used in building the other templates, including basing the exercise template on the work of The Cooper Institute in Dallas, TX.
  • Training nurses and physicians: All clinic staff underwent initial training on how to use the LESS templates and how to hold conversations with patients related to behavior change. This training continues on a regular basis, as the practice closes for a half-day each month to train nurses and physicians on use of the various computer templates (both LESS templates and separate disease management tools). Providers also have access to a LESS tutorial they can reference at any time. The practice CEO uses regular staff meetings as an opportunity to train staff on how to work effectively with patients to promote behavior change.

Resources Used and Skills Needed

  • Staffing: Upfront program development required part-time work for two individuals over a period of several months. The program requires little or no incremental staffing on an ongoing basis, as physicians and staff incorporate program-related activities into their regular duties. As noted, however, the practice does close a half-day each month for training, some of which relates directly to the LESS initiative.
  • Costs: Although hard data are not available, upfront development costs were fairly minimal, consisting primarily of staff time (to develop the templates and train staff to use them) and the purchase of printers for each examination room. Ongoing program-related expenses are negligible, consisting mostly of ink and paper costs for printing the customized patient reports.
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Funding Sources

Southeast Texas Medical Associates
Southeast Texas Medical Associates funds the program out of its internal operating budget.end fs

Tools and Other Resources

A tutorial on the various LESS initiative templates is available at: http://www.setma.com/epm-tools/. Full, electronic versions of these templates can be obtained by contacting Dr. Holly, the CEO of the practice and developer of this program. Information on other, related programs at Southeast Texas Medical Associates can be accessed through the practice’s Web site, http://www.setma.com.

Adoption Considerations

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Getting Started with This Innovation

  • Identify and cultivate a passionate champion: Getting the program off the ground requires the relentless commitment of a respected individual who will not be satisfied until the program becomes a part of everyday practice.
  • Leverage existing resources: Would-be adopters can build the program based on existing materials created by Southeast Texas Medical Associates, all of which can be obtained by contacting the program developer.
  • Make public commitment: Southeast Texas Medical Associates leaders told patients, staff, and the community at large that the practice was committed to using its EMR to promote health-related behavior changes, thus creating accountability among key stakeholders.
  • Ensure content focuses on realistic improvements: When creating content for the templates, emphasize the benefits of making modest, achievable changes. For example, make sure the templates are designed to urge a previously sedentary, obese individual to set realistic goals, such as exercising a few minutes a day (gradually increasing over time) and losing a few pounds. Telling this patient to strive for his or her ideal body weight or to exercise an hour a day would likely backfire because these goals will seem impossible to achieve.
  • Set up system to personalize documents: The effectiveness of the written document depends in large part on the degree to which it is personalized for the patient. To that end, design the system to print the patient's first and last name and to incorporate patient-specific data and information on every page. (See the Story section for an anecdote that demonstrates the power of this personalized approach.)

Sustaining This Innovation

  • Constantly reinforce key messages: The key to effectively promoting behavior change lies in repetition. To that end, providers should complete the templates and provide an updated document at virtually every visit, and generally use each visit as an opportunity to educate and influence the patient.
  • Audit and share data on provider adherence: To promote the repetition outlined above, monitor the degree to which nurses and physicians use the LESS templates at each visit. Southeast Texas Medical Associates regularly monitors and publicly shares clinician-specific adherence rates. This strategy has led to the templates being used more than 97 percent of the time, meaning that organizational leaders have achieved their goal of making LESS a routine, accepted part of everyday practice.

More Information

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Contact the Innovator

James L. Holly, MD
Chief Executive Officer
Southeast Texas Medical Associates, LLP
Beaumont, TX 77702
Tel: 409 654-6819 (office); 409 504-4517 (cell)
E-mail: jholly@setma.com

Innovator Disclosures

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

Footnotes

1 U.S. Centers for Disease Control and Prevention. Behavioral risk factor surveillance system survey data (BRFSS). Available at: http://apps.nccd.cdc.gov/BRFSS/list.asp?cat=OB&yr=2008&qkey=4409&state=All.
2 U.S. Centers for Disease Control and Prevention. Overweight and obesity: NHANES surveys (1976–1980 and 2003–2006). July 24, 2009. Available at: http://www.cdc.gov/obesity/childhood/prevalence.html.
3 Koplan J, Liverman C, Kraak V, editors. Preventing childhood obesity: health in the balance. Washington, DC: National Academies Press; 2005.
4 Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-45. [PubMed]
5 Krist AH, Woolf SH, Frazier CO, et al. An electronic linkage system for health behavior counseling effect on delivery of the 5A's. Am J Prev Med. 2008;35(5 Suppl):S350-8. [PubMed]
6 U.S. Preventive Services Task Force. Behavioral counseling in primary care to promote physical activity. Available at: http://www.ahrq.gov/clinic/3rduspstf/physactivity/physactrr.htm#clinical.
7 Galuska DA, Will JC, Serdula MK, et al. Are health care professionals advising obese patients to lose weight? JAMA. 1999;282(16):1576-8. [PubMed]
8 Baillie AJ, Mattick RP, Hall W. Quitting smoking: estimation by meta-analysis of the rate of unaided smoking cessation. Aust J Public Health. 1995;19(2):129–31. [PubMed]
9 American Cancer Society. Guide to quitting smoking. A word about quitting success rates. January 31, 2011. Available at: http://www.cancer.org/Healthy/StayAwayfromTobacco/GuidetoQuittingSmoking
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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: July 06, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 31, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 01, 2013.
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.

Back Story
Shortly after the LESS initiative began, a father who had smoked for many years came home after work and saw a document lying on the kitchen table with his son’s name on the cover. It had come from a Southeast Texas Medical Associates clinic that his wife and son had...

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