SummaryA solo-practice primary care physician leverages functions in an electronic medical record to redesign care processes. Key elements of the revamped care process include systematic review and electronic ordering of needed services in advance of the patient visit, further review during the visit using computerized decision support to identify and address additional needs, proactive outreach to those not seen recently who need preventive or chronic care services, practice-wide performance reports to identify and address systemic problem areas, and use of data from payers to enhance patient safety and improve quality. The program has led to significantly greater adherence to recommended care processes, including colorectal and breast cancer screenings and cardiovascular/stroke care, and to better outcomes for patients with diabetes. The practice has received recognition from multiple programs of the National Committee for Quality Assurance for its electronic medical record-facilitated care redesign and associated improvements in care processes and outcomes, including designation as a patient-centered medical home (the first solo practice in Connecticut to receive such designation).
See the Description of Innovative Activity for updated information about the program's use of data from payers to improve patient safety and improve quality. See the Resources Used section for information about an additional staff member added to the program and the Results section for information about additional funds the program received through the Centers for Medicare and Medicaid Services Electronic Health Record Incentive Program for Meaningful Use of Electronic Medical Records. (Updated January 2014.)Moderate: The evidence consists of pre- and post-implementation comparisons of various metrics related to the provision of recommended care processes and to outcomes for patients with diabetes.
Developing OrganizationsQuinnipiac Internal Medicine
Date First Implemented2006
The practice purchased and implemented the electronic medical record in 2005 and has been using its various functions (including new functions acquired in upgrades) to redesign care processes on an ongoing basis since that time.
Problem AddressedPhysicians in solo practice or small practices often lack the time, resources, and support necessary to ensure the provision of all recommended preventive and chronic care services. As a result, many patients who need such services do not get them, leading to suboptimal patient outcomes.
- Inadequate time and resources: Studies suggest that the typical primary care physician would need to devote 18 hours each day to provide a panel of 2,000 patients with all recommended screenings and chronic disease care.1,2 This large time requirement stems in part from a lack of resources in most primary care offices, which tend to have few support staff and little access to electronic medical records (EMRs) and other systems and tools to identify and address care gaps. Even physicians willing to put in the time often find it difficult to systematically manage their patient population in the absence of electronic tools. For example, the founder of Quinnipiac Internal Medicine used to rely on paper-based spreadsheets to identify needed services for patients, but this time-consuming approach worked only for patients who came in for care; it did not allow for the systematic identification of patients not seen by the practice who were in need of services.
- Failure to provide recommended care: Due in part to these time and resource constraints, physicians often fail to provide patients with needed services. For example, only about half (54.9 percent) of adult patients receive all recommended preventive and chronic care services.3 The failure to provide these effective services leads to suboptimal patient outcomes. For example, right after implementation of the EMR (but before care processes had changed in response to it), only 40 percent of Quinnipiac Internal Medicine patients with diabetes had optimal blood glucose levels.
Description of the Innovative ActivityA solo-practice primary care physician leverages functions in an EMR to redesign care processes. Key elements of the revamped process include systematic review and electronic ordering of needed services in advance of the patient visit, further review during the visit using clinical decision support (CDS) to identify and address additional needs, proactive outreach to those not seen recently who need preventive or chronic care services, practice-wide performance reports to identify and address systemic problems, and use of data from payers to enhance patient safety and improve quality (updated January 2014). More details on each of these key elements are provided below:
- Previsit review of upcoming schedule to order disease-related services: The practice configured template-based office notes and disease-specific order sets that track key metrics relevant to ongoing management of that disease or condition. For example, the diabetes set tracks roughly a dozen measures, including those related to blood pressure, blood glucose, cholesterol, retinal and foot examinations, and microalbumin. To prepare for an upcoming day’s visits, the physician reviews relevant order sets for each patient on the schedule and then orders needed services, including tests, referrals, and related educational materials. The process takes between 30 seconds and 2 minutes for each patient, meaning the doctor can complete an entire day’s schedule in about a half hour. The physician typically performs this review 2 or 3 days in advance of the scheduled visits.
- Medical assistant preparation for each visit: The practice’s medical assistant works with the physician’s previsit orders to prepare all relevant information for each patient in advance of the visit (usually the day before), including requested referrals and documents from the practice’s electronic library of educational materials. When the patient arrives for the visit, the medical assistant also performs the diagnostic testing delineated in the orders.
- Point-of-care identification of additional needs: During the patient visit, the physician uses CDS functions as well as practice-level alerts within the EMR to identify and address additional needs that arise. For example, for patients who come in for routine followup care related to diabetes or high cholesterol, the physician will use these functions to determine if the patient needs other, unrelated services, such as cancer screenings (e.g., mammography, colorectal cancer screening) or a flu shot. These systems use widely accepted national guidelines to determine these needs.
- Automatic documentation to facilitate progress notes, billing: The system automatically populates all relevant clinical information and the appropriate diagnosis and procedure codes into progress notes, along with the appropriate fields in the billing section of the EMR application, thus facilitating completion of these tasks.
- Proactive outreach facilitated by searchable registry: Every patient served by the practice has been entered into a searchable registry that can identify patients meeting virtually any criterion, such as all patients with diabetes who have not had a hemoglobin A1c test in the last 3 months. Using this function, the practice regularly performs customized searches to generate lists of patients in need of services, and then proactively reaches out to them to either schedule a visit (if the service can be provided by the practice) or encourage them to make an appointment with another provider. Outreach occurs through various methods, depending on patient preferences:
- Secure electronic message: The practice recently introduced a secure portal that allows patients to access their medical information and receive secure messages. Those who have signed up receive reminders about needed care through this system.
- Telephone: Many patients still resist the notion of using electronic technology to view their health information or to communicate with the practice. For these patients, the medical assistant and receptionist use registry-generated lists to place outbound calls during natural downtime in their day. The practice spreads out the work associated with outbound calls by running different registry searches throughout the year.
- (Occasional) paper letters: The practice used to send out many written reminders in the mail, which proved to be an expensive, time-consuming process. In many cases, the practice saw no return on this investment, since the needed services were provided by another organization (e.g., mammography services provided by an imaging center). As a result, the practice has significantly cut back on this approach, but still uses it when efficient to do so, such as sending letters to those due for an annual physical through a low-cost mail house.
- Practice-wide performance reporting to stimulate quality improvement: The practice uses EMR functionality to regularly monitor the degree to which the entire population of patients receives needed services and achieves desired outcomes. Much like the registry, the system can run customized reports based on a wide variety of practice-wide metrics, such as the percentage of diabetes patients receiving recommended care processes (e.g., retinal exams, foot exams, blood glucose screening, cholesterol screening) and achieving optimal blood glucose levels; the percentage of hypertensive patients who have the condition under control; and the percentage of all patients up to date on needed preventive services, including immunizations and cancer screenings. Whenever a report identifies a significant problem, the practice redoubles its efforts in that area. For example, in 2007, the practice discovered that only 40 percent of diabetes patients had their blood glucose under control; this discovery led to a significant outreach effort to provide needed followup care and support.
- Use of data from payers to improve patient safety and quality, reduce costs: According to information supplied in January 2014, the practice is launching a project in which commercial payers share data in order to enhance patient safety, collaborate on gaps in patient care, and reduce costs. For example, patients who are identified by the payer as at high risk for hospitalization or readmission would be contacted for an appointment within a short timeframe to assess chronic disease, recovery from acute illness, or preventable complications.
Context of the InnovationEdward Rippel, MD, operates a single-physician primary care practice, known as Quinnipiac Internal Medicine, in Hamden, CT, a suburban area that is roughly a 10-minute drive from Yale University. Dr. Rippel has long been interested in putting in place systems and processes that would allow his practice not only to provide "sick care," but also to ensure that all patients receive needed preventive care and chronic disease management. For many years, he attempted to realize this vision through use of paper-based systems, such as patient-specific spreadsheets that track needed services. Although these systems worked well for individual patients who came in for visits, they did little to help identify and address the needs of those not often seen by the practice, or to analyze practice-wide data to identify opportunities for quality improvement. In the 1990s, Dr. Rippel began learning about the potential of EMRs to facilitate systematic identification and provision of needed care, but for many years these systems remained prohibitively expensive for a solo practitioner. In 2005, he went to a conference sponsored by a local medical group, where he learned about the existence of pay-for-performance (P4P) programs that reward practices based on their ability to track data and improve performance. In some cases, these programs rewarded practices for data that Quinnipiac already tracked. Realizing that he could use P4P program payments to cover some of the costs of an EMR, Dr. Rippel began investigating various systems, with the goal of finding one that could facilitate care process redesign to enhance the provision of recommended services and improve patient outcomes.
ResultsThe program has led to significantly greater adherence to recommended care processes, including colorectal and breast cancer screenings and cardiovascular/stroke care, and to better outcomes for patients with diabetes.
Moderate: The evidence consists of pre- and post-implementation comparisons of various metrics related to the provision of recommended care processes and to outcomes for patients with diabetes.
- Greater adherence to recommended care processes: The program has significantly improved adherence to recommended care processes, as outlined below:
- Cancer screening: The percentage of eligible patients receiving colorectal cancer screening increased from 31 percent in 2007 (before implementation of the program) to 74 percent in 2010. The percentage of eligible patients documented as having received a mammogram rose from 55 percent to 80 percent over the same time period. (The practice would like to improve this performance further, both by identifying patients who received a mammogram ordered by another doctor but not reported to the practice, and by helping those still in need of a mammogram to get one.)
- Cardiovascular care: The percentage of eligible patients on appropriate blood-thinning medications (or having a legitimate reason documented for not being on such medications) rose from 76 percent in 2007 to 98 percent in 2010.
- Improved diabetes outcomes: The percentage of diabetes patients with their blood glucose under control rose from 40 percent in 2007 to 70 percent by 2010. In addition, no diabetes patients cared for by the practice currently require dialysis treatment.
- Continued high levels of quality improvement in preventive care and chronic disease management: The practice has become one of the first in its State to successfully attest to and receive compensation from the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Program for Meaningful Use of Electronic Medical Records for 2011, followed by successful re-attestation for 2012 and 2013 (updated January 2014).
Planning and Development ProcessKey steps included the following:
- Eliciting input from experts: Dr. Rippel asked several of his patients who worked in the medical software field for advice on how to evaluate and select an EMR system. They urged him not to send out a formal request for proposals, but rather to first develop a clear understanding of what he and his staff would like the system to do, and then to interview vendors one at a time to determine the degree to which the system and vendor could meet their needs.
- Brainstorming facilitated by workflow analysis: Dr. Rippel held a series of meetings with his staff to determine what they would like to see in a system. At first, his staff had a difficult time with this exercise, as they did not really understand what EMRs could potentially do. To facilitate progress, Dr. Rippel launched a comprehensive analysis of practice workflows, starting with the first step in the process (the patient calling for an appointment) and ending with getting payment from third-party payers and/or patients. This approach worked well, enabling Dr. Rippel and staff to identify a list of desired functions and questions for the vendors.
- Evaluating systems: Eight different EMR software vendors came to the practice to give a demonstration of their product and to answer questions. These demonstrations and interviews made the choice fairly easy, as one company stood out not only in terms of price, but also in terms of functionality, system flexibility, and support.
- Preparing for implementation: The vendor assigned a project manager to the practice and gave Dr. Rippel a rigid timeline that laid out what needed to be done in advance of implementation, such as buying compatible hardware (e.g., computers, printers, scanners) based on vendor-provided specifications. Dr. Rippel worked with a separate information technology (IT) company to assist with setting up a hardware network and training staff on how to use it. During this preparation stage, Dr. Rippel also converted his patient database into an electronic format and gathered pertinent information on all referring physicians and pharmacies. This process required several hours a day of Dr. Rippel’s time over the course of multiple weekends, with his support staff providing assistance with proofreading.
- Training staff to use new system and associated workflows: The vendor installed the system and made sure it worked correctly. The practice then closed its doors for 4 days so staff could receive onsite, all-day training from the vendor. Different modules covered different components of the process, such as registration, check-in, and capture of data for billing purposes. Dr. Rippel attended every session, while other staff attended only those related to their jobs. On the fifth day, the practice booked a light schedule (one visit every half hour) so that staff could practice using the system with real patients. Vendor representatives remained onsite that day to assist with any problems and to make sure everything functioned properly. As staff got used to the system, they began learning how to use more of its features, such as preinstalled template notes and flowsheets that automatically populate appropriate data fields. This learning process continues on an ongoing basis, particularly as minor and major updates get installed.
- Ongoing identification and resolution of problems: After implementation, staff met weekly to discuss and resolve any problems that arose. Over time, the need for such meetings declined, and today they are called on an as-needed basis if a problem merits formal discussion.
Resources Used and Skills Needed
- Staffing: Until 2014, the program had not required the addition of new staff; in fact, the EMR-facilitated care redesign enabled the practice to bring its billing function in-house, with existing staff now performing this function rather than a paid vendor. (The practice converted 120 square feet of office space previously used to store medical records into a “billing office.”) To accommodate the different workflows involved in the 2014 data-sharing project, another team member will be needed—possibly a nurse practitioner. As noted, Dr. Rippel and his three full-time staff (a medical assistant, medical receptionist, and practice manager/biller) dedicated a week to learning the system.
- Costs: The costs for the software, hardware, and training totaled roughly $50,000. The practice has more than recouped this investment through reduced billing expenses (as noted above), P4P payments from insurers, and increased revenues due to higher patient volumes generated by the practice’s proactive outreach and systematic provision of needed services. The cost of the additional provider mentioned above is anticipated to be offset by additional productivity associated with the project's outreach efforts, more cost-effective regimens, and avoidance of or reduction in hospitalizations. The additional funds received from the CMS EHR Incentive Program for Meaningful Use of Electronic Medical Records have helped offset the costs associated with successful patient-centered care and ongoing improvement in preventive care and chronic disease management outcomes.
Funding SourcesQuinnipiac Internal Medicine
The program was funded internally.
Tools and Other ResourcesMore information on Quinnipiac Internal Medicine can be found at: http://www.qimpc.com/.
Information about the CMS Medicare and Medicaid EHR Incentive Programs is available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html.
Getting Started with This Innovation
- Use strong leadership to address staff concerns proactively : In a small or solo practice, one reluctant or “nay-saying” staff member can prevent the effort from getting off the ground (unlike in a larger practice, where a handful of naysayers among many supporters can create challenges, but will generally not derail the effort). Dr. Rippel spent significant time with one “technophobic” staff member who initially resisted the idea of an EMR. He met with her on several occasions before and during the transition process, in many cases pointing out specific instances where the new system and redesigned care processes would make her life easier.
- Use workflows to elicit staff input on desired system attributes: The use of workflows to identify desired system attributes proved quite useful, not only as a way to engage staff, but also as an aid in choosing a system.
- Invest in training: Staff must be comfortable with the new system and care processes before using them with live patients. As noted, Dr. Rippel decided to close the practice for nearly a week for training.
Sustaining This Innovation
- Identify and address staff concerns: Staff must have a clear mechanism for raising any problems or concerns they may be having, particularly during the period right after implementation. As noted, Quinnipiac staff initially met on a weekly basis to discuss problems, and now meet on an as-needed basis.
- Ensure availability of ongoing IT support: Outside resources must be available before, during, and after implementation to help the practice address any software-, hardware-, or other system-related problems that arise in a timely manner. Without such support, staff or patients may get frustrated with and lose enthusiasm for the revamped care processes.
- Plan for periodic upgrades: EMR systems generally offer both minor and major upgrades that can be used to stimulate further improvements in care processes and outcomes but require time to learn. For example, Quinnipiac recently installed a major upgrade that included the new patient portal. This upgrade required staff to undergo significant training to understand how the portal works and how to explain its features and benefits to patients.
Additional ConsiderationsQuinnipiac Internal Medicine has received recognition from several National Committee for Quality Assurance (NCQA) programs for its EMR-facilitated care redesign and associated improvements in care processes and outcomes, including the following:
- Designation in 2009 from NCQA’s Diabetes Recognition Program, which recognizes organizations that perform well on 10 common metrics for diabetes care.
- Designation in 2010 from NCQA’s Heart/Stroke Recognition Program, which recognizes organizations that provide high-quality, evidence-based care to patients with cardiovascular disease.
- Recognition in January 2011 by NCQA’s Patient-Centered Medical Home™ program, making Dr. Rippel the first solo practitioner in the State (and one of relatively few nationwide) to be designated a medical home by NCQA.
Contact the InnovatorEdward Rippel, MD
Quinnipiac Internal Medicine, PC
1952 Whitney Avenue
Hamden, CT 06517
Innovator DisclosuresDr. Rippel has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesBecker AL. A Hamden doctor explores the changing medical landscape on his own. Connecticut Mirror [Internet]. 2011 June 20. Available at: http://ctmirror.org/hamden-doctor-explores-changing-medical-landscape-his-own/
Østbye T, Yarnall KS, Krause KM, et al. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3(3):209-14. [PubMed]
Yarnall KS, Pollak KI, Østbye T, et al. Primary care: is there enough time for prevention? Am J Public Health. 2003 Apr;93(4):635-41. [PubMed]
McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-45. [PubMed]
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Original publication: December 21, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: January 09, 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.