SummaryTo facilitate test ordering and specialty referrals and thus expedite patient care, the Northwestern Memorial Physicians Group bundles orders and referrals for "inflection points" in a patient's health—that is, times when it is clinically important to perform a series of steps for additional evaluation or management. Examples include new findings, such as hematuria (blood in the urine), lung nodules, atrial fibrillation, or cancer, as well as poorly controlled conditions, such as diabetes, hypertension, or chronic kidney disease. Physicians choose a "pathway" message in the electronic medical record system that includes a pre-arranged checklist of tests and referrals, along with educational details about the condition. They send these messages to care coordination team members, who obtain referral authorization, help set up test and specialty visits in the correct sequence and, after 4 weeks, confirm that all steps have been completed. An analysis of the program for hematuria care found that it reduced the time between diagnosis and test completion, increased the likelihood of tests being completed before the first urology visit and of the evaluation being completed in one visit, and generated high levels of physician satisfaction. The program also enhanced capacity for urology care and increased adherence to pre-authorization procedures, nearly eliminating the need for retroactive authorizations.Moderate: The evidence consists of nonrandomized comparisons of key process measures related to hematuria care between May 2009 and May 2010 among participants and similar patients not served by the program, along with pre- and post-implementation data on adherence to preauthorization procedures and post-implementation reports on physician satisfaction.
Developing OrganizationsNorthwestern Memorial Physician's Group; Szollosi Healthcare Innovation Program
Northwestern Memorial Physicians Group and Szollosi Healthcare Innovation Program are both located in Chicago, IL.
Date First Implemented2006
Problem AddressedMany primary care practices do not have standardized orders related to diagnostic testing and specialist consultations for clinically important conditions, nor do they have a coordinated process for managing such testing and consultations. As a result, care delays can occur, along with problems in securing payment for those performing the tests and consults.
- Lack of standardized, coordinated processes: Many primary care practices (including Northwestern Memorial Physicians Group before the implementation of this program) do not have standard orders for common, clinically important conditions that physicians can follow for diagnostic testing and specialist consultations. Once orders have been made, these practices often ask patients to obtain authorization from their insurance company and schedule the tests and specialist visits on their own.
- Leading to care delays and payment problems: Lack of standardized orders and coordinated processes often lead to delays in care for patients and payment issues for those performing the services, as outlined below:
- Care delays: Without standardized orders, primary care physicians may fail to order necessary tests or fail to do them in the proper order. At Northwestern Memorial Physicians Group, patients with hematuria often visited a urologist before a computerized tomography (CT) scan had been ordered. The urologist then ordered the scan and asked the patient to come back a second time, after the test had been completed, to review the results. Had the primary care physician ordered the CT, the first visit to the urologist would have been unnecessary. Beyond ordering the appropriate tests and consults, patients often find the referral process to be cumbersome, confusing, and subject to delay, particularly because of the preauthorization requirements of payers.1,2 In fact, up to 30 percent of patients fail to set up their specialist appointments.3
- Payment problems: Those performing tests and consultations sometimes face difficulties receiving payment. Many patients arrive for scheduled testing without an order and/or authorization from their insurance company. Without an order, the test may be delayed or canceled, and physicians may have to be interrupted via a page while they are busy with another patient. If the test or consultation is performed without insurer authorization, patients are billed for the full cost and often end up calling their primary care practice to complain. As a result, administrative staff end up spending hours trying to obtain authorization retroactively from payers, a process that is often inefficient and unsuccessful, because many payers deny coverage when proper procedures have not been followed. As a result, patients may be forced to pay on their own, or commonly, hospitals and other providers may be forced to write off hundreds of thousands of dollars each year when payments cannot be collected from either payers or patients.
Description of the Innovative ActivityTo facilitate test ordering and specialty referrals and thus expedite patient care, the Northwestern Memorial Physicians Group bundles orders and referrals for inflection points in a patient's health—that is, times when it is clinically important to perform additional evaluation or management. Physicians send a pathway message in the electronic medical record (EMR) to care coordination team members, who obtain referral authorization, help set up test and specialty visits in the correct sequence and, after 4 weeks, confirm that all steps have been completed. Key elements include the following:
- Standardized orders via diagnosis-specific checklist: When a physician decides a patient meets the criteria for one of the predefined inflection points, he or she activates the process by sending the relevant pathway message in the EMR to the care coordination team. Examples of inflection points include new findings, such as hematuria, lung nodules, atrial fibrillation, or cancer, as well as poorly controlled conditions, such as diabetes, hypertension, or chronic kidney disease. Each pathway includes the following:
- Checklist for ordering: The pathway provides a standardized checklist of all needed tests and specialist referrals for that diagnosis, as well as the order in which they should be accomplished. For example, the hematuria pathway includes orders for a CT scan followed by a urology consult with cystoscopy, and the atrial fibrillation pathway includes orders for an echocardiogram and 24-hour heart rhythm test using a Holter monitor, followed by referral to a cardiologist. Physicians can accept the entire bundle or order only those tests and referrals they deem necessary by unchecking those they do not want performed.
- Detailed clinical justification and other information: An introductory section to each pathway provides a clinical justification for its various elements and other pertinent information. For example, the hematuria pathway includes the clinical criteria to justify the CT and cystoscopy testing. The atrial fibrillation pathway includes a list of clinical criteria to justify the various elements of the pathway, a list of circumstances under which patients should be sent directly to the emergency department, a format for quickly calculating the patient's CHADS-2 score (assessing risk factors for stroke, including congestive heart failure, hypertension, age greater than 75, diabetes, and prior stroke), and a set of orders for both low- and high-risk patients as determined by the CHADS-2 score.
- Care coordinator oversight of entire process: A care coordinator, called an inflection navigator, takes charge of obtaining needed authorizations, transmitting orders, and confirming their completion, as outlined below:
- Payer authorizations: The inflection navigator views the pathway message in the EMR and obtains needed authorizations from the insurance company. This process often includes reviewing the chart and printing out the physician's recent note or other relevant data to send to the payer.
- Transmitting orders: The inflection navigator electronically sends the authorization(s) to the hospital scheduling department, which then calls the patient to schedule the appointment(s). The inflection navigator also forwards the EMR message about the specialty referral request to a scheduler in the specialist's office, who reviews the record to see when testing will be completed and contacts the patient to schedule the appointment at the appropriate time.
- Confirmation that care steps have been completed: After approximately 4 weeks (depending on the pathway), the inflection navigator reviews the patient's chart to confirm completion of all pathway elements and notifies the primary care physician of any gaps in care.
- Feedback to encourage pathway use: Physicians receive updates on new pathways being implemented as well as periodic reports related to their use of pathways compared with peers. As appropriate, the practice's Medical Director of Information Technology and Innovation or the Care Coordination Manager contact individual physicians who are not consistently using the pathways to discuss their benefits and demonstrate their use.
Context of the InnovationNorthwestern Memorial Physicians Group, the largest primary care group in Chicago, has 15 offices located across the metropolitan area. Its physicians refer a high volume of patients to Northwestern Memorial Hospital, a 900-bed academic medical center. The impetus for this program came from Dr. Lyle Berkowitz, a practicing internist who serves as the practice's Medical Director of Information Technology & Innovation. After repeatedly hearing frustrations from physicians and staff about the inefficiencies of ordering tests and consults, Berkowitz worked with the group's manager of referral coordination (now the care coordination department) and the head of the hospital's outpatient test scheduling department to improve processes related to coordinating testing and specialty referrals.
ResultsAn analysis of the program for hematuria care found that it reduced the time between diagnosis and test completion, increased the likelihood of tests being completed before the first urology visit and of the evaluation being completed in one visit, and generated high levels of physician satisfaction. The program also enhanced capacity for urology care and increased adherence to preauthorization procedures for all patients who received care coordination, thus nearly eliminating the need for retroactive authorizations.
Moderate: The evidence consists of nonrandomized comparisons of key process measures related to hematuria care between May 2009 and May 2010 among participants and similar patients not served by the program, along with pre- and post-implementation data on adherence to preauthorization procedures and post-implementation reports on physician satisfaction.
- Shorter time between diagnosis and test completion: For patients with hematuria who received care coordination (known as "navigated patients"), the time between diagnosis and completion of the CT scan averaged 22 days, less than half the 45.2-day average for similar patients not referred through the program. Similarly, the time between diagnosis and completion of cystoscopy averaged 38 days for those in the program, well below the 70.6-day average for those not in it.
- More patients with testing completed prior to first visit: Three-fourths (75.5 percent) of navigated patients with hematuria had their CT scan completed before the first urology visit, compared with just 28.8 percent of other patients.
- More patients completing evaluation in one visit: More than half (56.6 percent) of navigated patients with hematuria had their evaluation completed in one visit, compared with only 21.9 percent of other patients.
- High physician satisfaction: Physicians report being highly satisfied with the system, noting that it has significantly reduced care disruptions.
- Freed-up capacity: By eliminating the initial visit for some patients with hematuria, the urology group has more appointment slots open, enhancing access to care and theoretically allowing the group to increase revenues by attracting new patients and/or performing additional procedures.
- Near elimination of retroactive authorization for all navigated patients: Previously, the practice's administrative staff attempted to obtain retroactive payer authorization for approximately 20 to 25 patients each month. At present, an average of less than one navigated patient a month requires retroactive authorization. This average includes all patients who receive care coordination, not only patients with hematuria. The resulting time saved has allowed administrative staff to manage the care coordination system without the need to hire additional personnel.
Planning and Development ProcessSelected steps included the following:
- Making iterative improvements in radiology ordering: Berkowitz brainstormed with the group's director of referral coordination and the hospital's radiology scheduling team about various improvements that could be made to the radiology ordering and referral process. Over a period of approximately 1 year, various ideas were tested iteratively, as outlined below:
- Iteration 1: Individual physicians filled out the form and then had their office staff fax orders directly to the hospital, where the radiology scheduling team contacted the patient to schedule the test. The hospital created five different forms based on the type of test ordered.
- Iteration 2: To facilitate the process, the medical group developed a single order form that included all types of tests.
- Iteration 3: To ensure proper authorization, the offices started faxing the order form to both the referral department, which obtained prior authorization for testing from payers, and to the hospital scheduling department, which called the patient to schedule the test. Very quickly, referral department staff realized that they could obtain authorization and send the order to the hospital themselves.
- Iteration 4: To further improve the process, manual faxing was eliminated. The ordering physician used the messaging function in the EMR to complete a template and send it electronically to the referral department, which then obtained prior authorization and sent it to the hospital via the EMR's fax function. The hospital scheduling department agreed to accept this faxed form, even though it contained just an electronic stamp of the ordering physician's name rather than his or her written signature.
- Expanding to ordering of other hospital-based tests: Once the radiology ordering system was finished, the Northwestern Memorial Physicians Group and Northwestern Memorial Hospital realized they could use the same system for other hospital tests (e.g., echocardiogram, stress tests, Holter monitors, and doppler and pulmonary function tests). With the infrastructure already built, it became relatively easy to add this content to the options for physicians. Already comfortable and satisfied with the radiology ordering system, physicians readily accepted the expansion of options.
- Expanding to ordering of specialty consults: Around the same time, the Northwestern Memorial Physicians Group worked with a large multispecialty group to facilitate the specialist referral process. The two groups agreed to train scheduling staff at the multispecialty group on the Northwestern Memorial Physician's Group's EMR system, thus allowing primary care physicians to use the EMR messaging system to order a specialty consult. The multispecialty group received these messages, set up the appointments, and then notified the ordering physician of the date and specialist name. In addition, the schedulers let the ordering physician know if the appointment was not set up for some reason.
- Developing checklists and inflection navigator tool: As part of his work with the Szollosi Healthcare Innovation Program, Berkowitz studied how to improve the patient experience when dealing with "inflection points" in their care. Because these inflection points required a lot of resources in a short period of time, it became clear that care coordination would be extremely helpful. Furthermore, he recognized that the "checklist philosophy" for procedures (popularized by Drs. Atul Gawande and Peter Pronovost) could also be applied to processes. He therefore worked with various specialists to develop checklists that incorporated all testing and consult orders required for the initial evaluation and management of a variety of conditions. Initially, an open source, Web-based tool to facilitate the care coordination process helped the care coordination team keep track of these patients. Eventually, the functionality of this tool was incorporated into the EMR to facilitate usability.
- Creating care coordination team: The Northwestern Memorial Physician's Group's referral coordination team seamlessly evolved into the care coordination team. Because of their referral experience, team members knew how to get authorizations and use the EMR for both messaging and data retrieval. In addition, they were very comfortable talking to patients. Because all steps were handled electronically, they were eventually able to work from home, which has improved staff satisfaction and reduced costs.
- Introducing program to physicians: Physicians received e-mails that introduced the system and explained how using these bundled pathways was much easier than placing each order separately.
- Exploring possible future expansion to other practices: The Northwestern Memorial Physicians Group is considering offering the care coordination service to other medical groups affiliated with the hospital. This step would generate revenues to cover the costs of expanding the care coordination team, and, more important, would improve quality and efficiency for all patients on campus. The resulting infrastructure could be used to support an accountable care organization in the future. Information provided in October 2013 indicates that the group size has recently doubled from 40 to 80 primary care providers, with plans to expand to all primary care providers across the enterprise in the near future.
Resources Used and Skills Needed
- Staffing: The program is staffed by the director of care coordination and five care coordinators. As noted, the director and her team were previously known as the referral team, which was renamed the care coordination team as the team's responsibilities expanded. All team members have high school or college degrees, good computer skills, and strong social skills.
- Costs: The program has not generated additional costs, since no additional hiring has been necessary. As the process became fully computerized, the majority of staff started working from home, thus reducing overhead costs. Ongoing costs include the salaries of the care coordination personnel; care coordinators earn approximately $25,000 per year.
Funding SourcesSzollosi Healthcare Innovation Program; Grant Healthcare Foundation
The Szollosi Healthcare Innovation Program, a nonprofit health care technology development firm housed within Northwestern Memorial Hospital's nonprofit foundation, provided funding for the program as part of its efforts to leverage information technologies to facilitate provider communication and care coordination.
Tools and Other ResourcesInformation about this project and others conducted through the Szollosi Healthcare Innovation Program is available at www.TheSHIPHome.org.
Getting Started with This Innovation
- Expect development to take time: Planning and piloting this type of process enhancement takes time (possibly up to a year) because of the need to figure out current processes, develop protocols, and obtain physician support.
- Incorporate relevant decisionmakers: Working with people who have relevant decisionmaking authority (e.g., the director of hospital scheduling) helps to ensure that new processes are appropriately developed and embraced by the various stakeholders involved. Similarly, there must be a specialist "champion" for each pathway to assist with the content and workflow needed to make sure it succeeds.
- Win support by solving a known problem: Before implementation of this program, physicians routinely complained about being paged by radiology technicians when a patient showed up without a written order. With the creation of the initial ordering system, the doctors quickly recognized that they could substantially reduce the chance of this happening by using the system, which made the order available in an electronic format. Once they recognized this potential benefit, they became very supportive of future enhancements.
- Make it easy to use: Adding the order bundles into the typical EMR workflow made it easy for physicians to access and use them at the right point in the care process. The new approach was superior to the old, paper-based approach because (1) it already had the patient information attached to it, (2) all items were prechecked, (3) it explained when orders were appropriate, and (4) it bundled multiple orders and consults together.
- Systematize and shift tasks: To make the new system valuable and cost effective, shift as much work as possible from physicians to the care coordination team. As with any checklist, the goal is to systematize the steps involved and delegate as many as possible by breaking them into clear, unambiguous steps that need to occur with all patients. This approach increases the chance that all steps will be followed in a consistent manner.
- Make use optional: Physicians may be more willing to try a system if not mandated to do so. Once they try it, they will likely see the new program as an improvement rather than an onerous or intrusive task.
Sustaining This Innovation
- Educate/remind physicians about pathway use: To promote consistent, sustained use, regularly remind physicians about the system, especially when new pathways are implemented.
- Set expectations and learn from failures: Set expectations so that physicians know nothing is perfect and that they still might get an occasional call from the radiology center or from a patient who did not get called as expected. Each problem should be reviewed and the system continually optimized to minimize future problems.
- Provide positive feedback: Providing positive feedback to physicians who routinely use the system helps them feel good about what they are doing and increases the chances they will speak positively about the program to their colleagues. In addition, it can be helpful to identify a physician champion at each office site to promote use of the system among colleagues and support those not using it consistently.
- Explore reasons for non-use: Track and understand usage patterns by pathway and physician. Low use of a pathway may mean that more education of physicians is required. In addition, contacting physicians who do not regularly use the system can often generate greater acceptance of it. These infrequent users may need to be reminded about the bundled-order feature and/or may need demonstrations of how to use it. They often become major proponents of the program once they fully understand how it can make workflow easier for them and their patients.
- Information provided in October 2013 indicates that this program has collectively generated significant time efficiencies across the 80 physicians across two hospitals within Northwestern Memorial Physicians Group. It has not only resulted in higher-quality care, but has allowed for thorough documentation of care steps in situations where patients do not follow through as instructed. For example, Northwestern Memorial Physicians Group has avoided at least two malpractice cases in circumstances where a patient had a bad outcome. In both cases, a review designed to determine whether there had been a failure to diagnose uncovered sufficient documentation that the patients had been told to schedule a test or consult, but had refused multiple times with both schedulers and their own doctors. Furthermore, it is likely that other bad outcomes were avoided entirely because patients completed their care management times in a consistent and efficient manner.
Contact the InnovatorLyle Berkowitz, MD
Northwestern Memorial Physicians Group
1913 W. North Avenue
Chicago, Illinois 60622
Web site: www.DrLyle.com
References/Related ArticlesCasey JT, Cashy J, Tourne-Schwab A, et al. New care coordination system improves the quality, efficiency and cost of care for patients with hematuria. Abstract. Provided by program developer.
caBIG® and Patients: Navigating Cancer Complexities Together. caBIG® LINKS (newsletter). Available at: http://cabig.cancer.gov/resources/newsletter/issueXXV/action.asp
1 Laufer N. Health Plan Preauthorizations – a necessary evil to lower cost, or an obstacle to care? Maricopa County (AZ) Medical Society. Available at: http://www.mcmsonline.com/president/nathan-laufer-md/health-plan-preauthorizations-%E2%80%93-necessary-evil-lower-cost-or-obstacle-car
3 Martin A. Preventing missed appointments with specialists: doctors, patients try to close gap between primary and specialty care. MarketWatch. April 22, 2010. Available at: http://www.marketwatch.com/story/doctors-work-to-reduce-costly-patient-no-shows-2010-04-22?pagenumber=1
4 Berkowitz LL. "The Inflection Navigator." Innovation with Information Technologies in Healthcare, Ed. Berkowitz LL and McCarthy C. First Edition. London: Springer Publishing, 2013.
Casey JT, Berkowitz LL, et al. A Protocol-based, EMR-enabled Care Coordination System Improves the Timeliness, Efficiency, and Quality of Care for Patients with Hematuria. The Journal of Urology, July, 2013. [PubMed]
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Original publication: October 24, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 23, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.