Pennsylvania AFP Assists Primary Care Residencies, Practices With PCMH, EHR Initiatives

During a recent noontime conference with his residents, family physician Timothy Heilmann, M.D., asked them, "Who here thinks they're doing a good job managing a diabetic patient?"

All of the residents' hands shot up.

But Heilmann, associate director of the family medicine residency at Williamsport Regional Medical Center in Williamsport, Pa., had some disappointing data to share with his residents. Those data were the first to be collected as part of the Residency Program Collaborative, an initiative coordinated and funded by the Pennsylvania AFP in its role as a partner in the Pennsylvania Primary Care Coalition.

The residency collaborative is part of Pennsylvania Improving Performance in Practice, or PA IPIP, a program of the Pennsylvania Primary Care Coalition. In addition to the Pennsylvania AFP, the coalition includes the Pennsylvania chapters of the American Academy of Pediatrics and the American College of Physicians.

The collaborative's twin goals are to improve care at residency program clinics and prepare residents to work in patient-centered medical homes, or PCMHs.

Despite the confidence Heilman's residents displayed, the data told a grim story: None of the roughly 250 patients with diabetes in the practice had met the established criteria for excellent care -- not a single patient had received all of the exams, tests and referrals that he or she should have received.

"Getting that information was a real eye-opener," Heilmann told AAFP News Now.

The program's residents immediately began using the data to improve patient care, he said. Report cards were created for each patient with diabetes to show which services each patient has or has not received.

"Now we have residents calling patients up and saying, 'You need your flu shot,' or 'You need to go see your eye doctor,'" Heilmann said. "Unless you're measuring these things and you know what to measure, it's hard to improve."

The Residency Program Collaborative, which began in June 2010, is the largest state residency program collaborative in the United States, according to Pennsylvania AFP Vice President of Quality Initiatives Lee Ann Grajales, who oversees the program.

A key goal of the collaborative, said Grajales, is to build on those patient care improvements and assist practices in gaining National Committee for Quality Assurance, or NCQA, recognition as PCMHs. Of the 24 teams involved in the collaborative during its first year, 17 have achieved PCMH recognition, she said. Of those, 13 teams received the top recognition -- Level 3 -- from the NCQA.

Heilmann's residency practice was one of those that achieved the top PCMH status. "It would have taken a lot more time for us to get NCQA recognition and get our quality improvements off the ground if this collaborative hadn't been set up," he said.

According to William Warning II, M.D., one of the pioneers of the collaborative and program director of the Crozer-Keystone Family Medicine Residency Program in Springfield, Pa., the Pennsylvania AFP's Residency Program Collaborative is definitely improving patient outcomes.

The baseline data for Warning's residency were "quite embarrassing," he professed. Not unlike Heilmann's experiences in Williamsport, patients with diabetes at Crozer-Keystone were not always getting eye exams, foot checks and urine checks, for example.

"We were at the 50th percentile for patient care," Warning said. "Now we're at the 80th and 90th. That's gratifying.

"We can prove now that we provide higher quality of care, especially for diabetes. We know patients are getting better outcomes, just in our lab outcomes."

Warning said he hopes to someday prove that, within certain predetermined health care parameters, coordination of care will result in fewer overall acute problems, fewer hospitalizations, and -- specifically for patients with diabetes -- fewer amputations and cases of blindness.

For the time being, however, Warning is excited to see the impact of the initiative stretch well beyond family medicine residency practices. Last year's graduates, he said, purposefully sought out practices that operated as medical homes.

"It's a rude awakening when they graduate," he said, noting that it's still difficult to find a family medicine practice that has achieved PCMH status. According to the NCQA, 2,710 primary care sites staffed by 13,728 clinicians nationwide had been recognized as primary care medical homes as of August 2011.

Given the growing interest in PCMHs, residents involved in the Pennsylvania collaborative are being recruited to help practices that are interested in improving patient care and achieving medical home recognition, Warning said. The residents didn't realize what they were doing as part of the collaborative was such a big deal, he said. "It's amazing how quickly things become institutionalized."

"What we're doing is getting these young doctors of tomorrow while they're still formulating their habits and behaviors," Grajales explained. "Patient-centered medical homes and the chronic care model have been proven to improve patient care and the health of the patient specifically as it relates to chronic conditions."

In addition to funding the collaborative, the chapter coordinates monthly team meetings, learning sessions, and a performance improvement tracking tool to monitor and analyze the data collected by participants.

"We couldn't have done this without the PAFP," Warning said. "They are the backbone of our collaborative."

The Residency Program Collaborative is just one of the chapter's quality improvement initiatives, Grajales said. The Colorectal Cancer Screening Collaborative is another part of the PA IPIP, which is operated by the Pennsylvania AFP Foundation.

For many practices, a preliminary step in becoming a PCMH is adopting an electronic health record, or EHR, system, and the Pennsylvania AFP offers support to these practices, as well.

Currently, the chapter is working with 400 health care providers to aid them in achieving meaningful use status and qualifying for CMS' EHR incentive programs, said Grajales. As a subcontractor for the PA REACH program (Pennsylvania Regional Extension and Assistance Center for Health Information Technology), the Pennsylvania AFP has already directly helped 29 providers attest to meaningful use status in the past year.

Depending on the needs of a given practice, the chapter may assist with a request for proposals, conduct workflow analyses, intervene with vendors or teach staff how to run the necessary reports, Grajales said.

In July, the first group of doctors assisted by the Pennsylvania AFP's PA REACH team attested to meaningful use: 16 doctors at Family Practice Center in north central Pennsylvania. The large multisite practice already was committed to achieving this goal when it took advantage of the chapter's services through PA REACH.

James Chlebowski, M.D., a family physician in the practice's Selinsgrove, Pa., location was one of the doctors who attested in July.

"It's improved efficiency," Chlebowski said. "If a patient is seen in another office, that (fact) shows up in my office; it makes it easier to have access to the full record."

In addition to improving patient care, attesting to meaningful use also has financial benefits. Those who achieve meaningful use, for example, can receive as much as $44,000 in incentive funds in a five-year period from the Medicare EHR Incentive Program.

The bottom line for the Pennsylvania AFP's 26 staff members, Grajales said, is to be on the forefront of primary care.

"If there is a health care initiative in the state of Pennsylvania, we're going to be part of it and leading it," Grajales said. "Our goal is to be an innovator and a contributor to health care transformation across the country."