TransforMED National Demo Project
Iowa Practice Takes 'Baby Steps' Toward Transformation
By Sheri Porter
• Harlan, Iowa
7/25/2007
Don Klitgaard, M.D., a family physician in Harlan, Iowa, knew he wanted to take better care of his patients. Although his practice was doing a pretty good job in terms of patient care, he knew it could do better. That's when Klitgaard heard about a model of care that incorporates elements such as advance-access scheduling, point-of-care services, team care, office redesign and electronic health records, or EHRs. It sounded like something he could use.
Don Klitgaard, M.D., left, chats with Delores Ensley during a visit to Myrtue Medical Center's medical clinic in Harlan, Iowa. Ensley's husband, Wallace, accompanied her during the clinic visit.
View a video news story (6:51-minute MP4 file; About Downloading) on AAFP News Now's recent visit to Iowa to visit one of the family medicine practices participating in the TransforMED demonstration project.
Klitgaard looked at the TransforMED model of care and decided it could help his practice deliver high-quality care to patients in a patient-centered medical home. About 18 months ago, he rallied his colleagues at Myrtue Medical Center to opt for radical change by becoming one of TransforMED's national demonstration project practices.
"The idea behind TransforMED struck a lot of chords with me. The vision, and what the model stood for, was what we were trying to do (at Myrtue) every day," said Klitgaard. The practice had tried bits and pieces of the model for three to four years, but "couldn't get enough traction and momentum to keep things going," he said.
"The idea behind TransforMED struck a lot of chords with me. The vision, and what the model stood for, was what we were trying to do (at Myrtue) every day," said Klitgaard. The practice had tried bits and pieces of the model for three to four years, but "couldn't get enough traction and momentum to keep things going," he said.
Editor's Note: In June 2006, TransforMED, a practice redesign initiative of the AAFP, launched a 24-month national demonstration project to test the implementation of the TransforMED model of care in dozens of family medicine practices across the country. AAFP News Now recently visited one of those practices -- a rural family medicine group with a hospital-owned clinic in Harlan, Iowa, and satellite clinics in the neighboring towns of Avoca, Elk Horn and Shelby to report on the group's progress midway through the project.
After discussions with the hospital administrator, the medical center's chief financial officer and his physician partners, Klitgaard realized he could get everyone in Myrtue's main and satellite clinics onboard. "It wasn't a hard sell. The ideas really hit home," said Klitgaard, "Most of us went into family medicine to do what the TransforMED model is set up to do."
Prioritizing Patient, Practice Needs
Klitgaard and his colleagues quickly found that embracing the TransforMED model of care was one thing, but implementing all the various aspects of the model was quite another.
"When you look at the TransforMED model of care (1-page PDF; About PDFs) and you see the bubble diagram -- and all the things that make up that vision of what a practice should strive to be -- it can be overwhelming," said Klitgaard.
"Incorporating all the aspects of the TransforMED model of care into an established busy practice is such a monumental change that you can't do everything at once. You have to prioritize and see what makes sense for your practice," said Klitgaard. "For us it was scheduling." The practice had to get that piece taken care of first because it was one of the biggest frustrations for patients, health professionals and staff, he added.
"When you look at the TransforMED model of care (1-page PDF; About PDFs) and you see the bubble diagram -- and all the things that make up that vision of what a practice should strive to be -- it can be overwhelming," said Klitgaard.
"Incorporating all the aspects of the TransforMED model of care into an established busy practice is such a monumental change that you can't do everything at once. You have to prioritize and see what makes sense for your practice," said Klitgaard. "For us it was scheduling." The practice had to get that piece taken care of first because it was one of the biggest frustrations for patients, health professionals and staff, he added.
Preparing for Advance-Access Scheduling
LaVonne Bargenquast, right, weighs in -- literally -- with Deb Busing, R.N., at a rural clinic in Avoca, Iowa. Bargenquast has lived in Avoca for nearly 40 years and has witnessed significant changes in the way health care is delivered in her hometown and the surrounding communities.
The TransforMED model recommends advance-access, or open-access, scheduling. To prepare for January implementation of this type of scheduling, staff members at the main clinic in Harlan conducted an audit of the nine physicians (seven FPs, one internist/pediatrician and one surgeon) and four mid-level providers. For six weeks, schedulers kept a manual log of every patient who called in, the provider each patient wanted to see, and the day and time the patient wanted to be seen.
"In a busy practice, the opportunity to have enough open slots in a practice day that can be filled by acutely ill patients is difficult," said Janelle Nielsen, R.N., Myrtue's chief clinical officer and a key player in the project. "We also have a high volume of patients with other needs, such as ongoing treatment for chronic conditions and well visits." The fact that most of the physicians and mid-level providers split their time between Harlan and the smaller clinics, which are 12 to 18 miles away, further complicated scheduling.
By tracking patient requests and recording request outcomes, the practice could learn whether those requests actually were being met. The audit showed Harlan clinic schedulers which days tended to be high-volume days, so they could leave more patient slots open on those days. "It's a work in progress, and we're still tweaking the number of open-access slots per practitioner," said scheduler Betty Martens, R.N. "It's not perfect, but no scheduling is."
"In a busy practice, the opportunity to have enough open slots in a practice day that can be filled by acutely ill patients is difficult," said Janelle Nielsen, R.N., Myrtue's chief clinical officer and a key player in the project. "We also have a high volume of patients with other needs, such as ongoing treatment for chronic conditions and well visits." The fact that most of the physicians and mid-level providers split their time between Harlan and the smaller clinics, which are 12 to 18 miles away, further complicated scheduling.
By tracking patient requests and recording request outcomes, the practice could learn whether those requests actually were being met. The audit showed Harlan clinic schedulers which days tended to be high-volume days, so they could leave more patient slots open on those days. "It's a work in progress, and we're still tweaking the number of open-access slots per practitioner," said scheduler Betty Martens, R.N. "It's not perfect, but no scheduling is."
Implementing an EHR System
February marked the implementation of an EHR system at all four of the Myrtue clinic sites. Going live with the system changed the work world for the clinics' 13 health care providers, 30 nursing staff members and 20 support staff members, according to Klitgaard. "We're five months into EHR and getting through some of the pain," he said.
"We're at a B- level," conceded Nielsen, in part, she added, because not all of the clinics' physicians are using the EHR to its full capacity yet. Some physicians use the system's patient visit and diagnosis templates, and some still rely on dictation. Nielsen insists that nursing notes be entered into patient records electronically, and paper messaging isn't allowed. Mandatory electronic prescribing generates a faxed prescription on the pharmacy end.
A boon of the EHR is the connectivity it offers among the four clinics and the medical center. "We're already starting to see some of the benefits that brings," said Klitgaard, because the clinics' health professionals have access -- with appropriate privacy guidelines in place -- to patient information from their homes, the clinics, the main hospital and the hospital ER.
"If I'm seeing an inpatient and want to review an outpatient chart to see what was done in the clinic that day or that week," it's possible, said Klitgaard. That's true of the main Harlan clinic and the satellite clinics. The physicians and other health care professionals can electronically access X-rays, lab results and medical charts. "That access to information improves care," said Klitgaard.
"We're at a B- level," conceded Nielsen, in part, she added, because not all of the clinics' physicians are using the EHR to its full capacity yet. Some physicians use the system's patient visit and diagnosis templates, and some still rely on dictation. Nielsen insists that nursing notes be entered into patient records electronically, and paper messaging isn't allowed. Mandatory electronic prescribing generates a faxed prescription on the pharmacy end.
A boon of the EHR is the connectivity it offers among the four clinics and the medical center. "We're already starting to see some of the benefits that brings," said Klitgaard, because the clinics' health professionals have access -- with appropriate privacy guidelines in place -- to patient information from their homes, the clinics, the main hospital and the hospital ER.
"If I'm seeing an inpatient and want to review an outpatient chart to see what was done in the clinic that day or that week," it's possible, said Klitgaard. That's true of the main Harlan clinic and the satellite clinics. The physicians and other health care professionals can electronically access X-rays, lab results and medical charts. "That access to information improves care," said Klitgaard.
Tweaking Processes
An earlier failed attempt at EHR implementation taught Nielsen that inputting patient data at the time of a patient visit was inefficient. With implementation of the new EHR system, she helped solve the problem by hiring a licensed practical nurse to convert patients' paper charts into electronic files before patient visits.
Lois Stockwell, L.P.N., started the project by gathering information from the clinics' extensive nursing home population. With as many as six nursing homes in the area and an average of 60 to 70 patients in each facility, it was a massive job. She finished stage one of the project just as the EHR went live last winter. Then she turned to daily patient visits. She tries to keep two days ahead of the patient schedule, inputting patients' primary problems and medicines.
"When the patient comes in, initial data entry is done," said Stockwell. "There are a lot of patients who come in who are on multiple medications, and if you had to sit down and put all of the them into the system at the time of the patient visit, that would take an awful lot of time," she said.
Lois Stockwell, L.P.N., started the project by gathering information from the clinics' extensive nursing home population. With as many as six nursing homes in the area and an average of 60 to 70 patients in each facility, it was a massive job. She finished stage one of the project just as the EHR went live last winter. Then she turned to daily patient visits. She tries to keep two days ahead of the patient schedule, inputting patients' primary problems and medicines.
"When the patient comes in, initial data entry is done," said Stockwell. "There are a lot of patients who come in who are on multiple medications, and if you had to sit down and put all of the them into the system at the time of the patient visit, that would take an awful lot of time," she said.
Measuring Patient Satisfaction
Patient satisfaction surveys, another part of the TransforMED model of care, are nothing new to inpatients at the Myrtue Medical Center, according to the medical center's CEO, Mark Woodring. "But up until a year ago, we had never surveyed our clinic patients," said Woodring. "Our current survey reinforces to our patients our desire to include their feedback and input, and it holds us accountable for the results."
Woodring said the bottom line should be about good patient care. "We want our patients to see improvement in how we deliver care. By embracing the TransforMED model, I can tell you, with confidence, we are already taking better care of our patients," he said.
"When hospitals and clinics align -- and if we focus on our patients -- we can provide a much more efficient, complementary health care system," said Woodring, adding that he'll consider it a measure of the clinics' success if patient visits to the hospital and the ER decrease.
Woodring said the bottom line should be about good patient care. "We want our patients to see improvement in how we deliver care. By embracing the TransforMED model, I can tell you, with confidence, we are already taking better care of our patients," he said.
"When hospitals and clinics align -- and if we focus on our patients -- we can provide a much more efficient, complementary health care system," said Woodring, adding that he'll consider it a measure of the clinics' success if patient visits to the hospital and the ER decrease.
Moving Forward With Chronic Care Management
Klitgaard predicts that the medical practice will make huge leaps forward during the second year of the demonstration project.
"I feel like while we've taken some baby steps so far … we're really on the cusp of seeing some big improvements," said Klitgaard. "A lot of what we've done up to this point is setting ourselves up for really implementing chronic disease management in a way that we would like to see happen for our patients."
The practice's rudimentary tracking system will soon evolve into a full-fledged electronic patient registry, beginning with patients with diabetes, said Klitgaard.
As he reminisced over the past year's work, Klitgaard mused, "Sometimes I shake my head and say, 'Why weren't we doing this before?'
"When we look back a year from now, I hope we can say, 'Wow, things have really started to change. We're taking better care of our diabetics; we're taking better care of our folks with congestive heart failure and hypertension. People aren't falling through the cracks,'" said Klitgaard.
Now that Myrtue's four clinics are participating in TransforMED's project, they're "operating as one big practice with agreed-upon protocols and processes," said Klitgaard. The TransforMED model has offered a structure that helps the clinics' physicians and staff take care of patients the way they want to and know they should, he added.
"I feel like while we've taken some baby steps so far … we're really on the cusp of seeing some big improvements," said Klitgaard. "A lot of what we've done up to this point is setting ourselves up for really implementing chronic disease management in a way that we would like to see happen for our patients."
The practice's rudimentary tracking system will soon evolve into a full-fledged electronic patient registry, beginning with patients with diabetes, said Klitgaard.
As he reminisced over the past year's work, Klitgaard mused, "Sometimes I shake my head and say, 'Why weren't we doing this before?'
"When we look back a year from now, I hope we can say, 'Wow, things have really started to change. We're taking better care of our diabetics; we're taking better care of our folks with congestive heart failure and hypertension. People aren't falling through the cracks,'" said Klitgaard.
Now that Myrtue's four clinics are participating in TransforMED's project, they're "operating as one big practice with agreed-upon protocols and processes," said Klitgaard. The TransforMED model has offered a structure that helps the clinics' physicians and staff take care of patients the way they want to and know they should, he added.
