September 2015 Newsletter
Wide Variations in Primary Care Workflow Emerge from 'Dance' Between Patients and Providers

Standardized workflow in primary care is not very standard, according to a recent study published online Sept. 2 by the Journal of the American Medical Informatics Association. The study analyzed workflow variation in terms of the sequence of tasks performed during patient visits and found significant variation, even for an individual physician.

In fact, the authors said, "Workflow emerges as the result of a 'dance' between physician and patient as their separate agendas are addressed." They documented a cyclical, yet unpredictable pattern of problems being raised, information being gathered, and care plans being negotiated throughout the primary care visit and called it "a side effect of patient-centered practice."

The researchers also found that electronic health records (EHRs)have not produced greater visit efficiency, as has been anticipated in the widespread adoption of EHRs.  "Most EHRs are organized on the assumption that physician workflows are linear or standardized or relate to a single problem," the authors wrote. "EHRs do not facilitate workflows that are more personalized and unpredictable."

Preliminary suggestions for improving primary visit efficiency included:
  • Have office staff type progress notes and enter orders to limit the burdens, distractions, and interruptions in workflow for providers.
  • Better estimate the length of time required for each visit by knowing the patient's agenda before he/she arrives at the office.
  • Do pre-visit planning to ensure providers and clinical staff have all the information they need in terms of test results, referral reports, and gaps in care before entering the exam room.
The AAFP News Now published by the American Academy of Family Physicians also recently reported on this study and discussed the need to design tools and technology that better support physicians.
Use of Practice-Based Non-licensed Care Coordinators Leads to 20% Reduction in ED Visits

Patients served by 14 primary care practices with embedded non-licensed care coordinators went to the emergency department (ED) 20% less than patients of 14 control group practices over a one-year period, according to a UCLA Health study published online Sept. 15 by the American Journal of Managed Care.

The care coordinators (one per practice) were tasked to provide additional support to any patient who needs it within the practice's panel and were not devoted only to higher risk patients or to patients with any specific disease or any single health insurance. However, they prioritized assistance to patients who had recently been hospitalized or used the emergency department, who had high rates of utilization or high-risk scores, and who had been referred directly by primary care providers.

During the one-year study, the care coordinators assisted 10,500 unique patients in executing care plans, coordinating transitions, supporting self-management, linking to community resources, and monitoring follow-up.

The care coordinators received 40 hours of initial training and ongoing support from a centralized team consisting of an RN program director, nurse case manager, and licensed social worker that provided consultation on complex cases and performed medical interventions, such as home visits, that require licensure and training. Many of the care coordinators had been medical assistants, military medics, emergency medical technicians (EMTs), or community health workers.

Practice size ranged from 3 to 11 providers per site across the 28 intervention and control practices.
Best Practices Spotlight

Last Minute
ICD-10 Tips
Physician Practice Blog offered some final advice before ICD-10 codes begin on October 1, 2015. Be prepared to jump into coding tomorrow. As coding for ICD-10 continues throughout the day and coming weeks, it will become more clear as to how the new codes will affect staff and their workflow. Be prepared to adjust workflows and conduct extra trainings as the coding set becomes more clear
In The Literature

Patient characteristics matter more than provider characteristics in terms of optimal glycemic control in patients with diabetes, a new study found. The study, published online Sept. 15 by the American Journal of Managed Care, concluded that improving systems of care, such as disease management services, may be a better use of resources than focusing on individual providers. Patient characteristics associated with optimal control included older age, lower baseline A1c, shorter diabetes duration, and not using insulin.
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