AHRQ Innovations Exchange | Electronic Medical Record–Facilitated Care Process Redesign Enhances Access to Care, Reduces Hospitalizations and Costs for Patients With Chronic Illnesses

Electronic Medical Record–Facilitated Care Process Redesign Enhances Access to Care, Reduces Hospitalizations and Costs for Patients With Chronic Illnesses

Snapshot
Summary
The Marshfield Clinic has long used information systems to facilitate care process redesign for patients with chronic illnesses, and the organization expanded its efforts after becoming a participant in the Centers for Medicare & Medicaid Services Physician Group Practice Demonstration Project. As a result of these expanded efforts, Marshfield Clinic has enhanced quality and access to care; reduced hospitalizations, adverse events, and clinical and administrative costs; and earned performance bonuses in both years of the demonstration project.

See Description of Innovative Activity, Results, and Adoption Considerations sections for updated information and outcomes (updated June 2009).
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Developing Organizations
Marshfield Clinic

The Marshfield Clinic is located in Marshfield, WI. end do
Date First Implemented
2004
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Patient Population
Geographic Location > Region; Vulnerable Populations > Medically or socially complex

What They Did
Problem Addressed
Health care organizations that have information systems, including electronic medical records (EMRs), often fail to take advantage of their capabilities, as they are not adequately integrated into care management processes and workflow. This problem is particularly significant for physician practices, which often do not take full advantage of such systems even when they have spent significant sums of money to purchase them. For example, a National Center for Health Statistics study found that, although 34.8 percent of office-based physicians reported using EMRs in 2008, an evaluation of the actual functions used suggests that only 20 percent are using the electronic systems in a meaningful way.1
Description of the Innovative Activity
The Marshfield Clinic has redesigned patient care and workflow processes for chronically ill patients to take advantage of the organization's full-function EMR and wireless tablet personal computer (PCs) technologies. These redesigned processes guide the care of all chronically ill patients, although they were motivated in part by the Centers for Medicare & Medicaid Services (CMS) Medicare Physician Group Practice Demonstration Project (see Context section for more information on this program). Key elements of the program are described below:
Revamped EMR, tablet PCs, and other information technologies: The clinic first implemented an EMR in 1985, and over time the practice has promoted adoption of the full functionality of the system. The clinic began using wireless tablet PCs for electronic prescribing and dictation in 2003; expansion of the system's use allowed the clinic to completely eliminate paper charts by the end of 2007, as all information is now readily available in electronic format to physicians at any time at any care site.
Leveraging the systems to redesign chronic care processes: Marshfield has developed a comprehensive package of initiatives that leverage the electronic technologies to redesign care for chronically ill patients, including the following:
Preventive services for diabetes, other chronic diseases: The EMR generates a preventive services list on the dashboard of each electronic patient record. This box compares the patient's clinical profile with evidence-based clinical practice guidelines formed from a number of sources including the American Diabetes Association and input from endocrinologists at Marshfield and highlights (in red) gaps in care related to preventive services, immunizations, routine screening, and diabetes care needs; eventually, this functionality will be expanded to cover additional disease states. The system prompts the physician to provide or schedule needed preventive services during the patient visit. In contrast to disease-specific programs and care registries, this list allows physicians to proactively plan and coordinate needed preventive, screening, treatment, monitoring, and education across a spectrum of diseases for each individual patient.
Flagging of high-priority patients: A "hierarchical recovery list" includes high-risk patients with multiple chronic conditions that are in need of immediate attention. High-risk patients with serious gaps in care (e.g., diabetes patients who have not made appointments for annual eye and foot examinations and whose hemoglobin A1c level is above goal) appear at the top of the list; physicians and staff use this list to work with the patient to provide or schedule needed care immediately.
Anticoagulation care management system: All patients who take warfarin are managed under a single set of protocols. Under this nurse-managed, physician-directed telephonic management program, nurses place outbound calls to patients to discuss their anticoagulation management and check on their general health. As needed, registered nurses adjust dosing based on written protocols and enter updates into the EMR.
Electronic prescribing to enhance safety: Physicians use tablet PCs for electronic prescribing, with prescriptions printed by computer, thus reducing the potential for medication errors.
24-hour nurse line: Patients have access to a 24-hour telephone number staffed by registered nurses. Nurses listen to the patient's concerns, refer to the EMR for background data and care plan, offer advice, and triage patients for physician appointments using physician-approved guidelines. An automated e-mail system notifies physicians whose patients have called the nurseline and provides a hyperlink to the patient's medical record.
Timely, actionable feedback and other programs to facilitate quality improvement: Through the EMR, Marshfield provides timely performance feedback designed to spur quality improvement. Through use of interactive "quality dashboards," Marshfield offers providers actionable information, including registries of patients with a particular condition, any needed tests or services for those patients, upcoming appointments, etc. The system also provides unblinded data showing performance for the system as a whole and by individual department and practitioner, thus allowing clinicians to seek out the best performers to learn what they are doing to achieve such good performance. The overall goal is to get clinicians to think about managing the health of their entire patient population, not just individual patients. Other quality improvement efforts facilitated by the EMR include continuing medical education, online provision of care guidelines, and coaching by quality improvement medical directors and clinical nurse specialists.
References/Related Articles
McCarthy D. Case study: improving quality and efficiency in response to pay-for-performance incentives under the Medicare Physician Group Practice Demonstration. The Commonwealth Fund. March 12, 2007. Available at: http://www.commonwealthfund.org/innovations/innovations_show.htm?doc_id=468900

Trisolini M, Pope G, Kautter J, et al. Medicare physician group practices: innovations in quality and efficiency. The Commonwealth Fund and RTI International. December 2006; 12-14. Available at: http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=428880

Institute of Medicine (IOM). Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.

Lohr S. The evidence gap: health care that puts a computer on the team. New York Times. December 27, 2008.

This profile is adapted from an Improvement Report by the Institute for Healthcare Improvement, available online at: http://www.ihi.org/IHI/Topics/OfficePractices/Access/ImprovementStories/
Contact the Innovator
Theodore A. Praxel, MD, MMM, FACP
Medical Director
Quality Improvement and Care Management
Marshfield Clinic
1000 North Oak Avenue
Marshfield, WI 54449
(715) 389-3188
E-mail: praxel.theodore@marshfieldclinic.org


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AHRQ Innovations Exchange | Electronic Medical Record–Facilitated Care Process Redesign Enhances Access to Care, Reduces Hospitalizations and Costs for Patients With Chronic Illnesses