Dr. Randy Walker
Family Practice & Allergy Clinic
Fort Lauderdale, Florida
Tel. (870) 584-3000
A profile of a rural, independent, single physician practice that successfully established a culture of continuous quality improvement using EHR data.
Dr. Randy Walker is a solo practitioner and one of six primary care physicians in DeQueen, Arkansas, a rural town in southwest Arkansas that is approximately 30% Hispanic. The practice opened in 2003 and currently has a staff of three licensed practical nurses, two medical assistants two front desk specialists, an office manager, and a part- time dietician. The practice has used Wellford Chart Notes as its electronic health record (EHR) system since opening, but it did not begin actively using the EHR data until 2009. Dr. Walker noted that during the first 4 years, the practice ran more like an emergency room, with a focus on solving the problems that came in the door without consideration to long-term interventions.
Beginning in 2009, the practice began participating in the Arkansas Chronic Illness Collaborative, which is now known as Arkansas Clinical Transformation. Before their participation in the program, Dr. Walker and his wife Angie, who is also his office manager, had never measured anything about their patient population and were unsure whether they would have the requisite 100 diabetic patients to participate in the program. Angie discovered that they did not in fact have 100 diabetic patients-they had 300. After this discovery, the Walkers also began to identify their hypertensive patients, and then moved on to identify the top 10 diagnoses within their practice. Once they understood the power of the EHR data available to them; the practice began to implement changes using data to improve quality of care.
One of the first actions the practice took in reaction to seeing the data was to create standing orders 1 for each of the top 10 diagnoses they had identified. It was a significant change to focus on preventive care instead of solely on the immediately presenting problem of the patient. To shift the practice toward more preventive medicine, the clinic adopted a team-based approach, which remains integral to their operations. This shift largely formalized already established roles within the practice, and this expansion of the existing collaborative approach helped to develop improved workflows for the practice and empower their employees to actively participate in patient care.
However, the transition period was challenging for both the staff and the patients. For example, a patient who was accustomed to receiving a prescription for 12 months of medication was now being prescribed 3 months at a time to ensure that appropriate follow-up could be done. Access issues also surfaced as a result of spending more time with each patient and scheduling more routine visits. The Walkers noted that this was their biggest challenge. To address this issue, the Walkers opened their office earlier than the first patient appointment for the day. For example, if a patient is scheduled at 9:00 a.m., the office opens at 8:30 or 8:45, so everyone is ready to work at full speed by the time the first patient walks in. They also implemented a dedicated walk-in hour for same-day appointments, allowing the practice to serve those needing same-day care without disrupting the existing schedule. Another key to managing the overflow was removing preconceived staff functions in the practice. Today, all staff members work to the top of their licenses so that patients can be seen as efficiently as possible. Few patients objected to seeing a nurse instead of a doctor for some services, and some even preferred being able to discuss their care with a female staff member.
Every patient is assigned a patient care coordinator who completes a health risk assessment (HRA) and all standing orders. The HRA evaluates a patient's utilization and assigns scores on a series of risk factors. Patients with high total scores are assigned a nurse. The practice currently uses standing orders for chronic obstructive pulmonary disease, rheumatoid arthritis, gastroesophageal reflux disease, early and periodic screening and diagnostic testing, vaccinations, and colorectal cancer screenings. These orders allow the nurses to assess for and order appropriate preventive care. The role of the physician then becomes deciding what not to do; for example, Dr. Walker could decide that a mammogram was contraindicated and thus should not be ordered. These processes ensure that the default care remains to "do everything."
Care coordination is expected both inside and outside of the practice. Dr. Walker's practice has a network of preferred specialists whom they trust will share appropriate medical information with the Walker practice. If a patient chooses to go elsewhere, the practice makes clear up front its expectations regarding information exchange. Patients transitioning care or receiving home health care are assigned a transitional care nurse, and patients receiving home health care are expected to participate in their own care for it to continue. All patients are expected to participate in shared decision making. Relevant patient educational materials (e.g., emergencydepartment use, hemoglobiA1c, and prostate-specific antigen testing) are attached to the chart to be shared with the patient. "Once we started looking at our patient population, we began to review patient education materials and services that were being offered in the office," said Angie Walker. "We noted that the majority of our waiting room materials were obstetrical, which are not services that our clinic provides. We had it stocked because it was free. We immediately discontinued this practice and began to stock the waiting room with material that were relevant to our patient population."
Beyond participating in their own care, patients are also invited to participate in shaping how the practice interacts with them. The Walkers have formed a patient advisory group to solicit feedback on topics such as how the educational and marketing materials can be better suited to patient needs. They even solicited feedback on the HRA, to which patients responded favorably. According to Angie, "They were grateful their physician was looking out for them and interested in what they had to say."
As noted, although the practice had an EHR system since opening in 2003, the practice did not begin to realize its potential until 2009. Once Dr. Walker began participating in various quality improvement initiatives, the practice began to use the EHR's patient list functions to describe and manage their patient population. As a small, solo-physician practice, the clinic has no dedicated IT staff. The practice relies entirely on the vendor, Wellford Chart Notes, for troubleshooting and helping them understand the EHR system's capabilities. Nonetheless, the practice has been able to customize the system to meet their specific needs. EHR templates were all developed internally, which allows the templates to vary on the basis of the populations they are used for. Also, the clinical decision support functions in the EHR mirror the physician's standing orders, providing prompts for the nurses. Although the HRAs are calculated by information in the EHR, they are not currently performed within the EHR. The practice is working to automate the HRA scoring in the EHR in the near future.
One of the challenges in using the EHR was making sure diagnosis codes were both started and stopped when appropriate. A failure to monitor and update these diagnoses can result in incorrect patient lists. To combat this problem and make sure all the clinical coding information is entered in the right place in the right way, Dr. Walker's practice provides only a single way to enter information into the EHR. Despite having the EHR system for 10 years, the practice still undergoes yearly IT training, which continues to improve efficiency within the practice.
The practice can now identify patients with particular conditions, such as diabetes, and calculate related quality measures for all such patients in their system. The measures can be also be customized based on the needs of the patients or the practice. Upon implementation of their new practice style, Dr. Walker saw quality improving within months, such as consistently measuring blood pressure on all patients. Rates of LDL cholesterol measurement rose from 28% to 72% between 2010 and 2012. Currently, the clinic is achieving 100% on some quality measures.
The current and continued success of the Walker practice is rooted in the staff. Angie has created a culture of responsibility where every staff member is clear on what is expected. In return, staff members feel empowered, with teamwork and good communication being the norm. When hiring, Angie places less importance on specific experience and more on whether the individual will be a good fit with the overall practice team. With such a small practice, staff could be called upon at any time to fill another person's role, whether large or small. Every staff member crosstrains within the office, spending at least one week in each position in the practice. The EHR system allows Angie to accurately estimate the resources needed for the practice so she knows whether additional staff is needed or existing resources can be distributed more efficiently. Additionally, the Walkers noted that physical medical record storage is more expensive than implementing and maintaining an EHR system, freeing up monetary resources.
To keep the staff motivated to address quality concerns, the Walkers hold weekly quality measure meetings. Currently the meetings focus on diabetes and also monitor the Meaningful Use and Comprehensive Primary Care Initiative (CPCI) measures to identify disparities and stratify patients based on risk. The practice was ready for Meaningful Use and CPCI, and it will soon look to become a patient-centered medical home.
The methods and approaches that allowed Dr. Walker's practice to begin its transformation will contribute to its continued evolution. Clinical and workflow processes are viewed as iterative and continue to improve with time. As Angie noted, they used constant Plan-Do-Study-Act cycles to improve their workflows; "it was 100 small changes." According to the Walkers, there are no disadvantages to being a small, independent, rural practice. They have the autonomy to make decisions and make them quickly. They can reach out to local and area agencies to get needed assistance for their patients. The Walkers find that their small size makes it easier to get things done for their patients. As the Walkers said many times, "They aren't just patients, they're our neighbors."
For contact information, please visit http://www.drrandywalker.com/ [www.drrandywalker.com] .