9 Steps to Transform Your Rheumatology Practice

High-performing practices use clinical process improvement methods to effectively manage their disease populations with robust care teams.

Dr. Erin Arnold limits her new patients to those with probable rheumatic diseases. Her wait times are less than two weeks, and she saw 662 new patients in 2018. Her schedule has increased from 24 to 33 patients per day (33%). Over five years, the ORNS RA patient population has increased from 700, when Dr. Bill Arnold retired, to 1,700. The total number of patient visits in 2016 and 2019 numbered 6,399 and 8,931 respectively. This increased productivity has more than paid for increased staffing. Dr. Erin Arnold is able to successfully balance her professional and family time, while her father enjoys his retirement and his daughter’s success.

This increased capacity has not compromised the practice’s quality of care or patient satisfaction. The Arnolds’ baseline disease activity distributions were among the most favorable in the RAPP project. These have improved further even as Dr. Erin Arnold has continued to add new, active RA patients (see Table 1).

Table 1: Vectra Test RA Disease Activity Distribution (%)

Practice No. 2: Gary Crump, MD, Louisville, Ky.

Rheumatology Associates PLLC is an independent rheumatology practice with three physicians and four nurse practitioners. It cares for patients from the Greater Louisville, Ky., area. The practice maintains an in-office infusion center and an imaging facility that offers digital X-ray and technician-performed musculoskeletal ultrasound. Laboratory testing is provided by a commercial laboratory and several specialty reference labs.

When Dr. Crump participated in the first 2013 RAPP project consultants meeting, he was a junior partner in a five-physician practice that employed no APCs. Each rheumatologist cared for their separate, relatively small patient panels and used paper records. After two partners left the practice, Dr. Crump bought out his senior partner, and the other stayed on as an employee. He has since employed one additional rheumatologist and another is on deck. Unlike his previous partners, Dr. Crump’s new colleagues are like-minded about team care and continuous practice improvement, because he assessed these characteristics before hiring them. A partnership option is available.

The practice has also added four APCs who work collaboratively with the physicians. The APCs see the majority of established RA patients for assessment and routine management visits. The practice uses standardized assessments, including RAPID3 and the Clinical Disease Activity Index (CDAI), at every visit. Vectra tests and diagnostic ultrasounds with scoring protocols are added at specified frequencies based on a patient’s disease activity status. The care team has developed and copyrighted rheumatic disease care pathways to further facilitate team care. Staff proactively track missed appointments and other services for all patients. The analytic electronic medical record (EMR) provides individual and population run charts based on standardized clinical metrics. Encounter documentation formats have been standardized and recently upgraded voice recognition software has been implemented.

Dr. Crump’s practice has dramatically improved its access and productivity from 2013 to 2018. Its RA population has increased from 122 to 521 patients per physician. New patient visits per year per physician have increased from 468 to 832. New patient wait times have decreased from six to four weeks, on average. The practice’s current RA population’s Vectra test distribution is 51% controlled, 24% moderate and 25% high disease activity.

Physician and staff satisfaction and camaraderie are high, and the practice has low employee turnover. Rheumatology Associates honors patients’ preferences for physician and APC visits, and surveys reflect a high level of patient satisfaction. Dr. Crump has shortened his work week to four days while increasing his productivity, allowing him to pursue his passion for riding and driving American Saddlebred horses.

Practice No. 3: David Sikes, MD, Zephyrhills, Fla.

Florida Medical Clinic (FMC) is an independent, physician-owned multi-specialty group founded in 1993 by Dr. Sikes, a gastro­enterologist and family physician in an underserved rural area near Tampa, Fla. In 25 years, FMC has grown to 275 physicians and 75 APCs, representing most medical and surgical specialties. It now cares for 1.6 million citizens in two counties, including Northeast Tampa and the adjoining rural area. It owns 14 campuses, with a robust complement of laboratories, medical imaging centers, a cardiac catheterization center, physical therapy services, infusion centers and clinical research programs. The center purchased the Greenway EMR in 1995, and continues to redesign it to support the center’s clinical and business needs. The administration continues to be physician led.

When Dr. Sikes attended the first 2014 RAPP project consultant meeting, his rheuma­tology department included three physicians practicing traditionally with only one APC—a PharmD. The RAPP project motivated him to transform the practice’s staffing, clinical processes, patient access and quality of care. It has standardized and expanded disease activity and other clinical assessments, including training APCs to perform joint examinations. Practice performance measures have been established, and these data are being used to guide patient management and other improvement projects.

In six years, the center has added two rheumatologists, five nurse practitioners/physician assistants, three infusion nurses, a pharmacy technician and three ultrasound technicians, building a comprehensive interdisciplinary care team using disease population medicine processes. The diagnostic ultrasound and infusion services are expanded product lines. Everyone works to the top of their license (i.e., practicing to the full extent of their education and training) to perform total patient work and free the physicians to do what only they can do for many more patients.

Depending on the individual patient’s disease activity, comorbidities and complexity, an office visit may involve different combinations of physicians and staff. Pre-visits are used to obtain ultrasound and lab testing in advance. One unique innovation involves the PharmD, a pharmacy technician, two patient counselors and the medical assistants, who coordinate all patients’ medication prescriptions, education and pre-certifications.

The growth of Dr. Sikes’ rheumatology department and his own practice has been driven not only by the transition from physician-centric to team practice, but also by the increase in patients managed by Florida Medical Clinic overall, the broadening of his department’s scope of practice to provide comprehensive musculoskeletal disease care, and more rigorous and timely APC patient assessment visits.

Between 2013 and 2018, the center maintained a four-week wait time for routine new patient visits in spite of 110% growth in total new patient referrals per year, while also implementing a 48-hour priority scheduling process.

About 20% of established patients are managed for RA, similar to other large multi-specialty group rheumatology practices, but lower than many single specialty practices that focus more on inflammatory rheumatic diseases. Team care has enabled Dr. Sikes’ personal RA panel to grow by 25%, even as he spends one day each week in group administration. His RA population’s disease activity distribution has improved over time, as with other practices that have implemented more robust, on-time assessment processes (see Table 2).

Table 2: Vectra Test RA Disease Activity Distribution (%)

The growth and success of FMC and its rheumatology practice have derived from the culture of innovation in practice and patient service instilled by Dr. Sikes and his founding colleagues from the outset. FMC has carefully chosen new physicians who share this perspective.

Visitors comment on the rheumatology team’s joy in working together. Patient feedback reflects appreciation for the efficiency, predictability, thoroughness and accessibility of their care.

While Dr. Sikes maintains a busy practice and administrative schedule, he finds time for family, training for competitive bicycle team racing and regular ballroom dancing with his spouse.