High-Impact Rheumatology Practice Redesign

Our purpose in this perspective is to describe clinical process changes for rheumatology practices that will have a high impact on the value of our services and support a brighter future for the patients we serve as well as our practices and our specialty. These ideas are drawn from physicians and nurses who manage various chronic diseases within high-performing specialty practices and health systems, and who contributed to our recently published book, Great Health Care: Making It Happen.¹

Why Focus on Redesign?

The Centers for Medicare and Medicaid Services have launched a four-year initiative that mandates step-wise adoption of  “certified” electronic health records (EHRs), electronic prescribing, a shift to more demanding ICD-10 diagnostic coding, reporting of quality measures through the Physicians Quality Reporting System, and the documented meaningful use of information technology (IT) to improve the processes and outcomes of care for Medicare, Medicaid, and other patients. Initial financial incentives will be provided, followed by payment penalties for not participating. These changes will be difficult at times, failures will be possible, and their adoption will transform practice as we know it.

The ACR has initiated educational, policy, and support programs to brace rheumatologists for the requirements mandated by the Patient Protection and Affordable Care Act and the Health Information Technology for Economic and Clinical Health Act. The question remains as to whether rheumatologists will respond to these imperatives, are prepared to perform the work of change, and understand what priorities are most important to make us successful. The large percent of our specialty in independent, single-specialty practices contribute to these daunting challenges.

“The Biggest Bang for Our Buck” Changes

Changing clinical processes in real time and the work involved in doing so are challenging. Most of us were not taught the clinical process methods required to accomplish meaningful redesign of complex systems, unlike managers in other U.S. industries who use them routinely to continuously improve performance. We wrote Great Health Care to provide this information for physicians treating chronic diseases as well as faculty and trainees charged by the Accreditation Council for Graduate Medical Education (ACGME) to prepare for system-based care and continuous quality improvement. We suggest the following priorities based on our own experiences and those shared by our contributing authors. These priorities are often interdependent, and once addressed, they should be pursued over time to their full advantages.

Standardizing Clinical Processes

Jerry Yee, MD, Mark D. Faber, MD, and Sandep Soman, MD, of the division of nephrology and hypertension at the Henry Ford Health System in Detroit, Mich., begin their chapter in our book like this: “What follows is how our group of nephrologists transformed the delivery of healthcare to our patient population with chronic kidney disease over eight years. This required significant changes in our mindset and attitudes. The changes primarily involved adopting a highly automated and protocol-driven style of care that was geared toward efficiency without a sacrifice in quality.”

The journey of transforming rheumatology practice must begin with setting aside our attachment to individualism. “Doing it my way” won’t work much longer. This perspective is, in fact, a major reason for our current performance problems. It produces high variance and lowers efficiency and effectiveness in healthcare and all other complex systems. The commitment to process standardization is a characteristic of the high performing practices described in Great Health Care.

Other high-priority initiatives cannot be pursued if each physician’s practice is a one-off. Medical practice is not sustainable as a cottage industry. Solo practice will wither before the demands for system-based integration, such as accountable care organizations (ACOs), and the need to achieve economies of scale to maintain profitability. Process improvements at the practice and system levels cannot occur without physicians’ shared commitment to standardize around best practices and then to improve these continuously.

As one example, consider how staff in a rheumatology practice struggle to do things differently for each rheumatologist. How can we justify care being determined by which physician a patient sees more than their disease itself and the documented best practice protocols?

Standardizing what clinical data we collect will be paramount, as will how we document it, analyze it, and share it with others. The information sharing advantages of EHRs will only happen if the formatting and content of information is predictable. Not long ago, physicians scribbled illegible notes in paper charts until Medicare declared, “If we can’t read it, we won’t pay for it.” So we started dictating narrative notes and paying transcriptionists to word process them. “Not good enough,” the payers said. “You need to document specific elements of care to earn different levels of payment,” and physicians’ dictation time increased. High-performing practices have not only standardized their data but have transformed how they collect, document, and use data: patient- and physician-generated data questionnaires, direct electronic entry, auto-generated clinical notes, clinical data tables and flow charts, and so on. Collecting more robust clinical data more efficiently and improving its organization will improve the providers’ critical problem defining and solving functions.

Measuring Processes and Outcomes of Care

In Great Health Care, we assert, “What we don’t measure, we can’t manage, and we don’t.” Our clinical processes are measurable, but we seldom measure them and therefore don’t have the data required to track and improve them. High-performing practices measure routinely, and we must all imbed measurement into our practice management if we are to improve, even transform, our practices within increasingly integrated local health systems.

Disease-activity measurement is required for treating all chronic diseases optimally, and standardized measures have been developed for virtually all of them. Yet, physicians don’t use disease-activity measures dependably and often undertreat, as Lawrence Phillips has shown most persuasively.² Suboptimal disease control increases avoidable long-term morbidities of all chronic diseases. The Treat to Target initiative for rheumatoid arthritis (RA) advocates frequent measurement and acceleration of treatment for this reason.³ We regularly ask our colleagues, “What disease-activity score are you using for RA, how many RA patients do you care for, what percent of your patients have controlled disease, and what are you doing for those who don’t?” The most common answers are “None; I don’t know; All of them, I think; and Hmm…next question.” How can we improve care delivery for the population we serve without objectively monitoring how they are doing?

Measurement requires dependably collecting robust clinical data from patients and physicians. We must also create disease registries to move from care of individual patients during routine office visits to more intensively managing those within our disease populations with the highest disease activity and clinical morbidities “offline”—not just when they show up for a clinic visit (see below). Again, as we build interdisciplinary care teams, we must use clinical data to develop rational work flows, allocating routine monitoring, education, and therapeutic management to other health professionals and diagnostic evaluations and problem solving to rheumatologists.

Team Practice

High-performing chronic disease management is a team sport in which physicians, mid-level providers, nurses, pharmacists, and other professionals provide those aspects of patient care that each are best prepared to provide—and patients are engaged as well. This is not only required as a response to decreasing rheumatology manpower and increasing patient numbers, but also because it provides more effective care at a lower cost.⁴ Team care and different workflows characterize high-performing practices. Charles King, MD, chair of the ACR Committee on Rheumatologic Care, has created a team practice with other professionals, including a nurse practitioner and nurses. His team manages two to three times the patients per rheumatologist as traditional practices and increases profitability. He evaluates and solves patients’ more complex problems while others focus on coordination of care, patient education, safety monitoring, and population management.

Several Great Health Care practices, including the Henry Ford Chronic Kidney Disease Clinic and Advocate Health’s Chicago-based high-risk asthma program, emphasize the requirement for teams to achieve a common knowledge base about their diseases and guidelines for care. Again, standardized processes and electronic documentation and information sharing are required.

Finally, an emerging key principle for effective chronic disease management is the shift from physicians managing individual patients during office visits to nurse coordinators managing disease populations outside of visits, assisted by care algorithms and work-management software programs. Telephone follow-up is a powerful tool in the hands of nurse coordinators, optimal care can be assured across the inpatient–outpatient interface, and community resources can be mobilized for home care.

This population management approach will allow rheumatology practice teams to say, “We have 1,500 RA patients, 80% of them have controlled disease, and we are focused on maintaining these and improving the rest.”

21st-Century Information Technology

Different rheumatology practices are at different stages of implementing EHRs. While early adopters have already suffered through the learning curve for a decade, experiencing added time burdens, lower patient throughput, and “death by 1,000 clicks” common to switching to EHRs, others are only beginning to recognize what they are in for. Some practice tasks are facilitated by an EHR: lab review, e-prescribing, phone messaging, and information sharing among users. The benefits for performing other work are not so obvious to providers—diagnostic ordering, for one. Implementing today’s EHRs will not always improve care and efficiency, even if they are used as effectively as possible; new generations of IT will be needed.

Today’s EHRs are transactional databases with information stored in files, like paper medical records. Different bits of information have fixed relationships to others. In contrast, analytic databases store pieces of data in individual cells that can be more flexibly sorted and related to others. This leaves today’s EHRs weaker than analytic databases for analyzing patients’ clinical data and for organizing work within provider teams and disease populations. Analytic disease registry and work management software products are beginning to emerge for these critical functionalities that may interact with, but are separate from, EHRs. Some are even able to manage patients with comorbidities, the most challenging cases for improving outcomes and reducing resource use and costs. IT “meaningful use” will require both EHRs and disease-registry/work-management software programs. Building these within health systems is time and money intensive; using web-based and turnkey programs will be more practical for many practices and systems.

The potential for EHRs to improve patient care is also compromised in many health systems by the multiple brands being installed in different practices, Health Insurance Portability and Accountability Act regulations preventing information sharing among providers about shared patients, the focus on billing documentation rather than optimizing care, and the multiple functional options that compromise standardization. EHRs are often less efficient for consulting specialists whose patients come from referring physicians with different IT systems. Learning to use one EHR is daunting; learning one for the office and one for the hospital is worse.

Access to Rheumatology Care

Problems with patients accessing rheumatology care are widely documented, as is true for other chronic disease specialties as well. Moreover, referring physicians’ and patients’ decisions are often suboptimal, causing a waste of limited specialty resources and further delays in diagnosis and treatment. The increasing imbalance between patient and provider numbers and the priority for early diagnosis and treatment will only worsen this problem, and increasing the numbers of providers using usual clinical processes will not correct this imbalance. Moreover, referring physicians and consultants must work together instead of blaming one another if access to and timeliness of care are to improve.

Improving referral processes needs to be addressed through testing and implementing alternatives. In Great Health Care, John J. Cush, MD, director of clinical rheumatology at Baylor Research Institute, describes his testing of various options for improving access to rheumatology care in Dallas. His insightful findings include:

• Referring physicians and patients prefer to be seen by rheumatologists to participating in various referral management programs; and
• Rheumatologists are wedded to initially providing comprehensive consultations while acknowledging that they often know what’s going on within 90 seconds of being face to face with the patient.

Dr. Cush proposes a radical change: The rheumatologist sees referred patients immediately for a brief screening visit rather than their waiting weeks for a comprehensive evaluation. Follow-up care would then be scheduled as needed with the rheumatologist or other providers, or even other specialists, and urgently if needed. As a similar example, a health system in Wales, U.K., has reported a face-to-face musculoskeletal triage program by trained mid-level providers that performs well in directing patients to timely, most appropriate care for their problems, and with a higher accuracy than decisions made by the referring physicians themselves.⁵ High-performing practices have tested and implemented a variety of new referral processes, none of which depend on traditional, first-come-first-served consultative processes. Such processes might be implemented easily in the evolving multispecialty musculoskeletal disease practices that include rheumatology.

Interdisciplinary Chronic Disease Management

Managing chronic disease patients and disease populations over years and decades is an increasing challenge due to exploding knowledge and therapeutic options, and the better-recognized interactions between inflammatory, vascular, and metabolic comorbidities. Great Health Care explores these challenges and provides examples of highly effective chronic disease management. We also suggest that the Patient Centered Medical Home is insufficient for coordinating systems of care through primary-care practices, as we also did in 2009.⁶ System-based, integrated, interdisciplinary care and coordination of care are necessary, as the ACO concept and bundled payments are beginning to incentivize. The ACGME has defined system-based care experience and continuous process improvement methods as core postgraduate training priorities. Academic and practicing rheumatologists and trainees need to learn these competencies.

How should rheumatologists get started in practice redesign?

• Begin by recognizing that redesigning our practices and health systems is an unavoidable necessity.
• Form an improvement team, meet regularly, and begin using continuous improvement methods to redesign your practice processes.
• Assess your practice’s strengths and weaknesses in these high-impact aspects of practice: process standardization, clinical data and disease management, team practice, IT resources, access to care, and system-based interdisciplinary care.
• Choose one or more problem areas, measure current performance, begin improving, and keep going.
• Develop an RA patient list, and begin calculating and documenting each patient’s disease activity in an Excel spreadsheet or in a disease management software program.
• Look for opportunities to participate in building interdisciplinary management programs with other interested colleagues in your health system. Hospitals will be increasingly at risk financially for “accountable care,” and those of us who help them in meeting their requirements will be rewarded.
• Try, learn, and try again.

We hope you will join us in redesigning the rheumatology practice.

Dr. Harrington recently retired from the division of rheumatology at the University of Wisconsin School of Medicine and Public Health in Madison, and is a partner in Joiner Associates LLC. Dr. Newman is director of the department of rheumatology and vice-chair of the division of medicine at Geisinger Health System in Danville, Pa.

References

1. Harrington JT and Newman, ED, eds. Great Health Care: Making It Happen. 2012. New York: Springer.
2. Phillips LS, Twombly JG. It’s time to overcome clinical inertia. Annals Intern Med. 2008;148:783-785.
3. Smolen JS, Aletaha D, Bijlsma WJ, et al. Treating rheumatoid arthritis to target: Recommendations of an international task force. Annals Rheumatic Dis. 2010;69:631-637.
4. Deal CL, Hocker R, Harrington T, et al. The United States rheumatology workforce: Supply and demand, 2005-2025. Arthritis Rheum. 2007;56:722-729.
5. Maddison P, Jones J, Breslin A, et al. Improved access and targeting of musculoskeletal services (TEAMS) programme. BMJ. 2004;329:1325-1327.
6. Harrington JT, Newman ED. Rheumatology and the patient-centered medical home: Is it the end of the tunnel or an oncoming train? The Rheumatologist. 2010;4;1:16-18.