Idaho Clinic Embraces a Culture of Quality Improvement

Pocatello Family Medicine (PFM), which currently comprises 6 medical faculty, 21 residents, and 4 midlevel providers, is the clinic of the Idaho State University (ISU) Department of Family Medicine residency program. Located in the state with the lowest number of physicians per capita, PFM sees roughly 10,000 patients out of one full-service outpatient clinic in the southeast Idaho community of Pocatello. PFM’s patients are covered fairly evenly by Medicare, Medicaid, and private insurance, with roughly 8% uninsured or covered by other insurance. The practice became part of Health West Community Health Center in October 2012. PFM implemented its electronic health record (EHR) system, GE Centricity, in January 2005 and is currently using Version 9.5, with Centricity Practice Solution 10 for practice management. All 6 faculty physicians achieved Meaningful Use in 2011 and all 21 residents and midlevel practitioners are currently meeting Meaningful Use criteria.

When the practice decided to transition to an EHR system, Dr. Jonathan Cree , the Residency Director, looked at five different EHR systems. One of the most important features for meeting the needs of a residency program clinic was allowing two signatures on each record so both the resident and supervisor could sign off on the record. PFM ultimately selected GE Centricity, which has strengths such as the capability to have multiple staff contribute to a patient’s medical record with a clear record of each person’s contribution, the usability of templates, and the ability to measure quality and compare the practice’s performance to other GE Centricity users through the GE Medical Quality Improvement Consortium. Looking back, the practice noted that implementation was very smooth, aided by staff discussions and a team approach to EHR implementation, internal data sharing, and plenty of training. Training emphasized the value of the EHR system’s ability to answer providers’ questions about patients, trends, and outcomes. The engagement of leadership was another key to success emphasized by everyone at the clinic. Showing the clinic staff examples of patient reports helped to illustrate what the EHR could do. This success allowed PFM to be one of the first practices in town to e-prescribe.

• Find an EHR system with the data-mining capabilities the practice is interested in using. Help staff to gain direct access to data they need to find answers to clinical and quality questions on their own.
• Take advantage of your REC’s knowledge to navigate Meaningful Use requirements.
• Create a culture of quality improvement and work together on the details of workflow and clinical practice changes. 

PFM participated in a number of quality measurement programs, including the Safety Net Medical Home Initiative, Physician Quality Reporting System, GE’s Medical Quality Improvement Consortium, Active Families for Life Therapeutic Lifestyle Center, Idaho Medicaid Pay for Performance, and others. In choosing which measures to monitor, they considered how to streamline these slightly different initiatives; they started with diabetes-focused measures because they applied to multiple quality measurement programs. Through these programs the practice has also monitored a range of other measures, including screening mammography, tobacco cessation, and body mass index assessment. PFM relied on their regional extension center (REC) to determine how to best leverage existing quality initiatives to meet Meaningful Use requirements. The practice attested to Meaningful Use reporting on the three core clinical quality measures and three additional measures for which GE Centricity is certified:

• NQF #0059: Diabetes: HbA1c Poor Control
• NQF #0061: Diabetes: Blood Pressure Management
• NQF #0064: Diabetes: LDL Management and Control

Workflow

To collect data for these quality measures, the practice uses both GE Centricity’s and additional customized templates. Jeremy Smuin, Information Technology (IT) and Quality Specialist, worked closely with the practice to add these additional templates to the practice’s toolkit. When a provider requests that a template be added, Jeremy or Mark Adams, Director of IT Services, will search the Centricity Healthcare Users Group for existing templates created by other GE Centricity users or develop the template on his own.

PFM also noted that all of their immunization data is entered into their EHR system as structured data. Laboratory test results, such as for low-density lipoprotein and hemoglobin A1c, are integrated into the EHR as structured data through lab interfaces with the local hospital. One part of the intake protocol for nurses is to ask patients with diabetes when they had their last eye exam and enter their responses as structured data. These processes enable staff to more easily measure and improve quality.

Staff

Laura Southworth, PFM’s Quality Coordinator, was identified by many of the practice’s staff as a key player in the practice’s quality improvement initiatives. Laura reviews the EHRs, including monthly reviews of the pediatric and obstetric charts and orders that are due. When due orders are identified, she sends a letter to the patients reminding them to come in for follow-up services. Laura integrates information in the EHR system by entering it as structured data wherever possible. Because Laura also has access to the hospital’s EHR system, she can identify which of PFM’s patients have been discharged and acquire their discharge reports. This facilitates better transitions of care between inpatient and outpatient settings.

Culture

PFM embraces opportunities for quality improvement. Public posting of quality measurement results helped to kick-start a culture of quality. Team-based care also dictates that poor performance on measures is a shared team responsibility. The care team works together to develop strategies to improve. If rates on certain measures are low, the practice holds monthly meetings to identify and address the issue. The practice can then identify areas of the workflow that can be improved and provide recommendations for how deficiencies may be reduced or eliminated.

One area where PFM has integrated quality into its workflow is in prescription renewals. The pharmacy, led by Dr. Rex Force, is heavily involved in workflow processes. Pharmacy involvement ensures the highest level of patient safety in prescribing medications, and Dr. Force has undertaken a number of practice-level evaluations of prescribing practices. In one example, he and others identified women of childbearing age who were taking certain teratogenic medications. They implemented an intervention to ensure that each patient’s fertility status was documented as structured data in her EHR and that all women at risk were taken off those medications, if possible, or were advised on informed consent. ISU’s pharmacy interns also make sure all pertinent data are included in renewal requests so that clinicians ordering renewals can have the information they need at their fingertips.

Staff at PFM is interested both in cutting-edge health information technology and the data it produces to drive improvement in patient safety, quality of care, financial responsibility, and efficiency. Faculty, residents, and staff appreciate the ability to find answers to data-driven questions on their own, without requiring assistance from specialized data analysis staff. Dr. Force noted that he is able to get roughly three-quarters of the data he needs solely from GE Centricity reports.

Another key to PFM’s success is the pervasive culture of quality improvement. Faculty has built a strong quality curriculum into the ISU Family Medicine Residency program, and each resident is required to complete at least one quality improvement project before graduation. An example of a current project is delivering evidence-based strep throat treatment to patients. These projects are not only educational, but many also address opportunities to improve and have led to workflow changes practice-wide.

Continue to find areas where quality can be improved and engage staff in finding out how to improve in those areas.