“BEST PRACTICES RESEARCH”

Jim Mold, M.D., M.P.H. The University of Oklahoma

Department of Family and Preventive Medicine

The Oklahoma Physicians Resource/Research Network (OKPRN)

OBJECTIVES• Teach you about “best practices

research” as a concept

• Teach you the method

• Give you enough examples that you feel that you could do it

• Share some of our discoveries

Process of Care Questions What is the best way to maximize

pneumococcal vaccination rates? What is the best way to handle laboratory

test results? What is the best way to manage

prescription refills? What is the best way to manage diabetic

patients What is the best way to maximize

colorectal cancer screening rates?

Traditional Approach Measure current performance

Choose or construct a theoretical model or examine barriers, facilitators, opportunities, and threats

Design an approach that ought to work

Test the approach in an RCT or before/after

“Best Practices Research” Identify the steps/components involved in

the process under investigation Define “best” for each step in terms of

values (e.g. accuracy, efficiency) Identify existing “best” methods for each

step by finding exemplars and examining their methods

Combine best approaches into a unified best method

(Test combined method in an RCT)

Advantages Draws upon the wisdom and

experience of clinicians/end user

Efficiently gets to an answer

The answer is likely to be practical, feasible, acceptable, and effective

Disadvantages Don’t learn much about why something

works

Perhaps no one has figured out a particular step

Solutions identified may be unique to a practice

Parts may not fit together well

First Effort – Pneumovax Funded by Merck Vaccine Division Steps not identified in this case Literature review summarized and

shared with participants Financial incentive and opportunity

to improve Highest baseline rate Most improvement

Increasing Pneumococcal Vaccination Rates

Practice Performance Audits

Clinician

A B C D E F

Initial Rate

12% 15% 18% 33% 35% 67%

Final Rate

15% 15% 22% 36% 36% 86%

Pneumococcal Immunization Physician must believe in it Nurse authorized to give it (standing

orders) Physician must conduct regular

oversight/review Immunization clinics in Fall;

pneumovax linked to flu shots

Increasing Delivery of Preventive Services

Preventive Services Reminder System Nurse-operated PDAs linked to

decision support and registry

Printed summary of services due and done for review by physician

Preventive Services Reminder System2

PDA/Clinic

Appointment Database

Prev. Serv. Database

IntoleranceRecord

AllergyRecord

RiskRecord

Service

NotServiceReason

PastServiceRecord

NotImmReason

PastImmRecord

Vaccination

PatientInsurance

PatientAppointment

PIF Enterprise Server

(Patient Info)

Reference TablesReference TablesReference TablesReference Tables

Pendragon Internet Forms (PIF) PIF Entp. Server

Java Server(Recommendations)

Patient Database

Central Server/OUHSC FMC

PSRS is a comprehensive electronic tool designed to improve documentation and enhance delivery of primary and secondary preventive services. This system includes 3 integrated subsystems: a Palm Operating System -based PDA (Palm, Handspring and Sony) & PC running Widows 98/2000/XP Operating System, connected to the PDA and a Central Server System (Enterprise Server and Recommendation JAVA Server).

Efficacy of the PDA Version

2-3 year olds Controls PSRS p-value

DTaP#4: 53% 86% 0.001

HepB#3: 61% 93% 0.0005

Pneumo: 27% 38% NS

MMR#1: 61% 93% 0.0005

Efficacy of the PDA Version

Adult Diabetics Controls PSRS p-value

Smoking status: 70% 93% 0.02

Smoking counselling: 13% 78% 0.0004

Pneumovax: 33% 78% 0.0003

Management of Laboratory Test Results

Identification of model/steps in the process Literature review

Focus groups

Listserv discussions

Delphi process

Management of Laboratory Test Results

1. Track tests sent out until the results come back

2. Notify patients of test results3. Document patient notification4. Track patients with abnormal

results to be sure that they follow-up

Defining “best” Identify values/Set standards

All steps: Accuracy (90%)

All steps: Cost (<$5 per patient)

Step 2: (Patient notification) patient satisfaction (>90% satisfied)

Physician surveys, blanket audits

Selective practice audits

Identifying potentially effective methods for each step

Lab Tests 11 practitioners satisfied with their

method for at least one step

2 different methods identified for each step

Audits of practices; time/motion studies

Patient reports regarding time/satisfaction

Combining Methods for Steps into a Combined Best Method

Choose best methods for individual steps

Try to put them together into a process that makes sense

Lab Tests Log and nurse tracking (dual system)

Physician writes note to patient on lab results sheet

Lab results sheet dated; copy mailed to patient generic explanation of tests for chemistry panels

??Tickler file system??

Lab Tests – Time/Cost $5.17 per set of lab tests for steps 1-

3 Almost half of the cost is physician

time Methods that rely on nurse/patient

call backs are more expensive

LabMan Laboratory Test Results Management

Appl. 5

Screen 1. Shows list of labs due “today” and list of follow-ups due “today”. This list can be populated by lab type (“Populate Labs Due By Type”) and by patient name. “Follow-ups Due” generates a list for due follow-ups only. “*” indicates that a lab is due, while “~” indicates that a follow-up is due on an abnormal lab result. Due lab and follow-up lists can be printed via an infrared printer port from the PDA for review, or documentation. Screen 2-3. Lab result data detail. Lab can be selected from a drop-down menu (“Lab Due”), and the lab result, lab order date and return time can be entered as well. Default return time can be customized for each lab. “Lab Due Date” is calculated by the PDA automatically. If labs come back, the user can check the lab off (“Check, if lab came back”). At this point the user can keep, or delete the lab and, if abnormal, can schedule a follow-up for the lab. Labs can also be deleted manually (“Delete Lab”). Screen 4. The user can schedule a follow-up for abnormal labs, by selecting the lab type and entering a short message that indicates the nature of the follow-up. A pre-formulated quick-entry drop-down menu assists the user in entering the free text information (“Message: Select”). A default follow-up time can be entered and the PDA calculates the due date on the follow-up. Checking off the follow-up is similar to that of the lab result cheek-off. Follow-ups can be deleted manually by the “Delete” button. Screen 5. Patient demographics (name, DOB, phone number) and individual patient lab profiles can be managed on this screen. Labs can be added quickly to the particular patient’s profile by the “Add Lab” button.

     

“Management of Laboratory Test Results In Family Practice” Mold, et al. J Fam Pract. 2000 Aug;49(8):709-15.

Management of Prescription Refills

Steps/Components Patient access to the system Clinical decision-making Notification of pharmacy Notification of patient Documentation

Values Patient access

Patient satisfaction Efficiency

Clinical decision-making Accuracy Efficiency

Values Notification of pharmacy

Accuracy Efficiency

Notification of patient Patient satisfaction Efficiency

Documentation Accuracy Efficiency

Practice Audits

3 4 5

A X X

B X X X

C X X

D X X

E X X X X X

Prescription Refills – Patient Access Patient calls pharmacy to request

refills 75% adherence rate Mean time required by patient: 2.5

minutes Satisfaction high

Prescription Refills – Decision-making Accuracy reduced by using written

protocol 4-10% error rate vs. 0-2% Too many special

circumstances/variability M.A. or L.P.N. more efficient and as

accurate as physician

Prescription Refills – Communication with Pharmacy/Patients

Pharmacy faxes prescription to office for authorization

Authorization faxed back to pharmacy Multiple methods less efficient (hot

line/phone/fax) Pharmacy communicates with patients Denials/reasons/instructions written on fax to

pharmacy If likely to be controversial, patient phoned by

nurse Mean patient satisfaction: 3.5-4.1/5

Prescription Refills – Documentation EMR increases efficiency

substantially $400-500 cost saving per MD per year

Error rates 0-3% no clear advantage for EMR Transfer of information (double entry)

should be avoided if possible

Maximizing Quality of Care for Diabetic Patients

Diabetes Quality Improvement Project Indicators

A1c Q 1 year Lipid panel Q 1 year UA for protein Q 1 year Eye exam Q 1 year Foot exam Q 1 year Flu shot Q 1 year Pneumococcal vaccine ever

Diabetes Care Oklahoma Foundation for Medical Quality

audits Exemplars (90% adherence) identified for

two or more items 5 exemplars covered all items with overlap

Phone interviews – transcripts Analysis of transcripts identified 6

principles

Diabetes Care See all diabetic patients every 3 months

for diabetes care Label diabetic charts with sticker Protocol for office staff Registry of diabetic patients Work with one or two eye doctors who are

faithful about sending reports Chart documentation sheet/flow sheet

PDAs and PEAs We developed a PDA-based

reminder/registry/flow sheet generator

Practice Enhancement Assistants work with 8 practices over an extended period of time to help them implement practice improvements

Diabetes Patient Tracker Enterprise MS Access and SQL Database

Versions

3

Diabetes Patient Tracker Enterprise is one of OKPRN’s most utilized PDA solution at this point. With it’s quick menu options and colorful icon-coded multiple object screens, this application is even more flexible, effective and user friendly. Individual patient report function and printable flowcharts along with enhanced electronic chart audit function can provide the ultimate solution for diabetes patient tracking, electronic documentation and clinical decision support system. Syncs up to a central MS Access, or an SQL database

Diabetes Care QI Studies Initial study of best practices plus practice

enhancement assistant completed 1/2003 30 clinicians in 10 practices I explained/we discussed the 6 principles

High rate of acceptance of six principles Wide acceptance of a PDA-based diabetic

registry Dramatic improvements in adherence to

guidelines

Quality of Care Indicators A1c: 87% - 96% p=0.0003 UA protein: 53% - 64% p=0.05 Lipid Panel: 69% - 80% p=0.02 Foot Exam: 71% - 82% p=0.004 Retinal Exam: 48% - 59% p=0.04 Pneumovax: 42% - 61% p=0.0006 ACEI for BP: 72% - 86% p=0.03 ACEI for prot: 53% - 64% p=0.05

Next Steps AHRQ grant to study feedback vs. FB

+ best practices vs. FP+BP+ practice enhancement assistant

Focus on the most effective ways to reduce BP, LDL, and A1c

Colorectal Cancer Screening

Steps: At risk patients identified Screening offered Screening completed Patients who screen positive receive

needed follow-up/further testing

NCI – Colorectal Cancer – Critiques “The ‘best practices’ approach has

enormous potential.” “To ‘systematically tap into the

wisdom of practicing physicians’ seems to have a lot more to recommend it than the usual top-down, theory driven efforts to improve practice.”

More Questions What is the best way to manage no-shows

and late cancellations What is the best way to deal with

pharmaceutical representatives What is the best way to manage drug

samples What is the best way to handle patient

phone calls What is the best way to deal with

residents who are performing poorly

Management of No-Shows Student summer project Survey of all FP residency program clinic

managers In depth interviews with exemplars• Steps

• Reduction in umber/% of no-shows• Management of no-shows when they occur

(e.g. number of patients seen/half-day)

What are your challenges?

Would the methods described be a potentially useful way to address them?

What are the implications of this approach for practice-based research networks?

How could such an approach be used to improve primary care practice nationally?

OBJECTIVES• Teach you about “best practices

research” as a concept

• Teach you the method

• Give you enough examples that you feel that you could do it

• Share some of our discoveries

Questions/Reference

Mold JW and Gregory ME Best practices research. Family Medicine 2003, 35 (2): 131-134