pbrns - learning communities
TRANSCRIPT
Can Family Medicine Can Family Medicine Become a Learning Become a Learning
Community?Community?James W. Mold, M.D., M.P.H.James W. Mold, M.D., M.P.H.Department of Family and Department of Family and
Preventive MedicinePreventive MedicineUniversity of Oklahoma Health University of Oklahoma Health
Sciences Center - OKCSciences Center - OKC
ObjectivesObjectives
• Introduce the idea of a learning Introduce the idea of a learning community and explain why Family community and explain why Family Medicine is well-positioned to become Medicine is well-positioned to become oneone
• Propose a sliding scale for evidencePropose a sliding scale for evidence• Discuss the role of practice-based Discuss the role of practice-based
research networksresearch networks• Point out some challenges and Point out some challenges and
unanswered questionsunanswered questions
Four Stories and a JokeFour Stories and a Joke
1.1. Mark Gregory, Okarche, OklahomaMark Gregory, Okarche, Oklahoma
2.2. The Great Harvest Bread CompanyThe Great Harvest Bread Company
3.3. Cystic fibrosisCystic fibrosis
4.4. Cooperative extensionCooperative extension
5.5. The man with the frog on his headThe man with the frog on his head
““If you’ve heard this story before, don’t stop me. I’d like to If you’ve heard this story before, don’t stop me. I’d like to hear it again.” Groucho Marxhear it again.” Groucho Marx
A 1960’s PerspectiveA 1960’s Perspective
• Just because we’ve always done it that way Just because we’ve always done it that way doesn’t mean it’s the best way to do it.doesn’t mean it’s the best way to do it.
• We’re all in this together.We’re all in this together.• We can make the world a better place.We can make the world a better place.• Each of us can have an impact.Each of us can have an impact.• If we work together, we can achieve If we work together, we can achieve
anything.anything.
• Don’t trust anyone over 30Don’t trust anyone over 30
In a Small Town (the first In a Small Town (the first story)story)
Okarche, Oklahoma 1998Okarche, Oklahoma 1998
““It doesn’t help when the QIO comes in, It doesn’t help when the QIO comes in, audits my charts, and tells me what a audits my charts, and tells me what a lousy job I am doing. If they would tell me lousy job I am doing. If they would tell me who is doing a good job, maybe I could who is doing a good job, maybe I could talk with them and find out how to do it talk with them and find out how to do it better.”better.”
Mark Gregory, Mark Gregory, M.D.M.D.
What’s the best way to …What’s the best way to …
• Manage laboratory test results?Manage laboratory test results?• Deliver preventive services?Deliver preventive services?• Improve my care for patients with Improve my care for patients with
diabetes?diabetes?• Handle prescription refills?Handle prescription refills?• Help patients remember to bring their Help patients remember to bring their
medications with them to appointments?medications with them to appointments?• Help overweight patients lose weight and Help overweight patients lose weight and
keep it off?keep it off?
How would you approach these questions?How would you approach these questions?
What Mark Didn’t Say
If they would just tell me:• What the literature says I should do.• What the specialists say I should do.• What the guidelines say I should do.• What my academic colleagues say I should do.• What CME resources are available.
Performance DistributionsPerformance Distributions• Virtually always presentVirtually always present• Wider than you would expectWider than you would expect• Within practices and between practicesWithin practices and between practices• High performers are often High performers are often notnot the “usual the “usual
suspects”suspects”• Highest performers in one area aren’t Highest performers in one area aren’t
necessarily the highest performers in other necessarily the highest performers in other areasareas– Some true exemplars (quest for Some true exemplars (quest for
excellence) excellence)
0
10
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40
50
60
70
80
90
100
Percent
E O J V U H W C L M A E G Y B S P D T Q R I N K
Clinician
CRC Screening
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10
20
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70
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Percent
J D H E P I G B L Q C F M A N K O
Clincian
Dtap#4
No Show Rates
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20
40
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100
70 137 136 19 14 4 18 92 121 105
Number of Residencies
Percent
CPCI Accumulated Knowledge
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10
20
30
40
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60
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100
35 4 34 6 30 15 12 24 5 3 1 2 10 22 37 28 7 9 18 39 8 29 36 38
Clinician
Percent
CPCI Comprehensiveness of Care
82
84
86
88
90
92
94
96
98
100
35 4 34 6 30 15 12 24 5 3 1 2 10 22 37 28 7 9 18 39 8 29 36 38
Clinician
Percent
What Exemplars Know
• Principles
• Techniques
• Scripts
Often don’t realize what they are doing differently or even that they are exemplars.
DiabetesDiabetes
Exemplar PrinciplesExemplar Principles
1.1. Diabetes visits every 3 monthsDiabetes visits every 3 months
2.2. Label chartsLabel charts
3.3. Use teamwork, protocolsUse teamwork, protocols
4.4. Use a registryUse a registry
5.5. Choose one eye specialistChoose one eye specialist
6.6. Flow sheet (?)Flow sheet (?)
DM Pilot StudyDM Pilot Study30 (non-exemplar) clinicians30 (non-exemplar) clinicians
Taught exemplar principlesTaught exemplar principles
Provided with:Provided with:
Practice facilitatorPractice facilitator
PDA-based registryPDA-based registry
High rate of acceptance of principles. No High rate of acceptance of principles. No disagreements.disagreements.• Mean of 4/6 principles implementedMean of 4/6 principles implemented
Quality of Care Indicators Quality of Care Indicators • A1c: A1c: 87% 87% 96% 96% p=0.0003p=0.0003• UA protein: 53% UA protein: 53% 64% 64% p=0.05p=0.05• Lipid Panel: Lipid Panel: 69% 69% 80% 80% p=0.02p=0.02• Foot Exam: 71% Foot Exam: 71% 82% 82% p=0.004p=0.004• Retinal Exam: Retinal Exam: 48% 48% 59% 59% p=0.04p=0.04• Pneumo: Pneumo: 42% 42% 61% 61% p=0.0006p=0.0006• ACEI for BP: 72% ACEI for BP: 72% 86% 86% p=0.03p=0.03• ACEI for prot: ACEI for prot: 53% 53% 64% 64% p=0.05p=0.05
Paired t-tests; physician as unit of analysis Paired t-tests; physician as unit of analysis
Best Practices ResearchBest Practices ResearchWhat’s the best way to do “x” ?What’s the best way to do “x” ?• Identify the steps or components of “x”Identify the steps or components of “x”• Define “best”Define “best”• Find exemplars for each componentFind exemplars for each component• Figure out what they do Figure out what they do
– PrinciplesPrinciples– TechniquesTechniques– ScriptsScripts
• Put pieces back together and test themPut pieces back together and test them
Mold JW and Gregory ME. Best practices research. Family Mold JW and Gregory ME. Best practices research. Family Medicine 2003; 35(2): 131-134.Medicine 2003; 35(2): 131-134.
Lab Test ManagementLab Test Management
1.1. Track results to be sure they come Track results to be sure they come back to chartback to chart
2.2. Notify patients of resultsNotify patients of results
3.3. Document patient notificationDocument patient notification
4.4. Assure that patients with abnormal Assure that patients with abnormal results get follow-up they needresults get follow-up they need
Lab Test ManagementLab Test Management• Wide range of methods used for each stepWide range of methods used for each step• 92% of clinicians within the same practice used 92% of clinicians within the same practice used
different methods to notify their patientsdifferent methods to notify their patients• Half of clinicians who said they were very Half of clinicians who said they were very
satisfied with their systems were exemplars. satisfied with their systems were exemplars. (Half were not.)(Half were not.)
• Combined best method works extremely wellCombined best method works extremely well• Cost: $5.19 per patientCost: $5.19 per patient
Mold JW et al. Management of Laboratory Test Results in Family Practice JFP (2000) 49(8):709-715
Where Are You Little Star?Where Are You Little Star?
Identifying exemplars:Identifying exemplars:• Show of handsShow of hands
– Simple, cheapSimple, cheap– Lots of false positives and false negativesLots of false positives and false negatives
• Audit everyone (external)Audit everyone (external)– Time consumingTime consuming– AccurateAccurate
• Self-assessment (internal) Self-assessment (internal) – Possible middle ground?Possible middle ground?
Bread and ButterBread and Butter
The Great Harvest Bread CompanyThe Great Harvest Bread Company
Freedom franchisees must:Freedom franchisees must:1.1. Use the grain chosen by the companyUse the grain chosen by the company2.2. Grind the grain in the bakeryGrind the grain in the bakery3.3. Give away samples of breadGive away samples of bread4.4. Share their successful innovations and Share their successful innovations and
discoveries with other franchiseesdiscoveries with other franchisees
Bread and Butter: What a bunch of bakers taught Bread and Butter: What a bunch of bakers taught me about business and happinessme about business and happiness by Tom by Tom McMakin St. Martins Press, New York, NYMcMakin St. Martins Press, New York, NY
Cystic FibrosisCystic Fibrosis
For 45 years, the Cystic Fibrosis Foundation has kept For 45 years, the Cystic Fibrosis Foundation has kept track of the outcomes of every cystic fibrosis child track of the outcomes of every cystic fibrosis child cared for in the 117 cystic fibrosis centers around cared for in the 117 cystic fibrosis centers around the U.S. By agreement with the centers, the data is the U.S. By agreement with the centers, the data is kept confidential.kept confidential.
In 2003, average life expectancy of people with cystic In 2003, average life expectancy of people with cystic fibrosis was 33. In the top performing center it was fibrosis was 33. In the top performing center it was 47.47.
At the median CF center, the average FEV1 was 75% At the median CF center, the average FEV1 was 75% of normal. At the top center it was 100% of normal.of normal. At the top center it was 100% of normal.
Qawande, A. The bell curve. New Yorker, Dec 2004Qawande, A. The bell curve. New Yorker, Dec 2004
Come a Little Bit CloserCome a Little Bit Closer
Exemplar methods:Exemplar methods:
• Very high expectations (e.g. normal FEV1)Very high expectations (e.g. normal FEV1)• Patient involvement (e.g. anticipatory Patient involvement (e.g. anticipatory
chest PT)chest PT)• Creative solutions to treatment challenges Creative solutions to treatment challenges
(e.g. electronic chest PT machine)(e.g. electronic chest PT machine)• Aggressive medical managementAggressive medical management
Beans in Their EarsBeans in Their Ears
Reactions of non-exemplary Reactions of non-exemplary (academic) centers:(academic) centers:
There must be something different There must be something different about the patient populationsabout the patient populations
There must be something different There must be something different about the environment (air about the environment (air quality/pollution)quality/pollution)
No randomized controlled trialsNo randomized controlled trials
Here in the Real WorldHere in the Real World
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Levelof
CertaintyNeeded
High Expectations Anticipatory ChestPT
Electronic Vest Drugs
Interventions
Sliding Scale for Evidence
Series1
The Times They are The Times They are ChangingChanging
• InterdependencyInterdependency• InterdiscipinaryInterdiscipinary• Teams/TeamworkTeams/Teamwork• NetworksNetworks• CollaborativesCollaboratives• Centers/InstitutesCenters/Institutes• Think tanksThink tanks• Multi-nationalMulti-national• World economyWorld economy
• InternetInternet• E-mailE-mail• GoogleGoogle• AmazonAmazon• eBayeBay• BlogsBlogs• YouTubeYouTube• My SpaceMy Space• IdolIdol
Bits and PiecesBits and Pieces• IHI Learning CollaborativesIHI Learning Collaboratives• Contact, Help, Advice, and Information Contact, Help, Advice, and Information
Networks (CHAINs)Networks (CHAINs)
http://chain.ulcc.ac.uk/chain/about.htmlhttp://chain.ulcc.ac.uk/chain/about.html• The Leapfrog GroupThe Leapfrog Group• VA best practices QI InitiativesVA best practices QI Initiatives• Regional Health Information OrganizationsRegional Health Information Organizations• IOM Report: IOM Report: The Learning Healthcare The Learning Healthcare
SystemSystem• NC Community CareNC Community Care
Communities of PracticeCommunities of PracticeCultivating Communities of PracticeCultivating Communities of Practice by by
Wenger, McDermott, and Snyder; Wenger, McDermott, and Snyder; Harvard Business School Press, 2002Harvard Business School Press, 2002
Requirements:Requirements:1.1. Domain (topic area or areas) - Creates Domain (topic area or areas) - Creates
common ground and sense of common common ground and sense of common identityidentity
2.2. Community – Creates the social fabric of Community – Creates the social fabric of learning (relationships based on respect learning (relationships based on respect and trust)and trust)
3.3. Practice (collective knowledge set) – Set Practice (collective knowledge set) – Set of frameworks, tools, styles, language, of frameworks, tools, styles, language, storiesstories
Communities of PracticeCommunities of PracticePrinciples:Principles:1.1. Design for evolution (organic, dynamic, Design for evolution (organic, dynamic,
developing)developing)2.2. Open a dialog between inside and outside Open a dialog between inside and outside
perspectives (outside perspective keeps perspectives (outside perspective keeps community aware of possibilities)community aware of possibilities)
3.3. Invite different levels of participationInvite different levels of participation4.4. Develop both public and private community Develop both public and private community
spacesspaces5.5. Focus on valueFocus on value6.6. Combine familiarity and excitementCombine familiarity and excitement7.7. Create a rhythm for the community (e.g. Create a rhythm for the community (e.g.
regular meetings)regular meetings)
Learning OrganizationsLearning OrganizationsMaster the five “learning disciplines”:Master the five “learning disciplines”:1.1. Personal mastery (expansion of personal Personal mastery (expansion of personal
capacity)capacity)2.2. Mental models (continually clarifying our Mental models (continually clarifying our
internal pictures of the world; constructivism)internal pictures of the world; constructivism)3.3. Shared vision (commitment to the group)Shared vision (commitment to the group)4.4. Team learning (developing intelligence and Team learning (developing intelligence and
abilities greater than the sum of the individuals)abilities greater than the sum of the individuals)5.5. Systems thinking (understanding the forces and Systems thinking (understanding the forces and
inter-relationships that shape the behavior of inter-relationships that shape the behavior of systems)systems)
The Fifth Discipline FieldbookThe Fifth Discipline Fieldbook by Peter Sege et al; Doubleday, by Peter Sege et al; Doubleday, 19941994
WE CAN DO THISIt’s who we are and what we like to do.
Leader of the PackLeader of the PackFamily MedicineFamily Medicine
• First medical specialty not defined by First medical specialty not defined by patient age, gender, or disease categoriespatient age, gender, or disease categories
• First specialty to recognize and emphasize First specialty to recognize and emphasize the importance of family systems to health the importance of family systems to health and health careand health care
• First specialty to emphasize longitudinal First specialty to emphasize longitudinal training in the outpatient settingtraining in the outpatient setting
• First specialty board to require periodic First specialty board to require periodic recertificationrecertification
• First specialty to create an organization First specialty to create an organization specifically for teachers of the disciplinespecifically for teachers of the discipline
ImagineImagineFamily Medicine as a Learning Family Medicine as a Learning
CommunityCommunity
Freedom franchise systemFreedom franchise system• Provision of a basic set of servicesProvision of a basic set of services• Obligation/expectation to share Obligation/expectation to share
successful innovationssuccessful innovations– Multiple communication channels and Multiple communication channels and
opportunities to share knowledgeopportunities to share knowledge– Funding for evaluation and dissemination of Funding for evaluation and dissemination of
innovationsinnovations– Early acculturation of FM residentsEarly acculturation of FM residents
Here Comes the SunHere Comes the Sun
• PBRNsPBRNs• Practice Inquiry groups (UCSF/Stanford)Practice Inquiry groups (UCSF/Stanford)• ABFM IPIP ProgramABFM IPIP Program• Family Practice Inquiries Network (FPIN)Family Practice Inquiries Network (FPIN)• TransforMedTransforMed
0
1
2
3
4
5
6
7
8
9
# of Starts
Primary Care PBRN Starts
Series1
19751975 20062006
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19921992 19991999
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Turn Around, Look at MeTurn Around, Look at Me
The JokeThe Joke
A man comes into a bar with a frog on his A man comes into a bar with a frog on his head.head.
The bartender asks, “Where’d you get The bartender asks, “Where’d you get that?”that?”
The Oklahoma Physicians The Oklahoma Physicians Resource/Research NetworkResource/Research Network
• www.okprn.orgwww.okprn.org• OKPRN ListservOKPRN Listserv• Biannual newslettersBiannual newsletters• Annual convocationsAnnual convocations• Practice enhancement assistantsPractice enhancement assistants• Access grid nodeAccess grid node• Clinical inquiries programClinical inquiries program
– Linking residents, faculty, and practitionersLinking residents, faculty, and practitioners

OKPRN Practices
Project Project DevelopmenDevelopment Advisory t Advisory CommitteeCommittee
Rural Rural Health Health
ProjectsProjects
PEAPEAPEAPEA
PEAPEA PEAPEA
PEAPEA PEAPEA
OKPRNOKPRNBoard of DirectorsBoard of Directors
Dept. Dept. of of FamilyFamily MedicineMedicine
www.okprn.org
In March 2007 (one month):• 3,900 personal visits (not machine generated)
• 88% are repeat visitors• Most frequent locations of visitors: OK, CA, WA,
IN, NY, and TX
• Total visit time: 90 hours• 48 different files were downloaded
• Most frequent downloads were best practices, newsletter, and PEA question of the week
Diffusion
The expeditious diffusion of innovations probably requires a well-developed, decentralized infrastructure that relies heavily upon personal relationships.
Diffusion of Innovations by Everett Rogers; The Free Press, 1962
Cooperative Extension
• 1796: George Washington proposed a board or office to promote dissemination and diffusion of modern agricultural methods
• 1810: First agricultural journals• 1862: Land-Grant College Act; enrollment slow;
many thought they could learn better by doing than by studying; very little to teach because little relevant science; mostly taught farm operations
• 1882: Hatch Act established funding for “experimental farms”
Cooperative Extension
• 1889: Dept of Agriculture began issuing Farmers’ Bulletins and the Yearbook of Agriculture; experimental farms issued research bulletins and “popular bulletins”; publications reached small proportion of farmers, many of whom distrusted “book farming”
• 1880 -1911: Widespread establishment of “farmers institutes” and even “mobile institutes” to reach more farmers
• 1906: S. A. Knapp hired the first county extension agent to develop a personal relationship with every farm family in the county and help them implement innovations
Cooperative Extension • Funding sources – 30% federal, 70% state and local• Headquartered in the land-grant university• Staffing – 1% federal, 32% university, 67% local in
nearly all of the 3,150 counties in the U.S.; plus more than 2 million volunteers
• Goal is to maintain meaningful bi-directional communication between the university and the farmers and provide on-site training and assistance to farmers and farm families so they can stay abreast of advances in science
Taking the University to the People by Wayne D. Rasmussen; Iowa State University Press, 1989
Cooperative Health Extension?County Health Extension:
• Bi-directional information conduits between community-based clinicians, PBRNs, and the university
• Free exchange of ideas and methods• Local assistance with implementation of
innovationsCPGs, CCM, EHRs, etc.
Bio-event/epidemic surveillance and preparedness
• Coordination of private, public, and community resources, initiatives
• Outcome tracking with goals, feedback
Cooperative Health Extension?
Community Care of NC: Regional 501c3
organizations; owned and run by primary care clinicians; supported by Medicaid care management funds ($2.50 pmpm); charged with improving quality of care for Medicaid patients.
Saved the state $60 million in Medicaid costs in 2003 and $120 million in 2004
A Place in this WorldA Place in this World
What role could each of the following What role could each of the following organizations play in a FM learning organizations play in a FM learning community?community?
• STFMSTFM• ABFMABFM• AAFP and state chapters and foundationsAAFP and state chapters and foundations• Departments of Family MedicineDepartments of Family Medicine• Community-based residency programsCommunity-based residency programs• NAPCRGNAPCRG
• Federation of PBRNsFederation of PBRNs
ObjectivesObjectives
• Introduce the idea of a learning Introduce the idea of a learning communitycommunity
• Explain why Family Medicine is well-Explain why Family Medicine is well-positioned to become onepositioned to become one
• Propose a sliding scale for evidencePropose a sliding scale for evidence• Discuss the role of practice-based Discuss the role of practice-based
research networksresearch networks• Point out some challenges and Point out some challenges and
unanswered questionsunanswered questions
In a Small TownIn a Small Town
Okarche, Oklahoma circa 1999Okarche, Oklahoma circa 1999
“ “Don’t forget, Jim, it’s about relationships. Don’t forget, Jim, it’s about relationships. Make sure the breaks are long.”Make sure the breaks are long.”
(When asked about the proposed (When asked about the proposed program program
for the OKPRN Annual Convocation.) for the OKPRN Annual Convocation.)
Mark Gregory, M.D.Mark Gregory, M.D.
Questions?Questions?