Practice Systems for Chronic Care: Frequency and Dependence on an Electronic Medical Record

Objectives: To document the presence and functioning of differentpractice systems in a small sample of medical groups inMinnesota and to examine the relationship between the presenceof practice systems and prior adoption of an electronic medicalrecord (EMR).

Study Design: Descriptive study of the frequency of practicesystems in 11 medical groups.

Methods: We recruited 11 medical groups for the study. Fourgroups had an EMR; the other groups used paper medical records,often supplemented by electronic ordering or data systems. Usingan on-site audit team, we validated the presence of practice systemsorganized under 8 categories.

Results: All of the medical groups had implemented a substantialnumber of practice systems for care management of patientswith chronic conditions. Although the medical groups with an EMRtended to have more comprehensive practice systems in place,the medical groups without an EMR also had most of the practicesystems.

Conclusions: Although required in some functions, an EMR maynot be necessary in facilitating practice systems that support consistentmanagement of patients with chronic illness. Approachesare needed that will encourage the implementation of practice systemsin medical groups with and without an EMR.

(Am J Manag Care 2005;11:789-796)

practice systems

The need for major improvements in medical carein the United States has become clear since therelease of important reports from the Institute ofMedicine^1,2 and the publication of a study of the qualityof national healthcare by McGlynn et al.³ This need isparticularly important in the care of patients withchronic disease, an area that will become even morecritical as the population of older persons with theseconditions increases.⁴ As illustrated by the chronic caremodel (the dominant conceptual framework for effectivecare of chronic conditions), care delivery organizationsof all sizes must implement practice systems toprovide consistent and comprehensive care.^5,6 The termrefers to organized processes designedto assure that certain information or services are collectedor provided routinely to patients or to healthcarepersonnel (eg, reminders, test results, and education).

care

management processes

The problem is that few of these practice systems arein place, even in larger medical groups. Casalino et al⁷studied the presence of practice systems (termed [CMPs] by them) in 1040 physicianorganizations with 20 or more physicians, medicalgroups that should have the resources to implementsuch support for delivery of quality healthcare. Of a possible16 CMPs, they found a mean of only 5 CMPs permedical group. Because the presence of external incentivesand clinical information technology systems wasstrongly associated with CMP use, they suggested thatproviding these might increase the use of CMPs.

Other than that study⁷ and other studies by Casalinoet al, there is little information in the medical literaturedocumenting the extent to which practice systems arepresent in medical groups. Moreover, the sparse informationthat is available about practice systems is neitherdetailed nor verified by on-site audits. As part of astudy testing the validity of a new questionnairemethod to measure the presence of practice systems forthe care of patients with chronic disease, we documenteddetailed information about practice systems among11 medical groups in Minnesota through self-assessmentand on-site audits. In addition, we wanted to learnwhether medical groups with an electronic medicalrecord (EMR) were more likely to have such practicesystems than medical groups without an EMR.

METHODS

This study was conducted in Minnesota in collaborationwith the Institute for Clinical Systems Improvement,a quality improvement collaborative that includes mostof the medical groups and hospitals in the state amongits members. At the time of this study, those memberorganizations included about 75% of the physicians inMinnesota.⁸ We obtained contact information from theInstitute for Clinical Systems Improvement for 19 oftheir 38 medical group members who provide primarycare to adults, specifying only that we wanted to recruitmedical groups with a diversity of locations, sizes, andsophistication about quality improvement methods.

Recruitment was conducted by first sending a letterdescribing the study to the medical director (or equivalent)of each medical group, followed by telephone callsfrom one of us (LIS) until each medical group had decidedwhether to participate. Three medical groupsdeclined participation (each on the grounds of havingtoo much activity or turmoil at the time), and 2 medicalgroups agreed too late to be included. Three medicalgroups participated in pretesting the survey and the onsiteaudit, leaving 11 medical groups with completeinformation for this report.

This article is based on information gathered in onsiteaudits conducted by 2 trained and experiencednurse auditors. The auditors met with each participatingmedical group's quality improvement director andother staff for assessment of information about whichthey had particular knowledge. The on-site audit coveredthe following 8 practice systems and their componentprocesses: (1) continuity of care (a system tomaintain an ongoing and effective relationship betweenan individual clinician and a group of healthcare practitionersinvolved in providing care for a given patient),(2) registry (an organized system that allows the officeor clinic to group patients by diagnoses and otherparameters and uses the groupings to assist in the provisionof care), (3) clinical information (systems andprocesses associated with a database of key patient andpatient population information that can help managepatient care), (4) systematic monitoring (the use of adatabase to monitor key indicators of chronically illpatients' medical conditions for information that mayrequire immediate attention), (5) clinician reminders(special communications intended to help the office orclinic team adhere to best practices related to the careof the individual patient), (6) performance tracking andfeedback (the process of using clinical information systemsto aggregate key indicators culled from a patientregistry or other data source for the purposes of benchmarkingperformance and directing improvement activities),(7) clinical quality evaluation and improvement(a formal process to assess care, develop interventions,and use data to monitor the effects), and (8) care management(a set of specifically defined services for managingpatients with chronic illness involving multiplepractitioners and care between office visits).

The 8 practice systems and their components hadbeen previously identified by an expert advisorypanel convened by the National Committee for QualityAssurance to create the Practice Systems AssessmentSurvey (http://www.ncqa.org/Programs/RADD/researchreports.htm). This advisory panel was formedto identify the practice systems and components importantfor implementing the chronic care model framework.For each of the 8 practice systems selected by theNational Committee for Quality Assurance panel, theon-site auditors in the present study reviewed evidencethat the practice system and its components were presentand usable. At the end of the on-site audit, the auditorscompleted an assessment of how well andconsistently each practice system that was present wasbeing used. An investigator or data collection supervisor(SCS) accompanied the auditors to most of the sitevisits to monitor them, and several debriefing sessionswere conducted with the entire investigator group toclarify and verify the information and its collectionprocess. After the on-site audit information was enteredinto an electronic database and the data werecleaned, item frequencies were organized by medicalgroup for the analysis herein. This study was approvedand monitored by the HealthPartners InstitutionalReview Board.

RESULTS

Descriptive information about the participatingmedical groups is given in Table 1. In this and subsequenttables, data from the 7 medical groups without anEMR are contrasted with data from the 4 medicalgroups with an EMR. One of the 4 medical groups hadan EMR that comprised all of the functions tested in theon-site audit; the other 3 supplemented their EMR withseparate ordering or data systems. Six of the 7 medicalgroups with paper medical records managed someinformation with separate electronic systems.Examples of such systems are registries created fromelectronic billing systems, electronic reporting systemsin in-house laboratories, and electronic appointmentsystems with the ability to include specific reminders.

Table 2 gives information about the presence of practicesystems as demonstrated in the on-site audit, withthe auditors' subjective assessment of how consistentlythe practice systems were being used. Although almost allof the 11 medical groups had at least some component ofeach practice system present, the auditors found thatsome practice systems were not consistently used, withthe medical groups with an EMR beingmore likely to consistently use existingpractice systems. Overall, the practice systemthat was least likely to be present wasregistry of patients with chronic conditions,and this was most lacking in themedical groups without an EMR. Based onthe auditors' assessments, some of the 7medical groups without an EMR did notuse systematic monitoring or clinicianreminders consistently even though theyhad a non-EMR method to do so.

Three items related to the practicesystem of continuity of care wereassessed. Because all 11 medical groupshad evidence of each of those components,findings for this practice systemare not given in a table. Each medicalgroup demonstrated that it had identifieda personal clinician for each patient, hada process to assure that most patient visitswere with that clinician, and had formalprimary care teams to facilitateaccess and follow-up, with expandedroles for nurses or other team members.

Tables 3, 4, 5, 6, 7, and 8 summarize the extent towhich the other 6 practice systems were present in the11 medical groups. These tables give the number ofmedical groups having the components of the practicesystem summarized in each table. Most components ofeach practice system were present in all of the 11 medicalgroups. Although the 4 medical groups with anEMR were somewhat more likely to have all of thepractice system components, the 7 medical groupswithout an EMR had other ways to perform the functionsof the practice systems. In particular, there is littledifference among the 11 medical groups in thepresence of most components of the performancetracking and feedback practice system and no differenceamong the 11 medical groups in the presence ofall components of the clinical quality evaluation andimprovement practice system. To clarify this, we italicizedeach table component in which the medicalgroups with an EMR were more than twice as likely asthe medical groups without an EMR to have that component.Most italicized components are found in Table3, which addresses the clinical information practicesystem.

DISCUSSION

Our findings demonstrate that the 11 medical groupsstudied had a high number of the practice systems thatare believed to be important for providing effective carefor patients with chronic conditions. They also had mostof the detailed components of those practice systems.Although the medical groups with an EMR had morepractice systems and components present, the medicalgroups relying on paper medical records had other waysto implement most of the components of the practicesystems. Only 13 of 60 total components in the practicesystems were more than twice as likely to be present inthe medical groups with an EMR, suggesting that anEMR is necessary for or enhances these capabilities. Asexpected, those components were largely related toinformation technology, such as reminders, registries,and data about individual clinicians.

Few studies have documented any aspect of the presenceof practice systems among medical groups. Afterpostulating the chronic care model,⁶ Wagner et al⁹ studied72 leading chronic disease programs. They foundthat only 1 program included all 6 elements of thechronic care model framework, and only 5 other programsincluded 5 of 6 elements. Solberg et al^10,11 assessedthe importance of practice systems in delivering preventiveservices and reported in the mid 1990s that practicesystems were infrequent findings among 44 medicalpractices in Minnesota.

In 2003, Casalino et al⁷ reported that, among 1040physician organizations (with ≥ 20 physicians) respondingto a survey about the extent to which physicianorganizations use CMPs, 50% had 4 or fewer of apossible 16 CMPs for chronic disease care (similar to thepractice systems described in this study), and only 22%had more than 8 CMPs. A subsequent investigation byLi et al¹² studied the presence of 4 CMPs (registry,guidelines, case management, and physician feedback)among 987 medical groups that provided care forpatients with diabetes mellitus. They found that 48%had 0 to 1, 20% had 2, and 32% had 3 to 4 of these CMPs.The characteristics associated with the presence ofthese CMPs were external incentives, a computerizedinformation system, and ownership by a hospital or ahealth maintenance organization. Results of otherinterview studies^13,14 among leading healthcare deliverysystems suggest that the main barriers to successfulimplementation of CMPs are inadequate resourcesor information systems, physician busyness or resistance,and lack of an effective means for reimbursement.The main facilitators were strong leadership, an organizationalculture valuing quality of care, the presence ofelectronic information systems, and supportive healthplans.

There seems to be widespread perception on the partof policy makers that an EMR is the principal or eventhe only change required for closing the quality of caregaps identified by the Institute of Medicine.^1,2 There islittle clear evidence on this important issue, but clearlyan EMR is not the sine qua non of efficacy. The VeteransHealth Administration has made remarkable strides inimproving its quality of care, with Asch et al¹⁵ documenting10% to 20% better performance by the VeteransHealth Administration in chronic disease care and preventivecare (but not acute care) compared with caredelivered by a national sample of providers. Although itsintegrated electronic information system was creditedfor some of this improvement, the Veterans Health Administrationhas implemented other quality improvementand comparative performance reporting activitiesas well. In a randomized trial of electronic informationsystem implementation of cardiac care guidelines targetingprimary care physicians and pharmacists inIndiana, Tierney et al¹⁶ found no effect of cardiac careguidelines generated by an EMR on physicians' adherenceto evidence-based guidelines and suggested thatmethods of affecting clinician behavior other than anEMR were needed.

Before the value of an EMR in improving healthcaredelivery can be thoroughly tested, the types of practicesystems that are primarily or exclusively driven by EMRadoption need to be characterized in detail. The presentstudy takes a first step toward that goal. Because the 11medical groups described herein appeared to be able toimplement almost as many practice system componentswithout an EMR as with an EMR, the stage is set forcomparison trials of the effectiveness of differentapproaches to information systems and of various typesof practice systems.

Although the present study is valuable in documentingin detail for the first time, to our knowledge, thepresence of a variety of practice systems in a sample ofmedical groups, it has significant limitations for generalizationof the results. The number of medical groupsstudied was small, and although we recruited a diversesample, the medical groups were all large, with moremidlevel practitioners and registered nurses (Table 1)than most primary care practices in the United States,where only 18% of physicians work in groups of 10 ormore.⁷ Also, the medical groups described herein wereall members of a sophisticated quality improvementcollaborative (the Institute for Clinical SystemsImprovement) that focuses on encouraging the developmentand effective use of practice systems, althoughhalf the medical groups were new to that membership.Whether increased use of practice systems is drivingquality improvement or, conversely, participation inquality improvement is driving the adoption of practicesystems (or some other factor is driving both) is a fertilearea for further inquiry. Despite these limitations,this study demonstrates that private medical groups,including those without an EMR, can organize theirpractices for systematic care of persons with chronicconditions.

Acknowledgments

This study would not have been possible without the close cooperationof the staff and leadership of the Institute for Clinical Systems Improvement.We are especially indebted to the leaders, physicians, and staff of the followingmedical groups that contributed to the implementation of this study:Affiliated Community Medical Center, CentraCare Clinic, CommunityUniversity Health Care Center, Fairview Lakes Regional Health Care,Fairview Red Wing Regional Health Care, Family Practice Medical Center,Grand Itasca Clinic and Hospital, Hutchinson Medical Center, MeritCare,North Clinic, Northwest Family Physicians, Olmsted Medical Center, ParkNicollet Health Services, and Stillwater Medical Group. We also appreciatethe careful work of the on-site audit team, including Laurie Van Arman, LPN,Betty Lindstrom, RN, and Colleen King.

From HealthPartners Research Foundation (LIS, SEA, MJT) and Institute for ClinicalSystems Improvement (ALRM), Minneapolis, Minn; and National Committee for QualityAssurance, Washington, DC (SHS, SCS, GP).

This study was supported by grant 048908 from The Robert Wood Johnson Foundation,Princeton, NJ.

Address correspondence to: Leif I. Solberg, MD, HealthPartners Research Foundation,PO Box 1524, MS 21111R, Minneapolis MN 55440-1524. E-mail: leif.i.solberg@healthpartners.com.

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