TransforMED: Renovating the specialty

Melissa Gerdes, M.D., examines a patient at Trinity Clinic in Whitehouse, one of 36 practices across the country chosen to participate in AAFP’s TransforMED project.

When AAFP published the Future of Family Medicine report three years ago, family physicians faced a tough ultimatum: change your ways or the specialty will perish within the next decade. This message wasn’t meant as a slight on family physicians and how they run their practices, but more a realization that family medicine and the U.S. health care system as a whole must change to meet the evolving needs of patients. Now the Academy is working to build the case that a primary care-based health system is the long-term, sustainable solution to what ails the country’s health system.

To Judith Chamberlain, M.D., AAFP board member and family physician in Brunswick, Maine, the actions required of family physicians are even more drastic than simply revamping common practices. “I hesitate to say we need to change the system because I don’t think we have a system,” Chamberlain said during the closing address at TAFP’s July Annual Session. “We need to create one, and I think that if [family physicians] don’t do it, nobody else is going to.”

AAFP launched the TransforMED initiative in 2005, putting the FFM practice redesign recommendations into action in 36 family medicine practices around the country. These practices form the base of the National Demonstration Project, a testing ground for the New Model of Family Medicine. The New Model focuses on implementing advanced information systems like electronic medical records, providing open access to patients, using a team approach to care, focusing on quality and safety, and redesigning offices to be more functional.

Half of the practices are considered “facilitated,” meaning they regularly participate in daily or monthly collaborative meetings, site visits, e-mails and phone calls with TransforMED staff and the other facilitated practices. The other half are self-directed. They use the plan as a compass, but apply their own ideas to the system to find what works best for their practice.

The one TransforMED practice in Texas—Trinity Clinic in Whitehouse—has been the “star” of the facilitated practices since the beginning, says practice enhancement facilitator David Garrett, M.H.A. One reason is the physicians. Melissa Gerdes, M.D., Janet Hurley, M.D., and Amy Mullins, M.D., provide leadership on an hourly basis—something you don’t often run across, he says. “That allows the practice to take chances and grow. A practice that size is generally into a system of rigidity and governed by bureaucracy, but they are willing to take chances and let the practice take chances.”

By the time they decided to apply, the Trinity Clinic physicians had also built momentum—they had already implemented roughly half of the TransforMED concepts. Having the commitment to make the changes and maintaining that commitment through the entire process meant the Trinity Clinic had a fairly good chance of being selected, Gerdes says.

According to Garrett, the first step of the entire process is to get everyone in the practice on board and have the staff understand the importance of making the changes. From there, the practices educate themselves on the concepts, work on teamwork and rethink how to conduct effective meetings.

By already having the leadership in place and a strong communication base through weekly “pow-wows” between the physicians and the larger staff, the Trinity Clinic began one step ahead. They also had an electronic medical record and provided same-day access slots for patients—two key TransforMED concepts.

Same-day access slots come in two forms at the clinic. Gerdes carves the lunch hour into five-minute slots to see established patients with upper respiratory problems. During these QuickSick visits, the patient can get in and out of the clinic in 15 to 20 minutes and Gerdes and her staff can see 12 patients in one hour. Mullins and Hurley offer additional slots during the lunch hour and at end of the day.

The physicians also reserve a certain percentage of visits for same-day slots, which Hurley sees as time savers for physicians in addition to being a great convenience for patients. “If your next sick visit is three days from now and your patient is sick today and they don’t want to wait, they’re either going to have get care elsewhere, in which case that’s a fairly fast visit you’re not going to be able to capitalize on, or they’re going to ask your nurse 25 questions about what they should do over the counter or leave [phone] messages for you.”

That ends up dragging you down, she says. “That’s extra phone messages, that’s extra work and it’s lower-quality care. Then they no-show three days later because they’re better.”

Janet Hurley, M.D., one of three physicians who practice at the Trinity Clinic, examines a new patient.

Gerdes says that not having a long wait list for appointments doesn’t worry her. “If you have a relatively mature practice, not a start-up, your patient base is pretty stable, and the demand is going to be fairly stable from day-to-day with seasonal things. You can do this study in any office to prove that, so why not just deal with it today? Then it’s done and the patient’s happy and you can move on to the next day.”

The proliferation of urgent care centers and retail health clinics shows that patients increasingly demand same-day visits, Hurley says. “If the patients can’t go through their primary care physician for care, then they’re going to seek someone who will do it for them and they’re going to try to do it at the lowest cost that they can. But I think that if they had the ability to come to their physician who they know and trust, and who they know knows them, they would do that as long as there’s a slot available for them.”

On the days when same-day scheduling is full, the practice has the opportunity to promote other avenues for care. For example, if a patient calls thinking he may have a sinus infection, the nurses can recommend that he go online for a virtual office visit instead of waiting or going to the emergency room.

Virtual office visits—answering patient inquiries and rendering basic medical advice through e-mail—can be helpful and effective in the right group of patients, Mullins says. She identifies which patients have rigid work schedules or other conflicts that keep them out of the office and recommends the low-cost, quick alternative. As a result, her patients use the e-visit system more frequently than her partners’ patients.

Mullins recalls one patient with depression who she’d seen off and on over the course of a couple of years. She didn’t have insurance, but Mullins wanted her to come back to the office for periodic checkups. The patient was hesitant about coming back until Mullins told her a virtual office visit would only cost $20—a price set by the practice based on the results of a patient survey and billed at the time of online service. “She said, ‘Well normally I wouldn’t have followed up with you at all, but I’ll get online and I’ll do that.’

“If you can just pick the right people to target, then they’ll do it and they really like it,” Mullins says. E-visits allow the physician to respond to patients’ inquiries between office visits, in the evenings after work or any other convenient time, and the Trinity Clinic physicians keep to a 24-hour turnaround. They have specifically limited the issues they’ll address online to problems such as allergies, colds, high blood pressure and obesity, referring all new patients and any that fall outside the scope of e-visits to come into the office.

To ensure its affiliated family medicine practices are meeting quality parameters, the Trinity Mother Frances Health System, to which the Trinity Clinic belongs, analyzes data from the clinics’ EMRs and sends reports to compare one practice’s numbers with others. Quality tracking was approached cautiously when the health system first began using the concept, but now Hurley says it breeds both efficiency and office visits as well as improving quality indices. She runs reports on her diabetic patients and others who require regular visits. “The important thing is we’re giving them higher-quality care and then, in a practical perspective, they’re coming back in for office visits and you’re getting to see them and know them already after they may or may not have been [the ones] who saw you all the time.”

While having an EMR is key to the New Model, a practice doesn’t have to have one to start implementing some of the recommendations. Garrett suggests starting with non-technology-specific steps such as same-day appointments, group visits, and wellness promotion and disease prevention projects.

“To those without [an EHR], put in a disease registry,” he says. “The first simple step of getting patients’ information electronic is a disease registry. Once you have been using it for a year or two, then you can implement the data into an EHR. I encourage them to start tomorrow, first with diabetes, then move to six or more diseases.”

Staff members at the Trinity Clinic work together to implement the TransforMED concepts. Back row from left: Anita Mitchell, R.T.; Jeannie Sigler, M.A.; Nikki Dillon, L.V.N.; Mandy Clayton; Virginia Dinger; Wendy Lafaitt, L.V.N.; Melissa Hurst. Front row: Melissa Gerdes, M.D.; Amy Mullins, M.D.; Janet Hurley, M.D.

After tackling the disease registry, practices can take other technology-specific steps such as establishing e-communication portals to integrate lab results and patient education information, online registration and appointment requests, and virtual visits.

The biggest change for the Trinity Clinic physicians since committing to TransforMED has been to follow the set timeline, though Gerdes says they would have probably completed all the recommendations on their own at the rate they were moving. “There’s a little more accountability because these things take a lot of time and a lot of manpower and a lot of energy to do.

“Getting to that point, everybody is so busy in their practice, that really setting aside time to do things to improve your practice—business functioning, communication, all these other issues that aren’t directly related to patient care—it’s hard to do especially if you can’t really see the payoff when you start,” she says.

Mullins agrees that making changes to an established practice is difficult, but worthwhile. “The time you put into it is just going to be a payoff that you may not see in the first six months you’ve been doing it or the first 12 months you’ve been doing it, but eventually the payoff’s going to be there and it’s going to be worth it.”

At the end of the day, implementing the TransforMED concepts means the patient’s care should be better managed based on agreed outcomes, which then leads to happier patients, staff and physicians. “It will eventually make your day easier and it will make the management of your practice easier and that makes everyone happier,” Mullins says.

The report from Task Force 6, “Report on Financing the New Model of Family Medicine,” estimates the cost of transition to the New Model to be as much as $90,000, but with a full recovery of the investment within one or two years. The report also predicts a 26-percent increase in income working the same number of hours or the ability to maintain your previous income with reduced hours.

Even with the New Model guidelines and its benefits, Gerdes says what we “transform into” isn’t the main objective. “I think it’s getting the message out that practices have to transform, they have to adapt to what’s going on in the rest of the world because many practices are still functioning the same way we did when family medicine became a specialty. You have to change, to transform... . That’s the key.”