Abstract Purpose The purpose of this study was to evaluate patient outcomes in the National Demonstration Project (NDP) of practices' transition to patient-centered medical homes (PCMHs). Methods In ...2006, a total of 36 family practices were randomized to facilitated or self-directed intervention groups. Progress toward the PCMH was measured by independent assessments of how many of 39 predominantly technological NDP model components the practices adopted. We evaluated 2 types of patient outcomes with repeated cross-sectional surveys and medical record audits at baseline, 9 months, and 26 months: patient-rated outcomes and condition-specific quality of care outcomes. Patient-rated outcomes included core primary care attributes, patient empowerment, general health status, and satisfaction with the service relationship. Condition-specific outcomes were measures of the quality of care from the Ambulatory Care Quality Alliance (ACQA) Starter Set and measures of delivery of clinical preventive services and chronic disease care. Results Practices adopted substantial numbers of NDP components over 26 months. Facilitated practices adopted more new components on average than self-directed practices (10.7 components vs 7.7 components, P = .005). ACQA scores improved over time in both groups (by 8.3% in the facilitated group and by 9.1% in the self-directed group, P <.0001) as did chronic care scores (by 5.2% in the facilitated group and by 5.0% in the self-directed group, P = .002), with no significant differences between groups. There were no improvements in patient-rated outcomes. Adoption of PCMH components was associated with improved access (standardized beta Sβ = 0.32, P = .04) and better prevention scores (Sβ = 0.42, P = .001), ACQA scores Sβ = 0.45, P = .007), and chronic care scores (Sβ = 0.25, P= .08). Conclusions After slightly more than 2 years, implementation of PCMH components, whether by facilitation or practice self-direction, was associated with small improvements in condition-specific quality of care but not patient experience. PCMH models that call for practice change without altering the broader delivery system may not achieve their intended results, at least in the short term.
Electronic health records (EHRs) have had mixed effects on the workflow of ambulatory primary care. In this study, we update previous research on the time required to care for patients in primary ...care clinics with EHRs.
We directly observed family physician (FP) attendings, residents, and their ambulatory patients in 982 visits in clinics affiliated with 10 residencies of the Residency Research Network of Texas. The FPs were purposely chosen to reflect a diversity of patient care styles. We measured total visit time, previsit chart time, face-to-face time, non-face time, out-of-hours EHR work time, and total EHR work time.
The mean (SD) visit length was 35.8 (16.6) minutes, not counting resident precepting time. The mean time components included 2.9 (3.8) minutes working in the EHR prior to entering the room, 16.5 (9.2) minutes of face-to-face time not working in the EHR, 2.0 (2.1) minutes working in the EHR in the room (which occurred in 73.4% of the visits), 7.5 (7.5) minutes of non-face time (mostly EHR time), and 6.9 (7.6) minutes of EHR work outside of normal clinic operational hours (which occurred in 64.6% of the visits). The total time and total EHR time varied only slightly between faculty physicians, third-year and second-year residents. Multivariable linear regression analysis revealed many factors associated with total visit time including patient, physician, and clinic infrastructure factors.
Primary care physicians spent more time working in the EHR than they spent in face-to-face time with patients in clinic visits.
Abstract Purpose The objective of this study was to elucidate the effect of facilitation on practice outcomes in the 2-year patient-centered medical home (PCMH) National Demonstration Project (NDP) ...intervention, and to describe practices' experience in implementing different components of the NDP model of the PCMH. Methods Thirty-six family practices were randomized to a facilitated intervention group or a self-directed intervention group. We measured 3 practice-level outcomes: (1) the proportion of 39 components of the NDP model that practices implemented, (2) the aggregate patient rating of the practices' PCMH attributes, and (3) the practices' ability to make and sustain change, which we term adaptive reserve. We used a repeated-measures analysis of variance to test the intervention effects. Results By the end of the 2 years of the NDP, practices in both facilitated and self-directed groups had at least 70% of the NDP model components in place. Implementation was relatively harder if the model component affected multiple roles and processes, required coordination across work units, necessitated additional resources and expertise, or challenged the traditional model of primary care. Electronic visits, group visits, team-based care, wellness promotion, and proactive population management presented the greatest challenges. Controlling for baseline differences and practice size, facilitated practices had greater increases in adaptive reserve (group difference by time, P = .005) and the proportion of NDP model components implemented (group difference by time, P = .02); the latter increased from 42% to 72% in the facilitated group and from 54% to 70% in the self-directed group. Patient ratings of the practices' PCMH attributes did not differ between groups and, in fact, diminished in both of them. Conclusions Highly motivated practices can implement many components of the PCMH in 2 years, but apparently at a cost of diminishing the patient's experience of care. Intense facilitation increases the number of components implemented and improves practices' adaptive reserve. Longer follow-up is needed to assess the sustained and evolving effects of moving independent practices toward PCMHs
Abstract Purpose We describe the experience of practices in transitioning toward patient-centered medical homes (PCMHs) in the National Demonstration Project (NDP). Methods The NDP was launched in ...June 2006 as the first national test of a model of the PCMH in a diverse sample of 36 family practices, randomized to facilitated and self-directed intervention groups. An independent evaluation team used a multimethod evaluation strategy, analyzing data from direct observation, depth interviews, e-mail streams, medical records, and patient and practice surveys. The evaluation team reviewed data from all practices as they became available and produced interim summaries. Four 2-to 3-day evaluation team retreats were held during which case summaries of all practices were discussed and patterns were described. Results The 6 themes that emerged from the data reflect major shifts in individual and practice roles and identities, as well as changes in practices' management strategies. The themes are (1) practice adaptive reserve is critical to managing change, (2) developmental pathways to success vary considerably by practice, (3) motivation of key practice members is critical, (4) the larger system can help or hinder, (5) practice transformation is more than a series of changes and requires shifts in roles and mental models, and (6) practice change is enabled by the multiple roles that facilitators play. Conclusions Transformation to a PCMH requires more than a sequence of discrete changes. The practice transformation process may be fostered by promoting adaptive reserve and local control of the developmental pathway.
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