Setting and Problem
The Accreditation Council for Graduate Medical Education Internal Medicine Milestones anticipate that residents should “monitor [their] practice with a goal for improvement” and “learn and improve via performance audit.” Performance audits can take the form of metric reports (for example, completion rates for cancer screening tests), but the relatability of metric audits is problematic for residents due to transitory stewardship of empaneled patients (the metric may not reflect resident performance) and potential overemphasis on numeric outcomes. A focus on quality metrics can lead residents to feel that they are treating a number, not treating a patient.
Intervention
Performance audit can alternatively be achieved through self-assessment of competency in comprehensive chronic illness management. At Oregon Health & Science University (OHSU), we facilitate a practice-based learning and improvement (PBLI) curriculum for residents in this model.
Prior to each session, a faculty champion prepares an illness registry report that displays an array of relevant data for resident-empaneled patients. The curriculum is provided in a conference room with computers for each resident.
We start each 90-minute session with a brief tutorial designed to expand resident awareness about primary care management for a common chronic disease. A typical tutorial might cover guideline recommendations, screening and immunization needs, awareness and prevention of complications, relevant clinic-based resources, and applicable electronic health record (EHR) tools. Residents are then guided to their subgroup listing of empaneled patients with that chronic illness diagnosis. If available, relevant lab, treatments, risk scores, and care gaps are highlighted in an accessible display. Time is provided for targeted chart review, patient-specific improvement planning (frequently, a deeper charting activity for 1 to 3 patients), and reflection. The faculty champion is available for mentorship and troubleshooting. Time spent in panel management engages learners in proactive planning, setting of chart reminders, and outreach to patients, with a goal to close gaps in care. The Table describes examples of activities undertaken as part of this curriculum. We leverage the use of our EHR for this curriculum. The faculty champion, having developed familiarity with EHR registry tools, prepares panel-specific dashboard reports and shares them with each resident to be “run by user.” The relevant subset of patients is identified through use of diagnosis grouper search tools. Our medical center utilizes EpicCare and other useful tools including Reporting Workbench, SlicerDicer, and Sticky Notes.
Table.
Sampling of Chronic Illness Panel Management Sessions: Audit and Activities
| Chronic Illness | Patient Subset Reviewed in Audit | Improvement Planning |
| Dementia | Dementia registry; grouper diagnoses: delirium, dementia, and amnestic disorders; dementia and mental degeneration (includes “memory complaint”) | Increase specificity of dementia diagnosis (update problem list); add cognitive testing reminders to chart; use of flowsheets in EHR; inform visit agenda by cognitive scores |
| Osteoporosis | Grouper diagnoses: osteoporosis, hip fracture, vertebral fracture | Q&A with guest bone specialist; treatment planning for selected patients; fall risk assessment |
| Atherosclerotic cardiovascular disease (ASCVD) | High risk by precalculated ASCVD risk score | Sticky Note reminders/outreach to patients to address gaps of care; guideline-directed lipid treatment; EHR tools to assess ASCVD risk; anticipate process for shared decision making (statin in intermediate risk); use of decision aid |
| Heart failure | Heart failure registry; grouper diagnosis: heart failure | Guideline-directed medical therapy; adherence monitoring; low-salt diet patient information |
| Hypertension | Grouper diagnosis: hypertension | Guideline-directed medication review; charting of target blood pressure; adherence monitoring and strategies to improve; low-salt diet patient information |
| Diabetes | Grouper diagnosis: diabetes | Consultation with onsite pharmacist; outreach for high A1C; outreach to unmonitored patients; team-based delegation (panel manager, nurse, schedulers); resources for nutrition and self-management education |
| Depression 1 | Grouper diagnosis: psychiatric/mental health/mental disorder (includes “stress,” “dysthymia”) | Identification of community resources and referral strategies; Sticky Note reminders; documenting mental health providers in care team section of EHR |
| Depression 2 | Bar graph display: antidepressant on medication list > 4 years, > 3 years, > 2 years, > 1 year, and < 1 year | Identification of stable patients on antidepressants > 3 years; reassess indication for long-term antidepressant; anticipate discontinuation symptoms |
| Cancer | Grouper diagnosis: cancer master, cancer concept (current or past cancer) | Annotate chart with chemo, radiation exposure history, and anticipate delayed effects of cancer treatment; primary care needs of cancer survivor: develop and document survivorship plan |
| Renal failure | Last lab value abnormal: glomerular filtration rate | Update CKD stage in problem list; Sticky Note reminders/health maintenance reminder prompts; medication review and dose adjustment planning; assess care gaps in metabolic bone disease monitoring |
| Reproductive health | Female patients aged 18–45 | Effective contraceptive assessment; review medication lists with attention to potential teratogens |
| Chronic pain | Current medication: includes opioid | Safe opioid prescribing; comprehensive pain management planning; case conference with linked preceptor for prescribing oversight |
| Geriatric syndromes | Patients > 65 ranked by total number of medications on current medication list | Assess anticholinergic load; Beer's list higher risk drugs in elderly; chart review of patients with high medication count; “Over-prescribers Anonymous”: round table discussion to plan deprescribing |
Abbreviations: EHR, electronic health record; CKD, chronic kidney disease.
Note: The residents participate in 1 session monthly. At our center scheduling is facilitated by having a 3+1 scheduling model, which includes weeks in ambulatory care, with time set aside for a practice-based learning and improvement curriculum.
Outcomes to Date
Chronic illness panel management provides a versatile framework for teaching core ambulatory medicine topics and is an active method of performance audit and improvement. This curriculum promotes a culture of resident engagement and stewardship in ambulatory care.
Relative to metric-based panel management, outcomes are less easily measured and are more often anecdotal. Residents commented, “This changed my framework of approaching cancer care. I realized that there is a great deal of responsibility…in long term care”; “I really appreciate PBL for the interaction with other residents—to learn from their troubles and victories!”; and “I am still [6 months later] using notes from this ASCVD review as I see patients.”
Since the development of this PBLI curriculum at OHSU's university-based clinic, it has been successfully spread to practice sites (with and without EpicCare), including the OHSU resident clinic at Central City Concern and the internal medicine clinic at the University of California, San Francisco.
PBLI sessions have felt meaningful to both faculty champions and residents. This program has encouraged the use of charting tools and reminders to enhance effective patient care. It has fostered peer teaching and camaraderie, facilitated outreach to patients with gaps in care, and enhanced team-based care. We have seen an increasing number of residents attracted to practice in primary care in our program, and the structure of this PBLI curriculum may be a factor.