TABLE. Ten Most Commonly Reported Structures and Processes From 22 High-Performing Primary Care Practices in the United States (2020).
| Structure and Process | # of Practices Reporting (N = 22) | Description | Representative Quote |
|---|---|---|---|
| Patient registry (Structure) | 20 | A patient registry is a system to evaluate a patient population by a specified disease, condition, or exposure. The functionality needed to create a report can be programmed as part of an EHR system but is more often maintained by an insurer or ACO. | “Our ACO support person comes about every week or every other week, depending on her schedule, and sits down with our clinical quality nurse. [...] They go through the list of all of our Medicare patients [...] and see where the gaps in care are. They identify those, and then that becomes our work list.” (Mississippi) |
| Templates with alerts for health maintenance and preventive care (Structure) | 19 | Many EHR systems developed the knowledge and capacity to use and create templates and alerts to ensure that evidence-based guidelines for health maintenance and preventive care are met for all patients. Practices can use the default templates provided by their EHR system or customized and create their own. | “I use the Health Maintenance tab in Epic. It gives you a big red flag of when patients are due for their mammogram, their pap, their colon cancer, and then it gives you the option to adjust those. If they have a breast lump that needs a repeat ultrasound in six months, you can go in and change the frequency on that. I basically make the Health Maintenance in Epic do that heavy lifting for me.” (Washington) |
| Contacting patients with unmet chronic care needs (Process) | 18 | Reactive outreach to patients is contacting patients who missed appointments. Proactive outreach, such as conducting check-in calls with patients in between scheduled visits, ensures patients adhered to their care plans. | “Every week, I give the medical assistants a new list of patients who have A1c's greater than 9 because our goal is to have A1c's less than 9. Every week, we generate that, we hand it out, and they do outreach for those patients. [...] I think having the data-driven tool [to generate reports] and having outreach workflow that medical assistants do is key.” (Massachusetts) |
| Referring patients to self-management resources provided by the community (Process) | 17 | Self-management resources include programs that help patients with chronic conditions learn behavioral strategies and acquire tools for improving their health. Such programs may not be available within the practice. | “We partner with another community organization all throughout the year—actually, a few of them. [Organization Name] is one of our inner-city organizations that puts on a farmer's market in the summer. We work with them to have vouchers for our patients with chronic illness so that they can get fresh vegetables. [...] Then, we have the cooking class. We have nutritional classes. We also, at one-point last year, got people connected with a walking club.” (Minnesota) |
| Web-based patient portal (Structure) | 17 | A patient portal is a Web-based interface (eg, MyChart in Epic) that complements patient-provider communication outside of office, phone, and video visits. Web-based patient portals are used to schedule appointments, send test results, review remote monitoring data, and answer patient questions (ie, e-visits), which can facilitate continuous care management. | “With new patients, I just tell them, ‘I will send your results through MyChart, and you can always contact me.’ Even my established patients, ‘If you have a question you can't get through the office, just send me a message. It's much quicker for me to address it on MyChart than playing phone tag for two hours to try to contact you.’ They've seen my responsiveness, so they keep it up. If they haven't been on it, and I get them to sign up, they're like, ‘Wow, this is great!’” (New York) |
| Routine generation of reports (Process) | 17 | Care quality reports may be generated through an EHR system or by an external organization (eg, insurer, ACO) to view aggregate patient data and track performance. | “We're in the data all the time. We run quarterly reports. That data is analyzed by our medical leadership team. It's given back to our providers. It's given to the team to say, ‘Hey, do we think there's some things going on?’ We take on quality improvement initiatives in response to the reports.” (Ohio) |
| EHR-based clinical decision support tool with best practice alerts (Structure) | 15 | Clinical decision support tools are computer-based programs that use EHR data to provide alerts and reminders to assist in implementation of evidence-based guidelines at the point of care. | “Our EHR system is on top of its game. When the patient is diagnosed with diabetes, it will give us a list of stuff that they are required to do. So, if they haven't had an A1c within three months, or if their A1c is not at goal, it will alert us every visit. So, we go through a little tab called PopHealth, and everything's read in—we stress, every visit—that you have to check it.” (Texas) |
| Standardized mental health screening tool (Structure) | 14 | Mental health screening tools, namely, the standardized PHQ-2 and PHQ-9, can be embedded into routine use. The PHQ-2 is a valid, quick depression screening instrument, and the PHQ-9 is often used as a follow-up to a positive PHQ-2 result and to monitor treatment response. | “We have that yearly to do the PHQ-2. The medical assistant would know when she needs to run the PHQ-9. And then we'd know they if there is a clear mental health need. We have also direct access to the behavioral health specialist that is going to be ready to assess this patient.” (Georgia) |
| Contacting patients with unmet preventive care needs (Process) | 14 | Outreach to patients for preventive health is typically a practice-wide initiatives to identify and contact patients for needs such as colorectal cancer screening and influenza vaccinations. | “Then we have colonoscopies, which are near impossible to get patients to be compliant with. But we do use Cologuard [at-home colon cancer screening kit]. We have the Cologuard website, so I can always look at that report and see who's done their Cologuard and who hasn't, and call and give them a little nudge, and say, ‘You're due, and you have the kit. All you gotta do is send it back.’” (Arizona) |
| Utilization of medical assistants to perform a wide range of patient care and education activities (Process) | 14 | Medical assistants are working “at the top of their license,” which includes activities such as triaging, taking vitals, providing patient education, and following up postvisit. | “We did lots of kinds of [things] like education with the MAs, even things like tobacco screening, BMI documentation, and allowing them to do some of the counseling for BMI and obesity. Just really giving them [the MAs] the encouragement and allowing them to work at the top of their licensing scope.” (Georgia) |
Abbreviations: ACO, accountable care organization; BMI, body mass index; EHR, electronic health record; MA, medical assistant; PHQ, Patient Health Questionnaire, standardized depression screening tool.