You’re not alone: Notes from a primary care practice coach
By Cullen Conway, MPH, Practice Enhancement Research Coordinator at the Oregon Rural Practice-based Research Network
As a Practice Enhancement Research Coordinator with the Oregon Rural Practice-based Research Network (ORPRN), I’m part of Healthy Hearts Northwest (H2N), a national initiative funded by the Agency for Healthcare Research and Quality to help primary care practices improve the cardiovascular care they provide to patients. A core component of the project is the dissemination of the latest evidence-based research via practice facilitators that are coaching clinical teams on improvement projects and better use of their health IT data.
I started my work with clinics in November of 2015. I’m assigned to about 20 practices in the Willamette Valley and on the Oregon coast. I live in Portland, and from there travelled to each of my clinics for an initial in-person visit to get acquainted, go over program basics, talk about their goals, and complete a data assessment. After that first meeting, I visit each clinic monthly. Initially, I alternated between in-person trips and video conference calls, but I realized that the face-to-face meetings were more enjoyable and effective so I’ve begun doing all visits in-person.
Out in the field there’s a wide range of capacity to do quality improvement (QI) work. For most clinics, during the second visit we looked at their data and did early brainstorming on PDSAs (plan-do-study-act cycles) . The PDSAs usually didn’t start until the third visit, but some practices are already in the swing of doing them. For instance, when I returned for the second visit to one of my clinics, they pulled out 3 or 4 PDSAs they’d run since my first visit. They learned from each experiment and created the next from that so this practice was involved from the start in the iterative learning cycles that I think PDSAs are really meant to be.
The “a-ha” moments with the clinics are the most gratifying. One clinic was questioning their aspirin levels and why they weren’t meeting the H2N measure. The numbers they were generating were disappointing them. Together we dug into this, figured out what was happening, and that they were actually doing well. Taking the time to do this gave them the confidence to move towards addressing the blood pressure (BP) measure. Once we’ve been able to help pull data and define the patient population - especially the high risk population - I’ve heard pleased comments about being able to view their patient panel this way, and generating alternative ways of allocating resources.
Frustration around electronic health record (EHR) software is common across clinics. With many EHR products, providers have great difficulty trying to pull data at a population level.
I’ve heard this from providers and practice managers many times: “We wanted the EHR to get population-level data that we still can’t get. It'd be much easier for us clinically to just have paper charts”. Providers have invested time and money into new systems for this type of data use, but the systems don’t readily deliver this functionality.
It can be anxiety to address data theoretically or conceptually. If a clinic sees it’s performing 55% on the blood pressure measure but can’t see the patient denominator it can be really frustrating. Part of what I do is go into clinics’ EHRs with my teams, create patient reports so they can see the patients who aren’t meeting the measure, and come up with ideas on how to help reach their goal. Pulling data then shifts from a burdensome administrative requirement to information that applies to daily practice -- and actually helps patients.
One of my most effective tools as a facilitator in this project is sharing what’s been working in one practice with another. When I go into a clinic, and ask them where they want to start, they may say “We’re interested in blood pressure” – and I say, “Ok these are a couple of things I’ve seen done” or “I’ve seen a lot of teams focus on outreach”, etc. Sharing those stories is a good way to get the QI wheels turning in peoples’ minds. If people hear that it’s been working in other clinic settings it holds a lot more weight than if it was just me saying, “Let’s try this.” With the other coaches at ORPRN, we support each other by telling these stories to each other – what we’re seeing in our clinics – and so there’s a form of cross-pollination happening on many levels.
Sharing stories is not just about the positive – the things that’ve worked – but the struggles and frustrations that are common across the board. So I find myself often saying “You’re not alone. Let’s see where we can start”. It’s such a powerful message.
Cullen Conway MPH is a Practice Enhancement Research Coordinator at the Oregon Rural Practice-based Research Network (ORPRN). His interests include social determinants of health, social justice, and working to reduce health disparities among underserved demographics. Cullen received his master's degree in Public Health from Columbia University, and his bachelor's degree in psychology from Lewis and Clark College.