In my last two blog postings (October and December) I wrote about a new practice paradigm called the Patient Center Medical Home or PCMH as we in the medical field affectionately refer to it.  In recent months, the physicians and staff at OFD have been working on our PCMH practice “re-design”.  Whether it’s been writing new policies and procedures, meeting with our PCMH consultants or piloting a host of PDSA (Plan Do Study Act) changes, we’ve been evolving.  I am happy to report that we are now officially “in the weeds” with regard to some of these PCMH changes.  What do I mean exactly by this? Ahhhh….. I thought you’d never ask.

PCMH represents the shift from physician-based care to team-based care, employing a host of new approaches and workflow changes that both improve efficiencies and quality of care.  This is done by focusing on evidence-based care guidelines orchestrated and delivered by a physician-led clinical team.  The end result will be a better patient experience, and just as importantly better long term health outcomes.

So, by “in the weeds” I mean that we have moved beyond preparing for this change, and are now either beta-testing workflow changes, or in many cases have fully implemented these changes already.   Some of these changes will be obvious to our patients during office visits, while others may not be.  Let me share just four examples of the obvious changes you may notice at your next visit. 

(1) OFD has become quite streamlined with our electronic prescribing of medications, now operating at greater than 90% in this area.  Most likely we will refill your medications from the exam room with you present. (2) For many office visits, patients will be receiving a clinical summary at the end of their visit.  These summaries will hopefully improve communication between our physicians and patients.  If you do not receive one at check out, please feel free to ask for one.  (3) We are tightening up both our referral tracking process as well as our communication with your specialist providers. (4) We have formalized our hospital follow up workflow so that if you are unfortunate enough to be hospitalized, we will know all about it when we see you in the office, and can better coordinate your care.

And now, for some of what is happening on the “back end” regarding clinical decision making at OFD.  Practices that go through the PCMH transformation must start with three focus diagnosis areas to really improve upon.  OFD has chosen to focus on Diabetes, Asthma and ADHD, which are all very common at our practice.  If you have one of these conditions, you will notice a more organized and comprehensive approach to your follow up visits.  Among other care parameters, Diabetics will be receiving more foot exams and more timely lab tests, Asthmatics will be taking an Asthma Control Test and offered spirometry testing more often, and ADHD patients will have a more thorough history taken.  In all of these cases, OFD physicians will be sharing appropriate websites and other patient education materials in an effort to enhance the patients understanding of their conditions. This is just the beginning, and we hope to employ this type of approach to other conditions like Hypertension, Depression and Heart Disease in the future.

And then there are the changes we have not yet begun.  The Patient Portal is one that will be coming later in the year.  With the OFD portal patients will be able to remotely check up on their lab results and perform other functions not currently available electronically at OFD.  We will also soon begin to use patient registries to better allow our staff to space appointments and track our high risk patients.  Additionally, we hope to form a patient advisory council which will allow us to get real-time feedback from patients and go beyond the surveys that some of you have already received in the mail. 

To sum it up, while change is hard for everybody, in the case of PCMH transformation, change is really a good thing.  Thanks again for being a part of our practice and sharing our goals toward an even better future at Our Family Doctor.

Michael Weizman, MD