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Using Checklists to Improve Primary Care for Seniors: the Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care system for Medicare patients, Oak Street Health, launched in September 2013. To read his prior posts about Oak Street Health, click here.]

Forgive me, I know it’s been a while. We’re now at 5 clinics, 2 more coming in the next few weeks, so I’ve been a bit distracted. That update another time. Here’s what I’ve been thinking about…

In a previous guest post, I blogged about building a foundation to collect data within the practice. Having data is nice. Of course, using it is better. As with my previous posts, we’ll use the Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America” as our guide. Here is the third of the 10 recommendations.

Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions.

First of all, I think it’s fair to say that my idea of clinical decision support is different from yours.My clinical training is in emergency medicine, and within that field there is a large and compelling body of evidence around decision rules. The Canadian Head and C-Spine CT Rules and Pulmonary Embolus Rule-out Criteria (PERC) are just a few of the most well known examples. These “rules” are all based upon large, multicenter trials, and are validated in later studies.

Where I trained at the Brigham & Womens’ Hospital in Boston, these rules were integrated into radiology order entry system. In other words, if I wanted to order a head CT, it had to meet those criteria…and I had to answer those questions in the computer.

It’s a nice way to build the evidence into the workflow, but it’s also pretty unrealistic to think that every primary care practice can build these tools into the EHR. And keep them up to date. And so on…

What about guidelines, such as those from CMS or the US Preventive Services Task Force? How are those coded in, and what if they change? And for everyone or just for the specific subpopulations to which they apply, say women between the ages of 65 and 75? What about which patients need an end-of-life plan documented?

Like I said: my idea of clinical decision support is probably different from yours. The simplest way I know of to manage through complexity is checklists.

How Oak Street Health Uses Checklists to Improve Primary Care

So we’ve developed a set of checklists for each step in the visit workflow, as well as over the life of the patient.

Here’s an example for how a Medical Assistant rooms a patient, complete with time-study data of how long that has been taking in our practice.

Inline image 2

And while we’d love to code answers to problems, we’re now fighting software with humans. Said differently, we’re actually adding scribes to the workflow as well. It’s hard for a physician to see a patient and manage a checklist…but if someone is in the room with you to remind you to go through the diabetes checklist for all diabetic patients?

And if we have a team to keep those checklists up to date and continuously improving? That might work, and it seems like it is…30% reduction in admissions thus far this year relative to the Cook County average?

We’re starting to call our scribes by a different term as a consequence of all these extra responsibilities. We call them “ninjas.”

So where technology can’t help us with decision support, maybe ninjas can?

Griffin Myers, M.D., M.B.A. is a founder and the Chief Medical Officer at Oak Street Health in Chicago. You can contact him at griffin (at) oakstreethealth (dot) com.

Digital Infrastructure for Medicare Primary Care: the Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care clinic for Medicare patients, Oak Street Health, opened its doors in September 2013.]

Welcome back; this is the second in a series of guest posts I’ve been invited to write for GeriTech. As mentioned in my previous post, one nice way to think about our model of primary care for Medicare beneficiaries at Oak Street Health is using the list of recommendations put forth in the Institute of Medicine report “Best Care at Lower Cost.”

This post is about the first recommendation, which falls into what the report groups into the category of “Foundational Elements.” Ironically we’ve found these to be the hardest objectives thus far. We’re still in a bit of flux as we get settled into our new setup, but I’ll give an introduction.

“Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.”

This immediately brings to mind a super-EHR: one product for charting, practice management, financials, claims, population health, and clinical decision support.

But, surprise: there is no off-the-shelf product that integrates all of this for primary care, never mind primary care for seniors. At least not that we’ve found after an extensive search. There are products for each of those functions, but not a single package. And asking providers to use multiple non-integrated products isn’t a real solution. Here’s our approach.

How we chose an EHR & practice management system [Read more…] about Digital Infrastructure for Medicare Primary Care: the Oak Street Health Story