This used to be the start of a typical day in my (Dr. Hopkins') office: 18-25 patient visits on the schedule, 30 test results in my inbox, and 20 phone encounters that I didn't get to the day before. I also had office notes from two days ago still needing documentation, patients wondering when I would finish their Family Medical Leave Act forms, and an email from the information technology department about allowing patients to ask me questions through a secure computer portal, which I anticipated would further eat into my personal time. It frequently had me beginning the day in a bad mood and wondering how I was ever going to get all of this done by myself.

I often wondered, “Why can't I just focus on the things I'm uniquely allowed to do as a physician and let others do the rest?” I knew it was possible because I had experienced it.

At Cleveland Clinic, innovation is one of our core values. But three years out of residency in 2008, I was struck by the fact that, compared with the latest surgical techniques and inpatient procedures, the typical primary care outpatient visit had not seen a lot of innovation. In addition, as a poor typist, I was struggling with my first exposure to an electronic health record (EHR), which was further slowing me down.

I realized that I was going to need some help if I wanted to practice medicine for the next 30 years.

Around that time, I was inspired by a Family Practice Management article coauthored by Peter Anderson, MD, who had implemented a new type of practice in Newport News, Virginia, and achieved dramatic improvements in key metrics.¹ Sometimes referred to as “collaborative care,” “turbo practice,” “shared care,” or “team care,” this high-efficiency alternative to the traditional medical practice model is designed to reduce patient waiting times and increase quality of care, accessibility, and the satisfaction of physicians, clinical employees, and patients. Practice management journals have published articles about similar practice models over the past several years.² In April 2010, as I began writing a business plan to apply this model across multiple outpatient service lines in our organization, my medical assistant (MA) and I spent two days at Anderson's practice to see this innovative practice style first-hand. I quickly became convinced that this was how primary care, and primary care physicians, could survive.

Rethinking – and delegating – documentation

The model uses a team approach to care for patients. Each individual performs at the highest level of his or her qualifications. The physician performs the functions that only he or she is qualified to do and delegates the other tasks to well-trained clinical assistants. These clinical assistants could be registered nurses (RNs), licensed practice nurses, or very capable and experienced MAs. In a traditional practice model, failure to delegate often limits efficiency. The physician is typically the only person in the office who can generate revenue. If the physician is spending time entering data in an EHR or filling out forms that do not require his or her expertise, that is time not spent seeing patients and generating income for the practice.

The majority of outpatient office visits can be divided into four distinct stages:

• Stage 1: Gathering data,

• Stage 2: Physical examination and synthesis of data,

• Stage 3: Medical decision-making,

• Stage 4: Patient education and plan-of-care implementation.

In a traditional practice model, the physician is solely responsible for most, if not all, of these four stages. With a “team care” model, however, the physician and clinical assistant share these responsibilities. The clinical assistant handles much of the data gathering, including documenting the patient's complaints and gaining additional detail through questioning. The physician can develop protocols and templates based on specific patient complaints and chronic conditions that direct the clinical assistant's questioning. My MAs and I constantly revise and update these templates, and we have also developed standardized text that the MA can drop into a note for “oh, by the way” complaints that invariably come up. The assistant also reviews and makes necessary updates to the patient's medical, surgical, social, and family histories; reviews approaching or overdue health maintenance topics and pending orders for tests or procedures the patient is willing to pursue; and reviews the patient's medication list and upcoming refills.

Once stage 1 of the visit is complete, the assistant presents the case to the physician, who reviews the patient's chart. The two then enter the exam room together, and the physician greets the patient for the first time. The assistant remains in the exam room during the visit, sitting at the computer and serving as a scribe for the physician. The physician checks with the patient regarding the accuracy and completeness of the information gathered by the assistant, asks more directed, specific questions of the patient, and performs the physical exam. The assistant documents and immediately enters into the EHR any additional data, including pertinent exam findings. The physician then formulates a diagnosis and care plan with the patient and the clinical assistant The assistant records all diagnoses for the visit as well as any orders needing the physician's approval. If directed by the physician, the assistant may also maintain the problem list. The patient is given an opportunity to ask questions, to make sure he or she understands the results of the visit, and then the physician exits the exam room to review and file the orders for the encounter.

The clinical assistant remains with the patient to end the visit by reinforcing the physician's instructions, providing prescriptions and referral information, delivering patient education, answering questions, and arranging appropriate follow-up, such as scheduling future visits. This allows the physician to move on to the next patient with whom another clinical assistant has performed stage 1 of the office visit, and the process repeats. The interaction between the physician, assistant, and patient, when it works well, is like a well-choreographed dance.

Selling the change to those in charge

Convincing administrators to support a practice transformation like this isn't easy. Our organization, like most, is constantly tracking head count, full-time equivalents (FTEs), and the all-important bottom line. However, when you describe the plan in terms that are easy to understand, it just makes sense. (See “Team care frequently asked questions.”)

Value. With a nationwide shift to value-based care, primary care physicians have a responsibility to do whatever we can to increase value by improving quality and lowering costs.

Access. Many primary care groups are functioning at capacity, so access is already a problem. As more and more people gain insurance coverage, primary care groups will have to absorb more volume or refer patients to emergency rooms, urgent care centers, or other sources of care, resulting in lost opportunities to create revenue and provide higher-quality care. At the same time, the health care system is moving more acute care out of the inpatient setting and into primary care offices to reduce costs, meaning the patients we see are sicker than in the past. Team-based care has taken place in hospitals and extended care facilities for years, and patients consider it normal to have a team of doctors, nurses, technicians, pharmacists, and assistants care for them during a hospital admission. Why should it be different in the outpatient office?

Training. When my two MAs and I first started out, we had no formal training but instead relied on trial and error and on-the-fly instruction and coaching. We set aside an hour per week for additional training and to discuss what was going well and what needed to be done differently. I spent a lot of time editing the MAs' notes and giving them feedback on how to improve their documentation. I taught them how I went about collecting a history of present illness and a review of systems. We discussed effective oral presentations and the essential components of a good subjective, objective, assessment, and plan (SOAP) note. They learned why we do certain things, such as the importance of checking the urine microalbumin for patients with diabetes. Ultimately, we developed a training manual so that future training of clinical staff would be more formalized and we could reproduce the model elsewhere.

Honestly, retraining the physicians – who can be set in their ways and uncomfortable giving up even a little control – has often been more difficult than training the assistants. The physicians needed to learn how best to communicate with MAs about physical exam findings, diagnoses, orders, patient education materials, and so on, and had to understand that the MAs could not read their minds. As time passed, though, the MAs did learn the physicians' patterns and began to anticipate what we would say and do in particular circumstances.

Results

We didn't initially try to see more patients using this model; instead, we focused on getting the workflow right. After about two months, we felt comfortable enough to add a single patient per half-day session. As we continued to gain efficiency and expertise, we eventually were able to add four patients per half-day session compared with the old model. As an example, when we schedule a 40-minute patient physical and a 20-minute acute-care visit, we can easily double-book them. By the time one MA has finished the data collection and documentation for the physical, I am usually finished with the acute visit with the other MA. I can then enter the next exam room and conduct my portion of the physical – complete the exam, develop a treatment or diagnostic plan, and provide patient education. Once I'm through in that exam room, we've completed essentially 60 minutes of patient care in 40 minutes. My productivity has increased by 40 percent since 2010, and as we've expanded this model to six of the seven physicians in our group, our total productivity has increased by approximately 20 percent. (See “Average annual RVUs per physician FTE.”)

In our experience, moving to team-based care made good financial sense, and the initial financial investment wasn't as great as we originally thought it might be. Using historical visit and financial data from my practice, we determined that hiring an additional MA for each physician would pay for itself if each physician was able to see just one additional patient per half-day clinical session. An additional RN would require two additional patients per half-day session. We set a target for our group that each team would see three additional patients per half-day session in order to offset the additional expenses and improve our margin. With increased volume comes increased revenue. From 2010 to 2013, our group's gross patient revenue has increased 23 percent, or almost $2 million a year. This is almost as much as we would expect to see by adding two new full-time physicians to our practice. (See “Annual gross patient revenue.”)

By adding volume, we have been able to take the modest increase in overhead and spread it out over more patient visits. By also reducing unnecessary variation in the practice, such as when certain lab tests should be ordered, we have been able to show reductions in the direct cost per encounter. (See “Comparison of revenue and costs per encounter.”)

We've also noted significant increases in our patient satisfaction scores as we've adopted this new model of care. (See “Patient satisfaction indicators.”) One thing that surprised me was the relationships my patients developed with my MAs, sometimes telling my MAs things they won't tell me. Patients consider the MAs as additional advocates to whom they can go with problems or questions. I thought more patients would object to having another person in the exam room, but that has not been the case. As our clinical support staff has taken more initiative and taken on more responsibility, we've also noticed modest improvements in several key quality metrics. For example, in the third quarter of 2012, 78 percent of the clinic's patients had their blood pressure under control and 93 percent had been screened for diabetes. This is an increase from 74 percent and 89 percent, respectively, in the first quarter of 2011.

At Cleveland Clinic, we have rolled out team-based care across the organization's primary care practices. We currently have 15 to 20 primary care physicians using this model and hope to have up to 40 in the next year. Training more MAs will also make it easier to provide cross-coverage for vacations or illnesses. We are beginning to move the team model into specialty areas as well.

We have also added other support staff into our practices, including care coordinators, clinical pharmacists, and MAs who do previsit planning for our upcoming appointments. Medical assistants are now helping with scheduling patients for follow-up visits while they are in the office or on the phone. With the additional staff, we've had to use more shared office space, but we've realized the benefits of co-location (that is, putting employees who depend on one another in close proximity to one another), including improved communication within the team.

I can say that I am much more satisfied with my work today than I was a few years ago. I feel less bogged down by details and busy work, and my MAs do a better job taking care of forms and paperwork than I ever did. They help me navigate through my day and address issues sooner than I might have otherwise gotten to them. My MAs also say they are more satisfied and feel their work is more fulfilling because they have become an integral part of the care team.

On a typical day, I now see 29 patients and leave the office by 5:15 p.m. All of my notes are closed, and my laptop remains in its case at night. Patients appreciate that we are able to see them when they need to be seen, and I don't feel like I have to rush when “oh, by the way” conversations come up as I'm leaving the exam room. I can knock out refill requests pretty quickly because my MAs have prepared all of my orders for me and limited my messages to only the ones that I really need to address. One of my MAs will hand me a few forms, already completed, and just require my review and signature. I love my job. It doesn't always work perfectly. Sometimes in this dance, we step on each other's toes or the music comes to an abrupt unexpected stop, but it sure beats dancing alone.