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PBRNs - Learning Communities
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PBRNs - Learning Communities



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  • As I was preparing this talk, it occurred to me that it was a 1960’s king of topic. Thus the tie dye background on the slides.
  • In the sixties, there was a belief that… Please forgive me. I still believe those things. Fortunately I’m an exact multiple of 29.


  • 1. Can Family Medicine Become a Learning Community? James W. Mold, M.D., M.P.H. Department of Family and Preventive Medicine University of Oklahoma Health Sciences Center - OKC
  • 2. Objectives
    • Introduce the idea of a learning community and explain why Family Medicine is well-positioned to become one
    • Propose a sliding scale for evidence
    • Discuss the role of practice-based research networks
    • Point out some challenges and unanswered questions
  • 3. Four Stories and a Joke
    • Mark Gregory, Okarche, Oklahoma
    • The Great Harvest Bread Company
    • Cystic fibrosis
    • Cooperative extension
    • The man with the frog on his head
    • “ If you’ve heard this story before, don’t stop me. I’d like to hear it again.” Groucho Marx
  • 4. A 1960’s Perspective
    • Just because we’ve always done it that way doesn’t mean it’s the best way to do it.
    • We’re all in this together.
    • We can make the world a better place.
    • Each of us can have an impact.
    • If we work together, we can achieve anything.
    • Don’t trust anyone over 30
  • 5. In a Small Town (the first story)
    • Okarche, Oklahoma 1998
    • “ It doesn’t help when the QIO comes in, audits my charts, and tells me what a lousy job I am doing. If they would tell me who is doing a good job, maybe I could talk with them and find out how to do it better.”
    • Mark Gregory, M.D.
  • 6. What’s the best way to …
    • Manage laboratory test results?
    • Deliver preventive services?
    • Improve my care for patients with diabetes?
    • Handle prescription refills?
    • Help patients remember to bring their medications with them to appointments?
    • Help overweight patients lose weight and keep it off?
    • How would you approach these questions?
  • 7. What Mark Didn’t Say
    • If they would just tell me:
    • What the literature says I should do.
    • What the specialists say I should do.
    • What the guidelines say I should do.
    • What my academic colleagues say I should do.
    • What CME resources are available.
  • 8. Performance Distributions
    • Virtually always present
    • Wider than you would expect
    • Within practices and between practices
    • High performers are often not the “usual suspects”
    • Highest performers in one area aren’t necessarily the highest performers in other areas
      • Some true exemplars (quest for excellence)
  • 9.  
  • 10.  
  • 11.  
  • 12.  
  • 13.  
  • 14. What Exemplars Know
    • Principles
    • Techniques
    • Scripts
    • Often don’t realize what they are doing differently or even that they are exemplars.
  • 15. Diabetes
    • Exemplar Principles
    • Diabetes visits every 3 months
    • Label charts
    • Use teamwork, protocols
    • Use a registry
    • Choose one eye specialist
    • Flow sheet (?)
  • 16. DM Pilot Study
    • 30 (non-exemplar) clinicians
      • Taught exemplar principles
      • Provided with:
      • Practice facilitator
      • PDA-based registry
    • High rate of acceptance of principles. No disagreements.
      • Mean of 4/6 principles implemented
  • 17. Quality of Care Indicators
    • A1c: 87%  96% p=0.0003
    • UA protein: 53%  64% p=0.05
    • Lipid Panel: 69%  80% p=0.02
    • Foot Exam: 71%  82% p=0.004
    • Retinal Exam: 48%  59% p=0.04
    • Pneumo: 42%  61% p=0.0006
    • ACEI for BP: 72%  86% p=0.03
    • ACEI for prot: 53%  64% p=0.05
    • Paired t-tests; physician as unit of analysis
  • 18. Best Practices Research
    • What’s the best way to do “x” ?
    • Identify the steps or components of “x”
    • Define “best”
    • Find exemplars for each component
    • Figure out what they do
      • Principles
      • Techniques
      • Scripts
    • Put pieces back together and test them
    • Mold JW and Gregory ME. Best practices research. Family Medicine 2003; 35(2): 131-134.
  • 19. Lab Test Management
    • Track results to be sure they come back to chart
    • Notify patients of results
    • Document patient notification
    • Assure that patients with abnormal results get follow-up they need
  • 20. Lab Test Management
    • Wide range of methods used for each step
    • 92% of clinicians within the same practice used different methods to notify their patients
    • Half of clinicians who said they were very satisfied with their systems were exemplars. (Half were not.)
    • Combined best method works extremely well
    • Cost: $5.19 per patient
    • Mold JW et al. Management of Laboratory Test Results in Family Practice JFP (2000) 49(8):709-715
  • 21. Where Are You Little Star?
    • Identifying exemplars:
    • Show of hands
      • Simple, cheap
      • Lots of false positives and false negatives
    • Audit everyone (external)
      • Time consuming
      • Accurate
    • Self-assessment (internal)
      • Possible middle ground?
  • 22. Bread and Butter
    • The Great Harvest Bread Company
    • Freedom franchisees must:
    • Use the grain chosen by the company
    • Grind the grain in the bakery
    • Give away samples of bread
    • Share their successful innovations and discoveries with other franchisees
    • Bread and Butter: What a bunch of bakers taught me about business and happiness by Tom McMakin St. Martins Press, New York, NY
  • 23. Cystic Fibrosis
    • For 45 years, the Cystic Fibrosis Foundation has kept track of the outcomes of every cystic fibrosis child cared for in the 117 cystic fibrosis centers around the U.S. By agreement with the centers, the data is kept confidential.
    • In 2003, average life expectancy of people with cystic fibrosis was 33. In the top performing center it was 47.
    • At the median CF center, the average FEV1 was 75% of normal. At the top center it was 100% of normal.
    • Qawande, A. The bell curve. New Yorker, Dec 2004
  • 24. Come a Little Bit Closer
    • Exemplar methods:
    • Very high expectations (e.g. normal FEV1)
    • Patient involvement (e.g. anticipatory chest PT)
    • Creative solutions to treatment challenges (e.g. electronic chest PT machine)
    • Aggressive medical management
  • 25. Beans in Their Ears
    • Reactions of non-exemplary (academic) centers:
    • There must be something different about the patient populations
    • There must be something different about the environment (air quality/pollution)
    • No randomized controlled trials
  • 26. Here in the Real World
  • 27. The Times They are Changing
    • Interdependency
    • Interdiscipinary
    • Teams/Teamwork
    • Networks
    • Collaboratives
    • Centers/Institutes
    • Think tanks
    • Multi-national
    • World economy
    • Internet
    • E-mail
    • Google
    • Amazon
    • eBay
    • Blogs
    • YouTube
    • My Space
    • Idol
  • 28. Bits and Pieces
    • IHI Learning Collaboratives
    • Contact, Help, Advice, and Information Networks (CHAINs)
      • http://chain.ulcc.ac.uk/chain/about.html
    • The Leapfrog Group
    • VA best practices QI Initiatives
    • Regional Health Information Organizations
    • IOM Report: The Learning Healthcare System
    • NC Community Care
  • 29. Communities of Practice
    • Cultivating Communities of Practice by Wenger, McDermott, and Snyder; Harvard Business School Press, 2002
    • Requirements:
    • Domain (topic area or areas) - Creates common ground and sense of common identity
    • Community – Creates the social fabric of learning (relationships based on respect and trust)
    • Practice (collective knowledge set) – Set of frameworks, tools, styles, language, stories
  • 30. Communities of Practice
    • Principles:
    • Design for evolution (organic, dynamic, developing)
    • Open a dialog between inside and outside perspectives (outside perspective keeps community aware of possibilities)
    • Invite different levels of participation
    • Develop both public and private community spaces
    • Focus on value
    • Combine familiarity and excitement
    • Create a rhythm for the community (e.g. regular meetings)
  • 31. Learning Organizations
    • Master the five “learning disciplines”:
    • Personal mastery (expansion of personal capacity)
    • Mental models (continually clarifying our internal pictures of the world; constructivism)
    • Shared vision (commitment to the group)
    • Team learning (developing intelligence and abilities greater than the sum of the individuals)
    • Systems thinking (understanding the forces and inter-relationships that shape the behavior of systems)
    • The Fifth Discipline Fieldbook by Peter Sege et al; Doubleday, 1994
  • 32. WE CAN DO THIS It’s who we are and what we like to do.
  • 33. Leader of the Pack Family Medicine
    • First medical specialty not defined by patient age, gender, or disease categories
    • First specialty to recognize and emphasize the importance of family systems to health and health care
    • First specialty to emphasize longitudinal training in the outpatient setting
    • First specialty board to require periodic recertification
    • First specialty to create an organization specifically for teachers of the discipline
  • 34. Imagine
    • Family Medicine as a Learning Community
    • Freedom franchise system
    • Provision of a basic set of services
    • Obligation/expectation to share successful innovations
      • Multiple communication channels and opportunities to share knowledge
      • Funding for evaluation and dissemination of innovations
      • Early acculturation of FM residents
  • 35. Here Comes the Sun
    • PBRNs
    • Practice Inquiry groups (UCSF/Stanford)
    • ABFM IPIP Program
    • Family Practice Inquiries Network (FPIN)
    • TransforMed
  • 36. 1975 2006 Dartmouth COOP MAFPRN ASPN HRSA AHRQ 1992 1999 UPRNet, PPRG, CDN, CRN, PROS, WREN, MirNet OKPRN
  • 37. Turn Around, Look at Me
    • The Joke
    • A man comes into a bar with a frog on his head.
    • The bartender asks, “Where’d you get that?”
  • 38. The Oklahoma Physicians Resource/Research Network
    • www.okprn.org
    • OKPRN Listserv
    • Biannual newsletters
    • Annual convocations
    • Practice enhancement assistants
    • Access grid node
    • Clinical inquiries program
      • Linking residents, faculty, and practitioners
  • 39. OKPRN Practices  OKC
  • 40. Project Development Advisory Committee Rural Health Projects PEA OKPRN Board of Directors Dept. of Family Medicine PEA PEA PEA PEA PEA
  • 41. www.okprn.org
    • In March 2007 (one month):
      • 3,900 personal visits (not machine generated)
        • 88% are repeat visitors
        • Most frequent locations of visitors: OK, CA, WA, IN, NY, and TX
      • Total visit time: 90 hours
      • 48 different files were downloaded
        • Most frequent downloads were best practices, newsletter, and PEA question of the week
  • 42.  
  • 43. Diffusion
    • The expeditious diffusion of innovations probably requires a well-developed, decentralized infrastructure that relies heavily upon personal relationships.
    • Diffusion of Innovations by Everett Rogers; The Free Press, 1962
  • 44. Cooperative Extension
    • 1796: George Washington proposed a board or office to promote dissemination and diffusion of modern agricultural methods
    • 1810: First agricultural journals
    • 1862: Land-Grant College Act; enrollment slow; many thought they could learn better by doing than by studying; very little to teach because little relevant science; mostly taught farm operations
    • 1882: Hatch Act established funding for “experimental farms”
  • 45. Cooperative Extension
    • 1889: Dept of Agriculture began issuing Farmers’ Bulletins and the Yearbook of Agriculture ; experimental farms issued research bulletins and “popular bulletins”; publications reached small proportion of farmers, many of whom distrusted “book farming”
    • 1880 -1911: Widespread establishment of “farmers institutes” and even “mobile institutes” to reach more farmers
    • 1906: S. A. Knapp hired the first county extension agent to develop a personal relationship with every farm family in the county and help them implement innovations
  • 46. Cooperative Extension
    • Funding sources – 30% federal, 70% state and local
    • Headquartered in the land-grant university
    • Staffing – 1% federal, 32% university, 67% local in nearly all of the 3,150 counties in the U.S.; plus more than 2 million volunteers
    • Goal is to maintain meaningful bi-directional communication between the university and the farmers and provide on-site training and assistance to farmers and farm families so they can stay abreast of advances in science
    • Taking the University to the People by Wayne D. Rasmussen; Iowa State University Press, 1989
  • 47. Cooperative Health Extension?
    • County Health Extension:
      • Bi-directional information conduits between community-based clinicians, PBRNs, and the university
      • Free exchange of ideas and methods
      • Local assistance with implementation of innovations
        • CPGs, CCM, EHRs, etc.
        • Bio-event/epidemic surveillance and preparedness
      • Coordination of private, public, and community resources, initiatives
      • Outcome tracking with goals, feedback
  • 48. Cooperative Health Extension?
    • Community Care of NC: Regional 501c3 organizations; owned and run by primary care clinicians; supported by Medicaid care management funds ($2.50 pmpm); charged with improving quality of care for Medicaid patients.
    • Saved the state $60 million in Medicaid costs in 2003 and $120 million in 2004
  • 49. A Place in this World
    • What role could each of the following organizations play in a FM learning community?
    • STFM
    • ABFM
    • AAFP and state chapters and foundations
    • Departments of Family Medicine
    • Community-based residency programs
    • NAPCRG
    • Federation of PBRNs
  • 50. Objectives
    • Introduce the idea of a learning community
    • Explain why Family Medicine is well-positioned to become one
    • Propose a sliding scale for evidence
    • Discuss the role of practice-based research networks
    • Point out some challenges and unanswered questions
  • 51. In a Small Town
    • Okarche, Oklahoma circa 1999
    • “ Don’t forget, Jim, it’s about relationships. Make sure the breaks are long.”
    • (When asked about the proposed program
    • for the OKPRN Annual Convocation.)
    • Mark Gregory, M.D.
  • 52. Questions?