Tufano JT et al. 2008 "Providers' experience with an organizational redesign initiative to promote patient-centered access: a qualitative study."

Reference
Tufano JT, Ralston JD, Martin DP. Providers' experience with an organizational redesign initiative to promote patient-centered access: a qualitative study. J Gen Intern Med 2008 Nov;23(11):1778-1783.
Abstract
"BACKGROUND: Patient-centered access is a philosophy and a method that supports efforts to redesign health-care delivery systems to deliver higher quality care and to better meet the needs and preferences of patients. Since mid-2000, Group Health Cooperative has pursued an ensemble of strategic initiatives aimed at promoting patient-centered access, referred to as the Access Initiative. In support of this strategy, Group Health has also engaged in enterprise implementation of an electronic medical record and clinical information system that is integrated with their patient Web site, MyGroupHealth. OBJECTIVE: To elicit, describe, and characterize providers' perceptions of the effects of the Access Initiative, an information technology-enabled organizational redesign initiative intended to promote patient-centered access. DESIGN: Thematic analysis of semi-structured in-depth interviews. PARTICIPANTS: Twenty-two care providers representing 14 primary care, medical, and surgical specialties at Group Health Cooperative, an integrated health-care system based in Seattle, Washington. FINDINGS: Analyses of the interview transcripts revealed nine emergent themes, five of which have particular relevance for health-care organizations pursuing patient-centered access: the Access Initiative improved patient satisfaction, improved the quality of encounter-based care, compromised providers' focus on population health, created additional work for providers, and decreased job satisfaction for primary care providers and some medical specialists. CONCLUSIONS: Providers like that the Access Initiative is mostly good for their patients, but dislike the negative effects on their own quality of life - especially in primary care. These reforms may not be sustainable."
Objective
"To elicit, describe, and characterize providers' perceptions of the effects of the Access Initiative, an information technology-enabled organizational redesign initiative intended to promote patient-centered access."
Tools Used
Type Clinic
Primary care and specialty care
Size
Large
Geography
Urban and suburban
Other Information
The study involved "11 primary care physicians, 5 medical specialists, 5 surgeons and 1 physical therapist" at Group Health Cooperative in Seattle, Washington.
Type of Health IT
Patient access system
Type of Health IT Functions
The system included patient Web access to medical records, secure e-mail with providers, medication refills, appointment requests, discussion groups, and health promotion information. [NOTE: Other changes at the same time included giving patient direct access to specialists without requiring a referral from the primary care provider and variable compensation for physicians dependent on patient satisfaction, physician productivity, and coding accuracy.]
Context or other IT in place
"A commercial electronic medical record and clinical information system (CIS) that was integrated with the patient Web site," was already in place.
Workflow-Related Findings
"Providers reported that the Access Initiative improved patient satisfaction.... Patient Web Access [was] cited as particularly effective in achieving this outcome."
"Providers reported that their use of the [EHR] enables them to coordinate care and to provide more effective care during patient encounters."
"Even among providers who were particularly critical of the [EHR] (which included surgeons, medical specialists, and primary care physicians), none advocated for abandoning the system or 'going back' to paper-based systems when explicitly questioned."
"Providers from all specialities expressed concern that [these changes] compromised their ability to provide effective population-based preventative and chronic care.... For many of the study participants this was a particularly troubling and personally dissatisfying consequence."
"Providers reported that their use of the [EHR] and secure messaging created significant volumes of new work for them (e.g., data entry, documentation, managing the message inbox), slowed them down during patient encounters and ultimately extended their work days.... Some participants also commented that this was not a transitional phenomenon."
"Primary care providers also mentioned the long hours of constant interaction with the [new technologies] as a source of frustration and dissatisfaction."
"Perceived tradeoffs associated with short-term provider productivity and patient access gains included stagnation of providers' clinical knowledge and erosion in the quality of clinical documentation resulting from over-automation of electronic data entry."
Study Design
Only postintervention (no control group)
Study Participants
"Twenty-two care providers representing 14 medical specialities were recruited from 7 purposively selected Group Health Cooperative practice sites."