Anne Pendo: Well, welcome to Intermountain Healthcare and our podcast today. My name is Anne Pendo and I am an internist and also a medical director for Experience of Care and Clinical Integration. And I'm excited today to have as my guest Dr. Josh Romney. Josh and I are both internists and we've worked together for a long time, at different clinics, but have recently come together in a collaboration around our worked call Reimagine Primary Care, and in January of 2018, we were asked by Marc Harrison, Mark Briesacher, Michael Moore, and Rob Allen to look at doing and providing care for our patients in a different way, and that led us to setting up four clinics in the central Salt Lake Valley, that are doing what we are calling Reimagine Primary Care. And our focus is on our patients, and caregivers thinking about what matters most to them, what their needs are, how can we do work together as a team to provide improved care and improved experience. And one of the great opportunities in this work has been the bringing together of Josh and I as partners in rethinking how we do this work. And Josh, if you could just tell us a little bit about your area of interest in the electronic medical record and then we can talk a little bit more about how we've started working together.

Josh Romney: Okay, so I am a practicing internist, I've been working at a Primary Care Clinic in the Salt Lake Valley since 2006. In 2014, I was asked by Intermountain leaders to help work on our new project with our new EMR called iCentra, and since then I have taken on the title of a Medical Director for Care Transformation. It's been an exciting thing for me, it's fun to think of things I've always wanted to be able to do as a practicing doctor and internal medicine and to be able to develop tools to use on the computer to do those things better. Reimagine Primary Care is a perfect example of that, things that I've always tried to do, wanted to do, and now to be able to create some tools to be able to facilitate that work, and especially to facilitate it in a way that the team of people in my clinic around me can all work together to do it.

Anne Pendo: 02:59 Yeah, yeah I remember when you started working on our electronic medical record and your comment was, that you were committed to getting it right for the doctors, and I so appreciated that as we started this conversion from one electronic record to another. And then as you started that work, really this Reimagine Primary Care work gave us both an opportunity to really take a step back and think about what do we want? What is going to make it easier for us, as clinicians to take care of the patients with whom we work? And we didn't have a lot of restrictions, we were really able to just think and have a conversation, and when we were talking about this initially, and thinking about Reimagine Primary Care, what was, besides the fact that you could try new things, what were, as you thought about it, what were the things you thought, okay I'm going to make a difference in these areas?

Josh Romney: There's several things, but maybe two really stand out to me the most. As a primary care doctor, you take care of a wide breadth of medical problems and a variety of people from different backgrounds. And one of the challenges is to keep track for my population of patients, who I like to joke with, people working on the project they feel like my family, and what do all those patients need, what are the things they need to have done that might be slipping through the cracks. We call them care-gaps. And I was really interested in finding a way that I could better keep track of what were the gaps in care for each of my patients, and how could we make sure to fill those gaps? And then the other part of it that I was really interested in was, I'm working in the clinic but my patients sometimes go to the hospital when they're very sick, or to the emergency department. And finding a way for me and my team to consistently be able to know, who has been sick, who's been in the hospital, the emergency department and how can we make sure to facilitate their care so that they recover and don't end up having to go back?

Anne Pendo: Yeah, yeah I think that's been one of the really fun things, is thinking about what matters most to us as the people providing care, and to our patients, and then thinking about what we can do differently in the clinic. And I think one of the things that I've appreciated the most is the collaboration and conversation back and forth with, well this is what I want, and then you saying, well I know that's what you think you want but that's not really what you want. What you want is this, and then, I'm saying, you're right, that is what I want you are correct. And then working together to get it implemented and try it out, and see what's working, and what needs to be modified, and taking it to our teams in Reimagine Primary Care and getting feedback from them, this is working, this needs to be fixed a little bit differently. It's been a different way of thinking about problem solving, hasn't it?

Josh Romney: Yeah it's really fun to be around the table and not just thinking of you and I interacting, but to have a team of people around the table and to say, here's the problem we have, or are trying to solve, and lay that out on the table and to have the various voices brainstorm the solution. It's really effective I think, to have the people who are building the technical tools at the table with clinical experience behind them, to be able to say, okay you want to keep track of care-gaps, well let's think of the technical tools we have available to us and what could we possibly build to adapt to that need. And it's really fun to come up with an idea and try it out, get feedback from providers using it and adjust that to find something that works.

Anne Pendo: Yeah, yeah, I'm thinking as we started this, one of the things that we focused on first was closing care-gaps, thinking about quality, thinking about how can we do a better job, how can our teams do a better job of making sure patients get their cancer screening, their mammograms, and colonoscopy's and immunizations and be assessed for fall risks, you know all of those things that we think are really important to health promotion, the sentiment at the time was the tool in iCentra, which is what we call our EMR, was not being used because it was not useful. And take us through that process of figuring out how to make it better.

Josh Romney: Okay, yeah you know it's really interesting, changing to, when you're seeing patients, doctors have done that for years and years, and changing to a new computer program, it's a little bit more complex than just getting an upgrade in your iPhone or a new version of a word processor, really gets into everything you do during the day. In the past we never really had a good way to keep track of those care-gaps, and with our new EMR iCentra, we got a tool to do that, but it still has limitations. It can't access all of the information about a patient everywhere, all the time. And so it really, lots of people had a hard time using it because they needed a way, they needed to understand how the tool worked, but we also needed to give them a group of people around them to help them, and a process so that the whole team can use the tool together to make is usable. So we were able to take a combination of those three pieces, the people, the process and the technology, to adapt the technical tool to make it work for the clinical teams. And so we really didn't change the technical tool very much from what already existed, except that we spent some time figuring out what it really could do, what were its limitations and how could we overcome those limitations with people and process.

Anne Pendo: Yeah.

Josh Romney: And then we say down and said, okay if this is what it can do, how can we use this? And what was really fun is, we went straight not to doctors but to a group of people in our clinics called care guides. They're non-clinical people whose job is to kind of get the EMR ready for the visit with the doctor. We said, okay here's what the tool can do, and here's what we need to have happen. We need the doctor, when they see a patient, to be able walk into the room with a patient and to know what their gaps in care really are. How can we do this? And the care guides really helped us to say, well if you could help us to find this, this and this in a quick manner, we could do this a lot more effectively. We figured out how to do that, and tried out a process and refined it over time and found that it actually works really well, if the whole team does it together.

Anne Pendo: Yeah, yeah, and I think that, that's been, that was a little bit of a challenge for the doctors to believe that the information was accurate, and then as we got used to it, we felt more comfortable and felt we could trust the information in the advisories and the work that the care guides were doing. I know for me now, when I go in to see a patient, I know that what is showing up on the advisory section are the things that the patient needs. And I know you have a story about a patient of yours and a mammogram, maybe you could just share that with us.

Josh Romney: Sure. So I don't know if any doctor who doesn't think they do a good job, and I am one of those people, but as we started to really implement this process, I was one of the people sort of piloting it and working out the kinks, and so I was suddenly giving extra focus to looking at those patient advisories every day, and I have this patient, she's a wonderful woman, she's about 70 years old and she's got a bold personality and she loves to talk, and it's so fun when she comes in, we end up chatting a lot, and take caring of her medical problems some too. So at the time, when the visit is ending, a lot of times it's like oops did we cover everything, because we'd been chatting. Well she came in to see me earlier this year and we got to the end of the visit and time was up, and I thought, well I've got to make sure and look at these patient advisories, and I looked at them and said, holy cow, how is it that you've gone four years with getting a mammogram, let's get that mammogram set up, because that would be a gap in her care, and the patient advisories were telling me that that gap needed to be filled.

So we scheduled her mammogram and lo and behold, the mammogram was positive and she had to get a biopsy and the biopsy showed that she had breast cancer. She since successfully had her breast cancer treated and she's very likely to be cured of her breast cancer, and I was really grateful for that experience. It really reminded me the importance of teamwork, and the importance of using the tools that we have to improve our care for our patients.

Anne Pendo: Yeah, yeah I think that one of the things that I particularly like about this work is, that we look at it from two perspectives. One is how can we give our patients better care and I think your story is a really good example of that, and how can we make it easier for the people delivering that care. And I think your story really reflects that well, you didn't have a list of 10 things to do, you had a few things to do and you were able to take care of that really quickly. Let's talk a little about the creation of the huddle board that we're using in these clinics, because I think that as a system Intermountain Healthcare believes in the importance and value of doing huddles daily, and the way these Reimagine Primary Care clinics teams are working and using their huddles a little bit different.

Josh Romney: Yeah, I love huddle, I've said this a bunch, but I really love the concept of teamwork and huddle is the best way that we have in our clinics, to make sure that the whole team is aligned with each other. In the Reimagine Primary Care, they wanted to take huddle to a new level, they wanted huddle to become a discussion of specific patients that needed help, and to be able to get the whole team working together to help those patients. The perfect example is, those people that have been in the hospital the emergency department it's really costly to have to go there and inconvenient and how can we help those people to avoid having that experience in the future? And so we were able to develop a huddle board, or a report in the computer that could call out for them, those are patients that were needing our extra attention and care, so that we could coordinate it for them.

Anne Pendo: And the idea is, is that the team looks at this together, and it may be the team deciding that the care guide needs to contact these patients, and the care manager contact these patients to make sure that their discharge from the hospital is seamless, and they've got their oxygen and antibiotics, and their follow-up appointments and really thinking about, also who are we not seeing and should be seeing and those, the way the tool you and your team built the tool, is so that we know who needs to come in for a health visit, an Annual Wellness visit, so we can make sure that their medical problems have been addressed and create plans around treatment for those, and make sure that they've got their care-gaps, their immunizations, and cancer screenings addressed as well.

Josh Romney: It's so valuable for the team to be able to do that together, not every one of these patients that we review on this huddle board necessarily needs to come in for the visit, but to be able to discuss them individually as a team, to have that time to do that together is really valuable. The doctor who is in that exam room with the patient regularly know those patients, like their family, and is able to give that insight as that support team also does.

Anne Pendo: Maybe you could share with us a little bit about what kind of feedback you've gotten from the doc's in Reimagine Primary Care clinics, what have they, they're a vocal group, and when we started this process in the spring we talked about having a growth mindset. And that really kind of laid the foundation for starting this work, and we've referenced it on multiple occasions as we've learned a lot and in solving problems. So what's your experience been as you've worked with the clinicians, what have they shared with you?

Josh Romney: It's really been a great learning experience for me, they're so engaged, and any time you develop a technical tool there's always opportunities to improve it. And sometimes it feels overwhelming and frustrating, but they're so great at pointing out, well you put this patient on our huddle board but here is why this patient shouldn't have been there. And they've been so great to give us that feedback, and then we come back to them and say, okay we think we've fixed it, are the right patients showing up now? Okay now that's fixed but here's another problem. And it's been a really fun experience to use continuous improvement on a technical tool, and to make it better over time and to get it to a point where this is working the way we need it to work.

Anne Pendo: Yeah, my other observation is that it's been, even though it may take time to actually get to where we want to be, being able to, every week when we have our calls, get that feedback, okay we're going back to the drawing board, we're going to fix it. And then next week be able to share something, the repetitiveness with which we've been able to put these tools into use, get feedback, modify, improve has been pretty impressive, and I think that's something that's new and different in the way we're looking at this work as well.

Josh Romney: Yeah, I also think that it's to be in those weekly meetings and to be part of the Reimagine Primary Care team that's working on this, from the technical side of things, that small change in that relationship is really valuable. It's not just, oh we wish those technical guys would hurry and get this tool perfect, but it's, how can we as the team in Reimagine Primary Care get this tool perfect?

Anne Pendo: Yeah, it's been really, it's been fun, it's been really fun, it's been fun working with you and the clinics, and really feel like each week we're making progress towards the ultimate goal of improving patient care, improving their experience, for our patients and also for the care givers, providing the care. So as we wrap up today, what do you think your next project is going to be? What are you shifting to now in this work?

Josh Romney: I am really enjoying, some people would call this work, population health, changing the focus of doctors and clinicians to instead of, I see a patient and I bill them for the services I provide for them at a visit, to instead thinking of, how can I keep my whole population healthy? And some of those activities happen in the course of a doctor visit. But many of them happen without a patient actually having to come see the doctor, so I think I'll continue to work on those kinds of things. Improving, expanding the pre-visit chart preparation work that care guides are doing to all clinic in Intermountain Healthcare, developing tools so that doctors can more efficiently do a specific important kind of visit called a Medicare Annual Wellness visit, and continuing to provide to our both clinic teams but also Intermountain leader their ability to see how are we doing in meeting our goals from managing the health of our population.

Anne Pendo: Yeah, yeah that's exciting. I'm looking forward to doing that work with you together, and hopefully we'll have you come back and share some of the progress that we've made. So I appreciate you taking the time out of your busy schedule to join us today, and we'll look forward to chatting again in the future.

Thanks so much for joining us today from Intermountain Healthcare, and we'll talk soon.

Josh Romney: Thank you.