Communities of Practice: Leadership in practice

A group of innovative BC physicians supported through the Physician In­formation Technology Office (PITO) has developed communities of practice (COPs), leading groups of their colleagues who have joined together in the selection, implementation, and use of common electronic medical record (EMR) systems to enhance pa­tient care in a local area or specialty.

General practitioners and specialists across the province have formed 14 COPs so far, engaging in various areas of interest including:

• Advanced training, peer support, and knowledge exchange.
• Sharing of clinical templates.
• Electronic referral (e-referral) networks.

The South Okanagan and Powell River COPs tested the first implementations of e-referral solutions in 2009. These innovative projects are being evaluated and refined in preparation for expansion to other communities in 2010.

The value of collaboration
The South Okanagan COP physicians experienced the value of belonging to a COP firsthand when, in light of the H1N1 pandemic, Drs Jeff Harries and Peter Entwistle, two PITO local physician champions, worked with their EMR vendor in the fall of 2009 to create three templates to help them better document, track, treat, and care for their patients in the South Okanagan COP.

“We have shared the templates with all the physicians in our group and we have been working together toward a common clinical goal,” Dr Entwistle says. “It’s helped us take better care of our patients.” 

The three new templates are:
• H1N1 Observation Template—documentation template to capture influenza-like illness (ILI) observations.

• Flu/H1N1 Visit Template—a visit documentation guide that applies the H1N1 Observation Template and also includes diagnosis, billing code, and visit note (Figure).

• H1N1 Trigger CDS Template—a clinical decision support trigger that alerts physicians to ILI/H1N1 high-risk patients. 
The new templates have helped the South Okanagan COP physicians as a prompt for essential questions and examinations including recording neg­ative as well as positive symptoms, and as a reminder about pa­tients’ other conditions. The new templates allow quick prescriptions, patient sick notes, patient information leaflets, and follow-up advice.

Physicians report the early benefits of the COP approach to include the following: 
• Higher utilization—clinics that ob­tain physician peer mentor support achieve a higher utilization of the EMR in their practice and are better able to achieve their clinical goals through the use of advanced features (e.g., CDM management).

• Peer guidance—the COP leads (phy­sicians who have already im­plemented an EMR) share their ex­perience and knowledge with their peers through meetings, communications, and hands-on assistance in the clinic.

• Staff coverage—belonging to a COP makes it easier to find clinical staff who are familiar with the system, allowing for flexibility in filling positions when someone is on leave.

• Greater influence—a larger group using the same EMR system has more influence in coordinating and formalizing communications with a vendor to optimize program feature requests and training, and with the local health authority for interfacing of lab and other data.

Leading change
Dr Jeff Harries, an early EMR adopter himself, believes that good interpersonal communication is the key to implementing change. “To effect large-scale change, you need to rally people behind a common goal,” he explains. 

When he decided he wanted to form a COP in South Okanagan, Dr Harries picked up the phone and called almost every physician in his area. “I spoke with 122 docs to get their agreement to select a common vendor. Some people already had an EMR, some were close to retirement, and some were just starting their practice and couldn’t afford it. The more I spoke to people, the more I got confirmation that it was a good idea. There was excitement about data exchange and improved continuity of care. There was interest, trepidation, fear, excitement—a combination of reactions.”

Dr Deborah Hocking of the Powell River COP implemented the EMR-based system in her own office first. “I never would have had the time to lift my head from the treadmill to see the bigger picture without making the changes in my office first,” she says. “It’s the value-driven, morale-boosting abilities that create leadership. If it was just me who had to change, if it was just a snap of my fingers, I would have had a COP or an integrated health network 3 years ago. But it’s getting all the people involved to make it work, that’s the slowest part of change.” 

Drs Harries and Hocking made a concerted effort to present their vision and the business case for a common EMR equally to both GPs and specialists. They learned that the value of an EMR for specialists is significantly increased when integration with local GPs and health authorities is part of the solution.

With seemingly endless energy, the PITO peer champions continue to practise medicine while keeping in touch with the ever-evolving needs of their colleagues and patients in the COP. They have a lot of trust in the sustainability of the changes they have initiated in their communities. “There is no top-down pressure here,” says Dr Harries. “It’s a bottom-up model; it evolves in the directions that are needed.”

For more information about the Communities of Practice program and how to create a COP, please go to www.pito.bc.ca/programs/communities-of-practice.php.
—Jeremy Smith
PITO Program Director