The High-Performing Physician Network

3-minute case study: Chart prep that lasts a week

  | April 10, 2017

Researchers have identified top performers on key financial and clinical metrics across the athenahealth network — and are uncovering the innovations that drive their success. Here's a snapshot of one tactic on the road to lower cost, higher value care.

The problem

At Valley Medical Group, a multi-specialty network in Western Massachusetts, gaps in screening and incomplete charts meant practitioners didn't have all the tools they needed for clinical decision-making and care recommendations. They weren't hitting quality targets — and were missing opportunities to support their patients during those few times a year when a patient was right in front of them.

The solution

To ensure complete information for every patient and every visit, Valley Medical Group adopted the Proactive Office Encounter Team — known as POET — one of many cultural leftovers from their time as a part of Kaiser Permanente.

A team-based workflow, POET queues up care plans for every scheduled visit a full week before the patient arrives. Teams include practitioners, nurses, medical assistants, and nurse managers — along with reception staff, lab and radiology staff, and outreach personnel — each with a defined role in identifying care gaps and addressing them before the visit:

1 week prior - The team reviews the patient chart and identifies any required lab tests, missing results, or other critical information.

3 days prior - Reception staff review the schedule and identify patients who need colorectal cancer screening or chlamydia testing. These patients receive test kits at check-in.

Day of visit - All available documentation and results are given to the provider, who is then free to focus the visit on care objectives, rather than gaps in care.

Post-visit - At check-out, reception staff provide a written patient care summary (or deliver it via the patient portal), schedule any follow-up tests, and address any patient-specific needs outlined by the provider.

“The idea is to get the boring stuff done so that there's time and space for the caregiver and patient to interact," says Martha Mastroberti, Valley Medical Group's manager of healthcare informatics.

The outcome

When researchers analyzed performance on key quality metrics across the athenahealth network, Valley Medical Group emerged as one of the top 10 percent of performers. Tactics from the POET workflow — such as identifying patients who need colorectal cancer screenings — helped lead to those strong results.

And one powerful side effect, says president Joel Feinman, Ph.D., is patients' perception of the organization: They know a care team is thinking about their health, even when they're not in the office.

“Each patient deserves to have everything taken care of every time they're here," Feinman says. “So we work hard to make sure they do."

Data analysis and research by Stewart Richardson, David Clain, and Erica Granor. Lia Novotny is a contributing writer for athenaInsight. Image credit: Getty Images


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What would be even more amazing is if we could prep the actual chart for future appointments. For all gaps in care we order things in the preliminary chart note. If we know that this pt needs a follow up lab for something we go ahead and populate it. This reminds the provider that certain things need to be discussed and followed up at this visit. The way Athena runs now is that we have to wait until the 5 stage workflow is in #2 after the patient is here to enter all of this. In an effort to do "Today's work today" or today's work yesterday it would be nice if there was a prelim chart note. If the patient did not show up it would either be erased or stored as a prelim note so that the next time we see them we still know that those things need to be addressed.
Whitney Kennedy MD
Hi Dr. Kennedy: The issue you mentioned, not being able to "queue up" orders before an encounter is one of the main reasons customers reach out to us and start using the Avhana Health platform. As part of the MDP program, our unique platform contains a pre-visit planning dashboard that allows you to understand what gaps of care/guidelines/QM apply to a patient then fairly quickly queue up the follow-up action. This means when you open up the patient's chart for the first time during the encounter all the items are already there and ready to be completed. Feel free to reach out to us on our marketplace page at or check us out online at Thanks! Noah Weiner
Noah Weiner

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3-minute case study: Chart prep that lasts a week