Patient Engagement

How Can Ninjas Save Primary Care?

Article · September 15, 2016

Primary care is in trouble, and both physicians and patients know it. Both deserve better, and a few good ninjas may be part of the solution.

Being a great primary care physician seems impossible at times. A 2009 study found that a primary care physician with a standard patient panel would require more than 21 hours a day to provide guideline-advised care. Yet, according to the National Ambulatory Medical Care Survey, primary care visits increased in length from 14.9 minutes in 1989 to 21.4 minutes in 2012. Thus, contrary to popular belief, primary care physicians actually spend more time with their patients than in the past yet often feel justifiably overwhelmed.

At the same time, patients seem consistently disappointed. Substantial evidence suggests that patients do not receive all of the preventive and chronic disease care that the U.S. Preventive Services Task Force advises on the basis of its best evidence. Plus, the experience of receiving care is unsatisfying: a 2015 study by the Advisory Board found that primary care nationwide had a Net Promoter Score of just 3.

Recognizing the troubles of both physicians and patients, how do we balance competing priorities to deliver care that is evidence based, effective, and patient centered? At Oak Street Health, a de novo network of value-based primary care centers for older adults, we face the same challenges and have implemented a unique solution that has proven to be effective across many dimensions. In 2014, we developed the Clinical Informatics Specialist program with the specific aim of creating:

  1. Higher-quality interactions for physicians to build relationships with patients
  2. More structure in terms of the capture and use of data at the bedside
  3. More operational leverage for our physicians

And because “Clinical Informatics Specialist” is a mouthful, we lovingly call these colleagues our “ninjas” in honor of the legendarily efficient mercenaries of feudal Japan. We currently employ around 50 ninjas, and a similar number of alumni from our ninja program have moved on to advanced clinical training programs in nursing and medical schools.

Who Are the Ninjas?

Ninjas are elite informatics specialists who are hired and trained to ensure that clinical information is in the right place at the right time. The typical ninja is an early-career college graduate who is screened for interest in a career in health sciences and who is looking for a way to build practical experience in a clinical setting. The role is full time with benefits and has attracted a diverse cohort; current ninjas include a neuroscience graduate from Princeton who is completing a baccalaureate program in the evenings, a recent alumna of the Peace Corps who is studying for the MCAT, and an international medical graduate who is preparing for the Match. As in any first-year medical school class, ninjas often share apartments, and there is a strong social cohesion on the team.

Ninjas work in clinic as core members of our care teams and are responsible for making sure that all clinical information is managed appropriately. This role involves making all relevant historical data available at the point of care and capturing all new data in a structured format for future analysis. Ninjas serve as scribes in the traditional sense during clinic visits, but their responsibilities extend into non–encounter-based work as well. Ninjas provide data support for daily and weekly huddles, assist in obtaining outside medical records, and organize our proprietary population health dashboards. Naturally, physicians maintain complete ownership of all documentation and care, but it is up to the ninjas to provide the right data at the right time so that appropriate decisions can be made for each patient. For example:

  • At the 8:00 a.m. care team meeting, the ninja pulls the daily huddle form, which shows the clinic schedule for the day as well as any gaps in preventive or chronic disease care. The ninja highlights which patients need a mammogram referral and shares that information with the team so that the referral is made before the patient even arrives.
  • Before the huddle breaks, the ninja shares the inpatient census, and the team discusses the patients who are currently in the hospital or post-acute care facility. The ninja displays the latest notes from the care manager on the screen so that the team gets an update on each patient’s status. After the care team discussion, the ninja sends an electronic message to the transitions nurse in the hospital to facilitate discharge planning.
  • At the end of the day, the ninja pulls the list of open tasks to remind the physician about any items that still need to be addressed — for example, that the physician needs to call a patient back about a new medication that was started the week before. The ninja has the phone number ready and can draft a note for the physician to review in real time.

How Has the Program Performed?

We’ve measured the performance of the ninja program in a variety of dimensions. First, our patients and physicians have raved about the ninja program. Our Net Promoter Score improved from 89% to 92% over the first year of our ninja program, and physician survey data obtained before and after the program’s development have confirmed its popularity with our medical staff. Anecdotally, “Dojo Day” (during which the ninja is away for training and career advisory) has become a day of sadness as teams are forced to perform their duties without their ninjas. Many Oak Street physicians have reported, “I can never work anywhere that doesn’t have a ninja,” and several new physicians have joined our team precisely to practice with such support.

Furthermore, ninjas have become integral parts of our practice culture, and we have enjoyed meaningful improvements in Healthcare Effectiveness Data and Information Set (HEDIS) metrics as well as operational efficiency during this time. In a value-based practice, a true return on investment calculation requires too many assumptions to be statistically meaningful, but we’re confident from detailed before-and-after analysis that our ninjas have improved the quality of the care that we deliver to our patients and also have increased the joy of practice among our physicians.

What Does the Ninja Program Suggest About the Future of the Practice of Medicine?

As U.S. health care shifts from fee-for-service to value-based care, the number of requirements to use and capture data and to practice in cross-functional teams will only increase. This transition will occur in the context of a primary care system that is already widely viewed as broken. “Working to the limit of the license” sounds nice, but, without additional support, we’re unlikely to see the improvements in operational efficiency and quality outcomes that this concept suggests. The good news is that value-based economics allow for more innovative care models and programs, of which the ninja program at Oak Street Health is a prime example. As such, we anticipate that other practices will consider “ninja-like” programs to address the pressures experienced by physicians and patients alike, and we think that a few ninjas might just be what primary care needs.

New call for submissions ­to NEJM Catalyst

Now inviting longform articles

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Patient Engagement
Bilazarian01_pullquote patient engagement both sides of the bed

Patient Engagement from Both Sides of the Bed

When patients and families are included in medical rounds as valued members of the team, the quality of care improves.

Ten Guiding Principles for Patient-Centered Care as Described by Mountain States Health Alliance to consider with patient-centered outcomes research (PCOR)

Complementary Approaches to Patient Engagement in Patient-Centered Outcomes Research

It’s important for providers to understand and apply the key principles foundational to patient-centered outcomes research efforts.

Selected Advantages of Improved Patient Electronic Access to Health Data

Patient-Led Data Sharing — A New Paradigm for Electronic Health Data

The pieces are in place for a truly disruptive shift in how patients can access and use their own clinical data to improve their health.

Collapse of Two Online Health Communities as Result of Removal of Users Starting from Superusers

Online “Superusers” as Allies of the Health Care Workforce

Three proposed steps for integrating peer-driven online health communities with traditional services to improve health outcomes for people with chronic conditions.

The PEACE Project - Patient Experience for Acute Care Elders at Sarasota Memorial Hospital

The PEACE Project

Improving the acute care experience for our eldest patients.

Rabson01_pullquote barriers to patient engagement in primary care practices

What Does It Take to Increase Patient Engagement in Primary Care Settings?

Massachusetts primary care practices are beginning to invest in programs to increase patient engagement, but these strategies can be challenging to implement and remain underutilized and undervalued.

Many Barriers to Engaging Patients in Treatment for Obesity

Survey Snapshot: Approaches to Address Clinician and Societal Roles in Obesity

The obesity problem is getting larger and larger. Some solutions lie beyond the traditional medical setting.

Esch01_pullquote patient activation

OpenNotes, Patient Narratives, and Their Transformative Effects on Patient-Centered Care

The development of standardized tools and techniques are enhancing the ability of providers to interact with patients, but true patient engagement requires a common understanding of its theoretical foundation and an open mind for including patients’ needs and beliefs — in their language — as part of each encounter.

Patients and PCPs Hold Primary Responsibility for Addressing Obesity

Patient Engagement Survey: The Failure of Obesity Efforts and the Collective Nature of Solutions

Patients hold responsibility for their actions, but providers’ approaches to address obesity often fall short as well.

Items from the Shared Decision-Making Process Survey for Elective Surgical Procedures - patient decision aids - decision quality - informed consent

Shared Decision-Making: Staying Focused on the Ultimate Goal

Despite growing acceptance and enthusiasm for patient involvement in their health care decisions, clinicians, at times, lose focus on the ultimate goal of shared decision-making: better health decisions from the informed patient’s perspective.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Patient Incentives

68 Articles

Online “Superusers” as Allies of the…

Three proposed steps for integrating peer-driven online health communities with traditional services to improve health…

Patient-Centered Care

245 Articles

Engaging Stakeholders to Produce Sustainable Change…

How an initiative designed to improve patient outcomes and satisfaction while containing costs led to…

Patients As Customers

123 Articles

Patient Engagement from Both Sides of…

When patients and families are included in medical rounds as valued members of the team,…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now