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:
- Higher-quality interactions for physicians to build relationships with patients
- More structure in terms of the capture and use of data at the bedside
- 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.