James Mold, MD, MPH, George Lynn Cross Emeritus Professor in the Department of Family and Preventive Medicine at Oklahoma University College of Medicine
At the turn of the 20th century, after many other more traditional dissemination strategies had been tried, there remained a large gap between what was known about more efficient and effective farming methods and the way most farms were operating. In order to address this problem, the Smith Lever Act established a system of local agricultural extension services operated from land grant universities, bringing research and education through trusted agents “directly to the people to create positive changes.” Now called Cooperative Extension, this nationwide system also creates bidirectional channels of communication between farmers, researchers and educators assuring that research funds are directed to issues of greatest importance and research results are relevant and implementable. The success of the agricultural extension model in the U.S. and our own experience working with small rural practices throughout Oklahoma led us to believe that a similar extension model could help primary care practices and the communities they serve in the same ways Cooperative Extension revolutionized agriculture.
A primary health care extension system would assure that all primary care clinicians and staff had access to the most up-to-date information and recommendations as well as in-practice support to help implement them. I also believe that if practices had adequate external support, more of them could remain independent. Practices that remain independent, in my opinion, tend to be more connected to the communities and people that they serve. We have also found that, when resources are available, independent practices are generally more facile than employed practices in their ability to incorporate new approaches to care, and their patients are more satisfied with the care they receive.
Communities as the center of health improvement
It is clear that well-functioning communities are critical to the health and well-being of their citizens. We recognized that the extension system would therefore need to create key linkages between primary care practices and community resources and also engage key community organizations as partners in the extension work.
The EvidenceNOW initiative is making it possible for Oklahoma to expand its extension efforts.
During the initial round of AHRQ support for developing and testing primary care extension, the University of New Mexico, together with North Carolina, Oklahoma, and Pennsylvania, developed The Health Extension Toolkit, which outlined a model for how a health extension can work in different contexts. This model defines a health extension system as “a community-based, state-wide, but university-linked network of agents that can assist primary care practices with the best evidence-based practices to support the provision of quality care and practice transformation.”
The EvidenceNOW initiative is making it possible for Oklahoma to expand its extension efforts. In Oklahoma, the two University of Oklahoma academic medical centers coordinate practice improvement support focused on quickly getting relevant research into practice, while the larger extension system is also supported by the Public Health Institute of Oklahoma, the Community Services Council, and the Oklahoma State Department of Health.
Funding and sustainability
Without an extension system, most of the research funded by these national organizations will move into practices very slowly.
If primary health care extension systems are to be sustainable, there is need to demonstrate high value and identify reliable funding sources. Conceptually, funding primary health care extension should be relatively straightforward, requiring only a tiny fraction of the combined budgets of the NIH, CDC, DHHS, AHRQ, and PCORI. After all, without an extension system, most of the research funded by these national organizations will move into practices very slowly. However, it has, so far, been a difficult leap for organizations that focus on research to commit even a small percentage of their budget to implementation and dissemination. This could be because there seems to be a persistent belief that dissemination and implementation should be easier and less expensive than the evidence from both agriculture and primary care suggests.
Trustworthy and accessible data – ground truth
The good news is that the very process of extension can pinpoint and redress data shortcomings.
Proving the value of the extension system will depend upon reliable and accurate data or “ground truth.” Ground truth is information based on direct observation. In the case of primary care, ground truth would be what is actually happening at the level of practices and individual patients. Much of that data is present in the electronic health records of practices, but the problem continues to be how to extract it in ways that are both feasible and useful. For most of our EvidenceNOW practices we are able to compile information from a wide variety of sources (primary care practices, subspecialty practices, hospitals, pharmacies, clinical laboratories, etc.) through the health information exchange (HIE), MyHealth. However, some electronic health records cannot generate and transmit information to the HIE, and some cannot even produce data for more than one patient at a time.
Despite inaccurate or missing data, the good news is that the very process of extension can pinpoint and redress data shortcomings. For instance, prior to our extension program in Oklahoma, we did not have accurate information about primary care clinicians and practices in the state. However, with our state-wide extension program, we were able to compile the most accurate and compressive registry of primary care practices in existence. More generally, the linking and collaborating that is so essential to practice extension can improve the flow of information between various stakeholders; the future of healthcare is certainly one in which information and data will play an ever more important role. Extension systems can ensure that this data is accurate and focused on both practice and community needs and outcomes.
I’m hoping that, in addition to the quantitative measures of practice performance improvements and better patient outcomes, ESCALATES will be able to compile compelling stories that document the full range of benefits of extension to clinicians and practices. No matter how much the numbers improve, I suspect it will be anecdotes that will make the difference when it comes to sustainable funding decisions. I expect, for instance, to hear stories of physicians who chose to delay retirement because of a practice extension support network and of practices that decided not to sell to a health system because of the technical assistance and services offered by practice extension.
I hope that the evaluation of EvidenceNOW will not only provide compelling quantitative and qualitative evidence of the merits of an external practice extension resource, but also offer insight into how to implement such a resource across a primary health care system that is increasingly complex and unstable. If ESCALATES learns those things and can serve as a platform for telling stories about the power of primary health care extension, primary care professionals, their patients, and our nation as a whole will be much better off.