Mark Nunlist, TDI ’10: Closing the Gap in Primary Care

Mark Nunlist had been a primary care physician for almost 20 years when he became increasingly aware that there was something missing at the busy and well-respected White River Junction, Vt., practice where he was a partner. While he and his colleagues did a fine job of attending to the stream of patients who presented themselves, Nunlist felt that the practice was generally more reactive than prospective in its care.

Mark Nunlist

Mark Nunlist

“We weren’t consistently doing the health maintenance kinds of things that a patient should expect of their primary care doc—what I now refer to as the background hum of good primary care—because we didn’t have systems and processes that enabled that,” he explains. “For example, I couldn’t guarantee that the patients we were seeing regularly were current on even such a simple thing as a tetanus shot.”

This concern led Nunlist to The Dartmouth Institute for Health Policy and Clinical Practice (TDI) at the Geisel School of Medicine, where he enrolled as a part-time student in the master’s program in 2007. “TDI set me up to understand how to look at things differently. It taught me about processes, about team building, about how to measure where you are against where you want to be, and how to close the gap.”

Since then, White River Family Practice has initiated significant changes. Recently, the practice was honored with the prestigious 2013 Ambulatory HIMSS Davies Award of Excellence, recognizing its exemplary implementation of the electronic health record to improve patient care.

“The HIMSS Davies Award is a direct outgrowth of my TDI experience,” says Nunlist, who is also Vermont’s 2013 Physician of the Year and an assistant professor of community and family medicine at Geisel. Staff members from across the practice have embraced the new EHR, using it to analyze existing practice and workflows and begin implementing processes that allow for greater attention to preventive care, especially for patients with chronic health conditions.

Nunlist points to management of diabetes, asthma, and ischemic vascular disease, as well as smoking and alcohol cessation intervention, as some of the areas in which use of the EHR has allowed the practice to make measurable improvements.

“In all of these areas, we had to measure how we were doing—how many asthma action plans are there in the record for asthma patients, for example,” explains Nunlist. “It’s never as good as you’d like it to be. Never. When you’re willing to look, you find you actually have lots of room to improve.”

Nunlist, who plans to retire this year, is also excited about the cultural shift that engaging in this work has brought about at White River Family Practice. Where formerly the administrative staff did not think of themselves as part of the care team, now they do. “They’re much more energized about our mission,” says Nunlist.

“TDI taught me that one of the most powerful motivators for change is looking at the reality of what you’re actually doing, compared to what you think you’re doing. That gap is a powerful motivator,” says Nunlist. “That process is part of who we are at White River Family Practice now. It’s also clear that this is what a good primary care practice ought to do.”

Kate Villars is Director of Communications for the Office of Development and Alumni Relations at the Geisel School of Medicine at Dartmouth.

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