Primary Care Provider Familiarity and Compliance With Preferred Practice Patterns for Comprehensive Eye Examinations.

PURPOSE: To assess primary care practitioners' (PCPs) familiarity with American Academy of Ophthalmology Preferred Practice Pattern (PPP) guidelines on the frequency of comprehensive eye examinations (CEEs), and to explore their opinions and practices on counseling and referring patients for CEEs. DESIGN: Cross-sectional study. METHODS: Between February 1, 2019, and June 25, 2019, an anonymous survey was emailed to clinicians holding an MD, DO, PA, or NP degree, and residents at Brigham and Women's Hospital and the University of Oklahoma. Descriptive statistics of participants' responses were reported. RESULTS: Regarding patient counseling on CEEs, 15.4% of PCPs reported "always," 48.1% "usually," and 36.5% "seldom" or "never" doing so. Few PCPs (11.1%) reported being able to describe the guidelines, and 63.9% were unaware of their existence. A strong majority of PCPs (90.7%) correctly referred a type 2 diabetic patient at their time of diagnosis, but a similar majority (77.8%) prematurely referred a newly diagnosed type 1 diabetic patient. One in 7 PCPs (13.4%) would refer a patient with family history of glaucoma only upon developing visual/ocular symptoms. Compared to other providers, PAs/NPs were more likely to recommend unnecessary CEEs for low-risk individuals (P = .009), whereas residents counseled patients less frequently (P = .003), were less likely to be familiar with PPP guidelines (P = .026), and were less likely to recommend appropriate follow-ups for patients with family history of glaucoma (P = .004). CONCLUSIONS: PCPs' awareness of and familiarity with AAO CEE guidelines is variable and improves with provider age and experience. Efforts to improve PCP guideline awareness may be especially well suited to residents and mid-level practitioners.

Physicians' Response to Patients' Quality-of-Life Goals.

PURPOSE: Patients are able to participate in quality-of-life (QOL) discussions, but clinicians struggle to incorporate this information into encounters and shared decision making. We designed a study to determine if a clinician-initiated prompt could make patient visits more goal directed. METHODS: Patients were given a previsit questionnaire that included QOL questions. Physicians in the control were given no further prompting. The intervention physicians were prompted to ask a QOL question: what things are you unable to do because of your health problems today? A 2-pronged design was used: 1 prepost group where 3 physicians participated in 5 control and 5 intervention encounters (n = 30) and a randomized group in which 11 physicians and their patients were randomly assigned to control or intervention groups (n = 30). Video recordings of the encounters were reviewed to determine if QOL goals were mentioned and if they were utilized in decision making. RESULTS: Fifty-seven (95%) of the 60 patients provided written answers to at least 1 of the QOL questions on the intake form. QOL goals were mentioned during intervention encounters more often than in control groups. QOL information was used in shared decision making in only 4 of the 30 (13%) intervention encounters. CONCLUSIONS: Physicians were able to engage in QOL discussions with their patients, but did not translate that information to medical decision making. More research is needed to understand why clinicians opt not to use QOL information and how to make communication more goal directed.

Moving From Problem-Oriented to Goal-Directed Health Records.

Electronic health records (EHRs) have been in place for decades; however, most existing systems were designed in the prevailing disease- and payment-focused care paradigm that often loses sight of the goals, needs, and values of patients and clinicians. The goal-directed health care model was proposed more than 20 years ago, but no design principles have been developed for corresponding electronic record systems. Newly designed EHRs are needed to facilitate health care that is anchored by patient life and health goals. We explore the limitations of current EHRs and propose a blueprint for a new EHR design that may facilitate goal-directed health care. To reflect patient goals as a thread through the care continuum, we propose 5 major system functions for goal-directed health records based on the 8 characteristics of primary health care defined by the Institute of Medicine. We also discuss how new EHR functions could support goal-directed health care and how payment and quality measurement systems will need to be transformed. It may be possible for patient life and health goals to drive health care that is reinforced by a corresponding health record design; however, synchronized shifts must occur in the models of providing, documenting, and paying for health care.

An Innovative Community-based Model for Improving Preventive Care in Rural Counties.

OBJECTIVE: This quasi-experimental pilot study aimed to implement and evaluate a sustainable, rural community-based patient outreach model for preventive care provided through primary care practices (PCPs) located in a rural county in Oklahoma. A Wellness Coordinator (WC) working with PCPs, the county health department, the county hospital, and a health information exchange (HIE) organization helped county residents receive evidence-based preventive services. METHODS: The WC used a community wellness registry connected to electronic medical records via HIE and called patients at the county level based on PCP-prioritized and tailored protocols. The registry flagged patient-level preventive care gaps, tracked outreach efforts, and documented the delivery of preventive services throughout the community. Return on investment (ROI) for prioritized preventive services was estimated in participating organizations. RESULTS: Six of the 7 PCPs in the county expressed interest in the project. Three of these practices fully implemented the 1-year outreach program starting in mid 2015. The regional HIE supplied periodic data updates for 9138 county residents to help the coordinators address care gaps using the community registry. A total of 5034 outreach calls were made by the WC in the first year and 7776 prioritized recommendations were offered when care gaps were detected. Of the 5034 distinct patients who received a call, 1146 (22%) were up to date on all prioritized services, whereas 3888 (78%) were due for at least 1 of the selected services. Health care organizations in the county significantly improved the delivery of selected preventive services (mean increase, 35% across 10 services; P = .004; range, 3% to 215%) and realized a mean ROI of 80% for these services (range, 32% to 122%). The health system that employed the WC earned an estimated revenue of $52,000 realizing a 40% ROI for the coordinator position. CONCLUSIONS: Although more research is needed, our pilot study suggests that it may be feasible and cost effective to implement an innovative, county-level patient outreach program for improving preventive care in rural settings.

Improving Patient-Clinician Conversations During Annual Wellness Visits.

BACKGROUND: Health risk assessments (HRAs) have been implemented and studied for decades in various settings, but little is known about the effect of introducing HRAs on the dynamics and content of patient-clinician conversations during Medicare Annual Wellness Visits (AWVs) and whether the effective use of HRAs requires additional training and resources. METHODS: We used Conversation Analysis techniques to analyze 40 AWVs conducted in an academic family medicine residency practice. After a 3-month baseline period, a low-intensity intervention was implemented to explore improvements in the dynamics and content of conversations. Short exit interviews with patients and clinicians were evaluated by standard content analytic techniques. RESULTS: Six overarching themes emerged that described the dynamics of AWV conversations. Patients and clinicians sub-optimally utilized the HRA report and missed many opportunities for promoting behavior change. However, a low-intensity, multi-component intervention significantly decreased the proportion of clinician talk time per visit by 9% (P < .001), while it increased the proportion of patient talk time by 7% (P < .001), robustly increased the number and duration of "change talk" by 639% (P = .0007), increased the number of patient cut-ins by 237% (P = .04) and tended to increase the number and duration of clinician "advice talk" (P = .065). Patients felt more informed, empowered, and motivated by the HRA-enhanced wellness visit. Clinicians found that the process helped them construct a more effective visit agenda and it facilitated the convergence of patient goals with evidence-based recommendations. CONCLUSIONS: Our study suggests that HRAs introduced without proper framing, education, and additional resources may not allow patients and clinicians to leverage AWVs for effective health planning and improvement. A targeted, low-intensity intervention may help patients and clinicians improve the quality of HRA-guided health conversations during AWVs.

Team Science Approach to Developing Consensus on Research Good Practices for Practice-Based Research Networks: A Case Study.

Using peer learning strategies, seven experienced PBRNs working in collaborative teams articulated procedures for PBRN Research Good Practices (PRGPs). The PRGPs is a PBRN-specific resource to facilitate PBRN management and staff training, to promote adherence to study protocols, and to increase validity and generalizability of study findings. This paper describes the team science processes which culminated in the PRGPs. Skilled facilitators used team science strategies and methods from the Technology of Participation (ToP®), and the Consensus Workshop Method to support teams to codify diverse research expertise in practice-based research. The participatory nature of "sense-making" moved through identifiable stages. Lessons learned include (1) team input into the scope of the final outcome proved vital to project relevance; (2) PBRNs with diverse domains of research expertise contributed broad knowledge on each topic; and (3) ToP® structured facilitation techniques were critical for establishing trust and clarifying the "sense-making" process.

Practice-based Research Network Research Good Practices (PRGPs): Summary of Recommendations.

INTRODUCTION: Practice-based research networks (PBRNs) conduct research in community settings, which poses quality control challenges to the integrity of research, such as study implementation and data collection. A foundation for improving research processes within PBRNs is needed to ensure research integrity. METHODS: Network directors and coordinators from seven U.S.-based PBRNs worked with a professional team facilitator during semiannual in-person meetings and monthly conference calls to produce content for a compendium of recommended research practices specific to the context of PBRNs. Participants were assigned to contribute content congruent with their expertise. Feedback on the draft document was obtained from attendees at the preconference workshop at the annual PBRN meeting in 2013. A revised document was circulated to additional PBRN peers prior to finalization. RESULTS: The PBRN Research Good Practices (PRGPs) document is organized into four chapters: (1) Building PBRN Infrastructure; (2) Study Development and Implementation; (3) Data Management, and (4) Dissemination Policies. Each chapter contains an introduction, detailed procedures for each section, and example resources with information links. CONCLUSION: The PRGPs is a PBRN-specific resource to facilitate PBRN management and staff training, to promote adherence to study protocols, and to increase validity and generalizability of study findings.

Integrating mental health into adolescent annual visits: impact of previsit comprehensive screening on within-visit processes.

PURPOSE: To evaluate how a comprehensive, computerized, self-administered adolescent screener, the DartScreen, affects within-visit patient-doctor interactions such as data gathering, advice giving, counseling, and discussion of mental health issues. METHODS: Patient-doctor interaction was compared between visits without screening and those with the DartScreen completed before the visit. Teens, aged 15-19 years scheduled for an annual visit, were recruited at one urban and one rural pediatric primary care clinic. The doctor acted as his/her own control, first using his/her usual routine for five to six adolescent annual visits. Then, the DartScreen was introduced for five visits where at the beginning of the visit, the doctor received a summary report of the screening results. All visits were audio recorded and analyzed using the Roter interaction analysis system. Doctor and teen dialogue and topics discussed were compared between the two groups. RESULTS: Seven midcareer doctors and 72 adolescents participated; 37 visits without DartScreen and 35 with DartScreen were audio recorded. The Roter interaction analysis system defined medically related data gathering (mean, 36.8 vs. 32.7 statements; p = .03) and counseling (mean, 36.8 vs. 32.7 statements; p = .01) decreased with DartScreen; however, doctor responsiveness and engagement improved with DartScreen (mean, 4.8 vs. 5.1 statements; p = .00). Teens completing the DartScreen offered more psychosocial information (mean, 18.5 vs. 10.6 statements; p = .01), and mental health was discussed more after the DartScreen (mean, 93.7 vs. 43.5 statements; p = .03). Discussion of somatic and substance abuse topics did not change. Doctors reported that screening improved visit organization and efficiency. CONCLUSIONS: Use of the screener increased discussion of mental health but not at the expense of other adolescent health topics.

HIE-i-health information exchange with intelligence.

This article demonstrates the development and pilot testing of an innovative approach to implement health information exchange with intelligence (HIE-i) in primary care settings. Records of 346 patients were studied in 6 primary care practices. Clinical workflows were evaluated by time motion studies and observations. A viable and sustained HIE connection was adopted by primary care clinicians. Documentation and delivery of several preventive services, medication reconciliation, and workflow efficiency improved. The study was able to establish a sustained and effective HIE implementation. More research is needed to determine the clinical impact and sustainability of the HIE-i approach.

Engaging patients and clinicians through a wellness portal to improve the health of Oklahomans.

Patient-centeredness is one of the key dimensions of the patient-centered medical home model, yet it is still not uniformly understood. A goal-directed care approach that incorporates active preparation and comprehensive patient visits has been suggested to empower patients and improve health outcomes by various resources, including patient-side health IT (e.g. portals). In the context of a recent randomized controlled trial funded by the Agency of Healthcare Research and Quality, we developed a patient Wellness Portal that was linked to a previously designed and implemented clinician-portal. A six-month pilot implementation study was followed by a 12-month randomized controlled trial to determine the impact of the Portal on patient and practice-level outcomes. Results indicate that the Wellness Portal was easy to use, well received by patients, helped users educate themselves about their conditions, gauge their health status, and create a longitudinal wellness plan for discussion during an annual wellness visit. A preliminary analysis also showed that a greater proportion of patients received preventive services in the Portal intervention group than in the control group.