Twelve tips for medical educators to optimize their curricula vitae.

A good curriculum vitae (CV) highlights medical educators' academic achievements and supports their professional goals. Many faculty struggle with timely updates and strategic formatting. These twelve tips will help medical educators optimize their CV to best showcase their strengths and accomplishments. The first three tips outline a process: identify a system to collect potential entries and schedule regular time for updates. Tips four and five detail how to tailor traditional CV formatting to best describe the work of medical educators. The next few tips offer concrete strategies and examples of CV entries to consider for inclusion. The remaining tips remind faculty to ask for help from colleagues, who can share a sample CV and identify overlooked activities. Our intention is to transform a task that can be burdensome into a process that seamlessly captures the breadth of our work as medical educators and allows for introspection and growth.

Interventions to Reduce Hospital and Emergency Department Utilization Among People With Alcohol and Substance Use Disorders: A Scoping Review.

BACKGROUND: Substance use disorders (SUDs), prevalent worldwide, are associated with significant morbidity and health care utilization. OBJECTIVES: To identify interventions addressing hospital and emergency department utilization among people with substance use, to summarize findings for those seeking to implement such interventions, and to articulate gaps that can be addressed by future research. RESEARCH DESIGN: A scoping review of the literature. We searched PubMed, PsycInfo, and Google Scholar for any articles published from January 2010 to June 2020. The main search terms included the target population of adults with substance use or SUDs, the outcomes of hospital and emergency department utilization, and interventions aimed at improving these outcomes in the target population. SUBJECTS: Adults with substance use or SUDs, including alcohol use. MEASURES: Hospital and emergency department utilization. RESULTS: Our initial search identified 1807 titles, from which 44 articles were included in the review. Most interventions were implemented in the United States (n=35). Half focused on people using any substance (n=22) and a quarter on opioids (n=12). The tested approaches varied and included postdischarge services, medications, legislation, and counseling, among others. The majority of study designs were retrospective cohort studies (n=31). CONCLUSIONS: Overall, we found few studies assessing interventions to reduce health care utilization among people with SUDs. The studies that we did identify differed across multiple domains and included few randomized trials. Study heterogeneity limits our ability to compare interventions or to recommend one specific approach to reducing health care utilization among this high-risk population.

Innovative Use of a Mobile Web Application to Remotely Monitor Nonhospitalized Patients with COVID-19.

Introduction: Most patients with COVID-19 do not require hospitalization but may need close monitoring, which can strain primary care practices. Our objective was to describe the implementation of a mobile web application to monitor COVID-19 signs and symptoms among nonhospitalized primary care patients and to assess the feasibility and acceptability of the application. Study Design: Retrospective analysis of (1) mobile web application data from March through December 2020 and (2) cross-sectional surveys administered in June 2020. Materials and Methods: We enrolled nonhospitalized patients and staff from nine New England primary care practices across 29 sites. Outcomes included feasibility and acceptability of the application as measured by the proportion of texts that resulted in a response, proportion of patients who agreed using the application was easy, and proportion of practice staff who agreed the application reduced outreach burden and that they would recommend use. Results: Five thousand five hundred thirty-two patients used the mobile web application, with 26,466 total responses. Overall, 78% of the daily texts resulted in a response from patients. Most patients agreed that responding to texts was easy (95%) and that they would be willing to participate in other texting programs (78%). Most staff agreed that the program reduced burden of outreach (94%) and that they would recommend use to other practices (100%). Conclusions: Use of a COVID-19 symptom tracking application was feasible and acceptable to patients and primary care practice staff. Outpatient practices should consider use of mobile web applications to monitor nonhospitalized patients with other acute illnesses.

Physician Beliefs About Online Reporting of Quality and Experience Data.

IMPORTANCE: Physician attitudes about websites that publicly report health care quality and experience data have not been recently described. OBJECTIVES: To examine physician attitudes about the accuracy of websites that report information about quality of care and patient experience and to describe physician beliefs about the helpfulness of these data for patients choosing a physician. DESIGN, PARTICIPANTS, AND MEASURES: The Rhode Island Department of Health (RIDOH) and a multi-stakeholder group developed and piloted two questions that were added to RIDOH's biennial physician survey of all 4197 practicing physicians in Rhode Island: (1) "How accurate of a picture do you feel that the following types of online resources give about the quality of care that physicians provide?" (with choices) and (2) "Which types of physician-specific information (i.e., not about the practice overall) would be helpful to include in online resources for patients to help them choose a new physician? (Select all that apply)." Responses were stratified by primary care vs. subspecialty clinicians. Summary statistics and chi-squared tests were used to analyze the results. RESULTS: Among 1792 respondents (response rate 43%), 45% were unaware of RIDOH's site and 54% were unaware of the Centers for Medicare & Medicaid Services (CMS)' quality reporting sites. Only 2% felt that Medicare sites were "very accurate" in depicting physician quality. Most physicians supported public reporting of general information about physicians (e.g., board certification), but just over one-third of physicians felt that performance-based quality measures are "helpful" (and a similar percentage reported that patient reviews felt are "helpful") for patients choosing a physician. CONCLUSIONS: Physician-respondents were either uninformed or skeptical about public reporting websites. In contrast to prior reports that a majority of patients value some forms of publicly reported data, most physicians do not consider quality metrics and patient-generated reviews helpful for patients who are choosing a physician.

Use of Chronic Care Management Codes for Medicare Beneficiaries: a Missed Opportunity?

BACKGROUND: Physicians spend significant time outside of regular office visits caring for complex patients, and this work is often uncompensated. In 2015, the Centers for Medicare & Medicaid Services (CMS) introduced a billing code for care coordination between office visits for beneficiaries with multiple chronic conditions. OBJECTIVE: Characterize use of the Chronic Care Management (CCM) code in New England in 2015. DESIGN: Retrospective observational analysis. PARTICIPANTS: All Medicare fee-for-service beneficiaries in New England continuously enrolled in Parts A and B in 2015. INTERVENTION: None. MAIN MEASURES: The primary outcome was the number of beneficiaries with a CCM claim per 1000 eligible beneficiaries. Secondary outcomes included the total number of CCM claims, total reimbursement, mean number of claims per beneficiary, and beneficiary characteristics independently associated with receiving CCM services. KEY RESULTS: Of the more than two million Medicare fee-for-service beneficiaries in New England, almost 1.7 million were potentially eligible for CCM services. Among eligible beneficiaries, 10,951 (0.65%) had a CCM claim in 2015. Massachusetts had the highest penetration of CCM use (9.40 claims per 1000 eligible beneficiaries); Vermont had the lowest (0.54 claims per 1000 eligible beneficiaries). Mean reimbursement per physician was $1745.98. Age, race/ethnicity, dual-eligible status, income, number of chronic conditions, and state of residence were associated with receiving CCM services in an adjusted model. CONCLUSIONS: The CCM code is likely underutilized in New England; the program may therefore not be achieving its intended goal of encouraging consistent, team-based chronic care management for Medicare's most complex beneficiaries. Or practices may be foregoing reimbursement for care coordination that they are already providing. Recently implemented revisions may improve uptake of CCM services; it will be important to compare our results with future utilization.

Improving the quality of care and communication during patient transitions: best practices for urgent care centers.

BACKGROUND: Although high-quality care transitions require timely and accurate communication of clinical information between providers, such communication is inconsistent, and there are few established guidelines outside the hospital setting. METHODS: Using a systematic, collaborative quality improvement process, Healthcentric Advisors (Providence, Rhode Island) undertook a multistage approach to define best practices for care transitions in the urgent care setting. This approach entailed review of the medical literature to identify processes that improve care transitions outcomes, gathering of information about clinicians' preferences, and a statewide community meeting with urgent care clinicians and other stakeholders to vet draft guidelines and obtain consensus on the concepts. RESULTS: Because of an inability to identify any guidelines or research that globally addressed care transitions from the urgent care setting, information was gathered from studies on patient discharge instructions and extrapolated from the evidence base available for related settings. The resulting set of eight best practices for urgent care center transitions focuses on clinician-to-clinician communication and patient activation, which can be implemented to establish measurable, communitywide expectations for communication. CONCLUSION: This set of best practices constitutes the first known guidelines to establish expectations and measures tailored specifically to transitions from the urgent care setting to the emergency department or primary care office. They can serve as a resource and a framework for urgent care clinicians expanding their collaboration with community partners, such as emergency departments and primary care providers, particularly in the context of emerging payment models.

Closing the loop: best practices for cross-setting communication at ED discharge.

PURPOSE: This study aimed to develop emergency department best practice guidelines for improved communication during patient care transitions. BASIC PROCEDURES: To our knowledge, there are no specific guidelines for communication at the point of transition from the emergency department to the community. In Rhode Island, we used a multistage collaborative quality improvement process to define best practices for emergency department care transitions. We reviewed the medical literature, consensus statements, and materials from national campaigns; gathered preferences from emergency medicine and primary care clinicians; and created guidelines that we vetted with emergency medicine clinicians and other key stakeholders. MAIN FINDINGS: Because we did not find any guidelines that globally addressed care transitions from the emergency department, we drew from studies on patient discharge instructions and extrapolated from the evidence base available for other, related settings. Our key outcome is a set of care transition best practices for emergency departments, which can be implemented to establish measurable, communitywide expectations for cross-setting clinician-to-clinician communication. They include obtaining information about patients' outpatient clinicians, sending summary clinical information to downstream clinicians, performing modified medication reconciliation, and providing patients with effective education and written discharge instructions. PRINCIPAL CONCLUSIONS: The best practices provide feasible standards for evaluating and improving how patients transition out of the emergency department and can provide a framework for emergency department leaders expanding their collaboration with community partners, particularly in the context of emerging payment models. They also catalyze introspection and debate about how to improve communication and accountability across the care continuum.

Feasibility of a Self-Measured Blood Pressure Monitoring Program to Reduce Uncontrolled Hypertension.

BACKGROUND: Hypertension is a common, serious condition affecting about one-third of adults in the United States. Self-measured blood pressure (SMBP) monitoring, combined with clinical support, is recommended to improve hypertension control and patient outcomes. METHODS: We conducted a retrospective analysis of a SMBP monitoring program that supported recruited patients in using wireless Bluetooth monitors to track their blood pressure at home and gave outpatient practices real-time access to patients' measurements. We analyzed SMBP measurements, practice-user log data, and patient and practice experience evaluations. RESULTS: Project staff recruited 17 outpatient practices and 187 patients. After four weeks, 64% of participants consistently monitored their blood pressure at least three times per week. A majority of patients (79%) reported an increased ability to manage their hypertension. In total, clinicians received 1,849 alerts and documented 409 actions. CONCLUSIONS: This analysis demonstrates the feasibility of combining SMBP with real-time access to home measurements by outpatient practices.

Does gender influence emergency department management and outcomes in geriatric abdominal pain?

Prior studies have suggested gender-based differences in the care of elderly patients with acute medical conditions such as myocardial infarction and stroke, but it is unknown whether these differences are seen in the care of abdominal pain. The objective of this study was to examine differences in evaluation, management, and diagnoses between elderly men and women presenting to the Emergency Department (ED) with abdominal pain. For this observational cohort study, a chart review was conducted of consecutive patients aged 70 years or older presenting with a chief complaint of abdominal pain. Primary outcomes were care processes (e.g., receipt of pain medications, imaging) and clinical outcomes (e.g., hospitalization, etiology of pain, and mortality). Of 131 patients evaluated, 60% were women. Groups were similar in age, ethnicity, insurance status, and predicted mortality. Men and women did not differ in the frequency of medical (56% vs. 57%, respectively), surgical (25% vs. 18%, respectively), or non-specific abdominal pain (19% vs. 25%, respectively, p = 0.52) diagnoses. Similar proportions underwent abdominal imaging (62% vs. 68%, respectively, p = 0.42), received antibiotics (29% vs. 30%, respectively, p = 0.85), and opiates for pain (35% vs. 41%, respectively, p = 0.50). Men had a higher rate of death within 3 months of the visit (19% vs. 1%, respectively, p < 0.001). Unlike prior research in younger patients with abdominal pain and among elders with other acute conditions, we noted no difference in management and diagnoses between older men and women who presented with abdominal pain. Despite a similar predicted mortality and ED evaluation, men had a higher rate of death within 3 months.

Consolidation in the Electronic Health Record Market, 2009-2017.

BACKGROUND: To quantify changes to the electronic health record (EHR) market in Rhode Island and to assess the degree of EHR market consolidation between 2009 and 2017. METHODS: The EHR market in Rhode Island is represented by three measures: the proportion of physicians who have adopted an EHR, the number of EHR vendors in use, and EHR market competitiveness, captured by the Herfindahl-Hirschman Index (HHI). RESULTS: The EHR market became more consolidated overall between 2009 and 2017. Among outpatient physicians, the market has remained competitive, despite ongoing consolidation. In contrast, the EHR market among inpatient physicians crossed into the "highly concentrated" zone in 2015. DISCUSSION: While consolidation in the EHR market may facilitate the exchange of data across health systems, potentially reducing duplicative testing and facilitating timely diagnosis, limiting competition may affect vendors' responsiveness to calls for improved usability and innovation.

Are specific elements of electronic health record use associated with clinician burnout more than others?

OBJECTIVE: The study sought to examine the association between clinician burnout and measures of electronic health record (EHR) workload and efficiency, using vendor-derived EHR action log data. MATERIALS AND METHODS: We combined data from a statewide clinician survey on burnout with Epic EHR data from the ambulatory sites of 2 large health systems; the combined dataset included 422 clinicians. We examined whether specific EHR workload and efficiency measures were independently associated with burnout symptoms, using multivariable logistic regression and controlling for clinician characteristics. RESULTS: Clinicians with the highest volume of patient call messages had almost 4 times the odds of burnout compared with clinicians with the fewest (adjusted odds ratio, 3.81; 95% confidence interval, 1.44-10.14; P = .007). No other workload measures were significantly associated with burnout. No efficiency variables were significantly associated with burnout in the main analysis; however, in a subset of clinicians for whom note entry data were available, clinicians in the top quartile of copy and paste use were significantly less likely to report burnout, with an adjusted odds ratio of 0.22 (95% confidence interval, 0.05-0.93; P = .039). DISCUSSION: High volumes of patient call messages were significantly associated with clinician burnout, even when accounting for other measures of workload and efficiency. In the EHR, "patient calls" encompass many of the inbox tasks occurring outside of face-to-face visits and likely represent an important target for improving clinician well-being. CONCLUSIONS: Our results suggest that increased workload is associated with burnout and that EHR efficiency tools are not likely to reduce burnout symptoms, with the exception of copy and paste.

Dental and Oral Health Care in Nursing Homes: Results from Two Multi-Stakeholder Surveys.

STUDY OBJECTIVE: To characterize oral health practices using data from statewide, multi-stakeholder surveys. STUDY DESIGN AND METHODS: We analyzed data from two Rhode Island surveys. Together, the surveys targeted all nursing homes, residents, and resident representatives in Rhode Island, and asked about staff training on mouth care, frequency of dental provider visits, enrollment in nursing home dental programs, and barriers to oral health. Primary Results: Responding nursing home administrators reported high levels of commitment to oral health. Among residents enrolled in a nursing home dental care program, 76.1% had a preventive visit in the prior six months, compared to 31.0% of residents not enrolled. The majority of facilities (71.8%) reported that staff received training on routine mouth care at the time of hire. CONCLUSIONS: Our findings highlight opportunities to better support nursing homes in providing residents with high-quality oral health, including acquiring staff skills to manage care-resistant behaviors, and routinely assessing residents' ability to provide their own mouth care.

Use of Health Information Technology by Rhode Island Physicians and Advanced Practice Providers, 2019.

BACKGROUND: The Rhode Island Department of Health (RIDOH) has administered the Health Information Technology (HIT) Survey since 2009 to report clinician-level process measures relating to HIT adoption and use. METHODS: RIDOH administers the Rhode Island HIT Survey to all licensed independent practitioners. Descriptive analyses examined HIT adoption and the clinician experience working with HIT. RESULTS: Most physician and Advanced Practice Provider (APP) respondents report using an EHR (92.5% and 94.3%) and e-prescribing medications (84.1% and 81.6%). Less than half of physicians (40.9% or n=565) and APPs (35.4% or n=195) who prescribe controlled substances currently submit controlled substance prescriptions electronically. A higher percentage of physicians, compared to APPs, reported experiencing HIT-related stress (80.9% and 66.6%). The overall prevalence of physicians reporting symptoms of burnout was 29.7% (n=539) but varied between specialties. DISCUSSION: As of 2019, the majority of Rhode Island physicians have adopted EHRs and e-prescribing. Adoption plateaued after 2012, and challenges persist in integrating existing technology into practice.

Reducing Hospital Readmissions Through a Skilled Nursing Facility Discharge Intervention: A Pragmatic Trial.

OBJECTIVE: To determine if implementation of Project Re-Engineered Discharge (RED), designed for hospitals but adapted for skilled nursing facilities (SNFs), reduces hospital readmissions after SNF discharge to the community in residents admitted to the SNF following an index hospitalization. DESIGN: A pragmatic trial. SETTING AND PARTICIPANTS: SNFs in southeastern Massachusetts, and residents discharged to the community. METHODS: We compared SNFs that deployed an adapted RED intervention to a matched control group from the same region. The primary outcome was hospital readmission within 30 days after SNF discharge, among residents who had been admitted to the SNF following an index hospitalization and then discharged home. January 2016 through March 2017 was the baseline period; April 2017 through June 2018 was the follow-up period (after implementation of the intervention). We used a difference-in-differences analysis to compare the intervention SNFs to the control group, using generalized estimating equation regression and controlling for facility characteristics. RESULTS: After implementation of RED, readmission rates were lower across all 4 measures in the intervention group; control facilities' readmission rates remained stable or increased. The relative decrease was 0.9% for the primary outcome of hospital readmission within 30 days after SNF discharge and 1.7% for readmission within 30 days of the index hospitalization discharge date (P ≤ .001 for both comparisons). CONCLUSIONS AND IMPLICATIONS: We found that a systematic discharge process developed for the hospital can be adapted to the SNF environment and can reduce readmissions back to the hospital, perhaps through improved self-management skills and better engagement with community services. This work is particularly timely because of Medicare's new Value-Based Purchasing Program, in which nursing homes can receive incentive payments if their hospital readmission rates are low relative to their peers. To verify its scalability and broad potential, RED should be validated across a broader diversity of SNFs nationally.

Physician stress and burnout: the impact of health information technology.

Objective: To quantify how stress related to use of health information technology (HIT) predicts burnout among physicians. Methods: All 4197 practicing physicians in Rhode Island were surveyed in 2017 on their HIT use. Our main outcome was self-reported burnout. The presence of HIT-related stress was defined by report of at least 1 of the following: poor/marginal time for documentation, moderately high/excessive time spent on the electronic health record (EHR) at home, and agreement that using an EHR adds to daily frustration. We used logistic regression to assess the association between each HIT-related stress measure and burnout, adjusting for respondent demographics, practice characteristics, and the other stress measures. Results: Of the 1792 physician respondents (43% response rate), 26% reported burnout. Among EHR users (91%), 70% reported HIT-related stress, with the highest prevalence in primary care-oriented specialties. After adjustment, physicians reporting poor/marginal time for documentation had 2.8 times the odds of burnout (95% CI: 2.0-4.1; P < .0001), compared to those reporting sufficient time. Physicians reporting moderately high/excessive time on EHRs at home had 1.9 times the odds of burnout (95% CI: 1.4-2.8; P < .0001), compared to those with minimal/no EHR use at home. Those who agreed that EHRs add to their daily frustration had 2.4 times the odds of burnout (95% CI: 1.6-3.7; P < .0001), compared to those who disagreed. Conclusion: HIT-related stress is measurable, common (about 70% among respondents), specialty-related, and independently predictive of burnout symptoms. Identifying HIT-specific factors associated with burnout may guide healthcare organizations seeking to measure and remediate burnout among their physicians and staff.

Factors associated with longer ED lengths of stay.

OBJECTIVE: The aim of the study was to identify and quantify patient, physician, hospital, and system factors that are associated with a longer ED length of stay. METHODS: Data were from the 2001-2003 National Hospital Ambulatory Medical Care Survey. The primary outcome was length of stay in minutes. Predictor variables were patient level (eg, age, triage score), physician level (eg, level of training), and hospital/system level (eg, geographic location, ownership). RESULTS: Admitted patients' median length of stay was 255 minutes (interquartile range, 160-400); discharged patients stayed a median of 120 minutes (interquartile range, 70-199). Factors independently associated with longer ED stays for admitted patients were Hispanic ethnicity (+20 minutes), computed tomography scan or magnetic resonance imaging (+36 minutes), and hospital location in a metropolitan area (+32 minutes). Intensive care unit admissions had a shorter length of stay (-30 minutes). CONCLUSION: Several factors are associated with significant increases in ED length of stay and may be important factors in strategies to reduce length of stay.

"It's like texting at the dinner table": A qualitative analysis of the impact of electronic health records on patient-physician interaction in hospitals.

nBACKGROUND: Electronic health records (EHRs) may reduce medical errors and improve care, but can complicate clinical encounters. OBJECTIVE: To describe hospital-based physicians' perceptions of the impact of EHRs on patient-physician interactions and contrast these findings against office-based physicians' perceptionsMethods: We performed a qualitative analysis of comments submitted in response to the 2014 Rhode Island Health Information Technology Survey. Office- and hospital-based physicians licensed in Rhode Island, in active practice, and located in Rhode Island or neighboring states completed the survey about their Electronic Health Record use. RESULTS: The survey's response rate was 68.3% and 2,236 (87.1%) respondents had EHRs. Among survey respondents, 27.3% of hospital-based and 37.8% of office-based physicians with EHRs responded to the question about patient interaction. Five main themes emerged for hospital-based physicians, with respondents generally perceiving EHRs as negatively altering patient interactions. We noted the same five themes among office-based physicians, but the rank-order of the top two responses differed by setting: hospital-based physicians commented most frequently that they spend less time with patients because they have to spend more time on computers; office-based physicians commented most frequently on EHRs worsening the quality of their interactions and relationships with patients. CONCLUSION: In our analysis of a large sample of physicians, hospital-based physicians generally perceived EHRs as negatively altering patient interactions, although they emphasized different reasons than their office-based counterparts. These findings add to the prior literature, which focuses on outpatient physicians, and can shape interventions to improve how EHRs are used in inpatient settings.