Qualitative Assessment of Rapid System Transformation to Primary Care Video Visits at an Academic Medical Center.

BACKGROUND: The coronavirus disease 2019 pandemic spurred health systems across the world to quickly shift from in-person visits to safer video visits. OBJECTIVE: To seek stakeholder perspectives on video visits' acceptability and effect 3 weeks after near-total transition to video visits. DESIGN: Semistructured qualitative interviews. SETTING: 6 Stanford general primary care and express care clinics at 6 northern California sites, with 81 providers, 123 staff, and 97 614 patient visits in 2019. PARTICIPANTS: 53 program participants (overlapping roles as medical providers [n = 20], medical assistants [n = 16], nurses [n = 4], technologists [n = 4], and administrators [n = 13]) were interviewed about video visit transition and challenges. INTERVENTION: In 3 weeks, express care and primary care video visits increased from less than 10% to greater than 80% and from less than 10% to greater than 75%, respectively. New video visit providers received video visit training and care quality feedback. New system workflows were created to accommodate the new visit method. MEASUREMENTS: 9 faculty, trained in qualitative research methods, conducted 53 stakeholder interviews in 4 days using purposeful (administrators and technologists) and convenience (medical assistant, nurses, and providers) sampling. A rapid qualitative analytic approach for thematic analysis was used. RESULTS: The analysis revealed 12 themes, including Pandemic as Catalyst; Joy in Medicine; Safety in Medicine; Slipping Through the Cracks; My Role, Redefined; and The New Normal. Themes were analyzed using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to identify critical issues for continued program utilization. LIMITATIONS: Evaluation was done immediately after deployment. Although viewpoints may have evolved later, immediate evaluation allowed for prompt program changes and identified broader issues to address for program sustainability. CONCLUSION: After pandemic-related systems transformation at Stanford, critical issues to sustain video visit long-term viability were identified. Specifically, technology ease of use must improve and support multiparty videoconferencing. Providers should be able to care for their patients, regardless of geography. Providers need decision-making support with virtual examination training and home-based patient diagnostics. Finally, ongoing video visit reimbursement should be commensurate with value to the patients' health and well-being. PRIMARY FUNDING SOURCE: Stanford Department of Medicine and Stanford Health Care.

Predicting Turnover: The Moderating Effect of Functional Climates on Emotional Exhaustion and Work Attitudes.

High levels of emotional exhaustion are frequently reported among clinicians working in community mental health settings. This study draws on social exchange theory and examines the relationships between emotional exhaustion and mental health provider work attitudes and turnover, and the moderating effect of functional psychological climates. Data were analyzed using multilevel structural equation modeling in a sample of 311 mental health providers from 49 community mental health programs. Results revealed that emotional exhaustion was negatively related to work attitudes, and the relationship was moderated by functional climates characterized by high levels of cooperation, growth and advancement opportunities, and role clarity. Specifically, the relationship between emotional exhaustion and work attitudes was attenuated for providers working in programs with a more functional psychological climate. Lower work attitudes significantly predicted higher clinician turnover. Results are discussed as they relate to improving climates and enhancing mental health provider and organizational well-being.

Urinary incontinence in pregnant adolescents: A case series.

AIMS: Determine the severity of urinary incontinence (UI) and its effect on the quality of life (QoL) of pregnant adolescents, as well as explore the strategies used to manage UI and the reporting/investigation of this condition by healthcare professionals. METHODS: A case series was conducted in three Brazilian public hospitals that offer prenatal care. Inclusion criteria were: age between 10 and 19 years, gestational age of 27 weeks or more, and reported UI in the third trimester of pregnancy. All volunteers responded to the Incontinence Severity Index (to assess severity of UI) and the International Consultation on Incontinence Questionnaire for Urinary Incontinence-Short Form (to evaluate the effect of UI on QoL). A descriptive analysis of data were done. RESULTS: A total of 329 incontinent pregnant adolescents with mean age of 17.09 years (95%CI 16.92-17.26), who reported voiding urgency (72.0%), increased daytime urinary frequency (75.1%), nocturia (96.7%), and mixed UI (44.1%) were included in the study. UI was considered moderate to severe (79.3%) and had a moderate effect on QoL (mean 9.84; 95%CI 9.40-10.28). The volunteers used UI management strategies (66.6%), with bladder emptying prior to activities (56.8%) and the use of sanitary pads (29.5%) most frequently reported. UI is not disclosed voluntarily (89.1%) or explored by healthcare professionals (91.2%). CONCLUSION: UI can be moderate to severe and has a moderate effect on QoL in incontinent pregnant adolescents, who use strategies to manage this condition. Healthcare professionals do not identify this urinary symptom during prenatal care.

Training future clinicians in telehealth competencies: outcomes of a telehealth curriculum and teleOSCEs at an academic medical center.

Background: This study describes the program and learning outcomes of a telehealth skills curriculum based on the Association of American Medical Colleges (AAMC) telehealth competencies for clerkship-level medical students. Methods: A total of 133 third- and fourth-year medical students in a required family medicine clerkship at Stanford University School of Medicine participated in a telehealth curriculum, including a telehealth workshop, site-specific telehealth clinical encounters, and telemedicine objective structured clinical examinations (teleOSCEs) between July 2020 and August 2021. Their workshop communication and physical examination competencies were assessed in two teleOSCEs utilizing a novel telehealth assessment tool. Students' attitudes, skills, and self-efficacy were assessed through voluntary pre-clerkship, post-workshop, and post-OSCE surveys. Discussion: Most learners reported low confidence in their telehealth physical examinations [n = 79, mean = 1.6 (scale 0-5, 5 = very confident, SD = 1.0)], which improved post-workshop [n = 69, 3.3 (0.9), p < 0.001]; almost all (97%, 70/72) felt the workshop prepared them to see patients in the clinic. In formative OSCEs, learners demonstrated appropriate "webside manner" (communication scores 94-99%, four items) but did not confirm confidentiality (21%) or review limitations of the visit (35%). In a low back pain OSCE, most learners assessed pain location (90%) and range of motion (87%); nearly half (48%) omitted strength testing. Conclusion: Our telehealth curriculum demonstrated that telehealth competencies can be taught and assessed in medical student education. Improvement in self-efficacy scores suggests that an 80-min workshop can prepare students to see patients in the clinical setting. Assessment of OSCE data informs opportunities for growth for further development in the curriculum, including addressing visit limitations and confidentiality in telehealth visits.

Transforming Interprofessional Roles During Virtual Health Care: The Evolving Role of the Medical Assistant, in Relationship to National Health Profession Competency Standards.

INTRODUCTION: Medical assistants (MAs) were once limited to obtaining vital signs and office work. Now, MAs are foundational to team-based care, interacting with patients, systems, and teams in many ways. The transition to Virtual Health during the COVID-19 pandemic resulted in a further rapid and unique shift of MA roles and responsibilities. We sought to understand the impact of this shift and to place their new roles in the context of national professional competency standards. METHODS: In this qualitative, grounded theory study we conducted semi-structured interviews with 24 MAs at 10 primary care sites at a major academic medical center on their experiences during the shift from in-person to virtual care. MAs were selected by convenience sample. Coding was done in Dedoose version 8.335. Consensus-based inductive and deductive approaches were used for interview analysis. Identified MA roles were compared to national MA, Institute of Medicine, physician, and nursing professional competency domains. RESULTS: Three main themes emerged: Role Apprehension, Role Expansion, and Adaptability/Professionalism. Nine key roles emerged in the context of virtual visits: direct patient care (pre-visit and physical care), panel management, health systems ambassador, care coordination, patient flow coordination, scribing, quality improvement, and technology support. While some prior MA roles were limited by the virtual care shift, the majority translated directly or expanded in virtual care. Identified roles aligned better with Institute of Medicine, physician, and nursing professional competencies, than current national MA curricula. CONCLUSIONS: The transition to Virtual Health decreased MA's direct clinical work and expanded other roles within interprofessional care, notably quality improvement and technology support. Comparison of the current MA roles with national training program competencies identified new leadership and teamwork competencies which could be expanded during MA training to better support MA roles on inter-professional teams.