Coordination of Care as Experienced by the Specialist: Validation of the CSC-Specialist Survey in the Private Sector and the Effect of a Shared Electronic Health Record.

BACKGROUND: We previously developed 2 complementary surveys to measure coordination of care as experienced by the specialist and the primary care provider (PCP). These Coordination of Specialty Care (CSC) surveys were developed in the Veterans Health Administration (VA), under an integrated organizational umbrella that includes a shared electronic health record (EHR). OBJECTIVE: To develop an augmented version of the CSC-Specialist in the private sector and use that version (CSC-Specialist 2.0) to examine the effect of a shared EHR on coordination. RESEARCH DESIGN: We administered the survey online to a national sample of clinicians from 10 internal medicine subspecialties. We used multitrait analysis and confirmatory factor analysis to evaluate the psychometric properties of the original VA-based survey and develop an augmented private sector survey (CSC-Specialist 2.0). We tested construct validity by regressing a single-item measure of overall coordination onto the 4 scales. We used analysis of variance to examine the relationship of a shared EHR to coordination. RESULTS: Psychometric assessment supported the 13-item, 4-scale structure of the original VA measure and the augmented 18-item, 4-scale structure of the CSC-Specialist 2.0. The CSC-Specialist 2.0 scales together explained 45% of the variance in overall coordination. A shared EHR was associated with significantly better scores for the Roles and Responsibilities and Data Transfer scales, and for overall coordination. CONCLUSIONS: The CSC-Specialist 2.0 is a unique survey that demonstrates adequate psychometric performance and is sensitive to use of a shared EHR. It can be used alone or with the CSC-PCP to identify coordination problems, guide interventions, and measure improvements.

A commitment to high-value care education from the internal medicine community.

The Alliance for Academic Internal Medicine, American Board of Internal Medicine (ABIM), ABIM Foundation, and American College of Physicians are collaborating to enhance the education of physicians in high-value care (HVC) and make its practice an essential competency in undergraduate and postgraduate education by 2017. This article serves as the organizations' formal commitment to providing a foundation of HVC education on which others may build. The 5 key targets for HVC education are experiential learning and curriculum, environment and culture, clinical support, regulatory requirements, and sustainability. The goal is to train future health care professionals for whom HVC is part of normal practice, thus providing patients with improved clinical outcomes at a lower cost.

Development of a high-value care subscore on the internal medicine in-training examination.

BACKGROUND: Although high-value care (HVC) that balances benefits of tests or treatments against potential harms and costs has been a recently emphasized competency for internal medicine (IM) residents, few tools to assess residents' knowledge of HVC are available. OBJECTIVE: To describe the development and initial results of an HVC subscore of the Internal Medicine In-Training Examination (IM-ITE). DESIGN: The HVC concepts were introduced to IM-ITE authors during question development. Three physicians independently reviewed each examination question for selection in the HVC subscore according to 6 HVC principles. The final subscore was determined by consensus. Data from the IM-ITE administered in October 2012 were analyzed at the program level. SETTING: U.S. IM residency programs. PARTICIPANTS: 362 U.S. IM residency programs with IM-ITE data for at least 10 residents. MEASUREMENTS: Program-level performance on the HVC subscore was compared with performance on the overall IM-ITE, the Dartmouth Atlas hospital care intensity (HCI) index of the program's primary training hospital, and residents' attitudes about HVC assessed with a voluntary survey. RESULTS: The HVC subscore comprised 38 questions, including 21 (55%) on managing conservatively when appropriate and 14 (37%) on identifying low-value care. Of the 362 U.S. IM programs in the sample, 41% were in a different quartile when ranked based on the HVC subscore compared with overall IM-ITE performance. Rankings by HVC subscore and HCI index were modestly inversely associated, with 30% of programs ranked in the same quartile based on both measures. LIMITATION: Knowledge of HVC assessed from examination vignettes may not reflect practice of HVC. CONCLUSION: Although the HVC subscore has face validity and can contribute to evaluation of residents' HVC knowledge, additional tools are needed to accurately measure residents' proficiency in HVC. PRIMARY FUNDING SOURCE: None.

Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine­American College of Physicians Curriculum.

Health care expenditures are projected to reach nearly 20% of the U.S. gross domestic product by 2020. Up to $765 billion of this spending has been identified as potentially avoidable; many of the avoidable costs have been attributed to unnecessary services. Postgraduate trainees have historically received little specific training in the stewardship of health care resources and minimal feedback on resource utilization and its effect on the cost of care. This article describes a new curriculum that was developed collaboratively by the Alliance for Academic Internal Medicine and the American College of Physicians to address this training gap. The curriculum introduces a simple, stepwise framework for delivering high-value care and focuses on teaching trainees to incorporate high-value, cost-conscious care principles into their clinical practice. It consists of ten 1-hour, case-based, interactive sessions designed to be flexibly incorporated into the existing conference structure of a residency training program.

Relationship Between Institutional Investment in High-Value Care (HVC) Performance Improvement and Internal Medicine Residents' Perceptions of HVC Training.

PURPOSE: To measure the association between institutional investment in high-value care (HVC) performance improvement and resident HVC experiences. METHOD: The authors analyzed data from two 2014 surveys assessing institutions' investments in HVC performance improvement as reported by program directors (PDs) and residents' perceptions of the frequency of HVC teaching, participation in HVC-focused quality improvement (QI), and views on HVC topics. The authors measured the association between institutional investment and resident-reported experiences using logistic regression, controlling for program and resident characteristics. RESULTS: The sample included 214 programs and 9,854 residents (59.3% of 361 programs, 55.2% of 17,851 residents surveyed). Most PDs (158/209; 75.6%) reported some support. Residents were more likely to report HVC discussions with faculty at least a few times weekly if they trained in programs that offered HVC-focused faculty development (odds ratio [OR] = 1.19; 95% confidence interval [CI] 1.04-1.37; P = .01), that supported such faculty development (OR = 1.21; 95% CI 1.04-1.41; P = .02), or that provided physician cost-of-care performance data (OR = 1.19; 95% CI 1.03-1.39; P = .02). Residents were more likely to report participation in HVC QI if they trained in programs with a formal HVC curriculum (OR = 1.83; 95% CI 1.48-2.27; P < .001) or with HVC-focused faculty development (OR = 1.46; 95% CI 1.15-1.85; P = .002). CONCLUSIONS: Institutional investment in HVC-related faculty development and physician feedback on costs of care may increase the frequency of HVC teaching and resident participation in HVC-related QI.

Feasibility of Implementing Patient Priorities Care for Older Adults with Multiple Chronic Conditions.

Older adults with multiple chronic conditions (MCCs) receive care that is fragmented and burdensome, lacks evidence, and most importantly is not focused on what matters most to them. An implementation feasibility study of Patient Priorities Care (PPC), a new approach to care that is based on health outcome goals and healthcare preferences, was conducted. This study took place at 1 primary care and 1 cardiology practice in Connecticut and involved 9 primary care providers (PCPs), 5 cardiologists, and 119 older adults with MCCs. PPC was implemented using methods based on a practice change framework and continuous plan-do-study-act (PDSA) cycles. Core elements included leadership support, clinical champions, priorities facilitators, training, electronic health record (EHR) support, workflow development and continuous modification, and collaborative learning. PPC processes for clinic workflow and decision-making were developed, and clinicians were trained. After 10 months, 119 older adults enrolled and had priorities identified; 92 (77%) returned to their PCP after priorities identification. In 56 (46%) of these visits, clinicians documented patient priorities discussions. Workflow challenges identified and solved included patient enrollment lags, EHR documentation of priorities discussions, and interprofessional communication. Time for clinicians to provide PPC remains a challenge, as does decision-making, including clinicians' perceptions that they are already doing so; clinicians' concerns about guidelines, metrics, and unrealistic priorities; and differences between PCPs and patients and between PCPs and cardiologists about treatment decisions. PDSA cycles and continuing collaborative learning with national experts and peers are taking place to address workflow and clinical decision-making challenges. Translating disease-based to priorities-aligned decision-making appears challenging but feasible to implement in a clinical setting.

A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction.

Overuse of medical services is an increasingly recognized driver of poor-quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed, evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. This interaction is influenced by other utilization drivers, including healthcare system factors, the practice environment, the culture of professional medicine, the culture of healthcare consumption, and individual patient and clinician factors. The variable strength of the evidence supporting these domains highlights important areas for further investigation. Journal of Hospital Medicine 2017;12:346-351.

Trends in High-Value Care as Reported by Internal Medicine Program Directors.

BACKGROUND: The value of care, defined as the relationship of cost, harm, and benefit, has garnered increased focus in recent years. Program directors (PDs) can provide information about resident skill and institutional priorities related to high-value care. OBJECTIVE: The objective of the study was to evaluate changes between 2012 and 2014 in PD-reported resident skills and institutional priorities related to high-value care. METHODS: We performed annual surveys of US internal medicine PDs from 2012-2014 and evaluated responses to identical questions related to high care value. The survey was developed by the American College of Physicians and the Alliance for Academic Internal Medicine. RESULTS: Response rates were 235 of 378 (62.2%) in 2012, 213 of 380 (56.1%) in 2013, and 215 of 391 (54.9%) in 2014. The majority of PDs reported that balancing benefits, harms, and costs was (1) a teaching priority; (2) the subject of didactics; (3) discussed by residents; and (4) emphasized by institutional leadership. Approximately one-third reported that unnecessary ordering occurred most or all the time, with no changes in the survey period. When asked about resident ordering compared to 3 years ago, 42.5% (88 of 207) of PDs reported residents ordering fewer unnecessary tests most or all the time in 2014, compared to 28.1% (63 of 224) in 2012 (P = .002). CONCLUSIONS: Internal medicine PDs reported high levels of institutional interest in and teaching of care value between 2012 and 2014, but responses for later years suggest improvement in trainees avoiding unnecessary testing.

Important Skills for Internship and the Fourth-Year Medical School Courses to Acquire Them: A National Survey of Internal Medicine Residents.

PURPOSE: To obtain feedback from internal medicine residents, a key stakeholder group, regarding both the skills needed for internship and the fourth-year medical school courses that prepared them for residency. This feedback could inform fourth-year curriculum redesign efforts. METHOD: All internal medicine residents taking the 2013-2014 Internal Medicine In-Training Examination were asked to rank the importance of learning 10 predefined skills prior to internship and to use a dropdown menu of 11 common fourth-year courses to rank the 3 most helpful in preparing for internship. The predefined skills were chosen based on a review of the literature, a national subinternship curriculum, and expert consensus. Chi-square statistics were used to test for differences in responses between training levels. RESULTS: Of the 24,820 internal medicine residents who completed the exam, 20,484 (83%) completed the survey, had complete identification numbers, and consented to have their responses used for research. The three skills most frequently rated as very important were identifying when to seek additional help and expertise, prioritizing clinical tasks and managing time efficiently, and communicating with other providers around care transitions. The subinternship/acting internship was most often selected as being the most helpful course in preparing for internship. CONCLUSIONS: These findings indicate which skills and fourth-year medical school courses internal medicine residents found most helpful in preparing for internship and confirm the findings of prior studies highlighting the perceived value of subinternships. Internal medicine residents and medical educators agree on the skills students should learn prior to internship.

SOAP-V: Introducing a method to empower medical students to be change agents in bending the cost curve.

Medical students must learn how to practice high-value, cost-conscious care. By modifying the traditional SOAP (Subjective-Objective-Assessment-Plan) presentation to include a discussion of value (SOAP-V), we developed a cognitive forcing function designed to promote discussion of high-value, cost-conscious care during patient delivery. The SOAP-V model prompts the student to consider (1) the evidence that supports a test or treatment, (2) the patient's preferences and values, and (3) the financial cost of a test or treatment compared to alternatives. Students report their findings to their teams during patient care rounds. This tool has been successfully used at 3 medical schools. Preliminary results find that students who have been trained in SOAP-V feel more empowered to address the economic healthcare crisis, are more comfortable in initiating discussions about value, and are more likely to consider potential costs to the healthcare system.

U.S. Internal Medicine Residents' Knowledge and Practice of High-Value Care: A National Survey.

PURPOSE: To determine U.S. internal medicine (IM) residents' knowledge of, attitudes toward, and self-reported practice of high-value care (HVC), or care that balances the benefits, harms, and costs of tests and treatments. METHOD: The authors conducted a cross-sectional survey of U.S. IM residents who took the Internal Medicine In-Training Examination in October 2012. They used multivariable mixed-effects models to examine the relationships between self-reported knowledge and practice of HVC and both exposure to HVC teaching and the care intensity of the training hospital (based on a composite age-sex-race-illness standardized measure of hospital days and inpatient physician visits by Medicare recipients). RESULTS: Of 21,617 residents who received the survey, 18,102 (83.7%) completed it. Self-reported HVC practices varied: 4,187 of 17,633 respondents (23.7%) agreed that they "share estimated costs of tests and treatments with patients"; 15,549 of 17,626 (88.2%) agreed that they "incorporate patients' values and concerns into clinical decisions." Discussions about balancing the benefits, harms, and costs of treatments with faculty during patient care at least a few times a week were reported by 7,103 of 17,704 respondents (40.1%) and were associated with all self-reported HVC practices. The training hospital's care intensity was inversely associated with self-reported incorporation of costs and patient values into clinical decisions but not with other self-reported behaviors. CONCLUSIONS: U.S. IM residents reported varying HVC knowledge and practice. Faculty discussions of HVC during patient care correlated with such knowledge and practice and may represent an opportunity to improve residents' competency in providing value-based care.