Optimization of Electronic Health Record Usability Through a Department-Led Quality Improvement Process.

BACKGROUND: Electronic health records (EHR) have become commonplace in medicine. A disconnect between developers and users while creating the interface often fails to create a product that captures clinical workflow, and issues become apparent with implementation. Optimization allows collaboration of clinicians and informaticists after implementation, but documentation of success has only been at the institutional level. METHODS: A 4-month, department-wide EHR optimization was conducted with information technology (IT). Optimizations were developed from an intensive quality improvement process involving all levels of clinicians and clinical staff. The optimizations were then categorized as accommodations (department adjusted workflow to EHR), creations (IT developed new workflows within EHR), discoveries (department found workflows within EHR), and modifications (IT changed workflows within EHR). Departmental productivity, defined as number of visits, charges, and payments, was standardized to ratios prior to the COVID-19 pandemic and evaluated by Taylor's change point analysis. Significant improvements were defined as shifts (change points), trends (5 or more consecutive values above/below the mean), and values outside 95% CIs. RESULTS: The 124 optimizations were categorized as 43 accommodations, 13 creations, 54 discoveries, and 14 modifications. Productivity ratios of monthly charges (0.74 to 1.28) and payments (0.83 to 1.58) significantly improved with the optimization efforts. Monthly visit ratios increased (0.65 to 0.98) but did not change significantly. CONCLUSION: Departmental collaboration with organizational IT for EHR optimization focused on detailed analysis of how workflows can impact productivity. Discovery optimization predominance indicates many solutions to EHR usability problems were already in the system. A large proportion of accommodation optimizations reinforced the need for better developer-user collaboration before implementation.Annals Early Access.

Targeted care coordination towards patients with a history of multiple readmissions effectively reduces readmissions.

BACKGROUND: To decrease hospital readmission rates, clinical practices create a transition of care (TOC) process to assess patients and coordinate care postdischarge. As current evidence suggests lack of universal benefit, this study's objectives are to determine what patient and process factors associate with hospital readmissions, as well as construct a model to decrease 30-day readmissions. METHODS: Three months of retrospective discharged patient data (n = 123) were analysed for readmission influences including: patient-specific comorbidities, admission-specific diagnoses, and TOC components. A structured intervention of weekly contact, the Care Coordination Cocoon (CCC), was created for multiply readmitted patients (MRPs), defined as ≥2 readmissions. Three months of postintervention data (n = 141) were analysed. Overall readmission rates and patient- and process-specific characteristics were analysed for associations with hospital readmission. RESULTS: Standard TOC lacked significance. Patient-specific comorbidities of cancer (odds ratio [OR] 6.27; 95% confidence interval [CI] 1.73-22.75) and coronary artery disease (OR 6.71; 95% CI 1.84-24.46), and admission-specific diagnoses within pulmonary system admissions (OR 7.20; 95% CI 1.96-26.41) were associated with readmissions. Post-CCC data demonstrated a 48-h call (OR 0.21; 95% CI 0.09-0.50), answered calls (OR 0.16; CI 0.07-0.38), 14-day scheduled visit (OR 0.20; 95% CI 0.07-0.54), and visit arrival (OR 0.39; 95% CI 0.17-0.91) independently associated with decreased readmission rate. Patient-specific (hypertension-OR 3.65; CI 1.03-12.87) and admission-specific (nephrologic system-OR 3.22; CI 1.02-10.14) factors associated with readmissions which differed from the initial analysis. CONCLUSIONS: Targeting a practice's MRPs with CCC resources improves the association of TOC components with readmissions and rates decreased. This is a more efficient use of TOC resources.

Building a Culture of Scholarship Within a Family Medicine Department: a Successful Eight-Year Journey of Incremental Interventions Following a Historical Perspective of Family Medicine Research.

BACKGROUND AND OBJECTIVES: Family medicine (FM), a discipline that eschewed worshiping the ivory tower of research in favor of patient care, has struggled with its role in the world of scholarly activity. FM residencies mirror this conflict despite the Accreditation Council for Graduate Medical Education's requirements for creating an environment of inquiry and scholarship. Because of this, the faculty within the Department of Family and Community Health (dFCH) at Marshall University changed its culture of scholarship. METHODS: A faculty-driven needs-based assessment of the department's strengths and deficiencies for enhancing scholarship was conducted. A three-pronged approach of creating motivation, developing an infrastructure, and consolidating resources was created. This process was periodically re-evaluated and augmented. Departmental scholarly activity, defined as both publications and presentations, was tracked for an eight year period. RESULTS: Scholarly output increased by 483% (6 to 29) in year 1 and 10-fold by year 8 (6 to 60) from the pre-culture change baseline. This represents one- and eight-year increases for both publications (4 to 6 and 4 to 18 respectively) and presentations (2 to 23 and 2 to 42 respectively). Scholarly involvement became more widespread among faculty (n = 30) and increased linearly for residents (n = 19) and students (n = 13). CONCLUSION: Through a series of needs-based interventions with consistent reanalysis, the dFCH changed its culture of scholarship. Understanding that other departments have similar competing interests to negotiate, the principles of creating motivation, developing research infrastructure, and consolidating resources could be successfully applied elsewhere.

A Free Clinic Continuity Experience During Residency Is Associated With Practice in Underserved Areas.

BACKGROUND: Exposure to underserved areas during training may increase residents' likelihood of practice in these settings. The Marshall University Family Medicine Residency offers a supplemental continuity experience at a local free clinic to interested residents. OBJECTIVE: We assessed the association of such an experience with graduate practice choices. METHODS: We evaluated all residency graduates (N = 138) who completed our family medicine program from 1997 through 2014 and compared participants in the free clinic experience to nonparticipants. Various characteristics and outcome measures were collected retrospectively from resident records maintained for program accreditation. RESULTS: A total of 43 residents participated in the free clinic experience compared with 95 nonparticipants. Postgraduation practice in an area of need was seen for 56% (24 of 43) of participants compared with 31% (29 of 95) of nonparticipants (P = .005). The 53 graduates practicing in areas of need were nearly twice as likely to have taken part in the free clinic experience (45% [24 of 53] versus 22% [19 of 85], P = .005). Participants were more likely to practice in rural areas (63%, 27 of 43) than residents who did not participate (43% [41 of 95], P = .033). Board certification rates were high for both free clinic participants (98%, 42 of 43) and nonparticipants (95% [90 of 95], P = .43). CONCLUSIONS: Resident participation in a supplemental continuity experience at a free clinic was associated with practicing in areas of need and rural communities after graduation.

The Marshall Family Medicine Residency twINTERN Schedule: The Impact of an Innovative Hospital Coverage Scheme on Resident Fatigue.

BACKGROUND AND OBJECTIVES: Work hour restriction has strained the balance between resident service and education. Night Float (NF) rotations are a popular answer to managing this balance but weakens continuity, an essential tenant of family medicine. An innovative short call system for Marshall University's Family Medicine Hospital Service (FMHS), the twINTERN call model, was created in response. We studied the impact of this approach on resident fatigue. METHODS: Anonymous surveys assessed fatigue of the Marshall University's 2013-2014 Family Medicine intern resident class while on NF rotations (ICU, Pediatrics and Surgery) and the twINTERN call. Stanford Sleepiness Score (SSS) and Epworth Sleepiness Score (ESS) were administered trimonthly. RESULTS were categorized 'Alert' or 'Fatigued' and evaluated by Chi Square analysis. Also, outpatient office frequency was evaluated. RESULTS: 146 surveys were completed by eight residents. More even distribution of resident office experience was seen. The twINTERN call model didn't show worsening fatigue compared to NF systems in any parameter measured. It was superior mitigating fatigue by ESS for night shifts (P value 0.047). While fatigue was statistically worse for night float rotations by both parameters (ESS P value = 0.009; SSS P value = 0.008), the twINTERN call model only showed worsening fatigue in the SSS (P value = 0.038). CONCLUSIONS: Our study demonstrated that the twINTERN Call Model, which allows for improved continuity on the inpatient service, was at least as effective, and by some parameters superior to NF systems for mitigating resident fatigue.

The accelerated residency program: the Marshall University family practice 9-year experience.

BACKGROUND: In 1989, the American Board of Family Practice (ABFP) approved the first of 12 accelerated residency programs in family practice. These experimental programs provide a 1-year experience for select medical students that combines the requirements of the fourth year of medical school with those of the first year of residency, reducing the total training time by 1 year. This paper reports on the achievements and limitations of the Marshall University accelerated residency program over a 9-year period that began in 1992. METHODS: Several parameters have been monitored since the inception of the accelerated program and provide the basis for comparison of accelerated and traditional residents. These include initial resident characteristics, performance outcomes, and practice choices. RESULTS: A total of 16 students were accepted into the accelerated track from 1992 through 1998. During the same time period, 44 residents entered the traditional residency program. Accelerated resident tended to be older and had more career experience than their traditional counterparts. As a group, the accelerated residents scored an average of 30 points higher on the final in-training exams provided by the ABFP. All residents in both groups remained at Marshall to complete the full residency training experience, and all those who have taken the ABFP certifying exam have passed. Accelerated residents were more likely to practice in West Virginia, consistent with one of the initial goals for the program. In addition, accelerated residents were more likely to be elected chief resident and choose an academic career than those in the traditional group. Both groups opted for small town or rural practice equally. CONCLUSIONS: The Marshall University family practice 9-year experience with the accelerated residency track demonstrates that for carefully selected candidates, the program can provide an overall shortened path to board certification and attract students who excel academically and have high leadership potential. Reports from other accelerated programs are needed to fully assess the outcomes of this experiment in postgraduate medical education.

Knowledge and perceptions of the Affordable Care Act by uninsured patients at a free clinic.

The Affordable Care Act (ACA) has as one of its main objectives to reduce the number of uninsured Americans. The understanding of the ACA reforms by uninsured patients will likely influence the degree of success in achieving this objective. This study assessed the basic knowledge and opinions regarding the ACA of patients at a free clinic and the impact of a brief educational intervention on respondents' knowledge and opinions. One hundred uninsured adult patients completed a brief survey about the ACA before and after viewing a video outlining the major features of the act. The study cohort initially performed worse than national polls on all knowledge questions. Significant improvement was observed after the educational video. Our study suggests a need for educational efforts directed at those individuals most likely to benefit from the ACA. We demonstrated that a brief intervention during a routine office visit may improve knowledge of the ACA.

Comparison of academic and practice outcomes of rural and traditional track graduates of a family medicine residency program.

PURPOSE: The Marshall University Family Medicine Residency (MUFMR) implemented its rural track (RT) in 1994 to help achieve its mission of producing primary care physicians for practice in rural areas and West Virginia. This study examined the impact of the RT on the program's training outcomes and assessed the academic equivalence of the RT and traditional track (TT) curricula. METHOD: The authors analyzed academic outcomes (in-training examination [ITE] scores, board certification rates) and practice outcomes (location and type following graduation) for the 174 MUFMR graduates who entered the program from 1984 through 2006. They compared RT and TT graduates who entered after RT implementation (1994-2006) with each other and with graduates who entered during the decade before implementation (1984-1993). RESULTS: There were differences between the 12 RT and 94 TT graduates in rural practice upon graduation (RT: 83% versus TT: 40%; P<.01) and practice in West Virginia (RT 83% versus TT 68%; P=.34). RT and TT graduates had similar mean increases in ITE scores and board certification rates. The 106 post-implementation graduates had a significantly higher rate of West Virginia practice than did the 68 pre-implementation graduates (70% versus 52%; P=.02). CONCLUSIONS: RT development was associated with a substantial increase in MUFMR graduates practicing in West Virginia. RT graduates were more likely than TT graduates to practice in rural areas and in the state upon graduation. RT graduates seem to advance academically as well as their TT counterparts.