Patients Contributing to Visit Notes: Mixed Methods Evaluation of OurNotes.

BACKGROUND: Secure patient portals are widely available, and patients use them to view their electronic health records, including their clinical notes. We conducted experiments asking them to cogenerate notes with their clinicians, an intervention called OurNotes. OBJECTIVE: This study aims to assess patient and provider experiences and attitudes after 12 months of a pilot intervention. METHODS: Before scheduled primary care visits, patients were asked to submit a word-constrained, unstructured interval history and an agenda for what they would like to discuss at the visit. Using site-specific methods, their providers were invited to incorporate the submissions into notes documenting the visits. Sites served urban, suburban, and rural patients in primary care practices in 4 academic health centers in Boston (Massachusetts), Lebanon (New Hampshire), Denver (Colorado), and Seattle (Washington). Each practice offered electronic access to visit notes (open notes) to its patients for several years. A mixed methods evaluation used tracking data and electronic survey responses from patients and clinicians. Participants were 174 providers and 1962 patients who submitted at least 1 previsit form. We asked providers about the usefulness of the submissions, effects on workflow, and ideas for the future. We asked patients about difficulties and benefits of providing the requested information and ideas for future improvements. RESULTS: Forms were submitted before 9.15% (5365/58,652) eligible visits, and 43.7% (76/174) providers and 26.76% (525/1962) patients responded to the postintervention evaluation surveys; 74 providers and 321 patients remembered receiving and completing the forms and answered the survey questions. Most clinicians thought interim patient histories (69/74, 93%) and patient agendas (72/74, 97%) as good ideas, 70% (52/74) usually or always incorporated them into visit notes, 54% (40/74) reported no change in visit length, and 35% (26/74) thought they saved time. Their most common suggestions related to improving notifications when patient forms were received, making it easier to find the form and insert it into the note, and educating patients about how best to prepare their submissions. Patient respondents were generally well educated, most found the history (259/321, 80.7%) and agenda (286/321, 89.1%) questions not difficult to answer; more than 92.2% (296/321) thought sending answers before the visit a good idea; 68.8% (221/321) thought the questions helped them prepare for the visit. Common suggestions by patients included learning to write better answers and wanting to know that their submissions were read by their clinicians. At the end of the pilot, all participating providers chose to continue the OurNotes previsit form, and sites considered expanding the intervention to more clinicians and adapting it for telemedicine visits. CONCLUSIONS: OurNotes interests patients, and providers experience it as a positive intervention. Participation by patients, care partners, clinicians, and electronic health record experts will facilitate further development.

Coaching for primary care physician well-being: A randomized trial and follow-up analysis.

Primary Care Physicians (PCPs) are integral to the health of all people in the U.S. Many PCPs experience burnout, and declines in well-being. We conducted a randomized controlled trial of a six-session positive psychology-based coaching intervention to improve PCP personal and work-related well-being and decrease stress and burnout. Fifty-nine U.S.-based PCPs were randomized into a primary (n = 29) or a waitlisted control group (n = 30). Outcome measures were assessed preintervention, postintervention, and at three and six months post-intervention. Hypotheses 1a-1h were for a randomized controlled trial test of coaching on PCP burnout (a), stress (b), turnover intentions (c), work engagement (d), psychological capital (e), compassion (f), job self-efficacy (g), and job satisfaction (h). Results from 50 PCPs who completed coaching and follow-up assessments indicated significantly decreased burnout (H1a) and increased work engagement (H1d), psychological capital (H1e), and job satisfaction (H1h) for the primary group from pre- to postcoaching, compared to changes between comparable time points for the waitlisted group. Hypotheses 2a-2h were for stability of positive effects and were tested using follow-up data from participants in the primary and waitlisted groups combined. Results from 39 PCPs who completed the intervention and the six-month follow-up indicated that positive changes observed for H1a, H1d, H1e, and H1h were sustained during a six-month follow-up (supporting H2a, H2d, H2e, and H2h). Results indicate that coaching is a viable and effective intervention for PCPs in alleviating burnout and improving well-being. We recommend that employers implement coaching for PCPs alongside systemic changes to work factors driving PCP burnout. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

False-Negative Urine Human Chorionic Gonadotropin Testing in the Clinical Laboratory.

BACKGROUND: Human chorionic gonadotropin (hCG) assays are used to detect pregnancy, and urine point-of-care tests are frequently used to triage patients. Under certain conditions, urine tests can fail to detect pregnancy, which can have serious consequences for patient management. OBJECTIVES: To understand the prevalence of different factors contributing to false-negative urinary hCG testing results at our institution. METHODS: Clinical data for patients with negative urine hCG results and subsequent positive or equivocal serum hCG results within a 1-year period were reviewed. RESULTS: Out of 9447 negative urine hCG results, 11 potential missed diagnoses were identified, with early gestational age as the most common factor, followed by ß-core hook effects. CONCLUSIONS: Although false-negative urine hCG test results are rare, understanding the commonly encountered reasons for inaccurate testing results can help clinical centers develop strategies to minimize risk for patients.

Implementation of diagnostic pauses in the ambulatory setting.

BACKGROUND: Diagnostic errors result in preventable morbidity and mortality. The outpatient setting may be at increased risk, where time constraints, the indolent nature of outpatient complaints and single decision-maker practice models predominate. METHODS: We developed a self-administered diagnostic pause to address diagnostic error. Clinicians (physicians and nurse practitioners) in an academic primary care setting received the tool if they were seeing urgent care patients who had previously been seen in the past two weeks in urgent care. We used pre-post-intervention surveys, focus groups and chart audits 6 months after the urgent care visit to assess the impact of the intervention on participant perceptions and actions. RESULTS: We piloted diagnostic pauses in two phases (3 months and 6 months, respectively); 9 physicians participated in the first phase, and 16 physicians and 2 nurse practitioners in the second phase. Subjects received 135 alerts for diagnostic pauses and responded to 82 (61% response). Thirteen per cent of alerts resulted in clinicians reporting new actions as a result of the diagnostic pauses. Thirteen per cent of cases at a 6-month chart audit resulted in diagnostic discrepancies, defined as differences in diagnosis from the initial working diagnosis. Focus groups reported that the diagnostic pauses were brief and fairly well integrated into the overall workflow for evaluation but would have benefited as a real-time application for patients at higher risk for diagnostic error. CONCLUSION: This pilot represents the first known examination of diagnostic pauses in the outpatient setting, and this work potentially paves the way for more broad-based systems and/or electronic interventions to address diagnostic error.

Use of an electronic medical record reminder improves HIV screening.

BACKGROUND: More than 1 in 7 patients with human immunodeficiency virus (HIV) infection in the United States are unaware of their serostatus despite recommendations of US agencies that all adults through age 65 be screened for HIV at least once. To facilitate universal screening, an electronic medical record (EMR) reminder was created for our primary care practice. Screening rates before and after implementation were assessed to determine the impact of the reminder on screening rates. METHODS: A retrospective cohort analysis was performed for patients age 18-65 with visits between January 1, 2012-October 30, 2014. EMR databases were examined for HIV testing and selected patient characteristics. We evaluated the probability of HIV screening in unscreened patients before and after the reminder and used a multivariable generalized linear model to test the association between likelihood of HIV testing and specific patient characteristics. RESULTS: Prior to the reminder, the probability of receiving an HIV test for previously unscreened patients was 15.3%. This increased to 30.7% after the reminder (RR 2.02, CI 1.95-2.09, p < 0.0001). The impact was most significant in patients age 45-65. White race, English as primary language, and higher median household income were associated with lower likelihoods of screening both before and after implementation (RR 0.68, CI 0.65-0.72; RR 0.74, CI 0.67-0.82; RR 0.84, CI 0.80-0.88, respectively). CONCLUSIONS: The EMR reminder increased rates of HIV screening twofold in our practice. It was most effective in increasing screening rates in older patients. Patients who were white, English-speaking, and had higher incomes were less likely to be screened for HIV both before and after the reminder.

The Effects of Resident Peer- and Self-Chart Review on Outpatient Laboratory Result Follow-up.

PURPOSE: Performing and teaching appropriate follow-up of outpatient laboratory results (LRs) is a challenge. The authors tested peer-review among residents as a potentially valuable intervention. METHOD: Investigators assigned residents to perform self-review (n = 27), peer-review (n = 21), or self- + peer-review (n = 30) of outpatient charts. They also compared residence performance with that of historical controls (n = 20). In September 2012, residents examined 10 LRs from April 2012 onward. A second review in November 2012 ascertained whether performing chart review improved residents' practice behaviors. RESULTS: Initially, the least-square (LS) mean number of LRs without documentation of follow-up per resident in the self-, peer-, and self- + peer-review group was, respectively, 0.5 (SD 1.0), 1.0 (SD 1.7), and 0.9 (SD 1.3), and post intervention, this was 1.0 (SD 0.2), 0.3 (SD 0.2), and 0.6 (SD 0.2) (self- versus peer-review P = .03). Initially the LS mean follow-up time per resident in the self-, peer-, and self- + peer-review group was, respectively, 4.2 (SD 1.2), 6.9 (SD 1.4), and 5.9 (SD 1.2) days, and after the intervention, LS mean time was 5.0 (SD 0.5), 2.5 (SD 0.6), and 3.9 (SD 0.5) days (self- versus peer-review P < .01). Self-review was not associated with significant improvements in practice. CONCLUSIONS: In this comparison of self- and peer-review, only residents who performed peer-review demonstrated significant improvements in their documentation practices. These findings support the use of resident peer-review in improving LR follow-up, and potentially, in other, broader resident quality improvement initiatives.

Communicate, don't litigate: The Schwartz Center Connections Program.

Little is known about effective educational approaches intended to reduce malpractice risk by improving communication with patients and among multidisciplinary teams in outpatient settings in order to prevent diagnostic delays and errors. This article discusses a prospective, controlled educational intervention that aimed to open lines of communication among teams in two disciplines: identifying how and why communication lapses occur between disciplines and with patients, and articulating strategies to avert them.

The revolving door of resident continuity practice: identifying gaps in transitions of care.

BACKGROUND: It is well documented that transitions of care pose a risk to patient safety. Every year, graduating residents transfer their patient panels to incoming interns, yet in our practice we consistently find that approximately 50% of patients do not return for follow-up care within a year of their resident leaving. OBJECTIVE: To examine the implications of this lapse of care with respect to chronic disease management, follow-up of abnormal test results, and adherence with routine health care maintenance. DESIGN: Retrospective chart review SUBJECTS: We studied a subset of patients cared for by 46 senior internal medicine residents who graduated in the spring of 2008. 300 patients had been identified as high priority requiring follow-up within a year. We examined the records of the 130 of these patients who did not return for care. MAIN MEASURES: We tabulated unaddressed abnormal test results, missed health care screening opportunities and unmonitored chronic medical conditions. We also attempted to call these patients to identify barriers to follow-up. KEY RESULTS: These patients had a total of 185 chronic medical conditions. They missed a total of 106 screening opportunities including mammogram (24), Pap smear (60) and colon cancer screening (22). Thirty-two abnormal pathology, imaging and laboratory test results were not followed-up as the graduating senior intended. Among a small sample of patients who were reached by phone, barriers to follow-up included a lack of knowledge about the need to see a physician, distance between home and our office, difficulties with insurance, and transportation. CONCLUSIONS: This study demonstrates the high-risk nature of patient handoffs in the ambulatory setting when residents graduate. We discuss changes that might improve the panel transfer process.