Physician Electronic Health Record Use After Changes in US Centers for Medicare & Medicaid Services Documentation Requirements.

This cohort study examines changes in physician electronic health record (EHR) documentation time before and after changes in Centers for Medicare & Medicaid evaluation and management requirements.

Trustworthy Augmented Intelligence in Health Care.

Augmented Intelligence (AI) systems have the power to transform health care and bring us closer to the quadruple aim: enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers. Earning physicians' trust is critical for accelerating adoption of AI into patient care. As technology evolves, the medical community will need to develop standards for these innovative technologies and re-visit current regulatory systems that physicians and patients rely on to ensure that health care AI is responsible, evidence-based, free from bias, and designed and deployed to promote equity. To develop actionable guidance for trustworthy AI in health care, the AMA reviewed literature on the challenges health care AI poses and reflected on existing guidance as a starting point for addressing those challenges (including models for regulating the introduction of innovative technologies into clinical care).

Effects of Health Care Payment Models on Physician Practice in the United States: Follow-Up Study.

This study, sponsored by the American Medical Association (AMA), describes how alternative payment models (APMs) affect physicians, physicians' practices, and hospital systems in the United States and also provides updated data to the original 2014 study. Payment models discussed are core payment (fee for service, capitation, episode-based and bundled), supplementary payment (shared savings, pay for performance, retainer-based), and combined payment (medical homes and accountable care organizations). The effects of changes since 2014 in the Affordable Care Act (ACA) and of new alternative payment models (APMs), such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP), are also examined. This project uses the same qualitative multiple-case study method as the 2014 study, relying primarily on semistructured interviews with physician practice leaders, physicians, and other observers. Findings describe the challenges posed by APMs, strategies adopted to deal with APMs, the effects of rapidly changing and increasingly complex payment models, and how risk aversion influences physician practices' decisions to engage in new payment models. Project findings are intended to help guide efforts by the AMA and other stakeholders to improve current and future APMs and help physician practices succeed in them.

Factors Influencing Physician Practices' Adoption of Behavioral Health Integration in the United States: A Qualitative Study.

BACKGROUND: Behavioral health integration is uncommon among U.S. physician practices despite recent policy changes that may encourage its adoption. OBJECTIVE: To describe factors influencing physician practices' implementation of behavioral health integration. DESIGN: Semistructured interviews with leaders and clinicians from physician practices that adopted behavioral health integration, supplemented by contextual interviews with experts and vendors in behavioral health integration. SETTING: 30 physician practices, sampled for diversity on specialty, size, affiliation with parent organizations, geographic location, and behavioral health integration model (collaborative or co-located). PARTICIPANTS: 47 physician practice leaders and clinicians, 20 experts, and 5 vendors. MEASUREMENTS: Qualitative analysis (cyclical coding) of interview transcripts. RESULTS: Four overarching factors affecting physician practices' implementation of behavioral health integration were identified. First, practices' motivations for integrating behavioral health care included expanding access to behavioral health services, improving other clinicians' abilities to respond to patients' behavioral health needs, and enhancing practice reputation. Second, practices tailored their implementation of behavioral health integration to local resources, financial incentives, and patient populations. Third, barriers to behavioral health integration included cultural differences and incomplete information flow between behavioral and nonbehavioral health clinicians and billing difficulties. Fourth, practices described the advantages and disadvantages of both fee-for-service and alternative payment models, and few reported positive financial returns. LIMITATION: The practice sample was not nationally representative and excluded practices that did not implement or sustain behavioral health integration, potentially limiting generalizability. CONCLUSION: Practices currently using behavioral health integration face cultural, informational, and financial barriers to implementing and sustaining behavioral health integration. Tailored, context-specific technical support to guide practices' implementation and payment models that improve the business case for practices may enhance the dissemination and long-term sustainability of behavioral health integration. PRIMARY FUNDING SOURCE: American Medical Association and The Commonwealth Fund.

A Test of Sex Estimation in Subadults Using the Elevation of the Auricular Surface from Four Samples of Known Age and Sex.

Biological sex is foundational to the work of forensic anthropologists and bioarcheologists. The lack of reliable biological sex estimation methods for subadults has, thus, greatly limited forensic and bioarcheological analyses. Auricular surface elevation showed promise as a subadult sex estimation method in previous studies. This study examined two auricular surface elevation evaluation methods on four subadult samples of known age, sex, and ancestry. Samples were scored as "male," "female," or "indeterminate" and results were examined with chi-square analysis. No consistent sex estimation pattern, accuracy, or predictive value was produced between samples. Only one test was significant using Fisher's exact test analysis (FET = 7.501, p < 0.022): the composite approach on the Hamann-Todd sample. While age, sample size, or developmental factors may play a role in these results, clearly sample variation does as well. This study found auricular surface elevation was not a useful subadult sex estimation method.

Metric Assessment of the Pubic Bone Using Known and Novel Data Points for Sex Estimation.

Biological sex estimation of skeletal remains is essential in forensic and archaeological analyses. Anthropologists most often use the pelvis, which is the most sexually dimorphic element both morphologically and metrically. While nonmetric pubic bone features have been studied extensively, few metric studies have examined this individual bone for dimorphism. For this study, three observers examined three previously identified and ten novel measurements of the pubic body on a modern sample of isolated pubic bones from the Maricopa County Forensic Science Center (FSC), in Phoenix, Arizona (n = 400). A relationship between pubic body measurements and biological sex was demonstrated, with significant correlations. Discriminant function analyses found that five measurements, four of which were novel, discriminated between males (89%) and females (86%). Observer experience level did not significantly impact the results. These five measurements were reliable and show promise for inclusion in metric methods for assessment of sex.

Methods for Developing Patient-Reported Outcome-Based Performance Measures (PRO-PMs).

OBJECTIVE: To recommend methods for assessing quality of care via patient-reported outcome-based performance measures (PRO-PMs) of symptoms, functional status, and quality of life. METHODS: A Technical Expert Panel was assembled by the American Medical Association-convened Physician Consortium for Performance Improvement. An environmental scan and structured literature review were conducted to identify quality programs that integrate PRO-PMs. Key methodological considerations in the design, implementation, and analysis of these PRO-PM data were systematically identified. Recommended methods for addressing each identified consideration were developed on the basis of published patient-reported outcome (PRO) standards and refined through public comment. Literature review focused on programs using PROs to assess performance and on PRO guidance documents. RESULTS: Thirteen PRO programs and 10 guidance documents were identified. Nine best practices were developed, including the following: provide a rationale for measuring the outcome and for using a PRO-PM; describe the context of use; select a measure that is meaningful to patients with adequate psychometric properties; provide evidence of the measure's sensitivity to differences in care; address missing data and risk adjustment; and provide a framework for implementation, interpretation, dissemination, and continuous refinement. CONCLUSION: Methods for integrating PROs into performance measurement are available.

Postmarket surveillance of medical devices: current capabilities and future opportunities.

Recalls of cardiac implantable electrical devices (CIEDs) currently impact hundreds of thousands of patients worldwide. Premarket evaluation of CIEDs cannot be expected to eliminate all performance defects. Robust postmarket surveillance systems are needed to promote patient safety and reduce harm. Challenges impacting existing surveillance mechanisms include underreporting of defects, low rates of return of explanted CIEDs, lack of integration of surveillance into normal workflow, underutilization of existing resources including registries, a lack of capacity of aging resources, multiple proprietary platforms that lack interoperability, and the unmet need for common data variables as well as newer methods to generate, synthesize, analyze, and interpret evidence in order to respond rapidly to safety signals. Long-term solutions include establishing a unique device identification system; promoting expanded use of registries for surveillance and post-approval studies; developing additional methods to combine evidence from diverse data sources; creating tools and implementing strategies for universal automatic, triggered electronic event reporting; and refining methods to rapidly identify and interpret safety signals. Protection from litigation and creation of financial and other incentives by legislators, regulators, payers, accreditation organizations, and licensing boards can be expanded to increase participation in device surveillance by clinicians and health care facilities. Research to evaluate the comparative effectiveness of surveillance strategies is needed. Interim solutions to improve CIED surveillance while new initiatives are launched and the system strengthened are also presented.

Consequences of use of anabolic androgenic steroids.

Whether providing anticipatory guidance to the young adolescent patient, conducting a preparticipation examination on a young athlete, or treating a sick user of anabolic androgenic steroids (AASs), the primary care physician must be familiar with the adverse consequences of the use of these compounds. This article reviews the endocrine, cardiovascular, neuropsychiatric, musculoskeletal, hematologic, hepatic, and miscellaneous effects of AASs, highlighting effects reported in children and adolescents, and relying on consequences in adults when pediatric data is unavailable.