Goals of Care Documentation: Insights from A Pilot Implementation Study.

CONTEXT: The Life Sustaining Treatment Decision Initiative is a national effort by the Veterans Health Administration to ensure goals of care documentation occurs among all patients at high risk of life-threatening events. OBJECTIVES: Examine likelihood to receive goals of care documentation and explore associations between documentation and perceived patient care experience at the individual and site level. METHODS: Retrospective, quality improvement analysis of initiative pilot data from four geographically diverse Veterans Affairs (VA) sites (Fall 2014-Winter 2016) before national roll-out. Goals of care documentation according to gender, marital status, urban/rural status, race/ethnicity, age, serious health condition, and Care Assessment Needs scores. Association between goals of care documentation and perceived patient care experience analyzed based on Bereaved Family Survey outcomes of overall care, communication, and support. RESULTS: Veterans were more likely to have goals of care documentation if widowed, urban residents, and of white race. Patients older than 65-years and those with a higher Care Assessment Needs score were twice as likely as a frail patient to have goals of care documented. One pilot site demonstrated a positive association between documentation and perceived support. Pilot site was a statistically significant predictor of the occurrence of goals of care documentation and Bereaved Family Survey scores. CONCLUSION: Older and seriously ill patients were most likely to have goals of care documented. Association between a documented goals of care conversation and perceived patient care experience were largely unsupported. Site-level largely contributed to understanding the likelihood of documentation and care experience.

Provider Perceptions of Virtual Care During the Coronavirus Disease 2019 Pandemic: A Multispecialty Survey Study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to a dramatic increase in virtual care (VC) across outpatient specialties, but little is known regarding provider acceptance of VC. OBJECTIVE: The objective of this study was to assess provider perceptions of the quality, efficiency, and challenges of VC versus in-person care with masks. DESIGN: This was a voluntary survey. PARTICIPANTS: Mental health (MH), primary care, medical specialty, and surgical specialty providers across the 8 VA New England Healthcare System medical centers. MEASURES: Provider ratings of: (1) quality and efficiency of VC (phone and video telehealth) compared with in-person care with masks; (2) challenges of VC; and (3) percentage of patients that providers are comfortable seeing via VC in the future. RESULTS: The sample included 998 respondents (49.8% MH, 20.6% primary care, 20.4% medical specialty, 9.1% surgical specialty; 61% response rate). Most providers rated VC as equivalent to or higher in quality and efficiency compared with in-person care with masks. Quality ratings were significantly higher for video versus phone (χ2=61.4, P<0.0001), but efficiency ratings did not differ significantly. Ratings varied across specialties (highest in MH, lowest in SS; all χ2s>24.1, Ps<0.001). Inability to conduct a physical examination and patient technical difficulties were significant challenges. MH providers were comfortable seeing a larger proportion of patients virtually compared with the other specialties (all χ2s>12.2, Ps<0.01). CONCLUSIONS: Broad provider support for VC was stratified across specialties, with the highest ratings in MH and lowest ratings in SS. Findings will inform the improvement of VC processes and the planning of health care delivery during the COVID-19 pandemic and beyond.

Use, Perceived Usability, and Barriers to Implementation of a Patient Safety Dashboard Integrated within a Vendor EHR.

BACKGROUND: Preventable adverse events continue to be a threat to hospitalized patients. Clinical decision support in the form of dashboards may improve compliance with evidence-based safety practices. However, limited research describes providers' experiences with dashboards integrated into vendor electronic health record (EHR) systems. OBJECTIVE: This study was aimed to describe providers' use and perceived usability of the Patient Safety Dashboard and discuss barriers and facilitators to implementation. METHODS: The Patient Safety Dashboard was implemented in a cluster-randomized stepped wedge trial on 12 units in neurology, oncology, and general medicine services over an 18-month period. Use of the Dashboard was tracked during the implementation period and analyzed in-depth for two 1-week periods to gather a detailed representation of use. Providers' perceptions of tool usability were measured using the Health Information Technology Usability Evaluation Scale (rated 1-5). Research assistants conducted field observations throughout the duration of the study to describe use and provide insight into tool adoption. RESULTS: The Dashboard was used 70% of days the tool was available, with use varying by role, service, and time of day. On general medicine units, nurses logged in throughout the day, with many logins occurring during morning rounds, when not rounding with the care team. Prescribers logged in typically before and after morning rounds. On neurology units, physician assistants accounted for most logins, accessing the Dashboard during daily brief interdisciplinary rounding sessions. Use on oncology units was rare. Satisfaction with the tool was highest for perceived ease of use, with attendings giving the highest rating (4.23). The overall lowest rating was for quality of work life, with nurses rating the tool lowest (2.88). CONCLUSION: This mixed methods analysis provides insight into the use and usability of a dashboard tool integrated within a vendor EHR and can guide future improvements and more successful implementation of these types of tools.

Using the 4-S Framework to Guide Conversations With Patients About CRISPR.

As patients with genetic diseases seek to have healthy biologically connected children, they will undoubtedly turn to trusted health care professionals for guidance. "Doctor, should I enter a clinical trial to edit my embryos?" is likely to become a query posed by patients with genetic illnesses. Physicians need both empathic communication skills and a framework for responding to this question. Applying the 4-S framework to gene editing can guide clinicians' responses to patients' CRISPR queries by facilitating discussion of (1) safety, (2) significance of harm to be averted, (3) impact on succeeding generations, and (4) social consequences.

Early adoption of pharmacogenetic testing for veterans prescribed psychotropic medications.

Aim: Describe the characteristics of providers ordering, patients receiving, and clinical impact of a psychotropic pharmacogenetic test on veteran care. Patients & methods: Observational cohort study linking veterans' laboratory results to electronic health record data. Changes in psychotropic medication prescribing were measured as a function of test results. Results: A total of 38 providers tested 181 veterans between 10/6/2014 and 2/1/2018. Prescriptions for medications with severe gene-drug interactions decreased; however, 11 such medications were used after testing. For 43 patients, documentation of the results was missing. Conclusion: Most prescribing decisions were congruent with test results, but in a nontrivial number of cases, prescribers appeared not to act on the results. Poor result documentation impeded the potential of results to inform clinical care.

US Nationwide Disclosure of Industry Payments and Public Trust in Physicians.

Importance: Transparency of industry payments to physicians could engender greater public trust in physicians but might also lead to greater mistrust of physicians and the medical profession, adversely affecting the patient-physician relationship. Objective: To examine the association between nationwide public disclosure of industry payments and Americans' trust in their physicians and trust in the medical profession. Design, Setting, and Participants: Survey study using difference-in-difference analyses of a national longitudinal survey comparing changes in states where industry payments were newly disclosed by Open Payments with changes in states where payments information was already available because of state sunshine laws. The US population-based surveys were conducted in September 2014-shortly before the initial public disclosure of industry payments-and again in September 2016. Final analyses were conducted September through December 2018. Participants were adults 18 years and older (n = 1388). Exposures: National public disclosure through Open Payments of payments made by pharmaceutical and medical device firms to physicians. Main Outcomes and Measures: Wake Forest measure of trust in one's own physician and Wake Forest measure of trust in the medical profession. Results: Of the 3542 original survey respondents, 2180 (61.5%) completed the second survey 2 years later, and 1388 named the same most frequently seen physician in both surveys. The mean age of respondents at the time of the first survey was 53 years, and 749 (54.0%) were women. Race/ethnicity was white in 76.6% (1063 of 1388) and non-Hispanic black in 8.0% (111 of 1388). Public disclosure of payments was associated with lower trust in one's own physician regardless of whether respondents knew their physicians had received payments (decrease in Wake Forest measure of trust in one's own physician of 0.56 point; 95% CI, -0.79 to -0.32 point; P < .001). Open Payments was also associated with lower trust in the medical profession (decrease in Wake Forest measure of trust in the medical profession of 0.35 point; 95% CI, -0.58 to -0.12 point; P = .004). Conclusions and Relevance: Nationwide public disclosure of industry payments may be associated with decreased trust in physicians and in the medical profession. More judicious presentation of payments information may counteract unintended negative trust and spillover consequences of public disclosure.

Family Caregivers' Characterization of Conversations Following an ACP Event.

BACKGROUND: Advance care planning (ACP) has been shown to benefit patients and families, yet little is known about how an ACP event impacts communication and conversation about end-of-life treatment wishes and the content of such conversations between patients and family caregivers. OBJECTIVE: To characterize post-ACP conversations regarding medical wishes between seriously ill patients and their family caregivers. PARTICIPANTS: Patients with advanced illness and family caregivers. OUTCOME MEASURED: Post-ACP conversations. DESIGN: As part of a larger randomized controlled trial, dyads consisting of seriously ill patients and their identified family caregiver engaged in ACP and created an advance directive for the patient. Approximately 4 to 6 weeks later, semistructured interviews were conducted with the family caregivers to elucidate the subsequent communications regarding medical wishes. If the dyad did not have any conversations post-ACP, reasons and barriers were explored. RESULTS: The majority of dyads (131/188, 69.7%) had 2 to 3 conversations lasting 3 to 5 minutes each in the weeks immediately following ACP. These conversations most commonly addressed general patient wishes about quality of life and specific medical treatments. The most common reasons for not having conversations were a general discomfort with the topic (13/57, 22.8%) and previously having discussed medical wishes (16/57, 28.1%). CONCLUSION: The ACP events promote conversation regarding quality of life, general wishes at the end of life, and specific medical wishes. Barriers to conversation following ACP were similar to barriers to ACP in general, suggesting that a more intentional focus on addressing these barriers pre- and post-ACP may be necessary to improve communication.

A Randomized Controlled Trial of Strategies to Improve Family Members' Preparedness for Surrogate Decision-Making.

OBJECTIVE: To evaluate 2 strategies for preparing family members for surrogate decision-making. DESIGN: A 2 × 2 factorial, randomized controlled trial testing whether: (1) comprehensive online advance care planning (ACP) is superior to basic ACP, and (2) having patients engage in ACP together with family members is superior to ACP done by patients alone. SETTING: Tertiary care centers in Hershey, Pennsylvania, and Boston, Massachusetts. PARTICIPANTS: Dyads of patients with advanced, severe illness (mean age 64; 46% female; 72% white) and family members who would be their surrogate decision-makers (mean age 56; 75% female; 75% white). INTERVENTIONS: Basic ACP: state-approved online advance directive plus brochure. Making Your Wishes Known (MYWK): Comprehensive ACP decision aid including education and values clarification. MEASUREMENTS: Pre-post changes in family member self-efficacy (100-point scale) and postintervention concordance between patients and family members using clinical vignettes. RESULTS: A total 285 dyads enrolled; 267 patients and 267 family members completed measures. Baseline self-efficacy in both MYWK and basic ACP groups was high (90.2 and 90.1, respectively), and increased postintervention to 92.1 for MYWK ( P = .13) and 93.3 for basic ACP ( P = .004), with no between-group difference. Baseline self-efficacy in alone and together groups was also high (90.2 and 90.1, respectively), and increased to 92.6 for alone ( P = .03) and 92.8 for together ( P = .03), with no between-group difference. Overall adjusted concordance was higher in MYWK compared to basic ACP (85.2% vs 79.7%; P = .032), with no between-group difference. CONCLUSION: The disconnect between confidence and performance raises questions about how to prepare family members to be surrogate decision-makers.

User-Centered Collaborative Design and Development of an Inpatient Safety Dashboard.

Patient safety remains a key concern in hospital care. This article summarizes the iterative participatory development, features, functions, and preliminary evaluation of a patient safety dashboard for interdisciplinary rounding teams on inpatient medical services. This electronic health record (EHR)-embedded dashboard collects real-time data covering 13 safety domains through web services and applies logic to generate stratified alerts with an interactive check-box function. The technological infrastructure is adaptable to other EHR environments. Surveyed users perceived the tool as highly usable and useful. Integration of the dashboard into clinical care is intended to promote communication about patient safety and facilitate identification and management of safety concerns.

Improving the Informed Consent Conversation: A Standardized Checklist that Is Patient Centered, Quality Driven, and Legally Sound.

The informed consent conversation is a key component of patient-centered medicine, a concept that emphasizes the importance of patients actively participating in their care. Studies reveal that many informed consent conversations throughout medical practice lack essential elements and leave patients' needs unmet. This review addresses these deficiencies, discusses solutions, and introduces a standardized checklist that values the patient's role in shared decision making during the informed consent conversation. The checklist could be particularly helpful to interventional radiologists and other consulting physicians who usually obtain informed consent early in their encounters with patients.

Strategies for Managing Mobile Devices for Use by Hospitalized Inpatients.

Despite the potential advantages, implementation of mobile devices and ongoing management pose challenges in the hospital environment. Our team implemented the PROSPECT (Promoting Respect and Ongoing Safety through Patient-centeredness, Engagement, Communication and Technology) project at Brigham and Women's Hospital. The goal of PROSPECT is to transform the hospital environment by providing a suite of e-tools to facilitate teamwork among nurses, physicians, patients and to engage patients and care partners in their plan of care. In this paper, we describe the device-related decisions and challenges faced including device and accessory selection, integration, information and device security, infection control, user access, and ongoing operation and maintenance. We relate the strategies that we used for managing mobile devices and lessons learned based on our experiences.

The challenge of promoting professionalism through medical ethics and humanities education.

Given recent emphasis on professionalism training in medical schools by accrediting organizations, medical ethics and humanities educators need to develop a comprehensive understanding of this emphasis. To achieve this, the Project to Rebalance and Integrate Medical Education (PRIME) II Workshop (May 2011) enlisted representatives of the three major accreditation organizations to join with a national expert panel of medical educators in ethics, history, literature, and the visual arts. PRIME II faculty engaged in a dialogue on the future of professionalism in medical education. The authors present three overarching themes that resulted from the PRIME II discussions: transformation, question everything, and unity of vision and purpose.The first theme highlights that education toward professionalism requires transformational change, whereby medical ethics and humanities educators would make explicit the centrality of professionalism to the formation of physicians. The second theme emphasizes that the flourishing of professionalism must be based on first addressing the dysfunctional aspects of the current system of health care delivery and financing that undermine the goals of medical education. The third theme focuses on how ethics and humanities educators must have unity of vision and purpose in order to collaborate and identify how their disciplines advance professionalism. These themes should help shape discussions of the future of medical ethics and humanities teaching.The authors argue that improvement of the ethics and humanities-based knowledge, skills, and conduct that fosters professionalism should enhance patient care and be evaluated for its distinctive contributions to educational processes aimed at producing this outcome.

A position paper in support of face transplantation in the blind.

Facially disfigured blind patients have historically been considered for face transplantation with skepticism. Although no formal position paper regarding their exclusion has been published to date, functional, social, rehabilitative, and ethical concerns related to blind patients' candidacy for face transplantation may be inferred. The authors provide a summary of these reservations and a counterargument to their assumptions, drawing on outcomes measures reported for face transplant procedures performed to date, and their own institutional experience in performing face transplants on blind patients. The authors therefore provide a rationale for the inclusion of facially disfigured blind patients in face transplantation protocols in the future.

A position paper in support of hand transplantation in the blind.

Blind upper extremity amputees have historically been excluded from consideration for hand allotransplantation. Although no formal position statement regarding their exclusion has been published to date, functional, rehabilitative, and ethical concerns related to blind amputee candidacy for hand transplantation may be inferred. The authors provide a summary of these reservations and a counterargument to their assumptions, drawing on outcomes measures reported for hand transplantations completed to date. The authors therefore provide a rationale for the inclusion of blind amputees in hand transplantation protocols in the future.

Health-care referrals from direct-to-consumer genetic testing.

BACKGROUND: direct-to-consumer genetic testing (DTC-GT) provides personalized genetic risk information directly to consumers. Little is known about how and why consumers then communicate the results of this testing to health-care professionals. AIM: to query specialists in clinical genetics about their experience with individuals who consulted them after DTC-GT. METHODS: invitations to participate in a questionnaire were sent to three different groups of genetic professionals, totaling 4047 invitations, asking questions about individuals who consulted them after DTC-GT. For each case reported, respondents were asked to describe how the case was referred to them, the patient's rationale for DTC-GT, and the type of DTC-GT performed. Respondents were also queried about the consequences of the consultations in terms of additional testing ordered. The costs associated with each consultation were estimated. A clinical case series was compiled based upon clinician responses. RESULTS: the invitation resulted in 133 responses describing 22 cases of clinical interactions following DTC-GT. Most consultations (59.1%) were self-referred to genetics professionals, but 31.8% were physician referred. Among respondents, 52.3% deemed the DTC-GT to be "clinically useful." BRCA1/2 testing was considered clinically useful in 85.7% of cases; 35.7% of other tests were considered clinically useful. Subsequent referrals from genetics professionals to specialists and/or additional diagnostic testing were common, generating individual downstream costs estimated to range from $40 to $20,600. CONCLUSIONS: this clinical case series suggests that approximately half of clinical geneticists who saw patients after DTC-GT judged that testing was clinically useful, especially the BRCA1/2 testing. Further studies are needed in larger and more diverse populations to better understand the interactions between DTC-GT and the health-care system.