Utilizing a novel unified healthcare model to compare practice patterns between telemedicine and in-person visits.

OBJECTIVE: Telemedicine practice has been shown to vary from clinical guidelines. Variations in practice patterns may be caused by disruptions in the continuity of care between traditional and telemedicine providers. This study compares virtual and in-person visits in Stanford's ClickWell Care (CWC) - where patients see the same provider for both visit modalities. METHODS: Clinical data for two years of patient encounters at CWC from January 2015-2017 (5772 visits) were obtained through Stanford STRIDE. For the 20 most common visit categories, including 17 specific diagnoses, we compared the frequency of prescriptions, labs, procedures, and images ordered, as well as rates of repeat visits. RESULTS: For the 17 specific diagnoses, there are no differences in labs ordered. Two diagnoses show differences in images ordered, and four differences in prescriptions. Overall, there are more labs (0.16 virtual, 0.33 in-person p < 0.0001) and images ordered (0.07 virtual, 0.16 in-person, p < 0.0001) for in-person visits - due mainly to general medical exam visits. Repeat visits were more likely after in-person visits (19% virtual, 38% in-person, p < 0.0001), 10 out of 17 specific diagnoses showed differences in visit frequency between visit modalities. Visits for both anxiety (5.3x, p < 0.0001) and depression (5.1x, p < 0.0001) were much more frequent in the virtual setting. CONCLUSIONS: Prescriptions, labs, and images ordered were similar between in-person and virtual visits for most diagnoses. Overall however, for in-person visits we find increased orders for labs and images, primarily from general medical exams. Finally, for anxiety and depression patients show clear preferences for virtual visits.

A 15-year review of the Stanford Internal Medicine Residency Program: predictors of resident satisfaction and dissatisfaction.

INTRODUCTION: Satisfaction with training and with educational experiences represents important internal medicine (IM) programmatic goals. Graduates from IM residency programs are uniquely poised to provide insights into their educational and training experiences and to assess whether these experiences were satisfactory and relevant to their current employment. METHODS: We surveyed former IM residents from the training program held during the years 2000-2015 at the Department of Medicine, Stanford University. The first part of the survey reviewed the IM residency program and the second part sought identifying data regarding gender, race, ethnicity, work, relationships, and financial matters. The primary outcome was satisfaction with the residency experience. RESULTS: Of the 405 individuals who completed the Stanford IM residency program in the study period, we identified 384 (95%) former residents with a known email address. Two hundred and one (52%) former residents responded to the first part and 185 (48%) answered both the parts of the survey. The mean age of the respondents was 36.9 years; 44% were female and the mean time from IM residency was 6.1 (±4.3) years. Fifty-eight percent reported extreme satisfaction with their IM residency experience. Predictors associated with being less than extremely satisfied included insufficient outpatient experience, insufficient international experience, insufficient clinical research experience, and insufficient time spent with family and peers. CONCLUSION: The residents expressed an overall high satisfaction rate with their IM training. The survey results provided insights for improving satisfaction with IM residency training that includes diversifying and broadening IM training experiences.

New Delivery Model for Rising-Risk Patients: The Forgotten Lot?

BACKGROUND: Shared-risk models encourage providers to engage young patients early. Telemedicine may be well suited for younger, healthier patients although it is unclear how best to incorporate telemedicine into routine clinical care. INTRODUCTION: We test the assumptions surrounding the use of telemedicine, younger and rising-risk patients, and primary care in ClickWell Care (CWC), a care model developed at our institution for our own accountable care organization. MATERIALS AND METHODS: CWC's team of physicians and wellness coaches work together to provide comprehensive primary care through in-person, phone, and video visits. This study examines usage of the clinic over its initial year in operation. RESULTS: 1,464 unique patients conducted a total of 3,907 visits. 2,294 (58.7%) visits were completed virtually (1,382 [35.4%] by phone and 912 [23.3%] by video). Patients were more inclined to see the physician in-person for a new visit (1,065 visits [70.5%] vs. 362 [24%] phone and 83 [6%] video) and more likely to see the physician virtually for a return visit (606 [43.2%] phone and 249 [17.7%] video vs. 548 [39.1%] in-person), a statistically significant difference (X2 = 306.7, p < 0.00001). CONCLUSION: This new care model successfully engaged a younger population of patients. However, our data suggest young patients may not be inclined to establish care with a primary care physician virtually and, in fact, choose an initial in-person touch point, although many are willing to conduct return visits virtually. This new model of care could have a large impact on how care is delivered to low- and rising-risk patients.