Challenges and opportunities for advancing patient-centered clinical decision support: findings from a horizon scan.

OBJECTIVE: We conducted a horizon scan to (1) identify challenges in patient-centered clinical decision support (PC CDS) and (2) identify future directions for PC CDS. MATERIALS AND METHODS: We engaged a technical expert panel, conducted a scoping literature review, and interviewed key informants. We qualitatively analyzed literature and interview transcripts, mapping findings to the 4 phases for translating evidence into PC CDS interventions (Prioritizing, Authoring, Implementing, and Measuring) and to external factors. RESULTS: We identified 12 challenges for PC CDS development. Lack of patient input was identified as a critical challenge. The key informants noted that patient input is critical to prioritizing topics for PC CDS and to ensuring that CDS aligns with patients' routine behaviors. Lack of patient-centered terminology standards was viewed as a challenge in authoring PC CDS. We found a dearth of CDS studies that measured clinical outcomes, creating significant gaps in our understanding of PC CDS' impact. Across all phases of CDS development, there is a lack of patient and provider trust and limited attention to patients' and providers' concerns. DISCUSSION: These challenges suggest opportunities for advancing PC CDS. There are opportunities to develop industry-wide practices and standards to increase transparency, standardize terminologies, and incorporate patient input. There is also opportunity to engage patients throughout the PC CDS research process to ensure that outcome measures are relevant to their needs. CONCLUSION: Addressing these challenges and embracing these opportunities will help realize the promise of PC CDS-placing patients at the center of the healthcare system.

Patient and provider perspectives on using goal attainment scaling in care planning for older adults with complex needs.

BACKGROUND: Assess the feasibility of using goal attainment scaling (GAS) in care planning for older adults with complex needs. GAS is an individualized approach to goal setting and follow up using a quantified scale. To date, little is known about the feasibility of GAS among this population. METHODS: We conducted a qualitative study with a sample of 28 older adults and 23 providers from diverse settings to evaluate the value and challenges of this approach. We conducted semi-structured interviews and iteratively coded and analyzed interview transcripts for themes related to value, challenges, and implementation. RESULTS: Most older adults and providers reported that the GAS approach added value to the care encounter. GAS supported collaboration and patient accountability for their goals, though it could be demotivating to some patients. Some older adults and providers noted that GAS could be confusing and that it was uncomfortable to talk about negative outcomes (i.e., the - 2 and - 1 boxes of the scale). Factors that facilitated implementation included using visual copies of the GAS forms, having an established patient-provider relationship, practicing the approach, and having previous goal-related clinical training. CONCLUSIONS: GAS was feasible to implement across diverse settings, and, despite challenges, both older adults and providers reported that it added value to care planning encounters with the potential to improve delivery of person-centered care. Further efforts to demonstrate the applicability and benefit of this method for older adults are warranted, particularly to address implementation of the approach.

The technical landscape for patient-centered CDS: progress, gaps, and challenges.

Supporting healthcare decision-making that is patient-centered and evidence-based requires investments in the development of tools and techniques for dissemination of patient-centered outcomes research findings via methods such as clinical decision support (CDS). This article explores the technical landscape for patient-centered CDS (PC CDS) and the gaps in making PC CDS more shareable, standards-based, and publicly available, with the goal of improving patient care and clinical outcomes. This landscape assessment used: (1) a technical expert panel; (2) a literature review; and (3) interviews with 18 CDS stakeholders. We identified 7 salient technical considerations that span 5 phases of PC CDS development. While progress has been made in the technical landscape, the field must advance standards for translating clinical guidelines into PC CDS, the standardization of CDS insertion points into the clinical workflow, and processes to capture, standardize, and integrate patient-generated health data.

Refining a Taxonomy of Goals for Older Adults With Functional Limitations and Their Caregivers to Inform Care Planning.

Purpose: The purpose of the study is to capture goals expressed by older adults with functional limitations and their caregivers. Methods: Through focus groups and interviews, 76 older adults with ≥1 activity of daily living limitation and 28 family/friend caregivers were asked about what mattered most to them and their goals for care. Transcripts were coded using an existing taxonomy. Goals that did not fit the taxonomy were assigned new codes. Results: We identified more than 50 goals in eight domains. Domains included (a) Medical Care; (b) Quality of Life: Physical; (c) Quality of Life: Social and Emotional; (d) Access to Services and Supports; (e) Caregiver Needs and Concerns; (f) End of Life; (g) Independence; and (h) Acceptable Housing. Conclusion: While there is overlap between identified goals and the existing taxonomy, new goals emerged. The goal domains identified could serve as a framework to improve and measure the quality of goal-oriented care for older adults with complex needs.

Standardised approach to measuring goal-based outcomes among older disabled adults: results from a multisite pilot.

BACKGROUND: Older adults with complex care needs face trade-offs in determining the right course of treatment. The Centers for Medicare and Medicaid Services identified 'Care is personalized and aligned with patient's goals' as a key meaningful measures category, yet existing quality measures typically assess disease-specific care and may not effectively evaluate what is most important to older adults and family members. Measures based on individualised goals and goal-based outcomes have been proposed as an alternative but are not routinely assessed or implemented. OBJECTIVES: We tested two approaches to assessing goal-based outcomes that allow individuals to set goals based on their own priorities and measure progress-(1) goal attainment scaling and (2) existing, validated patient-reported outcome measures (PROM). METHODS: A prospective cohort study of feasibility in seven sites (33 clinicians) of the two approaches with 229 individuals. We calculated performance on a measure of achievement of individually identified goals. RESULTS: Both approaches were successfully implemented in a non-randomly selected population, and a goal-based outcome could be calculated for 189 (82%) of participants. Most individuals met their goal-based outcome (73%) with no statistical difference between the goal attainment scaling approach (74%) and the patient-reported outcomes approach (70%). Goals were heterogeneous ranging from participating in activities, health management, independence and physical health. Clinicians chose to use goal attainment scaling (n=184, 80%) more often than PROMs (n=49, 20%) and rated the goal attainment scaling approach as useful for providing patient care. CONCLUSION: Goal-based outcomes have the potential to both improve the way healthcare is provided and fill a critical gap in value-based payment.

Hennepin Health: a safety-net accountable care organization for the expanded Medicaid population.

Health care payment and delivery models that challenge providers to be accountable for outcomes have fueled interest in community-level partnerships that address the behavioral, social, and economic determinants of health. We describe how Hennepin Health--a county-based safety-net accountable care organization in Minnesota--has forged such a partnership to redesign the health care workforce and improve the coordination of the physical, behavioral, social, and economic dimensions of care for an expanded community of Medicaid beneficiaries. Early outcomes suggest that the program has had an impact in shifting care from hospitals to outpatient settings. For example, emergency department visits decreased 9.1 percent between 2012 and 2013, while outpatient visits increased 3.3 percent. An increasing percentage of patients have received diabetes, vascular, and asthma care at optimal levels. At the same time, Hennepin Health has realized savings and reinvested them in future improvements. Hennepin Health offers lessons for counties, states, and public hospitals grappling with the problem of how to make the best use of public funds in serving expanded Medicaid populations and other communities with high needs.

The role of medical school culture in primary care career choice.

PURPOSE: To examine individual-level and medical-school-level factors, including the school's primary care culture, that are associated with medical students' likelihood of practicing primary care. METHOD: In spring 2010, the Association of American Medical Colleges Center for Workforce Studies invited all fourth-year medical students at a stratified random sample of 20 U.S. MD-granting medical schools to participate in an online survey examining factors in specialty choice decisions. Schools were stratified according to the historical percentage of their graduates who became practicing primary care physicians. Multilevel logistic regression modeling was used to determine which individual- and school-level characteristics significantly predicted students' likelihood of practicing primary care. RESULTS: Of the 2,604 students invited, 1,661 (64%) responded. Of the 1,554 students with complete data on variables of interest, 207 (13%) planned to enter a primary care residency and stated they were "very likely" to become a primary care physician on completion of training. Students who attended schools with high reported levels of "badmouthing" primary care were less likely to practice primary care (OR, 0.6; 95% CI, 0.4-0.9). Attending a school where students had greater than the median number of positive experiences in primary care clerkships increased the likelihood of practicing primary care (OR, 1.6; 95% CI, 1.1-2.3). Overall, 8% of the total variation in a student's likelihood of practicing primary care was attributable to school-level factors. CONCLUSIONS: Although individual students' characteristics and preferences drive specialty choice decisions, the prevailing primary care culture at a school also plays a role.

Exploring the workforce implications of a decade of medical school expansion: variations in medical school growth and changes in student characteristics and career plans.

PURPOSE: To explore whether medical school enrollment growth may help address workforce priorities, including diversity, primary care, care for underserved populations, and academic faculty. METHOD: The authors compared U.S. MD-granting medical schools, applicants, and matriculants immediately before expansion (1999-2001) and 10 years later (2009-2011). Using data from the American Medical Association Physician Masterfile and the Association of American Medical Colleges, they examined medical schools' past production of physicians and changes in matriculant characteristics and practice intentions. RESULTS: Among the 124 schools existing in 1999-2001, growth varied substantially. Additionally, 11 new schools enrolled students by 2009-2011. Aggregate enrollment increased by 16.6%. Increases in applicants led to a lower likelihood of matriculation for all but those with rural backgrounds, racial/ethnic minorities, applicants >24 years old, and those with Medical College Admission Test scores > 33. The existing schools that expanded most had a history of producing the highest percentages of physicians practicing in primary care and in underserved and rural areas; those that expanded least had produced the greatest percentage of faculty. Compared with existing schools, new schools enrolled higher percentages of racial/ethnic minorities and of students with limited parental education or lower income. Matriculants' interest in primary care careers showed no decline; interest in practicing with underserved populations increased, while interest in rural practice declined. CONCLUSIONS: Despite expansion, the characteristics of matriculating medical students changed little, except at new schools. Further expansion may benefit from targeted consideration of workforce needs.