Drivers of telemedicine in primary care clinics at a large academic medical centre.

BACKGROUND: COVID-19 disrupted healthcare routines and prompted rapid telemedicine implementation. We investigated the drivers of visit modality selection (telemedicine versus in-person) in primary care clinics at an academic medical centre. METHODS: We used electronic medical record data from March 2020 to May 2022 from 13 primary care clinics (N = 21,031 new, N = 207,292 return visits), with 55% overall telemedicine use. Hierarchical logistic regression and cross-validation methods were used to estimate the variation in visit modality explained by the patient, clinician and visit factors as measured by the mean-test area under the curve (AUC). RESULTS: There was significant variation in telemedicine use across clinicians (ranging from 0-100%) for the same visit diagnosis. The strongest predictors of telemedicine were the clinician seen for new visits (mean AUC of 0.79) and the primary visit diagnosis for return visits (0.77). Models based on all patient characteristics combined accounted for relatively little variation in modality selection, 0.54 for new and 0.58 for return visits, respectively. Amongst patient characteristics, males, patients over 65 years, Asians and patient's with non-English language preferences used less telemedicine; however, those using interpreter services used significantly more telemedicine. CONCLUSION: Clinician seen and primary visit diagnoses were the best predictors of visit modality. The distinction between new and return visits and the minimal impact of patient characteristics on visit modality highlights the complexity of clinical care and warrants research approaches that go beyond linear models to uncover the emergent causal effects of specific technology features mediated by tasks, people and organisations.

A qualitative assessment of medical assistant professional aspirations and their alignment with career ladders across three institutions.

BACKGROUND: Growing demand for medical assistants (MAs) in team-based primary care has led health systems to explore career ladders based on expanded MA responsibilities as a solution to improve MA recruitment and retention. However, the practical implementation of career ladders remains a challenge for many health systems. In this study, we aim to understand MA career aspirations and their alignment with available advancement opportunities. METHODS: Semi-structured focus groups were conducted August to December 2019 in primary care clinics based in three health systems in California and Utah. MA perspectives of career aspirations and their alignment with existing career ladders were discussed, recorded, and qualitatively analyzed. RESULTS: Ten focus groups conducted with 59 participants revealed three major themes: mixed perceptions of expanded MA roles with concern over increased responsibility without commensurate increase in pay; divergent career aspirations among MAs not addressed by existing career ladders; and career ladder implementation challenges including opaque advancement requirements and lack of consistency across practice settings. CONCLUSION: MAs held positive perceptions of career ladders in theory, yet recommended a number of improvements to their practical implementation across three institutions including improving clarity and consistency around requirements for advancement and matching compensation to job responsibilities. The emergence of two distinct clusters of MA professional needs and desires suggests an opportunity to further optimize career ladders to provide tailored support to MAs in order to strengthen the healthcare workforce and talent pipeline.