RESUMO
There is an inherent tension between standardization and customization of care delivery processes. The challenge for health care systems is to achieve the right balance. At its best, standardized work can create efficiencies that generate the additional time needed for personalized care. Similarly, at its best, customization allows the people within a system to accommodate the needs, preferences, and circumstances of the unique individuals and local communities they serve. We provide examples and offer principles to decide when standardization offers the most successful path and when customization may be preferred. We believe that, in sum, the balance has shifted too far toward standardization and that a rebalancing toward customization will benefit patients, clinicians, and the health care system.
Assuntos
Atenção à Saúde/normas , Medicina de Precisão/métodos , Humanos , Qualidade da Assistência à Saúde , Padrões de ReferênciaRESUMO
PURPOSE: Primary care physicians spend nearly 2 hours on electronic health record (EHR) tasks per hour of direct patient care. Demand for non-face-to-face care, such as communication through a patient portal and administrative tasks, is increasing and contributing to burnout. The goal of this study was to assess time allocated by primary care physicians within the EHR as indicated by EHR user-event log data, both during clinic hours (defined as 8:00 am to 6:00 pm Monday through Friday) and outside clinic hours. METHODS: We conducted a retrospective cohort study of 142 family medicine physicians in a single system in southern Wisconsin. All Epic (Epic Systems Corporation) EHR interactions were captured from "event logging" records over a 3-year period for both direct patient care and non-face-to-face activities, and were validated by direct observation. EHR events were assigned to 1 of 15 EHR task categories and allocated to either during or after clinic hours. RESULTS: Clinicians spent 355 minutes (5.9 hours) of an 11.4-hour workday in the EHR per weekday per 1.0 clinical full-time equivalent: 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after clinic hours. Clerical and administrative tasks including documentation, order entry, billing and coding, and system security accounted for nearly one-half of the total EHR time (157 minutes, 44.2%). Inbox management accounted for another 85 minutes (23.7%). CONCLUSIONS: Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. EHR event logs can identify areas of EHR-related work that could be delegated, thus reducing workload, improving professional satisfaction, and decreasing burnout. Direct time-motion observations validated EHR-event log data as a reliable source of information regarding clinician time allocation.
Assuntos
Registros Eletrônicos de Saúde/estatística & dados numéricos , Médicos de Atenção Primária/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Estudos de Tempo e Movimento , Carga de Trabalho/estatística & dados numéricos , Adulto , Esgotamento Profissional/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Médicos de Atenção Primária/psicologia , Estudos Retrospectivos , Carga de Trabalho/psicologiaAssuntos
Pessoal de Saúde , Relações Profissional-Paciente , Terminologia como Assunto , Humanos , Moral , Sociedades , ConfiançaRESUMO
PURPOSE: Cardiovascular disease is the leading cause of mortality and morbidity in the United States. Primary care teams can be best suited to improve quality of care and lower costs for patients with cardiovascular disease. This study evaluates the associations between primary care team communication, interaction, and coordination (ie, social networks); quality of care; and costs for patients with cardiovascular disease. METHODS: Using a sociometric survey, 155 health professionals from 31 teams at 6 primary care clinics identified with whom they interact daily about patient care. Social network analysis calculated variables of density and centralization representing team interaction structures. Three-level hierarchical modeling evaluated the link between team network density, centralization, and number of patients with a diagnosis of cardiovascular disease for controlled blood pressure and cholesterol, counts of urgent care visits, emergency department visits, hospital days, and medical care costs in the previous 12 months. RESULTS: Teams with dense interactions among all team members were associated with fewer hospital days (rate ratio [RR] = 0.62; 95% CI, 0.50-0.77) and lower medical care costs (-$556; 95% CI, -$781 to -$331) for patients with cardiovascular disease. Conversely, teams with interactions revolving around a few central individuals were associated with increased hospital days (RR = 1.45; 95% CI, 1.09-1.94) and greater costs ($506; 95% CI, $202-$810). Team-shared vision about goals and expectations mediated the relationship between social network structures and patient quality of care outcomes. CONCLUSIONS: Primary care teams that are more interconnected and less centralized and that have a shared team vision are better positioned to deliver high-quality cardiovascular disease care at a lower cost.
Assuntos
Doenças Cardiovasculares/terapia , Custos de Cuidados de Saúde , Pessoal de Saúde/organização & administração , Relações Interprofissionais , Equipe de Assistência ao Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Qualidade da Assistência à Saúde , Apoio Social , Adulto , Idoso , Assistência Ambulatorial/economia , Assistência Ambulatorial/estatística & dados numéricos , Pressão Sanguínea , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/economia , LDL-Colesterol/sangue , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados da Assistência ao Paciente , Técnicas SociométricasRESUMO
Dr. Ben-Tzion (Bentzi) Karsh was a mentor, collaborator, colleague, and friend who profoundly impacted the fields of human factors and ergonomics (HFE), medical informatics, patient safety, and primary care, among others. In this paper we honor his contributions by reflecting on his scholarship, impact, and legacy in three ways: first, through an updated simplified bibliometric analysis in 2020, highlighting the breadth of his scholarly impact from the perspective of the number and types of communities and collaborators with which and whom he engaged; second, through targeted reflections on the history and impact of Dr. Karsh's most cited works, commenting on the particular ways they impacted our academic community; and lastly, through quotes from collaborators and mentees, illustrating Dr. Karsh's long-lasting impact on his contemporaries and students.
Assuntos
Bolsas de Estudo , Informática Médica , Ergonomia , História do Século XX , Humanos , Atenção Primária à SaúdeRESUMO
INTRODUCTION: Primary care is complex due to multiple health problems being addressed in each patient visit. Little is known about the effect of the number of problems per encounter (NPPE) on the resulting clinician workload (CWL), as measured using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). METHODS: We evaluated the relationship between NPPE and CWL across 608 adult patient visits, conducted by 31 clinicians, using hierarchical linear regression. Clinicians were interviewed about outlier visits to identify reasons for higher or lower than expected CWL. RESULTS: Mean NPPE was 3.30 ± 2.0 (sd) and CWL was 47.6 ± 18.4 from a maximum of 100. Mental demand, time demand and effort accounted for 71.5% of CWL. After adjustment for confounders, each additional problem increased CWL by 3.9 points (P < 0.001). Patient, problem, environmental and patient-physician relationship factors were qualitatively identified from interviews as moderators of this effect. CONCLUSION: CWL is positively related to NPPE. Several modifiable factors may enhance or mitigate this effect. Our findings have implications for using a Human Factors (HF) approach to managing CWL.
Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Médicos/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos , Adulto , Feminino , Humanos , Modelos Lineares , Masculino , Análise e Desempenho de Tarefas , Estados UnidosRESUMO
Primary health care is a complex, highly personal, and non-linear process. Care is often sub-optimal and professional burnout is high. Interventions intended to improve the situation have largely failed. This is due to a lack of a deep understanding of primary health care. Human Factors approaches and methods will aid in understanding the cognitive, social and technical needs of these specialties, and in designing and testing proposed innovations. In 2012, Ben-Tzion Karsh, Ph.D., conceived a transdisciplinary conference to frame the opportunities for research human factors and industrial engineering in primary care. In 2013, this conference brought together experts in primary care and human factors to outline areas where human factors methods can be applied. The results of this expert consensus panel highlighted four major research areas: Cognitive and social needs, patient engagement, care of community, and integration of care. Work in these areas can inform the design, implementation, and evaluation of innovations in Primary Care. We provide descriptions of these research areas, highlight examples and give suggestions for future research.
Assuntos
Atenção à Saúde/normas , Ergonomia , Formulação de Políticas , Atenção Primária à Saúde/normas , Melhoria de Qualidade , Humanos , Fluxo de TrabalhoRESUMO
This viewpoint discusses the need for physicians to give focused attention to patients and the challenges that prevent them from doing so and suggests goals to create conditions that ensure that physicians are fully present during patient visits.
Assuntos
Atenção , Relações Médico-Paciente , HumanosRESUMO
We present findings of an international conference of diverse participants exploring the influence of electronic health records (EHRs) on the patient-practitioner relationship. Attendees united around a belief in the primacy of this relationship and the importance of undistracted attention. They explored administrative, regulatory, and financial requirements that have guided United States (US) EHR design and challenged patient-care documentation, usability, user satisfaction, interconnectivity, and data sharing. The United States experience was contrasted with those of other nations, many of which have prioritized patient-care documentation rather than billing requirements and experienced high user satisfaction. Conference participants examined educational methods to teach diverse learners effective patient-centered EHR use, including alternative models of care delivery and documentation, and explored novel ways to involve patients as healthcare partners like health-data uploading, chart co-creation, shared practitioner notes, applications, and telehealth. Future best practices must preserve human relationships, while building an effective patient-practitioner (or team)-EHR triad.
RESUMO
Objective: The federal meaningful use (MU) program was aimed at improving adoption and use of electronic health records, but practicing physicians have criticized it. This study was aimed at quantifying the benefits (ie, usefulness) and burdens (ie, workload) of the MU program for practicing family physicians. Materials and Methods: An interdisciplinary national panel of experts (physicians and engineers) identified the work associated with MU criteria during patient encounters. They conducted a national survey to assess each criterion's level of patient benefit and compliance burden. Results: In 2015, 480 US family physicians responded to the survey. Their demographics were comparable to US norms. Eighteen of 31 MU criteria were perceived as useful for more than half of patient encounters, with 13 of those being useful for more than two-thirds. Thirteen criteria were useful for less than half of patient encounters. Four useful criteria were reported as having a high compliance burden. Discussion: There was high variability in physicians' perceived benefits and burdens of MU criteria. MU Stage 1 criteria, which are more related to basic/routine care, were perceived as beneficial by most physicians. Stage 2 criteria, which are more related to complex and population care, were perceived as less beneficial and more burdensome to comply with. Conclusion: MU was discontinued, but the merit-based incentive payment system within the Medicare Access and CHIP Reauthorization Act of 2015 adopted its criteria. For many physicians, MU created a significant practice burden without clear benefits to patient care. This study suggests that policymakers should not assess MU in aggregate, but as individual criteria for open discussion.
Assuntos
Atitude do Pessoal de Saúde , Registros Eletrônicos de Saúde , Uso Significativo , Médicos de Família , Atitude Frente aos Computadores , Registros Eletrônicos de Saúde/legislação & jurisprudência , Registros Eletrônicos de Saúde/normas , Pesquisas sobre Atenção à Saúde , Política de Saúde , Uso Significativo/legislação & jurisprudência , Medicare/legislação & jurisprudência , Reembolso de Incentivo/legislação & jurisprudência , Estados UnidosRESUMO
The release of the Institute of Medicine (Kohn et al., 2000) report "To Err is Human", brought attention to the problem of medical errors, which led to a concerted effort to study and design medical error reporting systems for the purpose of capturing and analyzing error data so that safety interventions could be designed. However, to make real gains in the efficacy of medical error or event reporting systems, it is necessary to begin developing a theory of reporting systems adoption and use and to understand how existing theories may play a role in explaining adoption and use. This paper presents the results of a 9-month study exploring the barriers and facilitators for the design of a statewide medical error reporting system and discusses how several existing theories of technology acceptance, adoption and implementation fit with many of the results. In addition we present an integrated theoretical model of medical error reporting system design and implementation.
Assuntos
Desenho de Equipamento , Sistemas de Informação Hospitalar/organização & administração , Erros Médicos , Gestão de Riscos , Grupos Focais , Humanos , Meio-Oeste dos Estados Unidos , Modelos Teóricos , MédicosRESUMO
BACKGROUND: Public reports ranking physician competence and quality often yield conflicting results and create confusion. METHODS: Bivariate Pearson correlation analyses were performed to compare states' rankings of physician discipline and physician quality, as reported by the Medicare program and National Practitioner Data Bank. Medical boards were surveyed on their rates of complaints against physicians and ratio of actions to complaints. RESULTS: For all states, there was a poor to negative correlation between state rankings of disciplinary rates and quality, as well as rates of complaints against physicians. As an example, Wisconsin ranked 50th out of the 50 states plus the District of Columbia (where 1 is most desirable and 51 is worst) in rates of "serious" licensure sanctions, but did well when ranked by Medicare quality (eighth out of 51) and the rate of NPDB adverse reports (second out of 51). Wisconsin had a low rate of complaints per physician, ranking second out of 35 responding states, and a high ratio of actions to complaints, ranking fourth out of 35. CONCLUSION: Conflicting conclusions among public reports on physician discipline and quality raise questions about their methods and validity. State rankings of physician discipline and quality should be viewed with caution.
Assuntos
Padrões de Prática Médica/normas , Indicadores de Qualidade em Assistência à Saúde , Interpretação Estatística de Dados , Humanos , Estados Unidos , WisconsinRESUMO
OBJECTIVE: Primary care efficiency and quality are essential for the nation's health. The demands on primary care physicians (PCPs) are increasing as healthcare becomes more complex. A more complete understanding of PCP workflow variation is needed to guide future healthcare redesigns. METHODS: This analysis evaluates workflow variation in terms of the sequence of tasks performed during patient visits. Two patient visits from 10 PCPs from 10 different United States Midwestern primary care clinics were analyzed to determine physician workflow. Tasks and the progressive sequence of those tasks were observed, documented, and coded by task category using a PCP task list. Variations in the sequence and prevalence of tasks at each stage of the primary care visit were assessed considering the physician, the patient, the visit's progression, and the presence of an electronic health record (EHR) at the clinic. RESULTS: PCP workflow during patient visits varies significantly, even for an individual physician, with no single or even common workflow pattern being present. The prevalence of specific tasks shifts significantly as primary care visits progress to their conclusion but, notably, PCPs collect patient information throughout the visit. DISCUSSION: PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a "dance" between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice. CONCLUSIONS: Future healthcare redesigns should support a wide variety of task sequences to deliver high-quality primary care. The development of tools such as electronic health records must be based on the realities of primary care visits if they are to successfully support a PCP's mental and physical work, resulting in effective, safe, and efficient primary care.