Do patients want clinicians to ask about social needs and include this information in their medical record?

BACKGROUND: Social needs screening in primary care may be valuable for addressing non-medical health-related factors, such as housing insecurity, that interfere with optimal medical care. Yet it is unclear if patients welcome such screening and how comfortable they are having this information included in electronic health records (EHR). OBJECTIVE: To assess patient attitudes toward inclusion of social needs information in the EHR and key correlates, such as sociodemographic status, self-rated health, and trust in health care. DESIGN, PARTICIPANTS, AND MAIN MEASURES: In a cross-sectional survey of patients attending a primary care clinic for annual or employment exams, 218/560 (38%) consented and completed a web survey or personal interview between 8/20/20-8/23/21. Patients provided social needs information using the Accountable Care Communities Screening Tool. For the primary outcome, patients were asked, "Would you be comfortable having these kinds of needs included in your health record (also known as your medical record or chart)?" ANALYSES: Regression models were estimated to assess correlates of patient comfort with including social needs information in medical records. KEY RESULTS: The median age was 45, 68.8% were female, and 78% were white. Median income was $75,000 and 84% reported education beyond high school. 85% of patients reported they were very or somewhat comfortable with questions about social needs, including patients reporting social needs. Social need ranged from 5.5% (utilities) to 26.6% (housing), and nonwhite and gender-nonconforming patients reported greater need. 20% reported "some" or "complete" discomfort with social needs information included in the EHR. Adjusting for age, gender, race, education, trust, and self-rated health, each additional reported social need significantly increased discomfort with the EHR for documenting social needs. CONCLUSIONS: People with greater social needs were more wary of having this information placed in the EHR. This is a concerning finding, since one rationale for collecting social need data is to use this information (presumably in the EHR) for addressing needs.

Lifestyle Habits Associated with Weight Regain After Intentional Loss in Primary Care Patients Participating in a Randomized Trial.

BACKGROUND: Though long-term weight loss maintenance is the treatment goal for obesity, weight regain is typical and few studies have evaluated lifestyle habits associated with weight regain. OBJECTIVE: To identify dietary and physical activity habits associated with 6- and 24-month weight regain among participants in a weight loss maintenance clinical trial. DESIGN: Secondary analysis of randomized clinical trial data. PARTICIPANTS: Adult primary care patients with recent, intentional weight loss of at least 5%. MAIN MEASURES: Lifestyle habits included consumption of low-fat foods, fish, desserts, sugary beverages, fruits, and vegetables and eating at restaurants from the Connor Diet Habit Survey; moderate-vigorous physical activity by self-report; steps recorded by a pedometer; and sedentary behavior by self-report. The outcome variable was weight change at 6 and 24 months. Linear regression models estimated adjusted associations between changes in weight and changes in dietary and physical activity habits. KEY RESULTS: Overall, participants (mean (SD): 53.4 (12.2) years old; 26% male; 88% white) maintained weight loss at 6 months (n = 178, mean (SD): - 0.02 (5.70)% change) but began to regain weight by 24 months (n = 157, mean (SD): 4.22 (9.15)% increase). When considered all together, more eating at restaurants, reduced fish consumption, and less physical activity were most consistently associated with weight regain in fully adjusted models at both 6 and 24 months of follow-up. In addition, more sedentary behavior was associated with weight regain at 6 months while reduced consumption of low-fat foods, and more desserts and sugary beverages were associated with weight regain at 24 months. CONCLUSIONS: Consuming less fish, fewer steps per day, and more frequent restaurant eating were most consistently associated with weight regain in primary care patients. Primary care providers may consider addressing specific lifestyle behaviors when counseling patients after successful weight loss. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01946191.

Effect of Electronic Health Record-Based Coaching on Weight Maintenance: A Randomized Trial.

Background: Weight regain after intentional loss is common. Most evidence-based weight management programs focus on short-term loss rather than long-term maintenance. Objective: To evaluate the benefit of coaching in an electronic health record (EHR)-based weight maintenance intervention. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT01946191). Setting: Practices affiliated with an academic medical center. Participants: Adult outpatients with body mass index (BMI) of 25 kg/m2 or higher, intentional weight loss of at least 5% in the previous 2 years, and no bariatric procedures in the previous 5 years. Intervention: Participants were randomly assigned to EHR tools (tracking group) versus EHR tools plus coaching (coaching group). The EHR tools included weight, diet, and physical activity tracking flow sheets; standardized surveys; and reminders. The coaching group received 24 months of personalized coaching through the EHR patient portal, with 24 scheduled contacts. Measurements: The primary outcome was weight change at 24 months. Secondary outcomes included 5% weight loss maintenance and changes in BMI, waist circumference, number of steps per day, health-related quality of life, physical function, blood pressure, and satisfaction. Results: Among 194 randomly assigned participants (mean age, 53.4 years [SD, 12.2]; 143 [74%] women; 171 [88%] white), 157 (81%) completed the trial. Mean baseline weight and BMI were 85.8 kg (SD, 19.1) and 30.4 kg/m2 (SD, 5.9). At 24 months, mean weight regain (± SE) was 2.1 ± 0.62 kg and 4.9 ± 0.63 kg in the coaching and tracking groups, respectively. The between-group difference in weight change at 24 months was significant (-2.86 kg [95% CI, -4.60 to -1.11 kg]) in the linear mixed model. At 24 months, 65% of participants in the coaching group and 50% in the tracking group maintained weight loss of at least 5%. Limitation: Single-site trial, which limits generalizability. Conclusion: Among adults with intentional weight loss of at least 5%, use of EHR tools plus coaching resulted in less weight regain than EHR tools alone. Primary Funding Source: Agency for Healthcare Research and Quality and National Institutes of Health.

The elephant in the room: a postphenomenological view on the electronic health record and its impact on the clinical encounter.

Use of electronic health records (EHR) within clinical encounters is increasingly pervasive. The digital record allows for data storage and sharing to facilitate patient care, billing, research, patient communication and quality-of-care improvement-all at once. However, this multifunctionality is also one of the main reasons care providers struggle with the EHR. These problems have often been described but are rarely approached from a philosophical point of view. We argue that a postphenomenological case study of the EHR could lead to more in-depth insights. We will focus on two concepts-transparency and multistability-and translate them to the specific situation of the EHR. Transparency is closely related to an embodiment relation in which the user becomes less aware of the technology: it fades into the background, becoming a means of experience. A second key concept is that of multistability, referring to how a technology can serve multiple purposes or can have different meanings in different contexts. The EHR in this sense is multistable by design. Future EHR design could incorporate multistable information differently, allowing the provider to focus on patient care when interacting with the EHR. Moreover we argue that the use of the EHR in the daily workflow should become more transparent, while awareness of the computer in the specific context of the patient-provider relationship should increase.

Online Lifestyle Modification Intervention: Survey of Primary Care Providers' Attitudes and Views.

BACKGROUND: Online tools are a convenient and effective method of delivering lifestyle interventions to obese adult primary care patients. A referral model allows physicians to efficiently direct their patients to the intervention during a primary care visit. However, little is known of physicians' perspectives and utilization of the referral model for an online lifestyle modification intervention. OBJECTIVE: The aim was to evaluate the response of primary care providers (PCPs) to a referral model for implementing a year-long online intervention for weight loss to obese adult patients. METHODS: The PCPs at six primary care clinics were asked to refer adult obese patients to a year-long online lifestyle intervention providing self-management support for weight loss. Following the 1-year intervention, all providers at the participating practices were surveyed regarding their views of the program. Respondents completed survey items assessing their attitudes regarding the 1-year intensive weight loss intervention and identifying resources they would find helpful for assisting patients with weight loss. Referring physicians were asked about their level of satisfaction with implementing the counseling services using standard electronic health record referral processes. Attitudes toward obesity counseling among referring and nonreferring providers were compared. Impressions of how smoothly the referral model of obesity treatment integrated with the clinical workflow were also quantified. RESULTS: Of the 67 providers who completed the surveys, nonreferring providers (n=17) were more likely to prefer counseling themselves (P=.04) and to report having sufficient time to do so (P=.03) than referring providers (n=50) were. Nonreferring providers were more likely to report that their patients lacked computer skills (76%, 13/17 vs 34%, 17/50) or had less access to the Internet (65%, 11/17 vs 32%, 16/50). CONCLUSIONS: Understanding providers' views and barriers regarding the integration of online tools will facilitate widespread implementation of an online lifestyle modification intervention.

Using Health Information Technology to Foster Engagement: Patients' Experiences with an Active Patient Health Record.

Personal health records (PHRs) typically employ "passive" communication strategies, such as non-personalized medical text, rather than direct patient engagement in care. Currently there is a call for more active PHRs that directly engage patients in an effort to improve their health by offering elements such as personalized medical information, health coaches, and secure messaging with primary care providers. As part of a randomized clinical trial comparing "passive" with "active" PHRs, we explore patients' experiences with using an "active" PHR known as HealthTrak. The "passive" elements of this PHR included problem lists, medication lists, information about patient allergies and immunizations, medical and surgical histories, lab test results, health reminders, and secure messaging. The active arm included all of these elements and added personalized alerts delivered through the secure messaging platform to patients for services coming due based on various demographic features (including age and sex) and chronic medical conditions. Our participants were part of the larger clinical trial and were eligible if they had been randomized to the active PHR arm, one that included regular personalized alerts. We conducted focus group discussions on the benefits of this active PHR for patients who are at risk for cardiovascular disease. Forty-one patients agreed to participate and were organized into five separate focus group sessions. Three main themes emerged from the qualitatively analyzed focus groups: participants reported that the active PHR promoted better communication with providers; enabled them to more effectively partner with their providers; and helped them become more proactive about tracking their health information. In conclusion, patients reported improved communication, partnership with their providers, and a sense of self-management, thus adding insights for PHR designers hoping to address low adoption rates and other patient barriers to the development and use of the technology.

Patterns of response to patient-centered decision support through a personal health record.

BACKGROUND: Over 140 million people in the United States have at least one chronic medical condition, but they receive fewer than 60% of guideline-recommended services for these conditions. Increasing patients' involvement in their own care may improve the receipt of guideline-recommended services. We evaluated patients' patterns of responses to notifications regarding guideline-recommended services delivered through a personalized health record (PHR). MATERIALS AND METHODS: We enrolled 584 participants with high cardiovascular disease risk from 73 primary care practices into an active PHR in which they received patient-centered decision support-notifications delivered via a PHR regarding prevention gaps (i.e., unmet preventive healthcare or chronic disease monitoring). Participants with prevention gaps received up to three weekly messages regarding all services due within a 2-month time frame. These three-message cycles could repeat up to every 2 months for a new, or continuing, prevention gap. RESULTS: Of the 584 participants, 501 (86%) received at least one reminder. Approximately 61% of these participants accessed the PHR or received the care that triggered the message after the first message and 73% after the first two messages. In subsequent three-message cycles, we observed no change in the number of messages required prior to participants accessing the PHR or receiving recommended care (chi-squared = 12.4, p = 0.3). Of the 2,656 prevention gaps these participants had over 1 year, 1,539 (58%) were closed. CONCLUSIONS: In this low-intensity intervention, participants accessed the PHR and received recommended care. Providing notification through the PHR allows patients to choose when they receive, and take action on, the message. Notifications can be provided to patients through a PHR without alert fatigue and may be an additional tool to help patients achieve better health.

Electronic Health Record Population Health Management for Chronic Kidney Disease Care: A Cluster Randomized Clinical Trial.

Importance: Large gaps in clinical care in patients with chronic kidney disease (CKD) lead to poor outcomes. Objective: To compare the effectiveness of an electronic health record-based population health management intervention vs usual care for reducing CKD progression and improving evidence-based care in high-risk CKD. Design, Setting, and Participants: The Kidney Coordinated Health Management Partnership (Kidney CHAMP) was a pragmatic cluster randomized clinical trial conducted between May 2019 and July 2022 in 101 primary care practices in Western Pennsylvania. It included patients aged 18 to 85 years with an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2 with high risk of CKD progression and no outpatient nephrology encounter within the previous 12 months. Interventions: Multifaceted intervention for CKD comanagement with primary care clinicians included a nephrology electronic consultation, pharmacist-led medication management, and CKD education for patients. The usual care group received CKD care from primary care clinicians as usual. Main Outcomes and Measures: The primary outcome was time to 40% or greater reduction in eGFR or end-stage kidney disease. Results: Among 1596 patients (754 intervention [47.2%]; 842 control [52.8%]) with a mean (SD) age of 74 (9) years, 928 (58%) were female, 127 (8%) were Black, 9 (0.6%) were Hispanic, and the mean (SD) estimated glomerular filtration rate was 36.8 (7.9) mL/min/1.73m2. Over a median follow-up of 17.0 months, there was no significant difference in rate of primary outcome between the 2 arms (adjusted hazard ratio, 0.96; 95% CI, 0.67-1.38; P = .82). Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker exposure was more frequent in intervention arm compared with the control group (rate ratio, 1.21; 95% CI, 1.02-1.43). There was no difference in the secondary outcomes of hypertension control and exposure to unsafe medications or adverse events between the arms. Several COVID-19-related issues contributed to null findings in the study. Conclusion and Relevance: In this study, among patients with moderate-risk to high-risk CKD, a multifaceted electronic health record-based population health management intervention resulted in more exposure days to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers but did not reduce risk of CKD progression or hypertension control vs usual care. Trial Registration: ClinicalTrials.gov Identifier: NCT03832595.

Electronic Health Record-Based Nudge Intervention and Axillary Surgery in Older Women With Breast Cancer: A Nonrandomized Controlled Trial.

Importance: Choosing Wisely recommendations advocate against routine use of axillary staging in older women with early-stage, clinically node-negative (cN0), hormone receptor-positive (HR+), and HER2-negative breast cancer. However, rates of sentinel lymph node biopsy (SLNB) in this population remain persistently high. Objective: To evaluate whether an electronic health record (EHR)-based nudge intervention targeting surgeons in their first outpatient visit with patients meeting Choosing Wisely criteria decreases rates of SLNB. Design, Setting, and Participants: This nonrandomized controlled trial was a hybrid type 1 effectiveness-implementation study with subsequent postintervention semistructured interviews and lasted from October 2021 to October 2023. Data came from EHRs at 8 outpatient clinics within an integrated health care system; participants included 7 breast surgical oncologists. Data were collected for female patients meeting Choosing Wisely criteria for omission of SLNB (aged ≥70 years with cT1 and cT2, cN0, HR+/HER2- breast cancer). The study included a 12-month preintervention control period; baseline surveys assessing perceived acceptability, appropriateness, and feasibility of the designed intervention; and a 12-month intervention period. Intervention: A column nudge was embedded into the surgeon's schedule in the EHR identifying patients meeting Choosing Wisely criteria for potential SLNB omission. Main Outcomes and Measures: The primary outcome was rate of SLNB following nudge deployment into the EHR. Results: Similar baseline demographic and tumor characteristics were observed before (control period, n = 194) and after (intervention period, n = 193) nudge deployment. Patients in both the control and intervention period had a median (IQR) age of 75 (72-79) years. Compared with the control period, unadjusted rates of SLNB decreased by 23.1 percentage points (46.9% SLNB rate prenudge to 23.8% after; 95% CI, -32.9 to -13.8) in the intervention period. An interrupted time series model showed a reduction in the rate of SLNB following nudge deployment (adjusted odds ratio, 0.26; 95% CI, 0.07 to 0.90; P = .03). The participating surgeons scored the intervention highly on acceptability, appropriateness, and feasibility. Dominant themes from semistructured interviews indicated that the intervention helped remind the surgeons of potential Choosing Wisely applicability without the need for additional clicks or actions on the day of the patient visit, which facilitated use. Conclusions and Relevance: This study showed that a nudge intervention in the EHR significantly decreased low-value axillary surgery in older women with early-stage, cN0, HR+/HER2- breast cancer. This user-friendly and easily implementable EHR-based intervention could be a beneficial approach for decreasing low-value care in other practice settings or patient populations. Trial Registration: ClinicalTrials.gov Identifier: NCT06006910.

The patient-centered medical home: an ethical analysis of principles and practice.

The patient-centered medical home (PCMH), with its focus on patient-centered care, holds promise as a way to reinvigorate the primary care of patients and as a necessary component of health care reform. While its tenets have been the subject of review, the ethical dimensions of the PCMH have not been fully explored. Consideration of the ethical foundations for the core principles of the PCMH can and should be part of the debate concerning its merits. The PCMH can align with the principles of medical ethics and potentially strengthen the patient-physician relationship and aspects of health care that patients value. Patient choice and these ethical considerations are central and at least as important as the economic and practical arguments in support of the PCMH, if not more so. Further, the ethical principles that support key concepts of the PCMH have implications for the design and implementation of the PCMH. This paper explores the PCMH in light of core principles of ethics and professionalism, with an emphasis both on how the concept of the PCMH may reinforce core ethical principles of medical practice and on further implications of these principles.

Electronic reminders to patients within an interactive patient health record.

Keeping patients with complex medical illnesses up to date with their preventive care and chronic disease management services, such as lipid testing and retinal exam in patients with diabetes, is challenging. Within a commercially available electronic health record (EHR) with a secure personal health record (PHR), we developed a system that sends up to three weekly reminders to patients who will soon be due for preventive care services. The reminder messages reside within the secure PHR, which is linked to the EHR, and are displayed on a screen where patients can also send to the physician's office an electronic message to request appointments for the needed services. The reminder messages stop when the patient logs on to review the reminders. The system, designed with patient input, groups together all services that will be due in the next 3 months to avoid repeatedly messaging the patient. After 2 months, the cycle of reminders begins again. This system, which is feasible and economical to build, has the potential to improve care and compliance with quality measures.

Electronic health record based population health management to optimize care in CKD: Design of the Kidney Coordinated HeAlth Management Partnership (K-CHAMP) trial.

Primary care physicians (PCPs) provide the majority of medical care to patients with non-dialysis dependent CKD. However, PCPs report numerous limitations to providing expert CKD care, including poor patient education, inadequate diagnostic evaluation, suboptimal use of medications, and time limitations. The Kidney Coordinated HeAlth Management Partnership (Kidney CHAMP) trial is a cluster randomized controlled trial to evaluate the effectiveness of a novel centralized electronic health records (EHR)-delivered population health management (PHM) strategy for high-risk CKD patients on patient care, safety, and other outcomes of interest to patients, providers, and payors. Over a 42-month period, the trial will compare the effectiveness of a multifaceted intervention that combines early identification of high-risk patients, timely nephrology guidance, pharmacist-led medication management services, and CKD patient education to usual care and enroll 1650 high-risk CKD patients from 100 primary care practices. The primary outcome will be ≥40% decline in estimated glomerular filtration rate (eGFR) or end stage kidney disease. Key secondary outcomes will include blood pressure, renin-angiotensin aldosterone system inhibitors use, and exposure to potentially unsafe medications. If successful, our treatment approach could improve CKD care delivery and safety, resource allocation, and adoption of evidence-based CKD guideline-concordant care.

Identifying barriers to shared decision-making about bariatric surgery in two large health systems.

OBJECTIVE: Prior research suggests shared decision-making (SDM) could improve patient and health care provider communication about bariatric surgery. The aim of this work was to identify and prioritize barriers to SDM around bariatric surgery to help guide implementation of SDM. METHODS: Two large US health care systems formed multidisciplinary teams to facilitate the implementation of SDM around bariatric surgery. The teams used a nominal group process approach involving (1) generation of multilevel barriers, (2) round-robin recording of barriers, (3) facilitated discussion, and (4) selection and ranking of barriers according to importance and feasibility to address. RESULTS: One health system identified 13 barriers and prioritized 5 as the most important and feasible to address. The second health system identified 14 barriers and prioritized 6. Both health systems commonly prioritized six barriers: lack of insurance coverage; lack of understanding of insurance coverage; lack of organizational prioritization of SDM; lack of knowledge about bariatric surgery; lack of interdepartmental clarity between primary and specialty care; and limited training on SDM conversations and tools. CONCLUSIONS: Health systems face numerous barriers to SDM around bariatric surgery, and these can be easily identified and prioritized by multistakeholder teams. Future research should seek to identify effective strategies to address these common barriers.

Lifestyle strategies after intentional weight loss: results from the MAINTAIN-pc randomized trial.

Introduction/Purpose: Weight maintenance following intentional weight loss is challenging and often unsuccessful. Physical activity and self-monitoring are strategies associated with successful weight loss maintenance. However, less is known about the type and number of lifestyle strategies used following intentional weight loss. The purpose of this study was to determine the types and amounts of strategies associated with successful long-term weight loss maintenance. Methods: Data from the 24-month Maintaining Activity and Nutrition Through Technology-Assisted Innovation in Primary Care (MAINTAIN-pc) trial were analyzed. MAINTAIN-pc recruited adults (n=194; 53.4±12.2 years of age, body mass index (BMI): 30.4±5.9 kg/m2, 74% female) with recent intentional weight loss of ≥5%, randomized to tracking tools plus coaching (i.e., coaching group) or tracking tools without coaching (i.e., tracking-only group). At baseline, 6, 12, and 24 months, participants reported lifestyle strategies used in the past 6 months, including self-monitoring, group support, behavioral skills, and professional support. General linear models evaluated changes in the number of strategies over time between groups and the consistency of strategies used over the 24-month intervention. Results: At baseline, 100% used behavioral skills, 73% used group support, 69% used self-monitoring, and 68% used professional support in the past 6 months; at 24 months, these rates were 98%, 60%, 75%, and 61%, respectively. While the number of participants utilizing individual strategies did not change significantly over time, the overall number of strategies participants reported decreased. More strategies were used at baseline and 6 months compared to 12- and 24-month follow-ups. The coaching group used more strategies at months 6 and 12 than the tracking-only group. Consistent use of professional support strategies over the 24-month study period was associated with less weight regain. Conclusion: Weight loss maintenance interventions that incorporate continued follow-up and support from healthcare professionals are likely to prevent weight regain after intentional weight loss.

Aspects of Program Engagement in an Online Physical Activity Intervention and Baseline Predictors of Engagement.

PURPOSE: Participant engagement in an online physical activity (PA) intervention is described and baseline factors related to engagement are identified. DESIGN: Longitudinal Study Within Randomized Controlled Trial. SETTING: Online/Internet. SAMPLE: Primary care patients (21-70 years). INTERVENTION: ActiveGOALS was a 3-month, self-directed online PA intervention (15 total lessons, remote coaching support, and a body-worn step-counter). MEASURES: Engagement was measured across six outcomes related to lesson completion (total number and time to complete), coach contact, and behavior tracking (PA, sedentary). Self-reported baseline factors were examined from seven domains (confidence, environment, health, health care, demographic, lifestyle, and quality of life). ANALYSIS: General linear and nonlinear mixed models were used to examine relationships between baseline factors and engagement outcomes within and across all domains. RESULTS: Seventy-nine participants were included in the sample (77.2% female; 74.7% white non-Hispanic). Program engagement was high (58.2% completed all lessons; PA was tracked ≥3 times/week for 11.3 ± 4.0 weeks on average). Average time between completed lessons (days) was longer than expected and participants only contacted their coach about 1 of every 3 weeks. Individual predictors related to health, health care, demographics, lifestyle, and quality of life were significantly related to engagement. CONCLUSION: Examining multiple aspects of engagement and a large number of potential predictors of engagement is likely needed to determine facilitators and barriers for high engagement in multi-faceted online intervention programs.

Clinical decision support to promote safe prescribing to women of reproductive age: a cluster-randomized trial.

BACKGROUND: Potentially teratogenic medications are frequently prescribed without provision of contraceptive counseling. OBJECTIVE: To evaluate whether computerized clinical decision support (CDS) can increase primary care providers' (PCPs') provision of family planning services when prescribing potentially teratogenic medications. DESIGN: Cluster-randomized trial conducted in one academic and one community-based practice between October of 2008 and April of 2010. PARTICIPANTS/INTERVENTIONS: Forty-one PCPs were randomized to receive one of two types of CDS which alerted them to risks of medication-induced birth defects when ordering potentially teratogenic medications for women who may become pregnant. The 'simple' CDS provided a cautionary alert; the 'multifaceted' CDS provided tailored information and links to a structured order set designed to facilitate safe prescribing. Both CDS systems alerted PCPs about medication risk only once per encounter. MAIN MEASURES: We assessed change in documented provision of family planning services using data from 35,110 encounters and mixed-effects models. PCPs completed surveys before and after the CDS systems were implemented, allowing assessment of change in PCP-reported counseling about the risks of medication-induced birth defects and contraception. KEY RESULTS: Both CDS systems were associated with slight increases in provision of family planning services when potential teratogens were prescribed, without a significant difference in improvement by CDS complexity (p = 0.87). Because CDS was not repeated, 13% of the times that PCPs received CDS they substituted another potential teratogen. PCPs reported significant improvements in several counseling and prescribing practices. The multifaceted group reported a greater increase in the number of times per month they discussed the risks of medication use during pregnancy (multifaceted: +4.9 ± 7.0 vs. simple: +0.8 ± 3.2, p = 0.03). The simple CDS system was associated with greater clinician satisfaction. CONCLUSIONS: CDS systems hold promise for increasing provision of family planning services when fertile women are prescribed potentially teratogenic medications, but further refinement of these systems is needed.

Exceptions to outpatient quality measures for coronary artery disease in electronic health records.

BACKGROUND: Physicians report outpatient quality measures from data in electronic health records to facilitate care improvement and qualify for incentive payments. OBJECTIVE: To determine the frequency and validity of exceptions to quality measures and to test a system for classifying the reasons for these exceptions. DESIGN: Cross-sectional observational study. SETTING: 5 internal medicine or cardiology practices. PARTICIPANTS: 47,075 patients with coronary artery disease between 2006 and 2007. MEASUREMENTS: Counts of adherence with and exceptions to 4 quality measures, on the basis of automatic reports of recommended drug therapy by computer software and separate manual reviews of electronic health records. RESULTS: 3.5% of patients who had a drug recommended had an exception to the drug and were not prescribed it (95% CI, 3.4% to 3.7%). Clinicians did prescribe the recommended drug for many other patients with exceptions. In 538 randomly selected records, 92.6% (CI, 90.3% to 94.9%) of the exceptions reported automatically by computer software were also exceptions during manual review. Most medical exceptions were clinical contraindications, drug allergies, or drug intolerances. In 592 randomly selected records, an unreported exception or a drug prescription was found during manual review for 74.6% (CI, 71.1% to 78.1%) of patients for whom automatic reporting recorded a quality failure. LIMITATION: The study used a convenience sample of practices, nonstandardized data extraction methods, only drug-related quality measures, and no financial incentives. CONCLUSION: Exceptions to recommended therapy occur infrequently and are usually valid. Physicians frequently prescribed drugs even when exceptions were present. Automated reports of quality failure often miss critical information. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Clinic Design for Safety During the Pandemic: Safety or Teamwork, Can We Only Pick One?

OBJECTIVE: This article aims to illustrate the design considerations of team-based primary care clinics in response to the pandemic. BACKGROUND: Due to COVID-19, physical distancing became a critical practice in our daily life, especially in healthcare settings where healthcare professionals must continue providing care to patients despite the manifold risks. Many healthcare facilities are implementing physical distancing in their clinic layouts, and healthcare professionals are adjusting their behaviors, so they can stay away from each other. METHODS: A total of four team-based primary care clinics were studied to identify their lessons learned regarding safety measures and space usage during the pandemic. RESULTS: The four team-based primary care clinics made changes to the clinic design (e.g., waiting areas, exam rooms, team workspaces), operational protocols (e.g., in-person huddles, social gatherings, staff work locations), and usage of spaces (e.g., outdoor spaces, utility rooms). Such changes enabled the implementation of safety measures during the pandemic. However, healthcare professionals also reported challenges regarding their team communication and coordination due to physical distancing and separation. CONCLUSIONS: Our findings suggest that the physical distancing may in fact contribute to less effective teamwork and patient care and negatively affect staff well-being. In this article, we ask healthcare system leaders and designers to continue supporting both safety and teamwork by paying attention to the flexibility and spatial relationships among healthcare professionals rather than fully sacrificing teamwork for safety. Also, now is the time when multidisciplinary collaborations are needed to establish and validate guidelines that can improve both factors.

Effect of Different Interventions to Help Primary Care Clinicians Avoid Unsafe Opioid Prescribing in Opioid-Naive Patients With Acute Noncancer Pain: A Cluster Randomized Clinical Trial.

Importance: Prescription opioids can treat acute pain in primary care but have potential for unsafe use and progression to prolonged opioid prescribing. Objective: To compare clinician-facing interventions to prevent unsafe opioid prescribing in opioid-naive primary care patients with acute noncancer pain. Design Setting and Participants: We conducted a multisite, cluster-randomized, 2 × 2 factorial, clinical trial in 3 health care systems that comprised 48 primary care practices and 525 participating clinicians from September 2018 through January 2021. Patient participants were opioid-naive outpatients, 18 years or older, who presented for a qualifying clinic visit with acute noncancer musculoskeletal pain or nonmigraine headache. Interventions: Practices randomized to: (1) control; (2) opioid justification; (3) monthly clinician comparison emails; or (4) opioid justification and clinician comparison. All groups received opioid prescribing guidelines via the electronic health record at the time of a new opioid prescription. Main Outcomes and Measures: Primary outcome measures were receipt of an initial opioid prescription at the qualifying clinic visit. Other outcomes were opioid prescribing for more than 3 months and a concurrent opioid/benzodiazepine prescription over 12-month follow-up. Results: Among 22 616 enrolled patient participants (9740 women [43.1%]; 64 American Indian/Alaska Native [0.3%]; 590 Asian [2.6%], 1120 Black/African American [5.0%], 1777 Hispanic [7.9%], 225 Native Hawaiian/Pacific Islander [1.0%], and 18 981 White [83.9%] individuals), the initial opioid prescribing rates at the qualifying clinic visit were 3.1% in the total sample, 4.2% in control, 3.6% in opioid justification, 2.6% in clinician comparison, and 1.9% in opioid justification and clinician comparison. Compared with control, the adjusted odds ratio (aOR) for a new opioid prescription was 0.74 (95% CI, 0.46-1.18; P = .20) for opioid justification and 0.60 (95% CI, 0.38-0.96; P = .03) for clinician comparison. Compared with control, clinician comparison was associated with decreased odds of opioid therapy of more than 3 months (aOR, 0.79; 95% CI, 0.69-0.91; P = .001) and concurrent opioid/benzodiazepine prescription (aOR, 0.85; 95% CI, 0.72-1.00; P = .04), whereas opioid justification did not have a significant effect. Conclusions and Relevance: In this cluster randomized clinical trial, comparison emails decreased the proportion of opioid-naive patients with acute noncancer pain who received an opioid prescription, progressed to treatment with long-term opioid therapy, or were exposed to concurrent opioid and benzodiazepine therapy. Health care systems can consider adding clinician-targeted nudges to other initiatives as an efficient, scalable approach to further decrease potentially unsafe opioid prescribing. Trial Registration: ClinicalTrials.gov Identifier: NCT03537573.

Automated clinical reminders for primary care providers in the care of CKD: a small cluster-randomized controlled trial.

BACKGROUND: Primary care physicians (PCPs) care for most non-dialysis-dependent patients with chronic kidney disease (CKD). Studies suggest that PCPs may deliver suboptimal CKD care. One means to improve PCP treatment of CKD is clinical decision support systems (CDSSs). STUDY DESIGN: Cluster-randomized controlled trial. SETTING & PARTICIPANTS: 30 PCPs in a university-based outpatient general internal medicine practice and their 248 patients with moderate to advanced CKD who had not been referred to a nephrologist. INTERVENTION: 2 CKD educational sessions were held for PCPs in both arms. The 15 intervention-arm PCPs also received real-time automated electronic medical record alerts for patients with estimated glomerular filtration rates <45 mL/min/1.73 m(2) recommending renal referral and urine albumin quantification if not done within the prior year. OUTCOMES: Primary outcome was referral to a nephrologist; secondary outcomes were albuminuria/proteinuria assessment, CKD documentation, optimal blood pressure (ie, <130/80 mm Hg), and use of renoprotective medications. RESULTS: The intervention and control arms did not differ in renal referrals (9.7% vs 16.5%, respectively; between-group difference, -6.8%; 95% CI, -15.5% to 1.8%; P = 0.1) or proteinuria assessments (39.3% vs 30.1%, respectively; between-group difference, 9.2%; 95% CI, -2.7% to 21.1%; P = 0.1). For intervention and control patients without a baseline proteinuria assessment, 27.7% versus 16.3%, respectively, had one at follow-up (P = 0.06). After controlling for clustering, these findings were largely unchanged and no significant differences were apparent between groups. LIMITATIONS: Small single-center university-based practice, use of a passive CDSS that required PCPs to trigger the electronic order set. CONCLUSIONS: PCPs were willing to partake in a randomized trial of a CDSS to improve outpatient CKD care. Although CDSSs may have potential, larger studies are needed to further explore how best to deploy them to enhance CKD care.