Impact of an Electronic Medical Record-Based System to Promote Human Immunodeficiency Virus/Hepatitis C Virus Screening in Public Hospital Primary Care Clinics.

BACKGROUND: United States guidelines recommend that all adolescents and adults be tested for human immunodeficiency virus (HIV) and that persons born between 1945 and 1965 be tested for hepatitis C virus (HCV). METHODS: We used electronic medical record (EMR) data to identify patients in 3 primary care clinics in Seattle, Washington who met national criteria for routine HCV or HIV testing and had no documented history of prior testing. Clinic staff received daily lists of untested patients with scheduled appointments. We used generalized linear models to compare the percentage of patients tested and newly diagnosed with HIV and HCV in the 18 months before and during the intervention. RESULTS: A total of 16784 patients aged 18-64 and 9370 patients born between 1945 and 1965 received care from January 2011 to December 2015. Comparing the preintervention and intervention periods, the percentage of previously untested patients tested for HIV and HCV increased from 14.9% to 30.8% and from 18.0% to 35.5%, respectively (P < .0001 for both). Despite this increase in testing, there was no change in the percentage of patients newly diagnosed with HIV (0.7% in both periods, P = .96) or HCV (3.6% vs 3.7%, P = .81). We estimate that 1.2%-15% of HCV-infected primary care patients in our medical center are undiagnosed. CONCLUSIONS: EMR-based HCV/HIV testing promotion increased testing but not case finding among primary care patients in our medical center. In our institution, most HCV-infected patients are already diagnosed, primarily through risk-based and clinical screening, highlighting the need to concentrate future efforts on increasing HCV treatment.

Prepared but not practicing: declining pregnancy care among recent family medicine residency graduates.

BACKGROUND AND OBJECTIVES: Pregnancy care has been an important component of family medicine in the Pacific Northwest. This paper describes a sudden decline in the provision of pregnancy care by recent family medicine residency graduates in the region. METHODS: Two cohorts of graduates from the University of Washington Family Medicine Residency Network were surveyed about their current pregnancy care practice patterns. A total of 205 graduates from 1997-1999 (surveyed in 2000) and 223 graduates from 2000-2002 (surveyed in 2003) completed the surveys (69% and 65% response rates). RESULTS: From 2000 to 2003, there was a 20% decline in the proportion of recent family medicine residency graduates performing deliveries in their practice (78% versus 58%). The proportion performing prenatal care declined from 81% to 64%. Graduates from all the programs across the region rated their preparation for the practice of pregnancy care highly, regardless of whether or not they currently provided such care. In addition to graduation cohort, the provision of pregnancy care was also related to practicing in the Washington, Alaska, Montana, and Idaho (WAMI) region, providing hospital care, and feeling well prepared to provide pregnancy care. (Wyoming residency programs became affiliated with the WAMI network in 2003 and are not included in this analysis.) CONCLUSIONS: Fewer new family physicians are providing pregnancy care in the Pacific Northwest. This decline does not appear to be related to training but threatens access to service for patients.

A Curriculum on Care for Complex Patients: Resident Perspectives.

BACKGROUND AND OBJECTIVES: Caring for patients with a challenging mix of medical, psychological, and social problems may easily overwhelm residents. We developed a month-long "Care for Complex Patients" curriculum for second-year residents to improve their ability to care for this group of patients by increasing their understanding of why the care is complex and by building communication, teamwork, and resource management skills. METHODS: Surveys and focus groups were used to assess the impact of the curriculum. Quantitative and qualitative methods were used to evaluate responses. RESULTS: Between 2008 and 2010, 24 residents completed our rotation. Eighty-three percent completed the pre-curriculum and post-curriculum surveys. Residents' self-ratings significantly improved in all 11 complex care management skills, and residents reported increased confidence when working with patients whose care was complex. Residents were surprised to learn about all the community resources and began using these resources when providing care for these patients. Despite rating themselves improved, a large number of residents still rated themselves as not competent in many of the skills. CONCLUSIONS: A curriculum for residents focused on education in 11 key skill areas in the care of complex patients led to increased self-confidence and willingness to provide complex care. However, 1 month of training is an insufficient amount of time to help most learners achieve self-assessed ratings of capable and competent in using these key skills when caring for complex patients.

Interdisciplinary direct observation: impact on precepting, residents, and faculty.

BACKGROUND: Direct observation of residents for training and assessment is a core recommendation in medical education policy initiatives. Limited research exists about the impact of direct observation on precepting, and we are unaware of any research examining the impact of interdisciplinary precepting on trainees or preceptors. Over the past 3 years we have implemented an Interdisciplinary Direct Observation Precepting Model (IDOPM). Residents are directly observed via closed-circuit television by a behavioral scientist and family physician team. METHODS: Surveys and focus groups were used to examine the impact of the IDOPM. Authors analyzed survey responses and focus group transcripts using an immersion/crystallization approach to arrive at themes. RESULTS: Between February and June 2009, 24 residents, 14 physician faculty, and eight behavioral science faculty members participated in 19 IDOPM clinics. Eighty-two percent of residents and 95% of faculty responded to surveys. Key findings were (1) Residents and faculty report addressing topics that are not usually discussed in traditional precepting, including communication skills, time management, electronic medical record use, responding to emotional complexity, and physical exam skills, (2) The model reinforced a biopsychosocial approach to care, (3) Residents report ambivalent feelings about being observed, and (4) Faculty value the team approach to strengthen training and promote faculty development. CONCLUSIONS: The IDOPM addresses many core skills that are overlooked in traditional precepting encounters. Interdisciplinary direct observation may strengthen faculty ability to provide formative competency assessment in preparing residents to work in the complex world of primary care.

Medical case teaching on the web.

BACKGROUND: Little is known about strategies for developing teaching cases and strategies for identifying design features that optimize a learner's interactions with Web-based cases. PURPOSES: We examined design features in Web cases that facilitated interactive and engaging learning. METHODS: Nine collaborators reviewed selected Web cases and documented the presence of features that facilitate interactive learning, including opportunities for information gathering, decision making, and receiving feedback. RESULTS: Eighteen Web sites offered cases. These cases mainly were narrated based on biomedical information without patient voices. The cases were organized in a linear structure from patient presentation to follow-up. Many cases presented only a single case. We found little use of features for augmenting a learner's interaction with cases. Only a handful of cases generated feedback on the basis of the learners' responses. CONCLUSION: Our study suggests ways to improve the development of Web cases. These methods contribute to future research in testing cases for educational effectiveness.

Pilot study of enhanced tobacco-cessation services coverage for low-income smokers.

This study explored the feasibility of covering nicotine replacement therapy (NRT) and paying for pharmacist-delivered smoking cessation counseling at the time of NRT pick-up for low-income, managed Medicaid and Basic Health Plan (a state insurance program) enrollees. A prospective pilot intervention was used at two community health centers (CHCs) and two community pharmacies. Participants were adult managed-Medicaid or Basic Health Plan enrollees who attended the pilot CHCs and smoked. An innovative insurance benefit that included coverage for NRT and $15 payment to the pharmacist to deliver cessation counseling with each prescription fill. Proportion of eligible patients who used the cessation benefit and patient and pharmacist satisfaction with the intervention. During the 9-month intervention, 32 patients at the pilot clinics were referred for NRT and pharmacist-delivered counseling. This number represented roughly 5% of eligible smokers. Of these, 26 received NRT with concomitant pharmacist-delivered cessation counseling at least once. Recipients reported a high level of satisfaction with this intervention. Pharmacists indicated they would continue providing counseling if reimbursement remained adequate and if counseling lasted no longer than 5-10 min. However, 12 (38%) who were referred were no longer insured by the sponsoring plan by the end of the 9-month pilot period. Pharmacist-delivered cessation counseling may be feasible and merits further study. More importantly, this pilot reveals two key obstacles in our low-income, culturally diverse setting: low participation and rapid turnover of insureds. Future interventions will need to address these barriers.