1
|
Chan KKY, Yeung NCY, Mo PKH, Yang X. Common stressors, coping processes, and professional help-seeking of medical professionals in Hong Kong: A qualitative study. J Health Psychol 2024; 29:891-904. [PMID: 38160404 DOI: 10.1177/13591053231218658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Despite the high prevalence of perceived stress and mental health problems among medical professionals (MPs), their professional help-seeking is extremely low. This qualitative study explored MPs' stressors, stress-coping, barriers and facilitators of professional help-seeking. 10 MPs (30% male, Mage = 34.8 years) were recruited by purposive-sampling for views from different roles/settings. Thematic analyses revealed five central stressors: emerging novel diseases, challenges from technology-advancement, patient-communication difficulties, lack of workplace mental health care culture, excessive workload/manpower shortage. Participants predominantly used peer support/supervision and de-stress activities for stress-coping. Five factors affecting professional help-seeking were time constraint versus flexibility, mental health stigma versus de-stigmatization, concern over confidentiality/anonymity versus sense of privacy, worry about damage on professional role versus least work disruption, doubts of service providers versus perceived efficacy. All participants indicated a preference for online mental health service delivery. Results reflected unmet needs and service gaps from MPs' perspectives for the development of future interventions.
Collapse
Affiliation(s)
| | | | | | - Xue Yang
- The Chinese University of Hong Kong, Hong Kong
| |
Collapse
|
2
|
Tawfik D, Bayati M, Liu J, Nguyen L, Sinha A, Kannampallil T, Shanafelt T, Profit J. Predicting Primary Care Physician Burnout From Electronic Health Record Use Measures. Mayo Clin Proc 2024:S0025-6196(24)00037-5. [PMID: 38573301 DOI: 10.1016/j.mayocp.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/08/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE To evaluate the ability of routinely collected electronic health record (EHR) use measures to predict clinical work units at increased risk of burnout and potentially most in need of targeted interventions. METHODS In this observational study of primary care physicians, we compiled clinical workload and EHR efficiency measures, then linked these measures to 2 years of well-being surveys (using the Stanford Professional Fulfillment Index) conducted from April 1, 2019, through October 16, 2020. Physicians were grouped into training and confirmation data sets to develop predictive models for burnout. We used gradient boosting classifier and other prediction modeling algorithms to quantify the predictive performance by the area under the receiver operating characteristics curve (AUC). RESULTS Of 278 invited physicians from across 60 clinics, 233 (84%) completed 396 surveys. Physicians were 67% women with a median age category of 45 to 49 years. Aggregate burnout score was in the high range (≥3.325/10) on 111 of 396 (28%) surveys. Gradient boosting classifier of EHR use measures to predict burnout achieved an AUC of 0.59 (95% CI, 0.48 to 0.77) and an area under the precision-recall curve of 0.29 (95% CI, 0.20 to 0.66). Other models' confirmation set AUCs ranged from 0.56 (random forest) to 0.66 (penalized linear regression followed by dichotomization). Among the most predictive features were physician age, team member contributions to notes, and orders placed with user-defined preferences. Clinic-level aggregate measures identified the top quartile of clinics with 56% sensitivity and 85% specificity. CONCLUSION In a sample of primary care physicians, routinely collected EHR use measures demonstrated limited ability to predict individual burnout and moderate ability to identify high-risk clinics.
Collapse
Affiliation(s)
- Daniel Tawfik
- Stanford University School of Medicine, Stanford, CA.
| | | | - Jessica Liu
- Stanford University School of Medicine, Stanford, CA
| | - Liem Nguyen
- Stanford University School of Engineering, Stanford, CA
| | | | | | - Tait Shanafelt
- Stanford University School of Medicine, Stanford, CA; Stanford Medicine WellMD & WellPhD Center, Stanford, CA
| | - Jochen Profit
- Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
3
|
Payne TH, Turner GK. I'm not burned out. This is how I write notes. JAMIA Open 2023; 6:ooad099. [PMID: 38033784 PMCID: PMC10684266 DOI: 10.1093/jamiaopen/ooad099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/27/2023] [Accepted: 11/13/2023] [Indexed: 12/02/2023] Open
Abstract
Objectives We describe an automated transcription system that addresses many documentation problems and fits within scheduled clinical hours. Materials and methods During visits, the provider listens to the patient while maintaining eye contact and making brief notes on paper. Immediately after the visit conclusion and before the next, the provider makes a short voice recording on a smartphone which is transmitted to the system. The system uses a public domain general language model, and a hypertuned provider-specific language model that is iteratively refined as each produced note is edited by the physician, followed by final automated processing steps to add any templated text to the note. Results The provider leaves the clinic having completed all voice files, median duration 3.4 minutes. Created notes are formatted as preferred and are a median of 363 words (range 125-1175). Discussion This approach permits documentation to occur almost entirely within scheduled clinic hours, without copy-forward errors, and without interference with patient-provider interaction. Conclusion Though no documentation method is likely to appeal to all, this approach may appeal to many physicians and avoid many current problems with documentation.
Collapse
Affiliation(s)
- Thomas H Payne
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98104-2499, United States
- Department of Biomedical Informatics & Medical Education, University of Washington School of Medicine, Seattle, WA 98104-2499, United States
| | - Grace K Turner
- Department of Biomedical Informatics & Medical Education, University of Washington School of Medicine, Seattle, WA 98104-2499, United States
| |
Collapse
|
4
|
Khazen M, Sullivan EE, Arabadjis S, Ramos J, Mirica M, Olson A, Linzer M, Schiff GD. How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care. BMJ Open 2023; 13:e071241. [PMID: 37147090 PMCID: PMC10163453 DOI: 10.1136/bmjopen-2022-071241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES The quest to measure and improve diagnosis has proven challenging; new approaches are needed to better understand and measure key elements of the diagnostic process in clinical encounters. The aim of this study was to develop a tool assessing key elements of the diagnostic assessment process and apply it to a series of diagnostic encounters examining clinical notes and encounters' recorded transcripts. Additionally, we aimed to correlate and contextualise these findings with measures of encounter time and physician burnout. DESIGN We audio-recorded encounters, reviewed their transcripts and associated them with their clinical notes and findings were correlated with concurrent Mini Z Worklife measures and physician burnout. SETTING Three primary urgent-care settings. PARTICIPANTS We conducted in-depth evaluations of 28 clinical encounters delivered by seven physicians. RESULTS Comparing encounter transcripts with clinical notes, in 24 of 28 (86%) there was high note/transcript concordance for the diagnostic elements on our tool. Reliably included elements were red flags (92% of notes/encounters), aetiologies (88%), likelihood/uncertainties (71%) and follow-up contingencies (71%), whereas psychosocial/contextual information (35%) and mentioning common pitfalls (7%) were often missing. In 22% of encounters, follow-up contingencies were in the note, but absent from the recorded encounter. There was a trend for higher burnout scores being associated with physicians less likely to address key diagnosis items, such as psychosocial history/context. CONCLUSIONS A new tool shows promise as a means of assessing key elements of diagnostic quality in clinical encounters. Work conditions and physician reactions appear to correlate with diagnostic behaviours. Future research should continue to assess relationships between time pressure and diagnostic quality.
Collapse
Affiliation(s)
- Maram Khazen
- Harvard Medical School, Center for Primary Care, Boston, Massachusetts, USA
- The Max Stern Yezreel Valley College, Emek Yezreel, Northern, Israel
| | - Erin E Sullivan
- Suffolk University Sawyer Business School, Boston, Massachusetts, USA
- Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Sophia Arabadjis
- University of California Santa Barbara, Santa Barbara, California, USA
| | - Jason Ramos
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maria Mirica
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrew Olson
- University of Minnesota Medical School Twin Cities, Minneapolis, Minnesota, USA
| | - Mark Linzer
- Hennepin Healthcare System Inc, Minneapolis, Minnesota, USA
| | - Gordon D Schiff
- Harvard Medical School, Center for Primary Care, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
5
|
McClafferty HH, Hubbard DK, Foradori D, Brown ML, Profit J, Tawfik DS. Physician Health and Wellness. Pediatrics 2022; 150:189767. [PMID: 36278292 DOI: 10.1542/peds.2022-059665] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 12/03/2022] Open
Abstract
Physician health and wellness is a complex topic relevant to all pediatricians. Survey studies have established that pediatricians experience burnout at comparable rates to colleagues across medical specialties. Prevalence of burnout increased for all pediatric disciplines from 2011 to 2014. During that time, general pediatricians experienced a more than 10% increase in burnout, from 35.3% to 46.3%. Pediatric medical subspecialists and pediatric surgical specialists experienced slightly higher baseline rates of burnout in 2011 and similarly increased to just under 50%. Women currently constitute a majority of pediatricians, and surveys report a 20% to 60% higher prevalence of burnout in women physicians compared with their male counterparts. The purpose of this report is to update the reader and explore approaches to pediatrician well-being and reduction of occupational burnout risk throughout the stages of training and practice. Topics covered include burnout prevalence and diagnosis; overview of national progress in physician wellness; update on physician wellness initiatives at the American Academy of Pediatrics; an update on pediatric-specific burnout and well-being; recognized drivers of burnout (organizational and individual); a review of the intersection of race, ethnicity, gender, and burnout; protective factors; and components of wellness (organizational and individual). The development of this clinical report has inevitably been shaped by the social, cultural, public health, and economic factors currently affecting our communities. The coronavirus disease 2019 (COVID-19) pandemic has layered new and significant stressors onto medical practice with physical, mental, and logistical challenges and effects that cannot be ignored.
Collapse
Affiliation(s)
- Hilary H McClafferty
- Department of Pediatrics, Section Chief, Pediatric Emergency Medicine, Tucson Medical Center, Tucson, Arizona
| | - Dena K Hubbard
- Children's Mercy Kansas City, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Dana Foradori
- Department of Pediatric Hospital Medicine, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Melanie L Brown
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Daniel S Tawfik
- Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | | |
Collapse
|
6
|
Barry MJ, Tseng CW. Moving to More Evidence-Based Primary Care Encounters: A Farewell to the Review of Systems. JAMA 2022; 328:1495-1496. [PMID: 36178699 DOI: 10.1001/jama.2022.18346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This Viewpoint discusses ways in which free time during patient visits, resulting from removal of tradition- and reimbursement-driven care in favor of more evidence-based care, could be used to achieve better health outcomes based on recommendations from the US Preventive Services Task Force evidence-based preventive care.
Collapse
Affiliation(s)
- Michael J Barry
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Chien-Wen Tseng
- Department of Family Medicine and Community Health, University of Hawaii John A. Burns School of Medicine, Honolulu
| |
Collapse
|
7
|
Robinson K, Barraclough S, Cummings E, Iedema R. The historiography of a profession: The societal and political drivers of the health information management profession in Australia. HEALTH INF MANAG J 2022; 52:64-71. [PMID: 35302403 DOI: 10.1177/18333583211070336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Health information permeates healthcare delivery from point-of-care, across the continuum of care and throughout the healthcare system's policy, population health, research, planning and funding arenas. Health information managers (HIMs) expertly manage that information. This commentary theorises the health information management profession for the first time. Its purpose is to identify and contextualise, via a historiographical account, the societal and political drivers that have shaped contemporary Australian health information management and HIMs' scientific work. It seeks to build our knowledge of the socio-political influences on the profession's emergence and development, and the projected drivers of its future. Eight critical, socio-political drivers were identified and are addressed in temporaneous order. Scientific medicine has reflected the influences on medicine in the past century and a half of the medical record and other technologies, laboratory-based sciences, evidence-based medicine and evidence-based health. Standardisation has underpinned and guided the profession's practice. The hegemony of non-medical healthcare managers and resource- and performance-related accountabilities emerged in the 1960s, as did the efficiencies of bureaucratisation in healthcare and post-bureaucratic shifts to textualisation and technogovernance. Technologisation has driven constant change in health information management, as have the forces of the fast-paced risk society. Since the 1980s, the health consumer movement has propelled regulatory mechanisms that accord patients' access rights to their medical records and mandate information privacy protections. Finally, a nascent commodification of health information has emerged. These forces exert ongoing impacts on the profession. They will, we conclude, singularly and collectively continue to shape its discourses and direction.
Collapse
Affiliation(s)
| | | | - Elizabeth Cummings
- 3925University of Tasmania, Hobart, TAS, Australia.,University of Victoria, Victoria, BC, Canada
| | | |
Collapse
|
8
|
Constructing Epidemiologic Cohorts from Electronic Health Record Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182413193. [PMID: 34948800 PMCID: PMC8701170 DOI: 10.3390/ijerph182413193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022]
Abstract
In the United States, electronic health records (EHR) are increasingly being incorporated into healthcare organizations to document patient health and services rendered. EHRs serve as a vast repository of demographic, diagnostic, procedural, therapeutic, and laboratory test data generated during the routine provision of health care. The appeal of using EHR data for epidemiologic research is clear: EHRs generate large datasets on real-world patient populations in an easily retrievable form permitting the cost-efficient execution of epidemiologic studies on a wide array of topics. Constructing epidemiologic cohorts from EHR data involves as a defining feature the development of data machinery, which transforms raw EHR data into an epidemiologic dataset from which appropriate inference can be drawn. Though data machinery includes many features, the current report focuses on three aspects of machinery development of high salience to EHR-based epidemiology: (1) selecting study participants; (2) defining “baseline” and assembly of baseline characteristics; and (3) follow-up for future outcomes. For each, the defining features and unique challenges with respect to EHR-based epidemiology are discussed. An ongoing example illustrates key points. EHR-based epidemiology will become more prominent as EHR data sources continue to proliferate. Epidemiologists must continue to improve the methods of EHR-based epidemiology given the relevance of EHRs in today’s healthcare ecosystem.
Collapse
|
9
|
Persell SD, Heiman HL. Rethinking What Is Essential in the Office Visit Note. J Gen Intern Med 2021; 36:3571-3572. [PMID: 34027603 PMCID: PMC8606504 DOI: 10.1007/s11606-021-06860-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/26/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Heather L Heiman
- Division of Academic Internal Medicine and Geriatrics, Department of Medicine, University of Illinois College of Medicine, Chicago, IL, USA.,Department of Medical Education, University of Illinois College of Medicine, Chicago, IL, USA
| |
Collapse
|
10
|
Maitra A, Kamdar MR, Zulman DM, Haverfield MC, Brown-Johnson C, Schwartz R, Israni ST, Verghese A, Musen MA. Using ethnographic methods to classify the human experience in medicine: a case study of the presence ontology. J Am Med Inform Assoc 2021; 28:1900-1909. [PMID: 34151988 PMCID: PMC8363802 DOI: 10.1093/jamia/ocab091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/26/2021] [Accepted: 05/13/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Although social and environmental factors are central to provider-patient interactions, the data that reflect these factors can be incomplete, vague, and subjective. We sought to create a conceptual framework to describe and classify data about presence, the domain of interpersonal connection in medicine. METHODS Our top-down approach for ontology development based on the concept of "relationality" included the following: 1) a broad survey of the social sciences literature and a systematic literature review of >20 000 articles around interpersonal connection in medicine, 2) relational ethnography of clinical encounters (n = 5 pilot, 27 full), and 3) interviews about relational work with 40 medical and nonmedical professionals. We formalized the model using the Web Ontology Language in the Protégé ontology editor. We iteratively evaluated and refined the Presence Ontology through manual expert review and automated annotation of literature. RESULTS AND DISCUSSION The Presence Ontology facilitates the naming and classification of concepts that would otherwise be vague. Our model categorizes contributors to healthcare encounters and factors such as communication, emotions, tools, and environment. Ontology evaluation indicated that cognitive models (both patients' explanatory models and providers' caregiving approaches) influenced encounters and were subsequently incorporated. We show how ethnographic methods based in relationality can aid the representation of experiential concepts (eg, empathy, trust). Our ontology could support investigative methods to improve healthcare processes for both patients and healthcare providers, including annotation of videotaped encounters, development of clinical instruments to measure presence, or implementation of electronic health record-based reminders for providers. CONCLUSION The Presence Ontology provides a model for using ethnographic approaches to classify interpersonal data.
Collapse
Affiliation(s)
- Amrapali Maitra
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Presence Center, Stanford University School of Medicine, Stanford, California, USA
| | - Maulik R Kamdar
- Stanford Center for Biomedical Informatics Research, Stanford University, Stanford, California, USA
| | - Donna M Zulman
- Division of Primary Care and Population Health, Stanford University, Stanford, California, USA
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Marie C Haverfield
- Department of Communication Studies, San Jose State University, San Jose, California, USA
| | - Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University, Stanford, California, USA
| | - Rachel Schwartz
- WellMD Center, Stanford University School of Medicine, Stanford, California, USA
| | | | - Abraham Verghese
- Presence Center, Stanford University School of Medicine, Stanford, California, USA
| | - Mark A Musen
- Stanford Center for Biomedical Informatics Research, Stanford University, Stanford, California, USA
| |
Collapse
|
11
|
Tawfik DS, Sinha A, Bayati M, Adair KC, Shanafelt TD, Sexton JB, Profit J. Frustration With Technology and its Relation to Emotional Exhaustion Among Health Care Workers: Cross-sectional Observational Study. J Med Internet Res 2021; 23:e26817. [PMID: 34255674 PMCID: PMC8292941 DOI: 10.2196/26817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/08/2021] [Accepted: 05/06/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND New technology adoption is common in health care, but it may elicit frustration if end users are not sufficiently considered in their design or trained in their use. These frustrations may contribute to burnout. OBJECTIVE This study aimed to evaluate and quantify health care workers' frustration with technology and its relationship with emotional exhaustion, after controlling for measures of work-life integration that may indicate excessive job demands. METHODS This was a cross-sectional, observational study of health care workers across 31 Michigan hospitals. We used the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey to measure work-life integration and emotional exhaustion among the survey respondents. We used mixed-effects hierarchical linear regression to evaluate the relationship among frustration with technology, other components of work-life integration, and emotional exhaustion, with adjustment for unit and health care worker characteristics. RESULTS Of 15,505 respondents, 5065 (32.7%) reported that they experienced frustration with technology on at least 3-5 days per week. Frustration with technology was associated with higher scores for the composite Emotional Exhaustion scale (r=0.35, P<.001) and each individual item on the Emotional Exhaustion scale (r=0.29-0.36, P<.001 for all). Each 10-point increase in the frustration with technology score was associated with a 1.2-point increase (95% CI 1.1-1.4) in emotional exhaustion (both measured on 100-point scales), after adjustment for other work-life integration items and unit and health care worker characteristics. CONCLUSIONS This study found that frustration with technology and several other markers of work-life integration are independently associated with emotional exhaustion among health care workers. Frustration with technology is common but not ubiquitous among health care workers, and it is one of several work-life integration factors associated with emotional exhaustion. Minimizing frustration with health care technology may be an effective approach in reducing burnout among health care workers.
Collapse
Affiliation(s)
- Daniel S Tawfik
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Amrita Sinha
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Mohsen Bayati
- Operations, Information, and Technology, Stanford University Graduate School of Business, Stanford, CA, United States
- Department of Biomedical Informatics, Stanford University School of Medicine, Stanford, CA, United States
| | - Kathryn C Adair
- Duke Center for Healthcare Safety and Quality, Duke University Health System, Durham, NC, United States
| | - Tait D Shanafelt
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
- WellMD Center, Stanford University School of Medicine, Stanford, CA, United States
| | - J Bryan Sexton
- Duke Center for Healthcare Safety and Quality, Duke University Health System, Durham, NC, United States
- Department of Psychiatry, Duke University School of Medicine, Duke University Health System, Durham, NC, United States
| | - Jochen Profit
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
- California Perinatal Quality Care Collaborative, Palo Alto, CA, United States
| |
Collapse
|
12
|
Martin DB, Stetson PD, Gilcrease GW, Stillman RC, Sugalski JM, Skinner J, Levy M. Preferences in Oncology History Documentation Styles Among Clinical Practitioners. JCO Oncol Pract 2021; 18:e1-e8. [PMID: 34228492 DOI: 10.1200/op.20.00756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Clinical notes function as the de facto handoff between providers and assume great importance during unplanned medical encounters. An organized and thorough oncology history is essential in care coordination. We sought to understand reader preferences for oncology history organization by comparing between chronologic and narrative formats. METHODS A convenience sample of 562 clinicians from 19 National Comprehensive Cancer Network Member Institutions responded to a survey comparing two formats of oncology histories, narrative and chronologic, for the same patient. Both histories were consensus-derived real-world examples. Each history was evaluated using semantic differential attributes (thorough, useful, organized, comprehensible, and succinct). Respondents choose a preference between the two styles for history gathering and as the basis of a new note. Open-ended responses were also solicited. RESULTS Respondents preferred the chronologic over the narrative history to prepare for a visit with an unknown patient (66% preference) and as a basis for their own note preparation (77% preference) (P < .01). The chronologic summary was preferred in four of the five measured attributes (useful, organized, comprehensible, and succinct); the narrative summary was favored for thoroughness (P < .01). Open-ended responses reflected the attribute scoring and noted the utility of content describing social determinants of health in the narrative history. CONCLUSION Respondents of this convenience sample preferred a chronologic oncology history to a concise narrative history. Further studies are needed to determine the optimal structure and content of chronologic documentation for oncology patients and the provider effort to use this format.
Collapse
Affiliation(s)
- Daniel B Martin
- Department of Medicine, University of Washington Medical Center, Seattle, WA.,Seattle Cancer Care Alliance, Seattle, WA
| | | | | | - Robert C Stillman
- The Ohio State University Comprehensive Cancer Center, James Cancer Hospital and Solove Research Institute Columbus, OH
| | | | | | - Mia Levy
- Rush University Cancer Center, Chicago, IL
| |
Collapse
|
13
|
Noble N, Bryant J, Maher L, Jackman D, Bonevski B, Shakeshaft A, Paul C. Patient self-report versus medical records for smoking status and alcohol consumption at Aboriginal Community Controlled Health Services. Aust N Z J Public Health 2021; 45:277-282. [PMID: 33970509 DOI: 10.1111/1753-6405.13114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 02/01/2021] [Accepted: 03/01/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE This study assessed the level of agreement, and predictors of agreement, between patient self-report and medical records for smoking status and alcohol consumption among patients attending one of four Aboriginal Community Controlled Health Service (ACCHSs). METHODS A convenience sample of 110 ACCHS patients self-reported whether they were current smokers or currently consumed alcohol. ACCHS staff completed a medical record audit for corresponding items for each patient. The level of agreement was evaluated using the kappa statistic. Factors associated with levels of agreement were explored using logistic regression. RESULTS The level of agreement between self-report and medical records was strong for smoking status (kappa=0.85; 95%CI: 0.75-0.96) and moderate for alcohol consumption (kappa=0.74; 95%CI: 0.60-0.88). None of the variables explored were significantly associated with levels of agreement for smoking status or alcohol consumption. CONCLUSIONS Medical records showed good agreement with patient self-report for smoking and alcohol status and are a reliable means of identifying potentially at-risk ACCHS patients. Implications for public health: ACCHS medical records are accurate for identifying smoking and alcohol risk factors for their patients. However, strategies to increase documentation and reduce missing data in the medical records are needed.
Collapse
Affiliation(s)
- Natasha Noble
- Health Behaviour Research Collaborative, School of Medicine and Public Health, University of Newcastle, New South Wales.,Priority Research Centre for Health Behaviour, University of Newcastle, New South Wales
| | - Jamie Bryant
- Health Behaviour Research Collaborative, School of Medicine and Public Health, University of Newcastle, New South Wales.,Priority Research Centre for Health Behaviour, University of Newcastle, New South Wales
| | - Louise Maher
- Centre for Epidemiology and Evidence, NSW Ministry of Health, New South Wales
| | - Daniel Jackman
- Maari Ma Health Aboriginal Corporation, New South Wales.,Outback Division of General Practice, New South Wales
| | - Billie Bonevski
- Hunter Medical Research Institute, New South Wales.,School of Medicine and Public Health, University of Newcastle, New South Wales
| | - Anthony Shakeshaft
- School of Medicine and Public Health, University of Newcastle, New South Wales.,National Drug and Alcohol Research Centre, University of NSW Sydney, New South Wales
| | - Christine Paul
- Health Behaviour Research Collaborative, School of Medicine and Public Health, University of Newcastle, New South Wales.,Priority Research Centre for Health Behaviour, University of Newcastle, New South Wales
| |
Collapse
|
14
|
Robinson K, Lee C. Light the candles! Happy 50th birthday HIMJ! Underpinning an agile, future-facing health information management profession. HEALTH INF MANAG J 2020; 50:3-5. [PMID: 33331180 DOI: 10.1177/1833358320965711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Cheens Lee
- 447879Health Information Management Association of Australia, Australia
| |
Collapse
|
15
|
Jhala M, Menon R. Examining the impact of an asynchronous communication platform versus existing communication methods: an observational study. ACTA ACUST UNITED AC 2020; 7:68-74. [PMID: 33479571 PMCID: PMC7808296 DOI: 10.1136/bmjinnov-2019-000409] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/15/2022]
Abstract
Background Healthcare systems revolve around intricate relations between humans and technology. System efficiency depends on information exchange that occur on synchronous and asynchronous platforms. Traditional synchronous methods of communication may pose risks to workflow integrity and contribute to inefficient service delivery and medical care. Aim To compare synchronous methods of communication to Medic Bleep, an instant messaging asynchronous platform, and observe its impact on clinical workflow, quality of work life and associations with patient safety outcomes and hospital core operations. Methods Cohorts of healthcare professionals were followed using the Time Motion Study methodology over a 2-week period, using both the asynchronous platform and the synchronous methods like the non-cardiac pager. Questionnaires and interviews were conducted to identify staff attitudes towards both platforms. Results A statistically significant figure (p<0.01) of 20.1 minutes’ reduction in average task completion was seen with asynchronous communication, saving 58.8% of time when compared with traditional synchronous methods. In subcategory analysis for staff: doctors, nurses and midwifery categories, a p value of <0.0495 and <0.01 were observed; a mean time reduction with statistical significance was also seen in specific task efficiencies of ‘To-Take-Out (TTO), patient review, discharge & patient transfer and escalation of care & procedure’. The platform was favoured with an average Likert value of 8.7; 67% found it easy to implement. Conclusion The asynchronous platform improved clinical communication compared with synchronous methods, contributing to efficiencies in workflow and may positively affect patient care.
Collapse
Affiliation(s)
| | - Rahul Menon
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
16
|
Sinsky C, Linzer M. Practice And Policy Reset Post-COVID-19: Reversion, Transition, Or Transformation? Health Aff (Millwood) 2020; 39:1405-1411. [PMID: 32744939 DOI: 10.1377/hlthaff.2020.00612] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Clinical care in the United States has been transformed during the coronavirus disease 2019 (COVID-19) pandemic. To support these changes, regulators and payers have temporarily modified long-standing policies, recognizing the need for a trade-off between the costs and benefits of oversight during times of crisis. Specifically, there has been a heightened receptivity to the importance of preserving physicians' and other health care professionals' time, cognitive bandwidth, and emotional reserve for the direct care of patients, instead of squandering these resources on low-value tasks and frustrating technology. Instead of reflexively reverting to past practices and policies, there is now an opportunity to take advantage of the lessons of COVID-19 for the further transformation of health care to achieve Quadruple Aim outcomes (better care for individuals, better health for the population, better experience for clinicians, and lower costs). We outline some of the policy and practice changes that we believe should endure after the crisis has passed, and we recommend using similar logic during noncrisis times to make additional changes to further reduce administrative burden, and thus improve patient care.
Collapse
Affiliation(s)
- Christine Sinsky
- Christine Sinsky is the vice president of professional satisfaction at the American Medical Association, in Chicago, Illinois
| | - Mark Linzer
- Mark Linzer is a vice chair of the Department of Medicine at Hennepin Healthcare, in Minneapolis, Minnesota
| |
Collapse
|
17
|
Rowlands S, Tariq A, Coverdale S, Walker S, Wood M. A qualitative investigation into clinical documentation: why do clinicians document the way they do? HEALTH INF MANAG J 2020; 51:126-134. [PMID: 32643428 DOI: 10.1177/1833358320929776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical documentation is a fundamental component of patient care. The transition from paper based to electronic medical records/electronic health records has highlighted a number of issues associated with documentation practices including duplication. Developing new ways to document the care provided to patients and in turn, persuading clinicians to accept a change, must be supported by evidence that a change is required. In Australia, there has been a limited number of studies exploring the clinical documentation practices and beliefs of clinicians. OBJECTIVE To gain an in-depth understanding of clinician documentation practices. METHOD A qualitative design using semi-structured interviews with clinicians (allied health professionals, doctors (physicians) and nurses) working in a tertiary-level hospital in South-East Queensland, Australia. RESULTS Several themes emerged from the data: environmental factors, including departmental policy and systemic issues, and personal factors, including verification, clinical reasoning and experience influencing documentation practices. CONCLUSION Our study identified that the documentation practices of clinicians are complex, being driven by both environmental and systemic factors and personal factors. This in turn leads to duplication and some redundancy. The documentation burden of duplication could be reduced by changes in policy, supported by multidisciplinary documentation procedures and electronic systems aligned with clinician workflows, while retaining some flexible documentation practices. The documentation practices of individuals, when considered from the perspective of enhancing quality care, are considered legitimate and therefore will continue to form part of the health (medical) record regardless of the format.
Collapse
Affiliation(s)
| | - Amina Tariq
- Queensland University of Technology, Australia
| | | | - Sue Walker
- Queensland University of Technology, Australia
| | | |
Collapse
|
18
|
Seu M, Cho BH, Pigott R, Sarmiento S, Pedreira R, Bhat D, Sacks J. Trends and Perceptions of Electronic Health Record Usage among Plastic Surgeons. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2709. [PMID: 32440400 PMCID: PMC7209869 DOI: 10.1097/gox.0000000000002709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 01/27/2020] [Indexed: 11/25/2022]
Abstract
Background Electronic health records (EHRs) should help physicians stay organized, improve patient safety, and facilitate communication with both patients and fellow healthcare providers. However, few studies have directly evaluated physician satisfaction with EHR and its perceived impact on patient care. This study assessed trends and perceptions of EHR within the American plastic surgery community. Methods An Institutional Review Board-approved survey that assessed demographics, patterns of EHR use, and attitudes toward EHR was deployed by the American Society of Plastic Surgeons Member Survey Research Services. Statistical analyses were performed using Stata 14.2 and QDA Miner Lite software (Version 2.0; Provalis, Montreal, Canada). Significance level was P < 0.05. Results Among plastic surgeons who use EHR, EPIC Systems software (Epic, Verona, Wisc.) was the most common vendor, with users noting a net positive effect on the quality of care they provided to patients. Younger age and less years of experience were correlated with a more positive attitude toward EHR. Positive attitude was closely linked to shared responsibility among support staff over data entry, whereas negative attitude was tightly tied to the perceived time wasted because of EHR, followed by poor technical support and design. Conclusions EHR use among plastic surgeons was more common in academic-associated specialties and larger practice groups. Overall, age and practice type had weak associations with perceptions of EHR usage. On average, there were slightly more positive perceptions of EHR usage than negative. The most commonly perceived issues with EHR were wasted time and barriers to user-friendliness. These findings suggest the need for greater physician involvement in EHR optimization.
Collapse
Affiliation(s)
- Michelle Seu
- Loyola University Chicago Stritch School of Medicine, Maywood, Ill
| | - Brian H Cho
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Rachel Pigott
- Bel Air Center for Plastic and Hand Surgery, Bel Air, Md
| | - Samuel Sarmiento
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Deepa Bhat
- Department of Plastic and Reconstructive Surgery, Albany Medical Center, Albany, N.Y
| | - Justin Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| |
Collapse
|
19
|
Organizational Influences on Time Pressure Stressors and Potential Patient Consequences in Primary Care. Med Care 2019; 56:822-830. [PMID: 30130270 PMCID: PMC6402989 DOI: 10.1097/mlr.0000000000000974] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Primary care teams face daily time pressures both during patient encounters and outside of appointments. OBJECTIVES We theorize 2 types of time pressure, and test hypotheses about organizational determinants and patient consequences of time pressure. RESEARCH DESIGN Cross-sectional, observational analysis of data from concurrent surveys of care team members and their patients. SUBJECTS Patients (n=1291 respondents, 73.5% response rate) with diabetes and/or coronary artery disease established with practice teams (n=353 respondents, 84% response rate) at 16 primary care sites, randomly selected from 2 Accountable Care Organizations. MEASURES AND ANALYSIS We measured team member perceptions of 2 potentially distinct time pressure constructs: (1) encounter-level, from 7 questions about likelihood that time pressure results in missing patient management opportunities; and (2) practice-level, using practice atmosphere rating from calm to chaotic. The Patient Assessment of Chronic Illness Care (PACIC-11) instrument measured patient-reported experience. Multivariate logistic regression models examined organizational predictors of each time pressure type, and hierarchical models examined time pressure predictors of patient-reported experiences. RESULTS Encounter-level and practice-level time pressure measures were not correlated, nor predicted by the same organizational variables, supporting the hypothesis of two distinct time pressure constructs. More encounter-level time pressure was most strongly associated with less health information technology capability (odds ratio, 0.33; P<0.01). Greater practice-level time pressure (chaos) was associated with lower PACIC-11 scores (odds ratio, 0.74; P<0.01). CONCLUSIONS Different organizational factors are associated with each forms of time pressure. Potential consequences for patients are missed opportunities in patient care and inadequate chronic care support.
Collapse
|
20
|
Adelman EE, Burke JF. Can Electronic Health Records Make Quality Measurement Fast and Easy? Circ Cardiovasc Qual Outcomes 2019; 10:CIRCOUTCOMES.117.004180. [PMID: 28912203 DOI: 10.1161/circoutcomes.117.004180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Eric E Adelman
- From the Department of Neurology, University of Wisconsin-Madison (E.E.A.); Stroke Program, University of Michigan, Ann Arbor (J.F.B.); and Department of Neurology, Veterans Affairs Health System, Ann Arbor, MI (J.F.B.)
| | - James F Burke
- From the Department of Neurology, University of Wisconsin-Madison (E.E.A.); Stroke Program, University of Michigan, Ann Arbor (J.F.B.); and Department of Neurology, Veterans Affairs Health System, Ann Arbor, MI (J.F.B.).
| |
Collapse
|
21
|
Assessing EHR use during hospital morning rounds: A multi-faceted study. PLoS One 2019; 14:e0212816. [PMID: 30802267 PMCID: PMC6388927 DOI: 10.1371/journal.pone.0212816] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/08/2019] [Indexed: 11/19/2022] Open
Abstract
Background The majority of U.S hospitals have implemented electronic health records (EHRs). While the benefits of EHRs have been widely touted, little is known about their effects on inpatient care, including how well they meet workflow needs and support care. Objective Assess the extent to which EHRs support care team workflow during hospital morning rounds. Design We applied a mixed-method approach including observations of care teams during morning rounds, semi-structured interviews and an electronic survey of hospital inpatient clinicians. Structured field notes taken during observations were used to identify workflow patterns for analysis. We applied a grounded theory approach to extract emerging themes from interview transcripts and used SPSS Statistics 24 to analyze survey responses. Setting Medical units at a major teaching hospital in New England. Results Data triangulation across the three analyses yielded four main findings: (1) a high degree of variance in the ways care teams use EHRs during morning rounds. (2) Pervasive use of workarounds at critical points of care (3) EHRs are not used for information sharing and frequently impede intra-care team communication. (4) System design and hospital room settings do not adequately support care team workflow. Conclusions Gaps between EHR design and the functionality needed in the complex inpatient environment result in lack of standardized workflows, extensive use of workarounds and team communication issues. These issues pose a threat to patient safety and quality of care. Possible solutions need to include improvements in EHR design, care team training and changes to the hospital room setting.
Collapse
|
22
|
Tawfik DS, Profit J, Webber S, Shanafelt TD. Organizational factors affecting physician well-being. ACTA ACUST UNITED AC 2019; 5:11-25. [PMID: 31632895 DOI: 10.1007/s40746-019-00147-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Purpose of review Symptoms of burnout affect approximately half of pediatricians and pediatric subspecialists at any given time, with similarly concerning prevalence of other aspects of physician distress, including fatigue, depressive symptoms, and suicidal ideation. Physician well-being affects quality of care, patient satisfaction, and physician turnover. Organizational factors influence well-being, stressing the need for organizations to address this epidemic. Recent findings Organizational characteristics, policies, and culture influence physician well-being, and specific strategies may support an environment where physicians thrive. We highlight four organizational opportunities to improve physician well-being: developing leaders, cultivating community and organizational culture, improving practice efficiency, and optimizing administrative policies. Leaders play a key role in aligning organizational and individual values, promoting professional fulfillment, and fostering a culture of collegiality and social support among physicians. Reducing documentation burden and improving practice efficiency may help balance job demands and resources. Finally, reforming administrative policies may reduce work-home conflict, support physician's efforts to attend to their own well-being, and normalize use of supportive resources. Summary Physician well-being is critical to organizational success, sustainment of an adequate workforce, and optimal patient outcomes. Because burnout is primarily influenced by organizational factors, organizational interventions are key to promoting well-being. Developing supportive leadership, fostering a culture of wellness, optimizing practice efficiency, and improving administrative policies are worthy of organizational action and further research.
Collapse
Affiliation(s)
- Daniel S Tawfik
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA.,California Perinatal Quality Care Collaborative, Palo Alto, CA
| | - Sarah Webber
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Tait D Shanafelt
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
23
|
Modi PK, Kaufman SR, Caram MV, Ellimoottil C, Shahinian VB, Hollenbeck BK. Impact of Medicare Office Visit Payment Reform on Urologic Practices. Urology 2019; 126:83-88. [PMID: 30682462 DOI: 10.1016/j.urology.2019.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/13/2018] [Accepted: 01/16/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the 2019 Medicare Physician Fee Schedule, which modifies reimbursement for office evaluation and management (E&M) visits. This policy moves payment to a single rate for levels 2 through 4 office E&M visits, regardless of complexity. METHODS Using a 20% sample of 2015 National Medicare claims, we identified urologic practices and their practice organization, academic affiliation, and degree of office focus (ie, proportion of revenues from office visits). Using billing data for each practice, we calculated the revenues expected under the current system and the new policy (both E&M payments and a new add-on code). For each practice, we determined the impact of new payment rates on total Medicare payments. RESULTS We identified 2822 practices: 1372 (48.6%) solo practices, 1033 (36.6%) multispecialty groups, 322 (11.4%) small urology groups, and 95 (3.4%) large urology groups. Under the new reimbursement rates, the median practice would have a 0.9% increase in Medicare Part B payments (range -20.4% to +50.3%) and, with the add-on code, an increase of 6.8% (range -7.5% to +74.9%). Solo practices had the most heterogeneity, with a quarter losing at least 2.3%. The median multispecialty group would increase payments by 0.4% (range -13.7% to 50.3%). However, the 107 (10.4%) academic multispecialty groups had a median gain of only 0.1% (range -2.8% to +8.1%). CONCLUSION Urology groups would, on average, benefit from the anticipated change in Medicare office E&M visit payments. However, solo practices with a high office focus and academic multispecialty practices may see reduced Medicare payments.
Collapse
Affiliation(s)
- Parth K Modi
- Division of Urologic Oncology, Department of Urology, University of Michigan, MI; Division of Health Services Research, Department of Urology, University of Michigan, MI.
| | - Samuel R Kaufman
- Division of Health Services Research, Department of Urology, University of Michigan, MI
| | - Megan V Caram
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, MI
| | - Chad Ellimoottil
- Division of Health Services Research, Department of Urology, University of Michigan, MI
| | - Vahakn B Shahinian
- Division of Health Services Research, Department of Urology, University of Michigan, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, MI
| | - Brent K Hollenbeck
- Division of Urologic Oncology, Department of Urology, University of Michigan, MI; Division of Health Services Research, Department of Urology, University of Michigan, MI
| |
Collapse
|
24
|
Brandão JRDM. Primary health care in Canada: current reality and challenges. CAD SAUDE PUBLICA 2019; 35:e00178217. [PMID: 30652821 DOI: 10.1590/0102-311x00178217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 11/08/2017] [Indexed: 11/21/2022] Open
|
25
|
Aminsharifi A, Schulman A, Anderson J, Fish L, Oeffinger K, Shah K, Sze C, Tay KJ, Tsivian E, Polascik TJ. Primary care perspective and implementation of a multidisciplinary, institutional prostate cancer screening algorithm embedded in the electronic health record. Urol Oncol 2018; 36:502.e1-502.e6. [PMID: 30170982 DOI: 10.1016/j.urolonc.2018.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/03/2018] [Accepted: 07/23/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE In response to controversy regarding prostate cancer (CaP) screening recommendations, a consolidated Duke Cancer Institute (DCI) multidisciplinary algorithm for CaP screening was developed and implemented. We conducted an online survey within the year following its implementation to assess primary care provider (PCP) attitudes and adoption as well as to evaluate how this program affects screening rates. METHODS A web-based 18-item survey was programmed and was electronically mailed to practicing PCPs at clinics affiliated with the Duke Primary Care system. The survey assessed provider practices and attitudes regarding CaP screening, factors that influenced their general screening recommendations and the confidence related to communicating with patients about screening. The rate of PSA screening before and after implementation of the algorithm was reported across age and race categories. RESULTS In sum, 94 of 106 respondents (88.6%) reported discussing the benefits and harms of screening and let their patients decide (52.8%) or recommended for (31.1%) or against (4.7%) screening. Three-fourths of respondents followed a specific panel recommendation such as the United States Preventative Services Task Force (USPSTF) (48.1%), DCI (20%), or the American Urological Association (AUA) (7.4%) guidelines. After integrating this algorithm into the electronic health record, the rate of prostate screening increased between 11% and 20.4% and 15.6% and 16.4% among different age and race categories, respectively. Overall, 79.2% of PCPs felt very confident regarding their ability to communicate the topic of CaP screening with patients. CONCLUSION The DCI multidisciplinary CaP screening algorithm was well adopted among PCPs shortly after its implementation. The rate of screening increased among all age and race categories thereafter. The majority of PCPs involved in this survey felt confident regarding their CaP screening knowledge and most discuss this topic with patients in a shared decision-making model.
Collapse
Affiliation(s)
- Alireza Aminsharifi
- Division of Urological Surgery, Durham, NC; Department of Urology Shiraz University of Medical Sciences Shiraz, Iran; Duke Cancer Institute, Duke University, Durham, NC
| | | | - John Anderson
- Department of Medicine, Duke Primary Care, Durham, NC
| | - Laura Fish
- Duke Cancer Institute, Duke University, Durham, NC
| | - Kevin Oeffinger
- Department of Medicine, Duke Primary Care, Durham, NC; Duke Cancer Institute, Duke University, Durham, NC
| | - Kevin Shah
- Department of Medicine, Duke Primary Care, Durham, NC
| | | | - Kae J Tay
- Division of Urological Surgery, Durham, NC; SingHealth, Singapore General Hospital, Singapore
| | | | - Thomas J Polascik
- Division of Urological Surgery, Durham, NC; Duke Cancer Institute, Duke University, Durham, NC.
| |
Collapse
|
26
|
Tange H, Nagykaldi Z, De Maeseneer J. Towards an overarching model for electronic medical-record systems, including problem-oriented, goal-oriented, and other approaches. Eur J Gen Pract 2018; 23:257-260. [PMID: 29148849 PMCID: PMC8816391 DOI: 10.1080/13814788.2017.1374367] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
There is no consensus among health professionals on how to structure medical records to serve clinical decision-making. Three approaches co-exist (source-oriented, problem-oriented, goal-oriented), each suiting a different subset of patients. In primary care, the problem-oriented approach is dominant, but for patients with multiple conditions (multimorbidity) the goal-oriented approach seems more appropriate. There is a need to combine different approaches in one medical-record system. In this article, we explain some misconceptions about 'problems' and 'goals' that hinder the way to consensus. When putting the approaches into historical perspective, it becomes evident that each relates to a different definition of health. Each approach has its specific merits that should be preserved even when health definitions change. Hence, we combine the merits of each approach into one overarching model, as to show the way to a new generation of electronic medical-record systems that can serve all patients. This model has three levels: a level of problems, diseases, and patient goals, a level of (shared) objectives, and a level of action plans and results.
Collapse
Affiliation(s)
- Huibert Tange
- a Department of Family Medicine , Maastricht University , Maastricht , The Netherlands
| | - Zsolt Nagykaldi
- b Department of Family & Preventive Medicine , University of Oklahoma , Oklahoma , OK , USA
| | - Jan De Maeseneer
- c Department of Family Medicine and Primary Healthcare , Ghent University , Ghent , Belgium
| |
Collapse
|
27
|
Kahn D, Stewart E, Duncan M, Lee E, Simon W, Lee C, Friedman J, Mosher H, Harris K, Bell J, Sharpe B, El-Farra N. A Prescription for Note Bloat: An Effective Progress Note Template. J Hosp Med 2018; 13:378-382. [PMID: 29350222 DOI: 10.12788/jhm.2898] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND United States hospitals have widely adopted electronic health records (EHRs). Despite the potential for EHRs to increase efficiency, there is concern that documentation quality has suffered. OBJECTIVE To examine the impact of an educational session bundled with a progress note template on note quality, length, and timeliness. DESIGN A multicenter, nonrandomized prospective trial. SETTING Four academic hospitals across the United States. PARTICIPANTS Intern physicians on inpatient internal medicine rotations at participating hospitals. INTERVENTION A task force delivered a lecture on current issues with documentation and suggested that interns use a newly designed best practice progress note template when writing daily progress notes. MEASUREMENTS Note quality was rated using a tool designed by the task force comprising a general impression score, the validated Physician Documentation Quality Instrument, 9-item version (PDQI-9), and a competency questionnaire. Reviewers documented number of lines per note and time signed. RESULTS Two hundred preintervention and 199 postintervention notes were collected. Seventy percent of postintervention notes used the template. Significant improvements were seen in the general impression score, all domains of the PDQI-9, and multiple competency items, including documentation of only relevant data, discussion of a discharge plan, and being concise while adequately complete. Notes had approximately 25% fewer lines and were signed on average 1.3 hours earlier in the day. CONCLUSIONS The bundled intervention for progress notes significantly improved the quality, decreased the length, and resulted in earlier note completion across 4 academic medical centers.
Collapse
Affiliation(s)
- Daniel Kahn
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA.
| | - Elizabeth Stewart
- Division of Hospital Medicine, Alameda Health System, Oakland, California, USA
| | - Mark Duncan
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Edward Lee
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Wendy Simon
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Clement Lee
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Jodi Friedman
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Hilary Mosher
- Department of Internal Medicine, Carver College of Medicine, Iowa City, Iowa, USA
| | - Katherine Harris
- Department of Internal Medicine, Carver College of Medicine, Iowa City, Iowa, USA
| | - John Bell
- Department of Internal Medicine, Division of Hospital Medicine, University of California, San Diego, San Diego, California, USA
| | - Bradley Sharpe
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Neveen El-Farra
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| |
Collapse
|
28
|
Developing a Medical Scribe Program at an Academic Hospital: The Hennepin County Medical Center Experience. Jt Comm J Qual Patient Saf 2018; 44:238-249. [DOI: 10.1016/j.jcjq.2018.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/19/2018] [Indexed: 11/19/2022]
|
29
|
Abstract
Electronic health records (EHRs) have been in place for decades; however, most existing systems were designed in the prevailing disease- and payment-focused care paradigm that often loses sight of the goals, needs, and values of patients and clinicians. The goal-directed health care model was proposed more than 20 years ago, but no design principles have been developed for corresponding electronic record systems. Newly designed EHRs are needed to facilitate health care that is anchored by patient life and health goals. We explore the limitations of current EHRs and propose a blueprint for a new EHR design that may facilitate goal-directed health care. To reflect patient goals as a thread through the care continuum, we propose 5 major system functions for goal-directed health records based on the 8 characteristics of primary health care defined by the Institute of Medicine. We also discuss how new EHR functions could support goal-directed health care and how payment and quality measurement systems will need to be transformed. It may be possible for patient life and health goals to drive health care that is reinforced by a corresponding health record design; however, synchronized shifts must occur in the models of providing, documenting, and paying for health care.
Collapse
Affiliation(s)
- Zsolt J Nagykaldi
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Huibert Tange
- Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Jan De Maeseneer
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| |
Collapse
|
30
|
Read-Brown S, Hribar MR, Reznick LG, Lombardi LH, Parikh M, Chamberlain WD, Bailey ST, Wallace JB, Yackel TR, Chiang MF. Time Requirements for Electronic Health Record Use in an Academic Ophthalmology Center. JAMA Ophthalmol 2017; 135:1250-1257. [PMID: 29049512 DOI: 10.1001/jamaophthalmol.2017.4187] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Electronic health record (EHR) systems have transformed the practice of medicine. However, physicians have raised concerns that EHR time requirements have negatively affected their productivity. Meanwhile, evolving approaches toward physician reimbursement will require additional documentation to measure quality and cost of care. To date, little quantitative analysis has rigorously studied these topics. Objective To examine ophthalmologist time requirements for EHR use. Design, Setting, and Participants A single-center cohort study was conducted between September 1, 2013, and December 31, 2016, among 27 stable departmental ophthalmologists (defined as attending ophthalmologists who worked at the study institution for ≥6 months before and after the study period). Ophthalmologists who did not have a standard clinical practice or who did not use the EHR were excluded. Exposures Time stamps from the medical record and EHR audit log were analyzed to measure the length of time required by ophthalmologists for EHR use. Ophthalmologists underwent manual time-motion observation to measure the length of time spent directly with patients on the following 3 activities: EHR use, conversation, and examination. Main Outcomes and Measures The study outcomes were time spent by ophthalmologists directly with patients on EHR use, conversation, and examination as well as total time required by ophthalmologists for EHR use. Results Among the 27 ophthalmologists in this study (10 women and 17 men; mean [SD] age, 47.3 [10.7] years [median, 44; range, 34-73 years]) the mean (SD) total ophthalmologist examination time was 11.2 (6.3) minutes per patient, of which 3.0 (1.8) minutes (27% of the examination time) were spent on EHR use, 4.7 (4.2) minutes (42%) on conversation, and 3.5 (2.3) minutes (31%) on examination. Mean (SD) total ophthalmologist time spent using the EHR was 10.8 (5.0) minutes per encounter (range, 5.8-28.6 minutes). The typical ophthalmologist spent 3.7 hours using the EHR for a full day of clinic: 2.1 hours during examinations and 1.6 hours outside the clinic session. Linear mixed effects models showed a positive association between EHR use and billing level and a negative association between EHR use per encounter and clinic volume. Each additional encounter per clinic was associated with a decrease of 1.7 minutes (95% CI, -4.3 to 1.0) of EHR use time per encounter for ophthalmologists with high mean billing levels (adjusted R2 = 0.42; P = .01). Conclusions and Relevance Ophthalmologists have limited time with patients during office visits, and EHR use requires a substantial portion of that time. There is variability in EHR use patterns among ophthalmologists.
Collapse
Affiliation(s)
- Sarah Read-Brown
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland
| | - Michelle R Hribar
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Leah G Reznick
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland
| | - Lorinna H Lombardi
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland
| | - Mansi Parikh
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland
| | - Winston D Chamberlain
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland
| | - Steven T Bailey
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland
| | - Jessica B Wallace
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Thomas R Yackel
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Michael F Chiang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland.,Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| |
Collapse
|
31
|
Ratanawongsa N, Matta GY, Lyles CR, Koenig CJ, Barton JL, Yu K, Schillinger D. Multitasking and Silent Electronic Health Record Use in Ambulatory Visits. JAMA Intern Med 2017; 177:1382-1385. [PMID: 28672379 PMCID: PMC5585046 DOI: 10.1001/jamainternmed.2017.2668] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Neda Ratanawongsa
- Division of General Internal Medicine, the University of California, San Francisco, San Francisco.,UCSF Center for Vulnerable Populations at San Francisco General Hospital, San Francisco
| | - George Y Matta
- Division of General Internal Medicine, the University of California, San Francisco, San Francisco.,UCSF Center for Vulnerable Populations at San Francisco General Hospital, San Francisco
| | - Courtney R Lyles
- Division of General Internal Medicine, the University of California, San Francisco, San Francisco.,UCSF Center for Vulnerable Populations at San Francisco General Hospital, San Francisco
| | - Christopher J Koenig
- Department of Communication Studies, San Francisco State University, San Francisco, California
| | - Jennifer L Barton
- Department of Medicine at Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon
| | - Kaylin Yu
- Department of Policy Analysis and Management, Cornell University, Ithaca, New York
| | - Dean Schillinger
- Division of General Internal Medicine, the University of California, San Francisco, San Francisco.,UCSF Center for Vulnerable Populations at San Francisco General Hospital, San Francisco
| |
Collapse
|
32
|
Turner P, Kushniruk A, Nohr C. Are We There Yet? Human Factors Knowledge and Health Information Technology - the Challenges of Implementation and Impact. Yearb Med Inform 2017; 26:84-91. [PMID: 29063542 PMCID: PMC6239238 DOI: 10.15265/iy-2017-014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective: To review the developments in human factors (HF) research on the challenges of health information technology (HIT) implementation and impact given the continuing incidence of usability problems and unintended consequences from HIT development and use. Methods: A search of PubMed/Medline and Web of Science® identified HF research published in 2015 and 2016. Electronic health records (EHRs) and patient-centred HIT emerged as significant foci of recent HF research. The authors selected prominent papers highlighting ongoing HF and usability challenges in these areas. This selective rather than systematic review of recent HF research highlights these key challenges and reflects on their implications on the future impact of HF research on HIT. Results: Research provides evidence of continued poor design, implementation, and usability of HIT, as well as technology-induced errors and unintended consequences. The paper highlights support for: (i) strengthening the evidence base on the benefits of HF approaches; (ii) improving knowledge translation in the implementation of HF approaches during HIT design, implementation, and evaluation; (iii) increasing transparency, governance, and enforcement of HF best practices at all stages of the HIT system development life cycle. Discussion and Conclusion: HF and usability approaches are yet to become embedded as integral components of HIT development, implementation, and impact assessment. As HIT becomes ever-more pervasive including with patients as end-users, there is a need to expand our conceptualisation of the problems to be addressed and the suite of tactics and strategies to be used to calibrate our pro-active involvement in its improvement.
Collapse
Affiliation(s)
- P. Turner
- eHealth Services Research Group (eHSRG), School of Engineering & ICT, University of Tasmania, Australia
| | - A. Kushniruk
- School of Health Information Science, University of Victoria, Victoria, Canada
- Department of Development and Planning, Aalborg University, Aalborg, Denmark
| | - C. Nohr
- Department of Development and Planning, Aalborg University, Aalborg, Denmark
| |
Collapse
|
33
|
Sittig DF, Belmont E, Singh H. Improving the safety of health information technology requires shared responsibility: It is time we all step up. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2017; 6:7-12. [PMID: 28716376 DOI: 10.1016/j.hjdsi.2017.06.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 06/19/2017] [Accepted: 06/21/2017] [Indexed: 02/08/2023]
Abstract
In 2011, an Institute of Medicine report on health information technology (IT) and patient safety highlighted that building health-IT for safer use is a shared responsibility between key stakeholders including: "vendors, care providers, healthcare organizations, health-IT departments, and public and private agencies". Use of electronic health records (EHRs) involves all these stakeholders, but they often have conflicting priorities and requirements. Since 2011, the concept of shared responsibility has gained little traction and EHR developers and users continue to attribute the substantial, long list of problems to each other. In this article, we discuss how these key stakeholders have complementary roles in improving EHR safety and must share responsibility to improve the current state of EHR use. We use real-world safety examples and outline a comprehensive shared responsibility approach to help guide development of future rules, regulations, and standards for EHR usability, interoperability and security as outlined in the 21st Century Cures Act. This approach clearly defines the responsibilities of each party and helps create appropriate measures for success. National and international policymakers must facilitate the local organizational and socio-political climate to stimulate the adoption of shared responsibility principles. When all major stakeholders are sharing responsibility, we will be more likely to usher in a new age of progress and innovation related to health IT.
Collapse
Affiliation(s)
- Dean F Sittig
- University of Texas - Memorial Hermann Center for Healthcare Quality & Safety, School of Biomedical Informatics, University of Texas Health Science Center at Houston, TX, United States.
| | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, United States
| |
Collapse
|
34
|
Young HM, Nesbitt TS. Increasing the Capacity of Primary Care Through Enabling Technology. J Gen Intern Med 2017; 32:398-403. [PMID: 28243871 PMCID: PMC5377889 DOI: 10.1007/s11606-016-3952-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/13/2016] [Accepted: 11/28/2016] [Indexed: 01/17/2023]
Abstract
Primary care is the foundation of effective and high-quality health care. The role of primary care clinicians has expanded to encompass coordination of care across multiple providers and management of more patients with complex conditions. Enabling technology has the potential to expand the capacity for primary care clinicians to provide integrated, accessible care that channels expertise to the patient and brings specialty consultations into the primary care clinic. Furthermore, technology offers opportunities to engage patients in advancing their health through improved communication and enhanced self-management of chronic conditions. This paper describes enabling technologies in four domains (the body, the home, the community, and the primary care clinic) that can support the critical role primary care clinicians play in the health care system. It also identifies challenges to incorporating these technologies into primary care clinics, care processes, and workflow.
Collapse
Affiliation(s)
- Heather M Young
- Betty Irene Moore School of Nursing, UC Davis Health System, Sacramento, CA, 95817, USA.
| | - Thomas S Nesbitt
- UC Davis Health System, Davis, CA, USA
- Family and Community Medicine, UC Davis, Davis, CA, USA
- Center for Information Technology Research in the Interest of Society, University of California, Davis, CA, USA
| |
Collapse
|
35
|
Ratanawongsa N, Chan LLS, Fouts MM, Murphy EJ. The Challenges of Electronic Health Records and Diabetes Electronic Prescribing: Implications for Safety Net Care for Diverse Populations. J Diabetes Res 2017; 2017:8983237. [PMID: 28197420 PMCID: PMC5286474 DOI: 10.1155/2017/8983237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 01/04/2017] [Indexed: 11/25/2022] Open
Abstract
Widespread electronic health record (EHR) implementation creates new challenges in the diabetes care of complex and diverse populations, including safe medication prescribing for patients with limited health literacy and limited English proficiency. This review highlights how the EHR electronic prescribing transformation has affected diabetes care for vulnerable patients and offers recommendations for improving patient safety through EHR electronic prescribing design, implementation, policy, and research. Specifically, we present evidence for (1) the adoption of RxNorm; (2) standardized naming and picklist options for high alert medications such as insulin; (3) the widespread implementation of universal medication schedule and language-concordant labels, with the expansion of electronic prescription 140-character limit; (4) enhanced bidirectional communication with pharmacy partners; and (5) informatics and implementation research in safety net healthcare systems to examine how EHR tools and practices affect diverse vulnerable populations.
Collapse
Affiliation(s)
- Neda Ratanawongsa
- Division of General Internal Medicine, Department of Medicine, UCSF Center for Vulnerable Populations, University of California, San Francisco, 1001 Potrero Avenue, Box 1364, San Francisco, CA 94143, USA
- *Neda Ratanawongsa:
| | - Lenny L. S. Chan
- San Francisco Department of Public Health, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | - Michelle M. Fouts
- Laguna Honda Hospital and Rehabilitation Center, 375 Laguna Honda Blvd, San Francisco, CA 94116, USA
| | - Elizabeth J. Murphy
- Division of Endocrinology, Department of Medicine, University of California, San Francisco, 1001 Potrero Avenue, Box 0862, San Francisco, CA 94143, USA
| |
Collapse
|