Patient-collected audio for performance assessment of the clinical encounter

Directly Observed Care: Crossing the Chasm of Quality Measurement

After more than two decades of national attention to quality improvement in US healthcare, significant gaps in quality remain. A fundamental problem is that current approaches to measure quality are indirect and therefore imprecise, focusing on clinical documentation of care rather than the actual delivery of care. The National Academy of Medicine (NAM) has identified six domains of quality that are essential to address to improve quality: patient-centeredness, equity, timeliness, efficiency, effectiveness, and safety. In this perspective, we describe how directly observed care-a recorded audit of clinical care delivery-may address problems with current quality measurement, providing a more holistic assessment of healthcare delivery. We further show how directly observed care has the potential to improve each NAM domain of quality.

Patient-centered quality measurement for opioid use disorder: Development of a taxonomy to address gaps in research and practice

Background: Evidence-based treatment is provided infrequently and inconsistently to patients with opioid use disorder (OUD). Treatment guidelines call for high-quality, patient-centered care that meets individual preferences and needs, but it is unclear whether current quality measures address individualized aspects of care and whether measures of patient-centered OUD care are supported by evidence. Methods: We conducted an environmental scan of OUD care quality to (1) evaluate patient-centeredness in current OUD quality measures endorsed by national agencies and in national OUD treatment guidelines; and (2) review literature evidence for patient-centered care in OUD diagnosis and management, including gaps in current guidelines, performance data, and quality measures. We then synthesized these findings to develop a new quality measurement taxonomy that incorporates patient-centered aspects of care and identifies priority areas for future research and quality measure development. Results: Across 31 endorsed OUD quality measures, only two measures of patient experience incorporated patient preferences and needs, while national guidelines emphasized providing patient-centered care. Among 689 articles reviewed, evidence varied for practices of patient-centered care. Many practices were supported by guidelines and substantial evidence, while others lacked evidence despite guideline support. Our synthesis of findings resulted in EQuIITable Care, a taxonomy comprised of six classifications: (1) patient Experience and engagement, (2) Quality of life; (3) Identification of patient risks; (4) Interventions to mitigate patient risks; (5) Treatment; and (6) Care coordination and navigation. Conclusions: Current quality measurement for OUD lacks patient-centeredness. EQuIITable Care for OUD provides a roadmap to develop measures of patient-centered care for OUD.

Effect of Electronic Health Record Clinical Decision Support on Contextualization of Care: A Randomized Clinical Trial

IMPORTANCE

Contextualizing care is a process of incorporating information about the life circumstances and behavior of individual patients, termed contextual factors, into their plan of care. In 4 steps, clinicians recognize clues (termed contextual red flags), clinicians ask about them (probe for context), patients disclose contextual factors, and clinicians adapt care accordingly. The process is associated with a desired outcome resolution of the presenting contextual red flag.

OBJECTIVE

To determine whether contextualized clinical decision support (CDS) tools in the electronic health record (EHR) improve clinician contextual probing, attention to contextual factors in care planning, and the presentation of contextual red flags.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was performed at the primary care clinics of 2 academic medical centers with different EHR systems. Participants were adults 18 years or older consenting to audio record their visits and their physicians between September 6, 2018, and March 4, 2021. Patients were randomized to an intervention or a control group. Analyses were performed on an intention-to-treat basis.

INTERVENTIONS

Patients completed a previsit questionnaire that elicited contextual red flags and factors and appeared in the clinician's note template in a contextual care box. The EHR also culled red flags from the medical record, included them in the contextual care box, used passive and interruptive alerts, and proposed relevant orders.

MAIN OUTCOMES AND MEASURES

Proportion of contextual red flags noted at the index visit that resolved 6 months later (primary outcome), proportion of red flags probed (secondary outcome), and proportion of contextual factors addressed in the care plan by clinicians (secondary outcome), adjusted for study site and for multiple red flags and factors within a visit.

RESULTS

Four hundred fifty-two patients (291 women [65.1%]; mean [SD] age, 55.6 [15.1] years) completed encounters with 39 clinicians (23 women [59.0%]). Contextual red flags were not more likely to resolve in the intervention vs control group (adjusted odds ratio [aOR], 0.96 [95% CI, 0.57-1.63]). However, the intervention increased both contextual probing (aOR, 2.12 [95% CI, 1.14-3.93]) and contextualization of the care plan (aOR, 2.67 [95% CI, 1.32-5.41]), controlling for whether a factor was identified by probing or otherwise. Across study groups, contextualized care plans were more likely than noncontextualized plans to result in improvement in the presenting red flag (aOR, 2.13 [95% CI, 1.38-3.28]).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that contextualized CDS did not improve patients' outcomes but did increase contextualization of their care, suggesting that use of this technology could ultimately help improve outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03244033.

Treatment access for opioid use disorder in pregnancy among rural and American Indian communities

BACKGROUND

Opioid use disorder (OUD) in pregnancy disproportionately impacts rural and American Indian (AI) communities. With limited data available about access to care for these populations, this study's objective was to assess clinic knowledge and new patient access for OUD treatment in three rural U.S. counties.

MATERIAL AND METHODS

The research team used unannounced standardized patients (USPs) to request new patient appointments by phone for white and AI pregnant individuals with OUD at primary care and OB/GYN clinics that provide prenatal care in three rural Utah counties. We assessed a) clinic familiarity with buprenorphine for OUD; b) appointment availability for buprenorphine treatment; c) appointment wait times; d) referral provision when care was unavailable; and e) availability of OUD care at referral locations. We compared outcomes for AI and white USP profiles using descriptive statistics.

RESULTS

The USPs made 34 calls to 17 clinics, including 4 with publicly listed buprenorphine prescribers on the Substance Abuse and Mental Health Services Administration website. Among clinical staff answering calls, 16 (47%) were unfamiliar with buprenorphine. OUD treatment was offered when requested in 6 calls (17.6%), with a median appointment wait time of 2.5 days (IQR 1-5). Among clinics with a listed buprenorphine prescriber, 2 of 4 (50%) offered OUD treatment. Most clinics (n = 24/28, 85.7%) not offering OUD treatment provided a referral; however, a buprenorphine provider was unavailable/unreachable 67% of the time. The study observed no differences in appointment availability between AI and white individuals.

CONCLUSIONS

Rural-dwelling AI and white pregnant individuals with OUD experience significant barriers to accessing care. Improving OUD knowledge and referral practices among rural clinics may increase access to care for this high-risk population.

Implementation of a patient-collected audio recording audit & feedback quality improvement program to prevent contextual error: stakeholder perspective

Background

Using patient audio recordings of medical visits to provide clinicians with feedback on their attention to patient life context in care planning can improve health care delivery and outcomes, and reduce costs. However, such an initiative can raise concerns across stakeholders about surveillance, intrusiveness and merit. This study examined the perspectives of patients, physicians and other clinical staff, and facility leaders over 3 years at six sites during the implementation of a patient-collected audio quality improvement program designed to improve patient-centered care in a non-threatening manner and with minimal effort required of patients and clinicians.

Methods

Patients were invited during the first and third year to complete exit surveys when they returned their audio recorders following visits, and clinicians to complete surveys annually. Clinicians were invited to participate in focus groups in the first and third years. Facility leaders were interviewed individually during the last 6 months of the study.

Results

There were a total of 12 focus groups with 89 participants, and 30 leadership interviews. Two hundred fourteen clinicians and 800 patients completed surveys. In a qualitative analysis of focus group data employing NVivo, clinicians initially expressed concerns that the program could be disruptive and/or burdensome, but these diminished with program exposure and were substantially replaced by an appreciation for the value of low stakes constructive feedback. They were also significantly more confident in the value of the intervention in the final year (p = .008), more likely to agree that leadership supports continuous improvement of patient care and gives feedback on outcomes (p = .02), and at a time that is convenient (p = .04). Patients who volunteered sometimes expressed concerns they were “spying” on their doctors, but most saw it as an opportunity to improve care. Leaders were supportive of the program but not yet prepared to commit to funding it exclusively with facility resources.

Conclusions

A patient-collected audio program can be implemented when it is perceived as safe, not disruptive or burdensome, and as contributing to better health care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06921-3.

Development of an unannounced standardized patient protocol to evaluate opioid use disorder treatment in pregnancy for American Indian and rural communities

BACKGROUND

Opioid use disorder (OUD) disproportionately impacts rural and American Indian communities and has quadrupled among pregnant individuals nationwide in the past two decades. Yet, limited data are available about access and quality of care available to pregnant individuals in rural areas, particularly among American Indians (AIs). Unannounced standardized patients (USPs), or "secret shoppers" with standardized characteristics, have been used to assess healthcare access and quality when outcomes cannot be measured by conventional methods or when differences may exist between actual versus reported care. While the USP approach has shown benefit in evaluating primary care and select specialties, its use to date for OUD and pregnancy is very limited.

METHODS

We used literature review, current practice guidelines for perinatal OUD management, and stakeholder engagement to design a novel USP protocol to assess healthcare access and quality for OUD in pregnancy. We developed two USP profiles-one white and one AI-to reflect our target study area consisting of three rural, predominantly white and AI US counties. We partnered with a local community health center network providing care to a large AI population to define six priority outcomes for evaluation: (1) OUD treatment knowledge among clinical staff answering telephones; (2) primary care clinic facilitation and provision of prenatal care and buprenorphine treatment; (3) appropriate completion of evidence-based screening, symptom assessment, and initial steps in management; (4) appropriate completion of risk factor screening/probing about individual circumstances that may affect care; (5) patient-directed tone, stigma, and professionalism by clinic staff; and (6) disparities in care between whites and American Indians.

DISCUSSION

The development of this USP protocol tailored to a specific environment and high-risk patient population establishes an innovative approach to evaluate healthcare access and quality for pregnant individuals with OUD. It is intended to serve as a roadmap for our own study and for future related work within the context of substance use disorders and pregnancy.

Impact of Unannounced Standardized Patient Audit and Feedback on Care, Documentation, and Costs: an Experiment and Claims Analysis

BACKGROUND

Meaningful variations in physician performance are not always discernible from the medical record.

OBJECTIVE

We used unannounced standardized patients to measure and provide feedback on care quality and fidelity of documentation, and examined downstream effects on reimbursement claims.

DESIGN

Static group pre-post comparison study conducted between 2017 and 2019.

SETTING

Fourteen New Jersey primary care practice groups (22 practices) enrolled in Horizon BCBS's value-based program received the intervention. For claims analyses, we identified 14 additional comparison practice groups matched on county, practice size, and claims activity.

PARTICIPANTS

Fifty-nine of 64 providers volunteered to participate.

INTERVENTION

Unannounced standardized patients (USPs) made 217 visits portraying patients with 1-2 focal conditions (diabetes, depression, back pain, smoking, or preventive cancer screening). After two baseline visits to a provider, we delivered feedback and conducted two follow-up visits.

MEASUREMENTS

USP-completed checklists of guideline-based provider care behaviors, visit audio recordings, and provider notes were used to measure behaviors performed and documentation errors pre- and post-feedback. We also compared changes in 3-month office-based claims by actual patients between the intervention and comparison practice groups before and after feedback.

RESULTS

Expected clinical behaviors increased from 46% to 56% (OR = 1.53, 95% CI 1.29-1.83, p < 0.0001), with significant improvements in smoking cessation, back pain, and depression screening. Providers were less likely to document unperformed tasks after (16%) than before feedback (18%; OR = 0.74, 95% CI 0.62 to 0.90, p = 0.002). Actual claim costs increased significantly less in the study than comparison group for diabetes and depression but significantly more for smoking cessation, cancer screening, and low back pain.

LIMITATIONS

Self-selection of participating practices and lack of access to prescription claims.

CONCLUSION

Direct observation of care identifies hidden deficits in practice and documentation, and with feedback can improve both, with concomitant effects on costs.

Evaluation of a Patient-Collected Audio Audit and Feedback Quality Improvement Program on Clinician Attention to Patient Life Context and Health Care Costs in the Veterans Affairs Health Care System

IMPORTANCE

Evidence-based care plans can fail when they do not consider relevant patient life circumstances, termed contextual factors, such as a loss of social support or financial hardship. Preventing these contextual errors can reduce obstacles to effective care.

OBJECTIVE

To evaluate the effectiveness of a quality improvement program in which clinicians receive ongoing feedback on their attention to patient contextual factors.

DESIGN, SETTING, AND PARTICIPANTS

In this quality improvement study, patients at 6 Department of Veterans Affairs outpatient facilities audio recorded their primary care visits from May 2017 to May 2019. Encounters were analyzed using the Content Coding for Contextualization of Care (4C) method. A feedback intervention based on the 4C coded analysis was introduced using a stepped wedge design. In the 4C coding schema, clues that patients are struggling with contextual factors are termed contextual red flags (eg, sudden loss of control of a chronic condition), and a positive outcome is prospectively defined for each encounter as a quantifiable improvement of the contextual red flag. Data analysis was performed from May to October 2019.

INTERVENTIONS

Clinicians received feedback at 2 intensity levels on their attention to patient contextual factors and on predefined patient outcomes at 4 to 6 months.

MAIN OUTCOMES AND MEASURES

Contextual error rates, patient outcomes, and hospitalization rates and costs were measured.

RESULTS

The patients (mean age, 62.0 years; 92% male) recorded 4496 encounters with 666 clinicians. At baseline, clinicians addressed 413 of 618 contextual factors in their care plans (67%). After either standard or enhanced feedback, they addressed 1707 of 2367 contextual factors (72%), a significant difference (odds ratio, 1.3; 95% CI, 1.1-1.6; P = .01). In a mixed-effects logistic regression model, contextualized care planning was associated with a greater likelihood of improved outcomes (adjusted odds ratio, 2.5; 95% CI, 1.5-4.1; P < .001). In a budget analysis, estimated savings from avoided hospitalizations were $25.2 million (95% CI, $23.9-$26.6 million), at a cost of $337 242 for the intervention.

CONCLUSIONS AND RELEVANCE

These findings suggest that patient-collected audio recordings of the medical encounter with feedback may enhance clinician attention to contextual factors, improve outcomes, and reduce hospitalizations. In addition, the intervention is associated with substantial cost savings.

Listening to the Patient: A Typology of Contextual Red Flags in Disease Management Encounters

PURPOSE

Patients send clues, often unwittingly, when they are grappling with a life challenge that complicates their care. For instance, a patient may lose control of a previously well-managed chronic condition or start missing appointments. When explored, these clues help clinicians uncover the life circumstance impacting the individual's ability to manage their health and health care. Such clues are termed "contextual red flags." Effective care requires recognizing them, asking about them, and customizing the care plan where feasible. We sought to develop a typology of contextual red flags by analyzing audio recordings along with the medical records of encounters between patients and providers in outpatient clinics.

METHODS

During the course of 3 studies on physician attention to patient context conducted over a 5-year span (2012-2016), 4 full-time coders listened to the audios and reviewed the medical records of 2963 clinician-patient encounters. A list of contextual red flags was accrued and categorized until saturation was achieved.

RESULTS

A total of 70 contextual red flags were sorted into 9 categories, comprising a typology of contextual red flags: uncontrolled chronic conditions; appointment adherence; resource utilization; medication adherence; adherence to plan of care; significant weight loss/gain; patient knowledge of health or health care status; medical equipment/supplies adherence; other.

CONCLUSIONS

A relatively small number of clues that patients are struggling to self-manage their care warrant clinicians' exploring opportunities to adapt care plans to individual life circumstances. These contextual red flags group into an even smaller set of logical categories, providing a framework to guide clinicians about when to elicit additional information from patients about life challenges they are facing.

Contextual Errors in Medical Decision Making: Overlooked and Understudied

Although it is widely recognized that effective clinical practice requires attending to the circumstances and needs of individual patients-their life context-rather than just treating disease, the implications of not doing so are rarely assessed. What are, for instance, the consequences of prescribing a medication that is appropriate for treating a clinical condition but inappropriate for a particular individual either because she or he cannot afford it, lacks the skills to administer it correctly, or is unable to adhere to the regimen because of competing responsibilities such as working the night shift? Conversely, what are the gains to health and health care when such contextual factors are addressed? Finally, can performance measures be employed and developed for the clinician behaviors associated with contextualizing care to guide improvements in care? The authors have explored these questions through observational and experimental studies to define the parameters of patient context, introduce strategies for measuring clinician attention to patient context, and assess the impact of that attention on care planning, patient health care outcomes, and costs. The authors suggest that inattention to patient context is an underrecognized cause of medical error ("contextual error"), that detecting its presence usually requires listening in on the visit, and that it has significant implications for quality of care. Also described is preliminary work to reduce contextual errors. Evidence suggests that this nascent area of research has significant implications for performance assessment and medical education in addressing deficits in quality of care.