Trauma-Informed Healthcare Leadership? Evidence and opportunities from interviews with leaders during COVID-19

BACKGROUND

COVID-19 impacted the mental health of healthcare workers, who endured pressures as they provided care during a prolonged crisis. We aimed to explore whether and how a Trauma-Informed Care (TIC) approach was reflected in qualitative perspectives from healthcare leaders of their experience during COVID-19 (2020-2021).

METHODS

Semi-structured interviews with healthcare leaders from four institutions were conducted. Data analysis consisted of four stages informed by interpretative phenomenological analysis: 1) deductive coding using TIC assumptions, 2) inductive thematic analysis of coded excerpts, 3) keyword-in-context coding of full transcripts for 6 TIC principles with integration into prior inductive themes, and 4) interpretation of themes through 6 TIC principles (safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and awareness of cultural, historical, and gender issues).

RESULTS

The actions of leaders (n = 28) that were reported as successful and supportive responses to the COVID-19 pandemic or else missed opportunities reflected core principles of Trauma-Informed Care. To promote safety, leaders reported affirmative efforts to protect staff by providing appropriate physical protection, and enhanced psychological safety by providing channels for communication about emotional well-being. To promote trustworthiness and transparency, leaders listened to their staff, shared current COVID-19 information, and increased frequency of meetings to disseminate accurate information. To promote mutual support, strategies included wellness check-ins, sharing uplifting stories, affirming common goals, articulating fears, and leading by example. Examples of empowerment included: making time and adjusting modalities for flexible communication; naming challenges outside of the hospital; and functioning as a channel for complaints. Reported missed opportunities included needing more dedicated time and space for healthcare employees to process emotions, failures in leadership managing their own anxiety, and needing better support for middle managers. Awareness of the TIC principle of cultural, historical, and gender issues was largely absent. Results informed the nascent Trauma-Informed Healthcare Leadership (TIHL) framework.

CONCLUSIONS

We propose the Trauma-Informed Healthcare Leadership framework as a useful schema for action and analysis. This approach yields recommendations for healthcare leaders including creating designated spaces for emotional processing, and establishing consistent check-ins that reference personal and professional well-being.

An initiative to promote value-based stress test selection in primary care and cardiology clinics: A mixed methods evaluation

OBJECTIVES

Exercise stress echocardiograms (stress echos) are overused, whereas exercise stress electrocardiograms (stress ECGs) can be an appropriate, lower-cost substitute. In this post hoc, mixed methods evaluation, we assessed an initiative promoting value-based, guideline-concordant ordering practices in primary care (PC) and cardiology clinics.

METHODS

Change in percent of stress ECGs ordered of all exercise stress tests (stress ECGs and echos) was calculated between three periods: baseline (January 2019-February 2020); Period 1 with reduced stress ECG report turnaround time + PC-targeted education (began June 2020); and Period 2 with the addition of electronic health record-based alternative alert (AA) providing point-of-care clinical decision support. The AA was deployed in two of five PC clinics in July 2020, two additional PC clinics in January 2021, and one of four cardiology clinics in February 2021. Nineteen primary care providers (PCPs) and five cardiologists were interviewed in Period 2.

RESULTS

Clinicians reported reducing ECG report turnaround time was crucial for adoption. PCPs specifically reported that value-based education helped change their practice. In PC, the percent of stress ECGs ordered increased by 38% ± 6% (SE) (p < 0.0001) from baseline to Period 1. Most PCPs identified the AA as the most impactful initiative, yet stress ECG ordering did not change (6% ± 6%; p = 0.34) between Periods 1 and 2. In contrast, cardiologists reportedly relied on their expertise rather than AAs, yet their stress ECGs orders increased from Period 1 to 2 to a larger degree in the cardiology clinic with the AA (12% ± 5%; p = 0.01) than clinics without the AA (6% ± 2%; p = 0.01). The percent of stress ECGs ordered was higher in Period 2 than baseline for both specialties (both p < 0.0001).

CONCLUSIONS

This initiative influenced ordering behaviour in PC and cardiology clinics. However, clinicians' perceptions of the initiative varied between specialties and did not always align with the observed behaviour change.

A Nurse-Led Care Delivery App and Telehealth System for Patients Requiring Wound Care: Mixed Methods Implementation and Evaluation Study

BACKGROUND

Innovative solutions to nursing care are needed to address nurse, health system, patient, and caregiver concerns related to nursing wellness, work flexibility and control, workforce retention and pipeline, and access to patient care. One innovative approach includes a novel health care delivery model enabling nurse-led, off-hours wound care (PocketRN) to triage emergent concerns and provide additional patient health education via telehealth.

OBJECTIVE

This pilot study aimed to evaluate the implementation of PocketRN from the perspective of nurses and patients.

METHODS

Patients and part-time or per-diem, wound care-certified and generalist nurses were recruited through the Stanford Medicine Advanced Wound Care Center in 2021 and 2022. Qualitative data included semistructured interviews with nurses and patients and clinical documentation review. Quantitative data included app use and brief end-of-interaction in-app satisfaction surveys.

RESULTS

This pilot study suggests that an app-based nursing care delivery model is acceptable, clinically appropriate, and feasible. Low technology literacy had a modest effect on initial patient adoption; this barrier was addressed with built-in outreach and by simplifying the patient experience (eg, via phone instead of video calls). This approach was acceptable for users, despite total patient enrollment and use numbers being lower than anticipated (N=49; 17/49, 35% of patients used the app at least once beyond the orientation call). We interviewed 10 patients: 7 who had used the app were satisfied with it and reported that real-time advice after hours reduced anxiety, and 3 who had not used the app after enrollment reported having other resources for health care advice and noted their perception that this tool was meant for urgent issues, which did not occur for them. Interviewed nurses (n=10) appreciated working from home, and they reported comfort with the scope of practice and added quality of care facilitated by video capabilities; there was interest in additional wound care-specific training for nonspecialized nurses. Nurses were able to provide direct patient care over the web, including the few participating nurses who were unable to perform in-person care (n=2).

CONCLUSIONS

This evaluation provides insights into the integration of technology into standard health care services, such as in-clinic wound care. Using in-system nurses with access to electronic medical records and specialized knowledge facilitated app integration and continuity of care. This care delivery model satisfied nurse desires for flexible and remote work and reduced patient anxiety, potentially reducing postoperative wound care complications. Feasibility was negatively impacted by patients' technology literacy and few language options; additional patient training, education, and language support are needed to support equitable access. Adoption was impacted by a lack of perceived need for additional care; lower-touch or higher-acuity settings with a longer wait between visits could be a better fit for this type of nurse-led care.

Evolution of a Project to Improve Inpatient-to-Outpatient Dermatology Care Transitions: Mixed Methods Evaluation

BACKGROUND

In-hospital dermatological care has shifted from dedicated dermatology wards to consultation services, and some consulted patients may require postdischarge follow-up in outpatient dermatology. Safe and timely care transitions from inpatient-to-outpatient specialty care are critical for patient health, but communication around these transitions can be disjointed, and workflows can be complex.

OBJECTIVE

In this 3-phase quality improvement effort, we developed and evaluated an intervention that leveraged an electronic health record (EHR) feature, known as SmartPhrase, to enable a new workflow to improve transitions from inpatient care to outpatient dermatology.

METHODS

Phase 1 (February-March 2021) included interviews with patients and process mapping with key stakeholders to identify gaps and inform an intervention: a SmartPhrase table and associated workflow to promote collection of patient information needed for scheduling follow-up and closed-loop communication between dermatology and scheduling teams. In phase 2 (April-May 2021), semistructured interviews-with dermatologists (n=5), dermatology residents (n=5), and schedulers (n=6)-identified pain points and refinements. In phase 3, the intervention was evaluated by triangulating data from these interviews with measured changes in scheduling efficiency, visit completion, and messaging volume preimplementation (January-February 2021) and postimplementation (April-May 2021).

RESULTS

Preintervention pain points included unclear workflow for care transitions, limited patient input in follow-up planning, multiple messaging channels (eg, EHR based, email, and phone messages), and time-inefficient patient tracking. The intervention addressed most pain points; interviewees reported the intervention was easy to adopt and improved scheduling efficiency, workload, and patient involvement. More visits were completed within the desired timeframe of 14 days after discharge during the postimplementation period (21/47, 45%) than the preimplementation period (28/41, 68%; P=.03). The messaging workload also decreased from 88 scheduling-related messages sent for 25 patients before implementation to 30 messages for 8 patients after implementation.

CONCLUSIONS

Inpatient-to-outpatient specialty care transitions are complex and involve multiple stakeholders, thus requiring multifaceted solutions. With deliberate evaluation, broad stakeholder input, and iteration, we designed and implemented a successful solution using a standard EHR feature, SmartPhrase, integrated into a standardized workflow to improve the timeliness of posthospital specialty care and reduce workload.

Perspectives on the Intersection of Electronic Health Records and Health Care Team Communication, Function, and Well-being

Importance

Understanding of the interplay between the electronic health record (EHR), health care team relations, and physician well-being is currently lacking. Approaches to cultivate interpersonal interactions may be necessary to complement advancements in health information technology with high-quality team function.

Objective

To examine ways in which the EHR, health care team functioning, and physician well-being intersect and interact.

Design, Setting, and Participants

Secondary qualitative analysis of semistructured interview data from 2 studies used keyword-in-context approaches to identify excerpts related to teams. Thematic analysis was conducted using pattern coding, then organized using the relationship-centered organization model. Two health care organizations in California from March 16 to October 13, 2017, and February 28 to April 21, 2022, participated, with respondents including attending and resident physicians.

Main Outcome and Measures

Across data sets, themes centered around the interactions between the EHR, health care team functioning, and physician well-being. The first study data focused on EHR-related distressing events and their role in attending physician and resident physician emotions and actions. The second study focused on EHR use and daily EHR irritants.

Results

The 73 respondents included attending physicians (53 [73%]) and resident physicians (20 [27%]). Demographic data were not collected. Participants worked in ambulatory specialties (33 [45%]), hospital medicine (10 [14%]), and surgery (10 [14%]). The EHR was reported to be the dominant communication modality among all teams. Interviewees indicated that the EHR facilitates task-related communication and is well suited to completing simple, uncomplicated tasks. However, EHR-based communication limited the rich communication and social connection required for building relationships and navigating conflict. The EHR was found to negatively impact team function by promoting disagreement and introducing areas of conflict into team relationships related to medical-legal pressures, role confusion, and undefined norms around EHR-related communication. In addition, interviewees expressed that physician EHR-related distress affects interactions within the team, eroding team well-being.

Conclusions and Relevance

In this study, the EHR supported task-oriented and efficient communication among team members to get work done and care for patients; however, participants felt that the technology shifts attention away from the human needs of the care team that are necessary for developing relationships, building trust, and resolving conflicts. Interventions to cultivate interpersonal interactions and team function are necessary to complement the efficiency benefits of health information technology.

Pandemic Through the Lens of Black Barbershops: COVID-19's Impact and Barbers' Potential Role as Public Health Extenders

We examined the impact of COVID-19 on Black barbershops and their potential role as public health extenders. A 30-item survey was distributed to predominantly Black barbershop owners and barbers across 40 different states/territories in the US between June and October 2020. The survey addressed the impact of COVID-19 on Black barbershops, and barbers' interest in engaging in health outreach programs. The majority reported that stay-at-home orders had significant to severe impact on their business; few were prepared for the financial impact and less than half thought they qualified for government assistance. The majority were already providing health education and outreach to the Black community and showed interest in continuing to provide such services, like information on COVID-19. Barbers in Black-serving barbershops, a well-documented effective place for public health outreach to the Black community, show promise as public health extenders in the response to the COVID-19 pandemic.

Professional Behavior and Value Erosion: A Qualitative Study of Physicians and the Electronic Health Record

GOAL

Occurrences of physician burnout have reached epidemic numbers, and the electronic health record (EHR) is a commonly cited cause of the distress. To enhance current understanding of the relationship between burnout and the EHR, we explored the connections between physicians' distress and the EHR.

METHODS

In this qualitative study, physicians and graduate medical trainees from two healthcare organizations in California were interviewed about EHR-related distressing events and the impact on their emotions and actions. We analyzed physician responses to identify themes regarding the negative impact of the EHR on physician experience and actions. EHR "distressing events" were categorized using the Accreditation Council for Graduate Medical Education (ACGME) Physician Professional Competencies.

PRINCIPAL FINDINGS

Every participating physician reported EHR-related distress affecting professional activities. Five main themes emerged from our analysis: system blocks to patient care; poor implementation, design, and functionality of the EHR; billing priorities conflicting with ideal workflow and best-practice care; lack of efficiency; and poor teamwork function. When mapped to the ACGME competencies, physician distress frequently stemmed from situations where physicians prioritized systems-based practice above other desired professional actions and behaviors. Physicians also reported a climate of silence in which physicians would not share problems due to fear of retribution or lack of confidence that the problems would be addressed.

PRACTICAL APPLICATIONS

Physicians and administrators need to address the hierarchy of values that prioritizes system requirements such as those required by the EHR above physicians' other desired professional actions and behaviors. Balancing the importance of competing competencies may help to address rising burnout. We also recommend that administrators consider qualitative anonymous interviews as an effective method to uncover and understand physician distress in light of physicians' reported climate of silence.

Performance and usability testing of an automated tool for detection of peripheral artery disease using electronic health records

Peripheral artery disease (PAD) is a common cardiovascular disorder that is frequently underdiagnosed, which can lead to poorer outcomes due to lower rates of medical optimization. We aimed to develop an automated tool to identify undiagnosed PAD and evaluate physician acceptance of a dashboard representation of risk assessment. Data were derived from electronic health records (EHR). We developed and compared traditional risk score models to novel machine learning models. For usability testing, primary and specialty care physicians were recruited and interviewed until thematic saturation. Data from 3168 patients with PAD and 16,863 controls were utilized. Results showed a deep learning model that utilized time engineered features outperformed random forest and traditional logistic regression models (average AUCs 0.96, 0.91 and 0.81, respectively), P < 0.0001. Of interviewed physicians, 75% were receptive to an EHR-based automated PAD model. Feedback emphasized workflow optimization, including integrating risk assessments directly into the EHR, using dashboard designs that minimize clicks, and providing risk assessments for clinically complex patients. In conclusion, we demonstrate that EHR-based machine learning models can accurately detect risk of PAD and that physicians are receptive to automated risk detection for PAD. Future research aims to prospectively validate model performance and impact on patient outcomes.

Teledermatology to Facilitate Patient Care Transitions from Inpatient to Outpatient Dermatology: a Mixed Methods Evaluation (Preprint)

Background

Both clinicians and patients have increasingly turned to telemedicine to improve care access, even in physical examination–dependent specialties such as dermatology. However, little is known about whether teledermatology supports effective and timely transitions from inpatient to outpatient care, which is a common care coordination gap.

Objective

Using mixed methods, this study sought to retrospectively evaluate how teledermatology affected clinic capacity, scheduling efficiency, and timeliness of follow-up care for patients transitioning from inpatient to outpatient dermatology care.

Methods

Patient-level encounter scheduling data were used to compare the number and proportion of patients who were scheduled and received in-clinic or video dermatology follow-ups within 14 and 90 days after discharge across 3 phases: June to September 2019 (before teledermatology), June to September 2020 (early teledermatology), and February to May 2021 (sustained teledermatology). The time from discharge to scheduling and completion of patient follow-up visits for each care modality was also compared. Dermatology clinicians and schedulers were also interviewed between April and May 2021 to assess their perceptions of teledermatology for postdischarge patients.

Results

More patients completed follow-up within 90 days after discharge during early (n=101) and sustained (n=100) teledermatology use than at baseline (n=74). Thus, the clinic’s capacity to provide follow-up to patients transitioning from inpatient increased from baseline by 36% in the early (101 from 74) and sustained (100 from 74) teledermatology periods. During early teledermatology use, 61.4% (62/101) of the follow-ups were conducted via video. This decreased significantly to 47% (47/100) in the following year, when COVID-19–related restrictions started to lift (P=.04), indicating more targeted but still substantial use. The proportion of patients who were followed up within the recommended 14 days after discharge did not differ significantly between video and in-clinic visits during the early (33/62, 53% vs 15/39, 38%; P=.15) or sustained (26/53, 60% vs 28/47, 49%; P=.29) teledermatology periods. Interviewees agreed that teledermatology would continue to be offered. Most considered postdischarge follow-up patients to be ideal candidates for teledermatology as they had undergone a recent in-person assessment and might have difficulty attending in-clinic visits because of competing health priorities. Some reported patients needing technological support. Ultimately, most agreed that the choice of follow-up care modality should be the patient’s own.

Conclusions

Teledermatology could be an important tool for maintaining accessible, flexible, and convenient care for recently discharged patients needing follow-up care. Teledermatology increased clinic capacity, even during the pandemic, although the timeliness of care transitions did not improve. Ultimately, the care modality should be determined through communication with patients to incorporate their and their caregivers’ preferences.

Nonmedical Transdisciplinary Perspectives of Black and Racially and Ethnically Diverse Individuals About Antiracism Practices: A Qualitative Study

IMPORTANCE

Overwhelming evidence that anti-Black racism is associated with health inequities is driving clinician demand for antiracism practices that promote health equity.

OBJECTIVE

To investigate how nonmedical professionals address personally mediated, institutional, and internalized racism and to adapt these practices for the clinical setting.

DESIGN, SETTING, AND PARTICIPANTS

Using an approach from human-centered design for this qualitative study, virtual qualitative interviews were conducted among 40 professionals from nonmedical fields to investigate antiracism practices used outside of medicine. Inductive thematic analysis was conducted to identify latent themes and practices that may be adaptable to health care, subsequently using an established theoretical framework describing levels of racism to interpret and organize themes. Convenience and purposive sampling was used to recruit participants via email, social media, and electronic flyers.

MAIN OUTCOMES AND MEASURES

Antiracism practices adapted to medicine.

RESULTS

Among 40 professionals from nonmedical fields, most were younger than age 40 years (23 individuals [57.5%]) and there were 20 (50.0%) women; there were 25 Black or African American individuals (62.5%); 4 East Asian, Southeast Asian, or South Asian individuals (10.0%); 3 individuals with Hispanic, Latinx, or Spanish origin (7.5%); and 3 White individuals. Participants described personally mediated, institutional, and internalized antiracism practices that may be adaptable to promote health equity for Black patients. Personally mediated antiracism practices included dialogue and humble inquiry, building trust, and allyship and shared humanity; clinicians may be able to adopt these practices by focusing on patient successes, avoiding stigmatizing language in the electronic health record, and using specific phrases to address racism in the moment. Institutional antiracism practices included education, representation, and mentorship; in the health care setting, clinics may be able to develop staff affiliate groups, focus on improving racial health equity outcomes, and conduct antiracism trainings. Internalized antiracism practices centered on authenticity; clinicians may be able to write positionality statements reflecting their identity and the expertise they bring to clinical encounters.

CONCLUSIONS AND RELEVANCE

This study's findings suggest that antiracism practices from outside the health care sector may offer innovative strategies to promote health equity by addressing personally mediated, institutional, and internalized racism in clinical care.

Patient and Clinician Perspectives of New and Return Ambulatory Teleneurology Visits

BACKGROUND AND OBJECTIVES

To evaluate the adoption and perceived utility of video visits for new and return patient encounters in ambulatory neurology subspecialties.

METHODS

Video visits were launched in an academic, multi-subspecialty, ambulatory neurology clinic in March 2020. Adoption of video visits for new and return patient visits was assessed using clinician-level scheduling data from March 22 to May 16, 2020. Perceived utility of video visits was explored via a clinician survey and semistructured interviews with clinicians and patients/caregivers. Findings were compared across 5 subspecialties and 2 visit types (new vs return).

RESULTS

Video visits were adopted rapidly; all clinicians (n = 65) integrated video visits into their workflow within the first 6 weeks, and 92% of visits were conducted via video, although this varied by subspecialty. Utility of video visits was higher for return than new patient visits, as indicated by surveyed (n = 48) and interviewed clinicians (n = 30), aligning with adoption patterns. Compared with in-person visits, clinicians believed that it was easier to achieve a similar physical examination, patient-clinician rapport, and perceived quality of care over video for return rather than new patient visits. Of the 25 patients/caregivers interviewed, most were satisfied with the care provided via video, regardless of visit type, with the main limitation being the physical examination.

DISCUSSION

Teleneurology was robustly adopted for both new and return ambulatory neurology patients during the COVID-19 pandemic. Return patient visits were preferred over new patient visits, but both were feasible. These results provide a foundation for developing targeted guidelines for sustaining teleneurology in ambulatory care.

Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool

BACKGROUND

Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.

METHODS

This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n = 20) and surgeons (n = 10) to explore stakeholder perspectives on video visits.

RESULTS

During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.

CONCLUSION

Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

Approach to Human-Centered, Evidence-Driven Adaptive Design (AHEAD) for Health Care Interventions: a Proposed Framework

Human-centered design (HCD), an empathy-driven approach to innovation that focuses on user needs, offers promise for the rapid design of health care interventions that are acceptable to patients, clinicians, and other stakeholders. Reviews of HCD in healthcare, however, note a need for greater rigor, suggesting an opportunity for integration of elements from traditional research and HCD. A strategy that combines HCD principles with evidence-grounded health services research (HSR) methods has the potential to strengthen the innovation process and outcomes. In this paper, we review the strengths and limitations of HCD and HSR methods for intervention design, and propose a novel Approach to Human-centered, Evidence-driven Adaptive Design (AHEAD) framework. AHEAD offers a practical guide for the design of creative, evidence-based, pragmatic solutions to modern healthcare challenges.

Implementation outcomes of Humanwide: integrated precision health in team-based family practice primary care

Background

Humanwide was precision health embedded in primary care aiming to leverage high-tech and high-touch medicine to promote wellness, predict and prevent illness, and tailor treatment to individual medical and psychosocial needs.

Methods

We conducted a study assessing implementation outcomes to inform spread and scale, using mixed methods of semi-structured interviews with diverse stakeholders and chart reviews.

Humanwide included: 1) health coaching; 2) four digital health tools for blood-pressure, weight, glucose, and activity; 3) pharmacogenomic testing; and 4) genetic screening/testing. We examined implementation science constructs: reach/penetration, acceptability, feasibility, and sustainability. Chart reviews captured preliminary clinical outcomes.

Results

Fifty of 69 patients (72%) invited by primary care providers participated in the Humanwide pilot. We performed chart reviews for the 50 participating patients. Participants were diverse overall (50% non-white, 66% female). Over half of the participants were obese and 58% had one or more major cardiovascular risk factor: dyslipidemia, hypertension, diabetes. Reach/penetration of Humanwide components varied: pharmacogenomics testing 94%, health coaching 80%, genetic testing 72%, and digital health 64%. Interview participants (n=27) included patients (n=16), providers (n=9), and the 2 staff who were allocated dedicated time for Humanwide patient intake and orientation. Patients and providers reported Humanwide was acceptable; it engaged patients holistically, supported faster medication titration, and strengthened patient-provider relationships. All patients benefited clinically from at least one Humanwide component. Feasibility challenges included: low provider self-efficacy for interpreting genetics and pharmacogenomics; difficulties with data integration; patient technology challenges; and additional staffing needs. Patient financial burden concerns surfaced with respect to sustainability.

Conclusion

This is the first report of implementation of a multi-component precision health model embedded in team-based primary care. We found acceptance from both patients and providers; however, feasibility barriers must be overcome to enable broad spread and sustainability. We found that barriers to implementation of precision health in a team-based primary care clinic are mundane and straightforward, though not necessarily easy to overcome. Future implementation endeavors should invest in basics: education, workflow, and reflection/evaluation. Strengthening fundamentals will enable healthcare systems to more nimbly accept the responsibility of meeting patients at the crossroads of innovative science and routinized clinical systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01373-4.

Rapid Implementation of Video Visits in Neurology During COVID-19: Mixed Methods Evaluation

BACKGROUND

Telemedicine has been used for decades. Despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology's ambulatory subspecialties has been sparse. However, the COVID-19 pandemic prompted health care systems worldwide to reconsider traditional health care delivery. To safeguard health care workers and patients, many health care systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care.

OBJECTIVE

To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess adoption, acceptability, appropriateness, and perceptions of potential sustainability.

METHODS

Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semistructured interviews with providers (n=30) completed between March and May 2020.

RESULTS

Video visits were adopted rapidly; overall, 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted their satisfaction. Video visits were reported to be more convenient for patients, families, and caregivers than in-person visits; however, access to technology, the patient's technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination.

CONCLUSIONS

Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.

Smoking and Unemployment: A Photo Elicitation Project

Introduction:

Research has documented higher smoking prevalence with unemployment and greater difficulty with gaining re-employment for those who smoke. Using photo elicitation methods, we sought to gain a deeper understanding of the connection between job-seeking and tobacco use.

Methods:

Unemployed daily smokers (18 men, 1 woman) were recruited from the San Francisco Employment Development Department (EDD) and provided disposable cameras with 27 exposures and a list of 20 photo prompts related to job-seeking and tobacco. Study staff reviewed the photos with the participants and audio-recorded their narratives. The photos and narratives were coded for themes.

Results:

Of 363 photos, the most frequent photo imagery related to transportation (n = 56, 15.4%), work or education (n = 39, 10.7%), and littered cigarettes (n = 39, 10.7%). Narrated themes centered on motivators to quit smoking (255 mentions from 15 participants); people, places, and things associated with smoking (248 mentions, 16 participants); and motivators to secure work (157 mentions, 13 participants). The intersection of smoking and unemployment received 92 mentions from 11 participants, with 60 mentions (8 participants) identifying smoking as a barrier to re-employment.

Conclusions:

Both motivators to quit and associated smoking cues were salient in the environments of job-seeking smokers. Struggles with quitting and perceptions that smoking is harming re-employment success suggest the potential for offering tobacco treatment in EDD settings. With permission, the photos and themes have been incorporated into a tobacco treatment intervention for job-seeking smokers.

Accelerated launch of video visits in ambulatory neurology during COVID-19: Key lessons from the Stanford experience

The SARS-CoV-2 (COVID-19) pandemic has rapidly moved telemedicine from discretionary to necessary. Here, we describe how the Stanford Neurology Department (1) rapidly adapted to the COVID-19 pandemic, resulting in over 1,000 video visits within 4 weeks, and (2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to equipment/software, provider engagement, workflow/triage, and training. On reflection, the key drivers of our success were provider engagement and dedicated support from a physician champion, who plays a critical role understanding stakeholder needs. Before COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated postpandemic era.

Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter

IMPORTANCE

Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.

OBJECTIVE

To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.

EVIDENCE REVIEW

Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.

FINDINGS

The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions).

CONCLUSIONS AND RELEVANCE

This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

Primary Care 2.0: Design of a Transformational Team-Based Practice Model to Meet the Quadruple Aim

A new transformational model of primary care is needed to address patient care complexity and provider burnout. An 18-month design effort (2015-2016) included the following: (1) Needs Finding, (2) Integrated Facility Design, (3) Design Process Assessment, and (4) Development of Evaluation. Initial outcome metrics were assessed. The design team successfully applied Integrated Facility Design to primary care transformation design; qualitative survey results suggest that design consensus was facilitated by team-building activities. Initial implementation of Quadruple Aim-related outcome metrics showed positive trends. Redesign processes may benefit from emphasis on team building to facilitate consensus and increased patient involvement to incorporate patient voices successfully.

Trust in Health Information Sources: Survey Analysis of Variation by Sociodemographic and Tobacco Use Status in Oklahoma

Background

Modern technology (ie, websites and social media) has significantly changed social mores in health information access and delivery. Although mass media campaigns for health intervention have proven effective and cost-effective in changing health behavior at a population scale, this is best studied in traditional media sources (ie, radio and television). Digital health interventions are options that use short message service/text messaging, social media, and internet technology. Although exposure to these products is becoming ubiquitous, electronic health information is novel, incompletely disseminated, and frequently inaccurate, which decreases public trust. Previous research has shown that audience trust in health care providers significantly moderates health outcomes, demographics significantly influence audience trust in electronic media, and preexisting health behaviors such as smoking status significantly moderate audience receptivity to traditional mass media. Therefore, modern health educators must assess audience trust in all sources, both media (traditional and digital) and interpersonal, to balance pros and cons before structuring multicomponent community health interventions.

Objective

We aimed to explore current trust and moderators of trust in health information sources given recent changes in digital health information access and delivery to inform design of future health interventions in Oklahoma.

Methods

We conducted phone surveys of a cross-sectional sample of 1001 Oklahoma adults (age 18-65 years) in spring 2015 to assess trust in seven media sources: traditional (television and radio), electronic (online and social media), and interpersonal (providers, insurers, and family/friends). We also gathered information on known moderators of trust (sociodemographics and tobacco use status). We modeled log odds of a participant rating a source as “trustworthy” (SAS PROC SURVEYLOGISTIC), with subanalysis for confounders (sociodemographics and tobacco use).

Results

Oklahomans showed the highest trust in interpersonal sources: 81% (808/994) reported providers were trustworthy, 55% (550/999) for friends and family, and 48% (485/998) for health insurers. For media sources, 24% of participants (232/989) rated the internet as trustworthy, followed by 21% of participants for television (225/998), 18% for radio (199/988), and only 11% for social media (110/991). Despite this low self-reported trust in social media, 40% (406/991) of participants reported using social media for tobacco-related health information. Trust in health providers did not vary by subpopulation, but sociodemographic variables (gender, income, and education) and tobacco use status significantly moderated trust in other sources. Women were on the whole more trusting than men, trust in media decreased with income, and trust in friends and family decreased with education.

Conclusions

Health education interventions should incorporate digital media, particularly when targeting low-income populations. Utilizing health care providers in social media settings could leverage high-trust and low-cost features of providers and social media, respectively.

Online Patient-Provider E-cigarette Consultations: Perceptions of Safety and Harm

INTRODUCTION

E-cigarettes are popular and unregulated. Patient-provider communications concerning e-cigarettes were characterized to identify patient concerns, provider advice and attitudes, and research needs.

METHODS

An observational study of online patient-provider communications was conducted January 2011-June 2015 from a network providing free medical advice, and analyzed July 2014-May 2016. Patient and provider themes, and provider attitudes toward e-cigarettes (positive, negative, or neutral) were coded qualitatively. Provider attitudes were analyzed with cumulative logit modeling to account for clustering. Patient satisfaction with provider responses was expressed via a Thank function.

RESULTS

An increase in e-cigarette-related questions was observed over time. Patient questions (N=512) primarily concerned specific side effects and harms (34%); general safety (27%); e-cigarettes as quit aids (19%); comparison of e-cigarette harms relative to combusted tobacco (18%); use with pre-existing medical conditions (18%); and nicotine-free e-cigarettes (14%). Half of provider responses discussed e-cigarettes as a harm reduction option (48%); 26% discussed them as quit aids. Overall, 47% of providers' responses represented a negative attitude toward e-cigarettes; 33% were neutral (contradictory or non-committal); and 20% were positive. Attitudes did not differ statistically by medical specialty; provider responses positive toward e-cigarettes received significantly more Thanks.

CONCLUSIONS

Examination of online patient-provider communications provides insight into consumer health experience with emerging alternative tobacco products. Patient concerns largely related to harms and safety, and patients preferred provider responses positively inclined toward e-cigarettes. Lacking conclusive evidence of e-cigarette safety or efficacy, healthcare providers encouraged smoking cessation and recommended first-line cessation treatment approaches.

"You have the right to protect your health": Perceptions of Secondhand Smoke and Exposure Mitigation Strategies in Low-Income Patients With Heart Disease, San Francisco, 2011-2012

We examined the understanding of the harms of secondhand smoke (SHS) exposure among low-income, hospitalized adults with cardiovascular disease. Participants were 15 nonsmokers reporting daily SHS exposure and 15 light or nondaily cigarette smokers. We coded responses from audiotaped semistructured interviews for themes. No participant spontaneously identified heart risks related to SHS exposure. Strategies to avoid SHS included verbal requests to not smoke and physically avoiding smoke; both smokers and nonsmokers prioritized politeness over urgency. Most participants thought a blood test quantifying SHS exposure would be clinically useful. Health education, assertiveness communication training, and protective policies (eg, smoke-free multiunit housing) also were supported.

Oklahoma "Tobacco Stops with Me"Media Campaign Effects on Attitudes toward Secondhand Smoke

IMPORTANCE

Public education campaigns in tobacco control play an important role in changing tobacco-related knowledge, attitudes and behaviors. The Oklahoma Tobacco Stops with Me campaign has been effective in changing attitudes overall and across subpopulations towards secondhand smoke risks.

OBJECTIVE

Investigate campaign impact on secondhand smoke policy and risk attitudes.

DESIGN

Serial cross-sectional data analyzed with univariate and multivariable models.

SETTING

Random-digit dialing surveys conducted in 2007 and 2015.

PARTICIPANTS

Oklahomans 18-65 years old.

MAIN OUTCOMES AND MEASURES

1) Support for smokefree bars; 2) risk assessment of secondhand smoke (very harmful, causes heart disease, causes sudden infant death); and 3) likelihood of protecting yourself from secondhand smoke.

RESULTS

With Tobacco Stops with Me exposure, from 2007 to 2015, Oklahomans demonstrated significant increases in: 1) supporting smokefree bars (23.7% to 55%); 2) reporting beliefs that SHS causes heart disease (58.5% to 72.6%), is very harmful (63.8% to 70.6%) and causes sudden infant death (24% to 34%); and 3) reporting they are very likely to ask someone not to smoke nearby (45% to 52%). Controlling for demographics, smokers and males showed reduced attitude change. In uncontrolled comparisons, high-school graduates faired better than non-diploma individuals, who lacked significant attitude changes.

CONCLUSIONS AND RELEVANCE

Tobacco Stops with Me achieved its mission to more closely align public perception of SHS with well-documented secondhand smoke risks. Efforts to target women were particularly successful. Smokers may be resistant to messaging; closing taglines that reinstate individual choice may help to reduce resistance/reactance (e.g., adding Oklahoma Helpline contact information).

Validity and reliability of the Internalized Stigma of Smoking Inventory: An exploration of shame, isolation, and discrimination in smokers with mental health diagnoses

BACKGROUND AND OBJECTIVES

De-normalization of smoking as a public health strategy may create shame and isolation in vulnerable groups unable to quit. To examine the nature and impact of smoking stigma, we developed the Internalized Stigma of Smoking Inventory (ISSI), tested its validity and reliability, and explored factors that may contribute to smoking stigma.

METHODS

We evaluated the ISSI in a sample of smokers with mental health diagnoses (N = 956), using exploratory and confirmatory factor analysis, and assessed construct validity.

RESULTS

Results reduced the ISSI to eight items with three subscales: smoking self-stigma related to shame, felt stigma related to social isolation, and discrimination experiences. Discrimination was the most commonly endorsed of the three subscales. A multivariate generalized linear model predicted 21-30% of the variance in the smoking stigma subscales. Self-stigma was greatest among those intending to quit; felt stigma was highest among those experiencing stigma in other domains, namely ethnicity and mental illness-based; and smoking-related discrimination was highest among women, Caucasians, and those with more education.

DISCUSSION AND CONCLUSION

Smoking stigma may compound stigma experiences in other areas. Aspects of smoking stigma in the domains of shame, isolation, and discrimination were related to modeled stigma responses, particularly readiness to quit and cigarette addiction, and were found to be more salient for groups where tobacco use is least prevalent.

SCIENTIFIC SIGNIFICANCE

The ISSI measure is useful for quantifying smoking-related stigma in multiple domains.

Development and usability evaluation of the mHealth Tool for Lung Cancer (mHealth TLC): a virtual world health game for lung cancer patients

OBJECTIVE

To test the feasibility and usability of mHealth TLC, an interactive, immersive 3-dimensional iPad health game that coaches lung cancer patients toward assertive communication strategies during first-person virtual clinics visits.

METHOD

We observed players and conducted semi-structured interviews. Research questions focused on scenario believability, the impact of technical issues, transparency of game goals, and potential of mHealth TLC to decrease lung cancer stigma (LCS) and improve patient-clinician communication.

RESULTS

Eight users confirmed mHealth TLC to be: (1) believable, (2) clinic-appropriate, and (3) helpful in support of informed healthcare consumers. Concerns were expressed about emotionally charged content and plans to use mHealth TLC in clinic settings as opposed to at home.

CONCLUSIONS

Although the dialog and interactions addressed emotionally charged issues, players were able to engage, learn, and benefit from role-play in a virtual world. Health games have the potential to improve patient-clinician communication, and mHealth TLC specifically may decrease LCS, and promote optimal self-management.

PRACTICE IMPLICATIONS

Process reflection revealed the need for health games to be created by experienced game developers in collaboration with health care experts. To prepare for this best practice, research institutions and game developers interested in health games should proactively seek out networking and collaboration opportunities.

Tobacco industry marketing to low socioeconomic status women in the U.S.A

OBJECTIVES

Describe tobacco companies' marketing strategies targeting low socioeconomic status (SES) females in the U.S.A.

METHODS

Analysis of previously secret tobacco industry documents.

RESULTS

Tobacco companies focused marketing on low SES women starting in the late 1970s, including military wives, low-income inner-city minority women, 'discount-susceptible' older female smokers and less-educated young white women. Strategies included distributing discount coupons with food stamps to reach the very poor, discount offers at point-of-sale and via direct mail to keep cigarette prices low, developing new brands for low SES females and promoting luxury images to low SES African-American women. More recently, companies integrated promotional strategies targeting low-income women into marketing plans for established brands.

CONCLUSIONS

Tobacco companies used numerous marketing strategies to reach low SES females in the U.S.A. for at least four decades. Strategies to counteract marketing to low SES women could include (1) counteracting price discounts and direct mail coupons that reduce the price of tobacco products, (2) instituting restrictions on point-of-sale advertising and retail display and (3) creating counteradvertising that builds resistance to psychosocial targeting of low SES women. To achieve health equity, tobacco control efforts are needed to counteract the influence of tobacco industry marketing to low-income women.

Online comments on smoking bans in psychiatric hospitals units

OBJECTIVE

Individuals with mental health concerns are disproportionately affected by and suffer the negative consequences of tobacco use disorder, perhaps because smoking has historically been part of psychiatry's culture. In the early 1990s, psychiatric inpatient facilities were exempted from U.S. hospital smoking bans, in response to public outcry with national media attention. Almost 2 decades later, the current study characterizes online conversation about psychiatric hospital smoking bans. Previous commenting studies have demonstrated commenting's negativity, documenting the "nasty effect" wherein negative comments color perceptions of neutral articles. Thus, we focused particular attention on cited barriers to implementing health-positive smoke-free policies.

METHODS

We collected online comments (N = 261) responding to popular media articles on smoking bans in inpatient psychiatry between 2013 and 2014 and conducted an inductive and exploratory qualitative content analysis.

RESULTS

Verifying previous studies documenting the prevalence of negative commenting, of the comments explicitly supporting or refuting psychiatry smoking bans, there were over twice as many con comments (n = 44) than pro (n = 18). Many commenters argued for access to outdoor smoking areas and warned of patient agitation and risk posed to care workers. Identified content themes included psychiatric medication and negative side effects, broken mental health systems and institutions, denigration of the health risks of tobacco in the context of mental illness, typical pro-smoking arguments about "smokers' rights" and alternatives (including e-cigarettes), addiction, and stigma.

CONCLUSIONS

The current findings provide a platform to begin to understand how people talk about mental health issues and smoking. Our analysis also raised complex issues concerning forces that impact U.S. patients with serious mental illness but over which they have little control, including medication, the U.S. health system, stigma, perceptions that life with chronic serious mental illness is not worth living, and psychological and physical pain of coping with mental illness. In consideration of identified barriers raised in opposition to smoking bans in inpatient psychiatry, efforts should emphasize patient stakeholder involvement; patient, visitor, and staff protection from smoke exposure; the effectiveness of nicotine replacement for managing withdrawal; and the lack of evidence that cigarettes are therapeutic.