Table of Contents
PLAIN LANGUAGE ARTICLE SUMMARIES ("IN BRIEF")
Uplifting Primary Care through the Electronic Health Record
Anthony Paulo Sunjaya
Background Anthony Paulo Sunjaya, MD, SM, writes Annals’s July/August editorial in which he highlights four newly-published papers about the electronic health record and its role in facilitating high-quality health care.
What This Study Found The 4 papers (Meltzer et al, Ghosh et al, Cohen et al, and Bunce et al) examine the
use, functionality and effectiveness of EHRs, as well as physicians’ and patients’
perspectives of the EHR on clinical effectiveness. Meltzer et al’s unique study assesses
patients’ experience with EHR use during clinic visits, with patients regarding the
experience more positively than physicians in terms of perceptions of listening quality.
Ghosh et al’s paper found that a substantial number of practices — both primary and
secondary care — continued to operate in siloes despite the presence of EHRs and the
ability to share patient clinical information. Sunjaya says this symbolizes a “forgetful
health care system” and causes inefficiencies, safety reductions and increased physician
burnout. He proposes developing a single national EHR system or mandating interoperability.
Two additional research papers highlight EHR utility, including the usability of an
EHR-integrated home blood pressure visualization tool that can promote beneficial
out-of-office health monitoring, with data linked to EHR systems (Cohen et al). This
study, Sunjaya notes, suggests that capturing reliable patient data remotely has become
more possible than ever. Bunce et al’s research suggests that the EHR can be used
to effectively collect more research data in primary care through the articulation
of practical steps to develop an EHR-embedded care study. This has the potential to
improve response rates and data quality while reducing the burden of users to participate
in research and facilitating higher quality primary care research at scale.
Implications
- Sunjaya argues that future research must focus on developing and utilizing metrics
that measure EHR’s benefits and harms. They should include measurement of any possible
unintended consequences on health equity, user wellbeing, and those with lower tech
literacy and socioeconomic status. Best practice goals for these EHR metrics can then
be developed and their achievement linked to reimbursement and other rewards to realize
benefits to clinicians, patients and health systems faster.
Impact of Home Blood Pressure Data Visualization on Hypertension Medical Decision Making in Primary Care
Deborah J. Cohen and colleagues
Background Researchers developed and implemented a new visualization tool that combines clinical and home blood pressure readings, displaying them within the patient’s electronic health record in a single chart for easy navigation and analysis. They then studied how the tool was used during primary care visits and its effect on doctor-patient communication as it relates to shared decision-making for effective blood pressure management.
What This Study Found The tool was tested by a 10-practice primary care network. Researchers found that physicians and patients reviewed the home blood pressure trends over time to determine if the patient’s blood pressure was adequately controlled, regardless of how the blood pressure readings were reviewed (i.e., paper or EHR). When using the visualization tool, however, all readings were presented in the same chart, eliminating time spent navigating between the two data sources. Additionally, researchers observed that medication records embedded in the tool prompted additional conversations about possible adverse effects of medications, dosage adjustments, and the correlation between medication use and reductions in blood pressure. There were missed opportunities for such discussions when the patient’s at-home readings were not integrated with their EHR.
Implications
- The tool was not found to have a significant impact on visit efficiency and length. However, the authors conclude that reviewing home blood pressure using a visualization tool is useful for clinicians and patients. It promotes shared decision making in blood pressure management in the primary care setting. Primary care practices and their patients need adequate funding and infrastructure support to realize these benefits.
- Rather than focusing on the patient experience, the authors argue that perceptions
of care involving EHR use demonstrate the need for organizations to address increasing
rates of clinician stress and burnout related to patient data documentation.
- The authors argue that their findings indicate further opportunity for medication optimization in the primary care setting for COPD management and call for more real-life effectiveness trials to better support treatment decisions at the primary care level.
- The researchers concluded that initiatives that are primarily limited to passive strategies, such as education and patient identification, may have limited success in lower prescription rates for older adults. They also suggest clinicians might benefit from additional recommendations, support, and incentives to modify prescribing practices.
- These findings demonstrate the feasibility of offering abortion services in a variety of medical settings and highlight the potential variations that can be made to adapt the service to patient needs.
Use of the Electronic Health Record During Clinical Encounters: An Experience Survey
Ellen C. Meltzer and colleagues
Background Researchers report the results of a survey to assess the impact of electronic health record use during face-to-face visits in the primary care setting. Fifty-nine clinicians (including physicians, physician assistants and nurse practitioners) and 1,000 adult patients were surveyed.
What This Study Found Clinicians reported that when they used an EHR system during a patient visit, they
felt that they maintained less eye contact (79.1%); listened less carefully (53.5%);
focused less on patients (65.1%); and that the visit felt less personal overall (62.8%).
Only one-third of providers felt that patients perceived EHR use as a positive experience.
However, the majority of surveyed patients felt that use of the EHR was a positive
experience (91.7%). Additionally, patients reported that clinicians using EHR technology
during their visit provided sufficient eye contact (96.8%) and listened carefully
(97.0%). They also disagreed that practitioners focused less on them (86.7%) and that
visits felt less personal when the technology was used (87.2%).
Implications
- Rather than focusing on the patient experience, the authors argue that perceptions
of care involving EHR use demonstrate the need for organizations to address increasing
rates of clinician stress and burnout related to patient data documentation.
David B. Price and colleagues
Background Researchers conducted a study to describe the demographic and clinical characteristics of patients receiving care for chronic obstructive pulmonary disease in the U.S. primary care setting. More than 17,000 electronic patient records were included in their analysis, drawn from the Chronic Obstructive Pulmonary Disease Optimum Patient Care DARTNet Research Database. (COPD-RD). The group also used an additional source of data for a subset of these patients called the Advancing the Patient Experience Chronic Obstructive Pulmonary Disease (APEX-COPD) registry, which includes patient-reported descriptive and longitudinal data of patients managing COPD in the primary care setting. One thousand three hundred and fifty four patients were included in this sub-sample.
What This Study Found Almost 50% (49.9%) of patients in the APEX registry self-reported experiencing more than one exacerbation episode in the past year. This exacerbation burden was surprising to the researchers, considering that 87.9% of these patients were on some form of maintenance therapy. Despite treatment, APEX patients continued to report high or very high levels of COPD symptoms, as measured by the COPD Assessment Test. They experienced significant levels of breathlessness, indicating that they may not be treated properly or may be poorly compliant with medication regimes. Additionally, the authors recommend a greater focus on non-pharmacologic treatment options to reduce symptom burden (37.4% of APEX patients also reported continuing to smoke) and additional physician education to improve early diagnosis and treatment.
Implications
- The authors argue that their findings indicate further opportunity for medication optimization in the primary care setting for COPD management and call for more real-life effectiveness trials to better support treatment decisions at the primary care level.
Donovan T. Maust and colleagues
Background A new study within the Veterans Health Administration system aimed to identify strategies to reduce benzodiazepine prescriptions for older adults. This is important because benzodiazepines have been known to impair cognition, mobility and driving skills in older people, as well as increase the risk of falls. Unlike many community-based health care clinic settings, the VA system has successfully decreased its rate of benzodiazepine prescriptions in older veterans since 2013.
What This Study Found At the time of this study, there were 24,512 veterans, 75 years old and older, who
were receiving long-term benzodiazepine treatment. All facilities that were interviewed,
regardless of performance, employed passive strategies primarily consisting of education
about appropriate prescribing, alternatives to prescribing benzodiazepines, and identifying
potential patients for discontinuation. However, high-performing facilities described
leveraging one or more active strategies including providing prescribing guidance
for clinicians, administrative restrictions on benzodizaepine prescriptions, and performance
measures to incentivize clinicians to lower prescriptions rates for benzodiazepines.
Implications
- The researchers concluded that initiatives that are primarily limited to passive strategies, such as education and patient identification, may have limited success in lower prescription rates for older adults. They also suggest clinicians might benefit from additional recommendations, support, and incentives to modify prescribing practices.
Anna E. Fiastro and colleagues
Background The COVID-19 pandemic disrupted the delivery of many health services, including abortion, prompting researchers in Seattle to examine the feasibility of telehealth to improve access to this important care. Researchers conducted 21 interviews with clinical staff from four practice settings: independent primary care practices; specialized family planning clinics; online medical services; and primary care clinics within multispecialty health systems.
What This Study Found Across all practice settings, the researchers found similar operational procedures
for remote medication abortion services, with each site following five basic steps
for care provision: patient engagement, care consultations, payment, medication dispensing
and follow-up communication. Though the overarching structure of services remained
consistent across clinics, each site adapted services to their specific setting, local
laws and regulations, and the needs of their patient populations. Service sites used
multiple methods of medication delivery, including on-site pharmacies, medication
dispensing protocols, and partner pharmacies. Family planning and health system clinics
mailed medications from clinic stock or internal pharmacies, while independent clinics
and online services often used mail-order pharmacies.
Implications
- These findings demonstrate the feasibility of offering abortion services in a variety of medical settings and highlight the potential variations that can be made to adapt the service to patient needs.
Communication Gaps Persist Between Primary Care and Specialist Physicians
Lori Timmins and colleagues
Background Researchers from Mathematica and Weill Cornell Medicine conducted a study to examine communication between primary care physicians and specialist physicians about their common patients, using data collected as part of the evaluation of the Comprehensive Primary Care Plus (CPC+) model. The researchers received survey responses from 4,754 physicians in CPC+ and comparison practices. They then measured the extent to which PCPs reported sending clinical information to specialist physicians at the time of referral and reported receiving information from specialists after consultation.
What This Study Found The researchers found that despite the penetration of electronic health records, the substantial growth in the number and sizes of vertically integrated health systems, and the proliferation of large-scale primary care redesign efforts (such as CPC+), gaps in communication between PCPs and specialist physicians have persisted over the last decade. Twenty-two percent of PCPs in CPC+ and comparison practices in both study tracks reported that they “sometimes” or “seldom or never” sent clinical information to the specialist at the time of referral. Similarly, less than 35% of PCPs in CPC+ and comparison sites reported that they either “sometimes” or “seldom or never” received information back from a specialist after a consultation.
Implications
Arwen Bunce and colleagues
Background A new study reports on the development and implementation of digital survey methods
that could replace a form of paper-based surveys, known as card studies, in clinic-based
research. While card studies are useful for collecting data at the point of care,
traditional paper-based methods can be costly and complicated. Additionally, clinical
workflows require that card studies be brief, making it challenging to obtain the
rich demographic and contextual data required for meaningful analyses using paper-based
methods.
What This Study Found Researchers developed and tested a digital parallel to these paper card studies, embedding
the tool into the clinic’s electronic health record and thus reducing the complexity
for participants. In addition, data collection became more meaningful as each participant’s
responses were linked to clinic and patient data.
Each survey took less than one minute to complete. When data collection was finalized,
survey responses were removed from the EHR and did not become part of the patient’s
legal medical record. At the end of implementation, participating clinicians had completed
79% of all card requests.
Implications
How Patient-Centered Medical Homes Can Bring Meaning to Health Care: A Call for Person-Centered Care
James W. Mold and colleagues;
Background As those in health care increasingly consider patient-centered medical homes an improvement for health care, two professors from the University of Oklahoma Health Sciences Center, Drs. James W. Mold and F. Daniel Duffy, assert that patient-centered medical homes do not address the underlying problem facing our health system: a disease-oriented health model. They add that in order for medical homes to deliver true person-centered care, physicians and their teams must fundamentally change the way they think about care by focusing more directly on the outcomes important to each patient, rather than on disease management alone.
What This Study Found The authors recommend two complementary approaches to encourage this paradigm shift: narrative medicine and goal-oriented care. Narrative medicine emphasizes the importance of patients’ personal stories, encouraging clinicians to absorb, interpret and respond to them throughout the care journey. Simultaneously, a goal-oriented care approach encourages clinicians to co-create plans of care that allow each individual patient to live a meaningful life, optimize personal growth, and experience a good death.
Implications
Improving Primary Health Care Data With ICPC-3: From a Medical to a Person-Centered Perspective
Huibertus Ten Napel and colleagues;
Background Through a series of patient visit episodes, members of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians demonstrate how the recently updated International Classification of Primary Care (ICPC-3) can allow primary care physicians to better document patient encounters with care providers and to understand trends in patient outcomes over time. The International Classification of Primary Care (ICPC) is the most widely used international classification for capturing and organizing clinical information in primary care. The third edition of the classification system, released in 2020, allows clinicians to record the reason for the encounter, patient functioning (activities and participation), and personal preferences linked to morbidity. The ICPC-3 has also added a new chapter on visits related to immunization; special screenings; public health promotion; classes for programs related to specific health conditions; and nationally- and regionally-relevant classes.
What This Study Found The authors assert that implementation of the ICPC-3 in an electronic health record yields improved health information to primary care professionals and supports better information exchange within medical teams and between primary and secondary care staff. It also provides policymakers and funders with insight into what is occuring in primary care and has the potential to improve care.
Implications
Centering Health Equity in Telemedicine
Courtney R. Lyles and colleagues
Background Researchers in San Francisco and New York have proposed a health equity framework to address growing disparities in the uptake of telehealth services across the United States during and after the COVID pandemic.
What This Study Found Using the Institute for Healthcare Improvement as a benchmark, the authors present
strategies to advance equity within a healthcare organization across the domains of:
1) making health and racial/ethnic equity in telemedicine a strategic priority, including
having committed leaders across the organization and using robust data to identify
disparities; 2) building structures and processes to support telemedicine equity,
including ensuring more direct input from marginalized patients; 3) deploying telemedicine
strategies to address social determinants of health and access barriers to telemedicine;
4) eliminating institutional racism in telemedicine provision, such as hiring and
retaining a health care workforce that reflects the diversity of the patients served
and; 5) partnering with patients and community organizations to implement telemedicine.
Most importantly, the researchers call for the integration of equity and innovation
efforts to ensure all people have access to telemedicine and other digitally-enabled
health tools.
Implications
Myles Leslie and colleagues;
Background Public health researchers in Canada developed an interactive, web-based guide to help family physicians better address a wide range of patient concerns related to the COVID-19 vaccine. To ensure relevancy, the researchers conducted qualitative interviews with primary care physicians in multiple Canadian provinces. The data was then used to identify commonly held beliefs, attitudes and perceptions that impact a patient’s willingness to receive the vaccine.
What This Study Found The research team found that physicians frequently encountered many of the same reasons for COVID-19 vaccine hesitancy, including concerns around safety; interactions with co-morbidities; conspiracy theories; religious or moral restrictions; and past traumas experienced in the medical setting. The free guide outlines four steps to help physicians have better conversations with vaccine-hesitant patients, emphasizing the physician’s role as an ally on the patient’s health journey. Steps include engaging with patients; affirming patient concerns; asking permission before sharing information; and evoking future risks to motivate patients to reconsider vaccine hesitancy.
Implications
How I Learned to Speak Up About Anti-Asian Racism
Jason Eric Cheng
Background Jason Eric Cheng, MD, a psychiatry residency program director of Asian descent at a historically Black institution, writes about his experience initially downplaying the effects of anti-Asian racism while at the same time providing forums for his majority-Black residents to express and process their feelings about the traumatic effects of racism on our society.
What This Study Found Cheng examined the personal impact of anti-Asian racism and how his internalization of the “model minority stereotype” caused him to suppress his own feelings in response to increasing reports of hate crimes targeting those in the Asian community.
Implications
Call to Action: Eliminate Barriers Faced by Medical Students With Disabilities
Brianna A. Marzolf and colleagues
Background A group of family doctors at the University of Michigan call attention to the many barriers that students with disabilities encounter when they enter medical school and how this adversely impacts the health care system. In addition to barriers, medical students with disabilities encounter ableism (i.e., discrimination in favor of people without disabilities). These barriers have negative repercussions for the health system as a whole and particularly for patients with disabilities who may not receive optimal care. The authors argue that physicians who have personal experiences with disability are better able to build empathy with patients, combat ableist biases, and address attitudinal barriers in health care.
What This Study Found The authors issue a call to action, charging the American Medical Association and
American Association of Medical Colleges to 1) adjust technical standards for medical
school admissions; 2) create a culture that supports universal design in hiring practices
and physical workspaces; 3) provide clear and accessible instructions for how to submit
accommodations requests; 4) foster a culture that normalizes help-seeking behaviors
and facilitates access to wellness services; and 5) incorporate training about people
with disabilities into medical school curriculum.
Implications
Why Warfarin Should Be Managed in Primary Care
Katherine Montag Schafer and colleagues
Background A family medicine clinic in Minnesota was recently notified by its health system that it would no longer be allowed to provide anticoagulation treatment for patients in the primary care setting. Instead, anticoagulation services were transitioned to a centralized anticoagulation clinic within the health system.
What This Study Found Co-authors Montag Schafer and Keenan argue that removing anticoagulation services from the primary care setting is detrimental to patients and opens the door to other possible restrictions on family medicine’s scope of practice.
Implications
A Mother's Tears: Contemplating Black Grief
Khaliah A. Johnson
Background In a moving reflection, Khaliah Johnson, MD, speaks from her experiences as a Black mother, survivor of sibling loss, and pediatric palliative care doctor to suggest how the medical community can stand with their Black patients in their grief experiences. She describes her personal experiences navigating intergenerational grief, suffering, and pain brought on by the legacy of racism against Black U.S. Americans over the last 400 years.
What This Study Found While the country continues to grapple with the effects of racism on the Black community, Johnson argues that the medical community has a special role to play in helping Black patients navigate feelings of pain, loss and grief brought on by these shared experiences.
Implications
Long COVID Shared Medical Appointments: Lifestyle and Mind-Body Medicine With Peer Support
Sonal J. Patil and colleagues
Background Members of the Wellness and Preventive Medicine Department at the Cleveland Clinical Community Care Institute created a novel shared medical appointment program to provide healthy lifestyle education, mindfulness training, and group peer support for patients experiencing long COVID symptoms. An interdisciplinary team of physicians, nurse practitioners and psychotherapists led the virtual SMA sessions.
What This Study Found Each SMA group met for two hours weekly for six weeks with a maximum of 10 participants. Since May 2021, eight SMA cohorts have been conducted, and more than 80% of participants attended at least four of the six sessions.
Implications
Adapting Primary Care Workflows to Promote Advance Care Planning
Kevin J. Valadares & colleagues
Background The University of Southern Indiana embedded a multi-modal Advanced Care Planning initiative in a primary care clinic, anchored by the Medicare Annual Wellness Visit.
What This Study Found Prior to the AWV, patients are reminded about the importance of advanced care planning and are given multiple opportunities to learn more about the planning process. After the AWV visit, patients are able to meet with a dedicated ACP facilitator to complete the ACP process.
Implications