Study of a novel curriculum on electronic communication in family medicine residencies.

Electronic communication between physicians and patients is common but can carry risks to users--both patients and physicians. Little is known about electronic communication between physicians and patients and even less about electronic communication during residency. We studied knowledge and practices before and after a controlled test of a novel curriculum teaching e-mail communication with patients using residents and faculty in 16 family medicine residencies in the United States. Both faculty and residents showed a lack of knowledge of confidentiality and encryption, little familiarity with published guidelines for physician-patient e-mail, and noncompliance with documentation requirements before the curriculum was presented. Posttests revealed a greater improvement in knowledge and appropriate behaviors related to patient-physician e-mail in the intervention group compared to control sites (mean intervention increase is 13 points[t=-4.065, P<.01], mean control increase is 5 points [t=-2.015, P<.05]). An increased uncertainty about comfort with patient e-mail among intervention residents is an interesting result that could be due to heightened awareness of issues but limited time devoted to absorbing the topic. Suggestions for delivering the curriculum are provided.

Implementing change in primary care practices using electronic medical records: a conceptual framework.

BACKGROUND: Implementing change in primary care is difficult, and little practical guidance is available to assist small primary care practices. Methods to structure care and develop new roles are often needed to implement an evidence-based practice that improves care. This study explored the process of change used to implement clinical guidelines for primary and secondary prevention of cardiovascular disease in primary care practices that used a common electronic medical record (EMR). METHODS: Multiple conceptual frameworks informed the design of this study designed to explain the complex phenomena of implementing change in primary care practice. Qualitative methods were used to examine the processes of change that practice members used to implement the guidelines. Purposive sampling in eight primary care practices within the Practice Partner Research Network-Translating Researching into Practice (PPRNet-TRIP II) clinical trial yielded 28 staff members and clinicians who were interviewed regarding how change in practice occurred while implementing clinical guidelines for primary and secondary prevention of cardiovascular disease and strokes. RESULTS: A conceptual framework for implementing clinical guidelines into primary care practice was developed through this research. Seven concepts and their relationships were modelled within this framework: leaders setting a vision with clear goals for staff to embrace; involving the team to enable the goals and vision for the practice to be achieved; enhancing communication systems to reinforce goals for patient care; developing the team to enable the staff to contribute toward practice improvement; taking small steps, encouraging practices' tests of small changes in practice; assimilating the electronic medical record to maximize clinical effectiveness, enhancing practices' use of the electronic tool they have invested in for patient care improvement; and providing feedback within a culture of improvement, leading to an iterative cycle of goal setting by leaders. CONCLUSION: This conceptual framework provides a mental model which can serve as a guide for practice leaders implementing clinical guidelines in primary care practice using electronic medical records. Using the concepts as implementation and evaluation criteria, program developers and teams can stimulate improvements in their practice settings. Investing in collaborative team development of clinicians and staff may enable the practice environment to be more adaptive to change and improvement.

Different paths to high-quality care: three archetypes of top-performing practice sites.

PURPOSE: Primary care practices use different approaches in their quest for high-quality care. Previous work in the Practice Partner Research Network (PPRNet) found that improved outcomes are associated with strategies to prioritize performance, involve staff, redesign elements of the delivery system, make patients active partners in guideline adherence, and use tools embedded in the electronic medical record. The aim of this study was to examine variations in the adoption of improvements among sites achieving the best outcomes. METHODS: This study used an observational case study design. A practice-level measure of adherence to clinical guidelines was used to identify the highest performing practices in a network of internal and family medicine practices participating in a national demonstration project. We analyzed qualitative and quantitative information derived from project documents, field notes, and evaluation questionnaires to develop and compare case studies. RESULTS: Nine cases are described. All use many of the same improvement strategies. Differences in the way improvements are organized define 3 distinct archetypes: the Technophiles, the Motivated Team, and the Care Enterprise. There is no single approach that explains the superior performance of high-performing practices, though each has adopted variations of PPRNet's improvement model. CONCLUSIONS: Practices will vary in their path to high-quality care. The archetypes could prove to be a useful guide to other practices selecting an overall quality improvement approach.

Using a summary measure for multiple quality indicators in primary care: the Summary QUality InDex (SQUID).

BACKGROUND: Assessing the quality of primary care is becoming a priority in national healthcare agendas. Audit and feedback on healthcare quality performance indicators can help improve the quality of care provided. In some instances, fewer numbers of more comprehensive indicators may be preferable. This paper describes the use of the Summary Quality Index (SQUID) in tracking quality of care among patients and primary care practices that use an electronic medical record (EMR). All practices are part of the Practice Partner Research Network, representing over 100 ambulatory care practices throughout the United States. METHODS: The SQUID is comprised of 36 process and outcome measures, all of which are obtained from the EMR. This paper describes algorithms for the SQUID calculations, various statistical properties, and use of the SQUID within the context of a multi-practice quality improvement (QI) project. RESULTS: At any given time point, the patient-level SQUID reflects the proportion of recommended care received, while the practice-level SQUID reflects the average proportion of recommended care received by that practice's patients. Using quarterly reports, practice- and patient-level SQUIDs are provided routinely to practices within the network. The SQUID is responsive, exhibiting highly significant (p < 0.0001) increases during a major QI initiative, and its internal consistency is excellent (Cronbach's alpha = 0.93). Feedback from physicians has been extremely positive, providing a high degree of face validity. CONCLUSION: The SQUID algorithm is feasible and straightforward, and provides a useful QI tool. Its statistical properties and clear interpretation make it appealing to providers, health plans, and researchers.

Improving diabetes care through a multicomponent quality improvement model in a practice-based research network.

This article reports the impact of a multicomponent quality improvement intervention on adherence with 13 measures of diabetes care and a summary measure, the Diabetes Summary Quality Index (Diabetes-SQUID). The intervention was conducted between January 1, 2004, and July 1, 2005, within 66 primary care practices in 33 states, including 372 providers and 24 250 adult patients with diabetes. Across all practices, the average Diabetes-SQUID was 50.6% (10th percentile 36.5%, 90th percentile 63.0%) on January 1, 2004, and 58.4% (10th percentile 47.6%, 90th percentile 69.7%) on July 1, 2005, with an average absolute improvement of 7.8% (95% confidence interval, 5.9%-9.7%). Significant improvements occurred for 12 of the 13 individual measures: blood pressure and urine microalbumin monitoring; HDL cholesterol, LDL cholesterol, triglyceride, and glycosylated hemoglobin measurements; prescription of antiplatelet therapy; and blood pressure, HDL-cholesterol, LDL-cholesterol, triglyceride, and glycosylated hemoglobin control. The findings suggest that a multicomponent intervention can have a robust impact on quality of care for diabetes.

Initial steps taken by nine primary care practices to implement alcohol screening guidelines with hypertensive patients: the AA-TRIP project.

Many medical conditions are caused or exacerbated by heavy drinking, necessitating alcohol screening and discussion in primary care practices. This is particularly true of hypertension, the most common primary diagnosis in the United States, which has been linked to the regular consumption of 3 or more standard alcoholic beverages a day. The Accelerating Alcohol Screening-Translating Research into Practice (AA-TRIP) project was designed to improve detection and management of alcohol problems in primary care patients with hypertension. Medical providers are being trained using the Practice Partner Research Network's- Translating Research into Practice (PPRNet-TRIP) quality improvement model. This includes a multi-method intervention (electronic medical records, on-site academic detailing, practice feedback reports and annual network meetings) to help practices increase adherence to clinical guidelines. Qualitative analyses of initial steps taken by nine primary care practices toward the routine implementation of alcohol screening guidelines are presented. Organizational factors and provider and patient characteristics all influenced the method and consistency of alcohol screening and intervention. Perceived time constraints, patient sensitivity to questions about alcohol, and possible stigma associated with a diagnosis of alcoholism were also relevant barriers requiring problem solving.

Challenges to improving chronic disease care and training in residencies.

PURPOSE: To improve quality of care for chronic disease, professional organizations and medical providers are adopting new care models. The transition to better delivery systems is not easy and there are many barriers under the best of circumstances. This study investigated residency-based experiences with changes in teaching and delivery of chronic disease care. METHOD: In 2004-05 at the University of Southern California, the authors conducted qualitative cross-sectional in-depth interviews with directors of grant-funded residency-based chronic care projects. Open- and closed-ended questions explored the intent of and the challenges encountered by primary care residencies implementing improvements in chronic disease care and training. RESULTS: Six out of 14 program director responded, reporting that rotation-based and longitudinal experiences were used to teach and deliver improved chronic disease care. Common challenges were identified across residency sites, as well as challenges unique to particular residency settings. Among these challenges were engaging faculty and residents who spend limited time in the practice center, as well as institutional barriers related to authority, competing priorities, process, and resources. CONCLUSIONS: Successful innovations for chronic disease care and training are possible in residencies, but their implementation cannot be taken lightly. There are predictable barriers that can be dealt with locally, but also others that would benefit from coordinated national attention.

The logic behind a multimethod intervention to improve adherence to clinical practice guidelines in a nationwide network of primary care practices.

The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.

Effect of terminal digit preference on blood pressure measurement and treatment in primary care.

BACKGROUND: Terminal digit preference in blood pressure (BP) measurement has been reported in both clinical and research settings. This article examines the prevalence of terminal digit preference (TDP) in primary care practices and the effect that a practice's level of TDP influences patients' BP measurements and management. METHODS: Data were obtained in cross-sectional fashion from the electronic medical records of active patients from 85 practices around the United States. The TDP prevalence was calculated, and statistical techniques were used to examine the influence of a practice's TDP on patients' BP measurements and on the likelihood that patients had an active prescription for selected antihypertensive medications. RESULTS: The TDP was common, with zero being recorded 44.6% and 47.5% of the time for systolic BP and diastolic BP, respectively. Patients belonging to practices with higher TDP levels had significantly (P < .01) lower systolic BP measurements than patients in practices with lower TDP levels. Patients belonging to practices with higher TDP levels also had significantly lower odds (odds ratio [OR] = 0.92, 95% confidence interval [CI] [0.85, 0.99], P = .036) of having an active prescription for an antihypertensive medication, an association that was stronger in women (OR = 0.91, P = .023) than in men (OR = 0.95, P = .21). CONCLUSIONS: The TDP for BP measurements is common. Although TDP effects on patients' BP measurements may appear modest, treatment of patients, especially women, with antihypertensive medication may be systematically affected by this preference.

The effect of ethnicity on outcomes in a practice-based trial to improve cardiovascular disease prevention.

BACKGROUND: Health disparities are a growing concern. Recently, we conducted a practice-based trial to help primary care physicians improve adherence with 21 quality indicators relevant to the primary and secondary prevention of cardiovascular disease and stroke. Although the primary concern in that study was whether patients in intervention practices outperformed those in control practices, we were also interested in determining whether minority patients were more, less, or just as likely to benefit from the intervention as non-minorities. METHODS: Baseline (fourth quarter 2000) and follow-up (fourth quarter 2002) data were obtained from 3 intervention practices believed to have at least 10% minority representation. Two practices had a black (non-Hispanic) population sufficient for analysis, while the other had a sufficient Hispanic population. Within each practice, changes in the 21 indicators were compared between the minority patient population and the entire patient population. The proportion of measures in which minority patients exhibited greater improvement was calculated for each practice and for all 3 practices combined, and comparisons were made using non-parametric methods. RESULTS: For all black patients, the observed improvement in 50% of 22 eligible study indicators was better than that observed among all white patients in the same practices. The average changes in the study indicators observed among the black and white patients were not significantly different (p = 0.300) from one another. Likewise for all minority patients in all 3 practices combined, the observed improvement in 14 of 29 (43.3%) eligible study indicators was better than that observed among all white patients. The average changes in the study indicators among all minority patients were not significantly different from the changes observed among the white patients (p = 0.272). CONCLUSIONS: Among 3 intervention practices involved in a quality improvement project, there did not appear to be any significant disparity between minority and non-minority patients in the improvement in study indicators.

A multimethod quality improvement intervention to improve preventive cardiovascular care: a cluster randomized trial.

BACKGROUND: Research is needed to validate effective and practical strategies for improving the provision of evidence-based medicine in primary care. OBJECTIVE: To determine whether a multimethod quality improvement intervention was more effective than a less intensive intervention for improving adherence to 21 quality indicators for primary and secondary prevention of cardiovascular disease and stroke. DESIGN: 2-year randomized, controlled clinical trial with the practice as the unit of randomization. SETTING: 20 community-based family or general internal medicine practices in 14 states. All used the same electronic medical record. PARTICIPANTS: 44 physicians, 17 midlevel providers, and approximately 200 staff members; data from the electronic medical records of 87,291 patients. INTERVENTIONS: All practices received copies of practice guidelines and quarterly performance reports. Intervention practices also hosted quarterly site visits to help them adopt quality improvement approaches and participated in 2 network meetings to share "best practice" approaches. MEASUREMENTS: The percentage of indicators at or above predefined targets and the percentage of patients who had achieved each clinical indicator. RESULTS: Intervention practices improved 22.4 percentage points (from 11.3% to 33.7%) in the percentage of indicators at or above the target; control practices improved 16.4 percentage points (from 6.3% to 22.7%). The 6.0-percentage point absolute difference between the intervention and control group was not statistically significant (P > 0.2). Patients in intervention practices had greater improvements than those in control practices for diagnoses of hypertension (improvement difference, 15.7 percentage points [95% CI, 5.2 to 26.3 percentage points]) and blood pressure control in patients with hypertension (improvement difference, 8.0 percentage points [CI, 0.0 to 16.0 percentage points]). LIMITATIONS: The study involved a small number of practices and lacked a pure control group. CONCLUSIONS: Primary care practices that use electronic medical records and receive regular performance reports can improve their adherence to clinical practice guidelines for cardiovascular disease and stroke prevention.

Strategies for increasing adherence to clinical guidelines and improving patient outcomes in small primary care practices.

BACKGROUND: The best way to get research findings into practice needs to be determined, particularly in small practices. The Practice Partner Research Network (PPRNet) is a nationwide practice-based research network of small primary care practices that use the same electronic medical record (EMR). Between 2000-2003 the PPRNet Translating Research into Practice (TRIP) project tested a multimethod intervention to help practices improve primary and secondary prevention of cardiovascular disease and stroke. Intervention sites each hosted six to seven site visits and participated in two annual network meetings during the two-year intervention period. A model describing practice-based improvement strategies was validated using prospective data from 10 intervention and 9 control sites. RESULTS: The model consisted of five categories of improvement strategies: Prioritize Performance, Involve All Staff, Redesign Delivery Systems, Activate Patients, and Use EMR Tools. PPRNet-TRIP intervention practices used more of the model items than did controls (69% versus 48%, p = .053), as did high-performing practices versus mid-range or low performers (81% versus 39% versus 46%, p = .001). CONCLUSION: The PPRNet-TRIP Improvement Model might guide small practices in their efforts to translate research into practice and improve care outcomes.

From research to daily clinical practice: what are the challenges in "translation"?

BACKGROUND: Translating research findings into sustainable improvements in clinical and patient outcomes remains a substantial obstacle to improving the quality and safety of care. The Agency for Healthcare Research and Quality funded two initiatives to assess strategies for improvements--Translating Research into Practice (TRIP). The TRIP II initiative supported 13 quality improvement projects. SURVEYING THE TRIP II STUDIES: The principal investigators (PIs) of the 13 projects were surveyed regarding encountered barriers to implementation at 6 months and 18 months (when they were also asked about solutions). RESULTS: Seven of the 13 PIs responded to the survey at both times--6 and 18 months. For each project stage--Select a TRIP focus and develop intervention strategies (Stage 1), Conduct the intervention (Stage 2), and Measure the Impact (Stage 3)--barriers were described, and field-tested solutions were provided. For example, for Stage 2, if the target audience lacked buy-in and would not participate, solutions would be to get up-front buy-in from all staff, not just leaders; address root causes of problems; use opinion leaders and incentives; plan interventions ahead and provide make-up videos; and accept that targets vary in their readiness to change. DISCUSSION: The framework and examples provided should help overcome challenges in any work in which research findings are applied to clinical practice.

Self-managing teams: a strategy for quality improvement.

Organizations are impacted by their environments, and health care settings are no different. Individuals charged with improving a practice are often impeded by environmental barriers, including incomplete information for decision making. One strategy to empower an organization for change is to form a self-managing team. This paper discusses the self-managing team concept and uses a case study to illustrate its application in primary care. Factors contributing to team success are presented as a guide, and a reminder--there is more to an effective team than gathering people in a room.

Determinants of pregnancy outcomes and targeting of maternal health services in Jamaica

Detailed nationally representative population level data were used to investigate the pre-natal care and delivery experiences of pregnant women in Jamiaca. The results of this study show that: (a) demographic criteria (particularly first births) and self-reported clinical pregnancy complications are valid predictors of deleterious maternal health outcomes and can be used to stratify mothers into risk groups. (b) There appears to be a significant problems of under and inappropriate utilization of pre-natal care services by all women and in particular by demographically 'high risk' women, i.e. young , first time mothers. Significant proportions of the latter group report either no pre-natal care visits at all or visits which are later than the first trimester. The problem of delayed initiation of pre-natal care are specially exacerbated for poor, teenage mothers who happen to be living in the Kingston Metropolitan Area. (c) In terms of the content and quality of pre-natal care services the message is somewhat mixed. On the positive side the pre-natal care system is doing a moderately satisfactory job with regards to diagnostic tests and educational advice. On the negative side however, the fact that once women entered the health care system they all receive the same moderately adequate care (in terms of diagnostic evaluations and educational advice) with no attempt to focus particular attention on high risk mothers is troublesome. (d) With regards to appropriate delivery venues for pregnant women, pre-natal care visits do not appear to significantly influence the choice of delivery venues. Moreover, rich urban women are much more likely to deliver in a hospital than their rural peers. In conclusion, the study discusses the social and behavioral context of these results, addresses the policy implications and makes some recommendations to improve maternal health services (AU)