Characteristics of the Audience Reached by the National Network of Sexually Transmitted Disease Clinical Prevention Training Centers and Correlation With Sexually Transmitted Infection Rates, 2015 to 2020.

BACKGROUND: The National Network of Sexually Transmitted Disease Clinical Prevention Training Centers (NNPTC) trains clinical providers to diagnose and treat sexually transmitted infections (STIs) in the United States. The purpose of this study was to examine the demographics of clinical providers and to correlate the number of training episodes with STI rates at the county level. METHODS: Registration data were collected between April 1, 2015, and March 31, 2020, in a custom Learning Management System from clinical providers taking NNPTC training. Using the 2018 STI surveillance data, counties were divided into quartiles based on reportable STI case rates and the number of county-level training events was compared per quartile. Univariate and multivariate analyses were conducted in IBM SPSS Statistics 23 (Armonk, NY) and SAS Enterprise Guide 7.1 (Cary, NC). RESULTS: From 2015 to 2020, the NNPTC trained 21,327 individuals, predominantly in the nursing professions and working in a public health environment. In multivariate analysis, the number of training events was significantly associated with higher STI rates at the county level (P < 0.0001) and the state where a prevention training center is located (P < 0001). CONCLUSIONS: The analysis suggests that NNPTC trainings are reaching the clinical providers working in geographic areas with higher STI rates.

Service line structure and decision-maker attention in three health systems: Implications for patient-centered care.

BACKGROUND: Scholars have noted a disconnect between the level at which structure is typically examined (the organization) and the level at which the relevant coordination takes place (service delivery). Accordingly, our understanding of the role structure plays in care coordination is limited. PURPOSE: In this article, we explore service line structure, with an aim of advancing our understanding of the role service line structure plays in producing coordinated, patient-centered care. We do so by giving special attention to the cognitive roots of patient-centeredness. METHODOLOGY/APPROACH: Our exploratory study relied on comparative case studies of the breast cancer service lines in three health systems. Nonprobability discriminative snowball sampling was used to identify the final sample of key informants. We employed a grounded approach to analyzing and interpreting the data. RESULTS: We found substantial variation across the three service lines in terms of their structure. We also found corresponding variation across the three case sites in terms of where informant attention was primarily focused in the process of coordinating care. Drawing on the attention-based view of the firm, our results draw a clear connection between structural characteristics and the dominant focus of attention (operational tactics, provider roles and relationships, or patient needs and engagement) in health care service lines. CONCLUSION: Our exploratory results suggest that service line structures influence attention in two ways: (a) by regulating the type and intensity of the problems facing service line participants and (b) by encouraging (or discouraging) a shared purpose around patient needs. PRACTICE IMPLICATIONS: Patient-centered attention-a precursor to coordinated, patient-centered care-depends on the internal choices organizations make around service line structure. Moreover, a key task for organizational and service line leaders is to structure service lines to create a context that minimizes distractions and enables care providers to focus their attention on the needs of their patients.

Keystrokes, Mouse Clicks, and Gazing at the Computer: How Physician Interaction with the EHR Affects Patient Participation.

BACKGROUND: Evidence is mixed regarding how physicians' use of the electronic health record (EHR) affects communication in medical encounters. OBJECTIVE: To investigate whether the different ways physicians interact with the computer (mouse clicks, key strokes, and gaze) vary in their effects on patient participation in the consultation, physicians' efforts to facilitate patient involvement, and silence. DESIGN: Cross-sectional, observational study of video and event recordings of primary care and specialty consultations. PARTICIPANTS: Thirty-two physicians and 217 patients. MAIN MEASURES: Predictor variables included measures of physician interaction with the EHR (mouse clicks, key strokes, gaze). Outcome measures included active patient participation (asking questions, stating preferences, expressing concerns), physician facilitation of patient involvement (partnership-building and supportive talk), and silence. KEY RESULTS: Patients were less active participants in consultations in which physicians engaged in more keyboard activity (b = -0.002, SE = 0.001, p = 0.02). More physician gaze at the computer was associated with more silence in the encounter (b = 0.21, SE = 0.09, p = 0.02). Physicians' facilitative communication, which predicted more active patient participation (b = 0.65, SE = 0.14, p < 0.001), was not related to EHR activity measures. CONCLUSIONS: Patients may be more reluctant to actively participate in medical encounters when physicians are more physically engaged with the computer (e.g., keyboard activity) than when their behavior is less demonstrative (e.g., gazing at EHR). Using easy to deploy communication tactics (e.g., asking about a patient's thoughts and concerns, social conversation) while working on the computer can help physicians engage patients as well as maintain conversational flow.

The Value of Experiential Sexually Transmitted Disease Clinical Training in the Digital Age.

BACKGROUND: The translation of evidence-based guidelines for sexually transmitted disease (STD) care into clinical practice is crucial for the prevention and control of STDs. METHODS: Participants in a hands-on, multifaceted, small-group STD Clinical Intensive Course from 2006 to 2013 were asked to complete a survey regarding course content and value compared with other continuing education courses. Survey respondents with demographic and professional information were compared with all other course participants. χ Statistics were used to test for differences in proportions; the Cochran-Armitage trend test was used to evaluate for trends in response rate by year of training. RESULTS: Of 113 respondents (35.9% response rate), 92.9% felt that clinical knowledge stayed longer, 84.1% changed clinical practice more, and 90.3% recommended the course more, compared with other continuing education programs in which they had participated previously. Respondents' average suggested registration fee should the course no longer be free was $188.90. Physician assistants and advanced practice nurses were overrepresented among respondents (69.4% vs. 58.1%, P = 0.04); more recent course participants were more likely to respond (P < 0.01). CONCLUSIONS: These findings suggest that this STD experiential clinical training program is still relevant to participants in the digital age and is valued more highly than other continuing education experiences. A significant disconnect was identified between what participants are willing/able to pay versus actual course costs, indicating that cost is likely to become a barrier to participation should the course no longer be free.

Strategizing EHR use to achieve patient-centered care in exam rooms: a qualitative study on primary care providers.

OBJECTIVE: Electronic health records (EHRs) have great potential to improve quality of care. However, their use may diminish "patient-centeredness" in exam rooms by distracting the healthcare provider from focusing on direct patient interaction. The authors conducted a qualitative interview study to understand the magnitude of this issue, and the strategies that primary care providers devised to mitigate the unintended adverse effect associated with EHR use. METHODS AND MATERIALS: Semi-structured interviews were conducted with 21 healthcare providers at 4 Veterans Affairs (VAs) outpatient primary care clinics in San Diego County. Data analysis was performed using the grounded theory approach. RESULTS: The results show that providers face demands from both patients and the EHR system. To cope with these demands, and to provide patient-centered care, providers attempt to perform EHR work outside of patient encounters and create templates to streamline documentation work. Providers also attempt to use the EHR to engage patients, establish patient buy-in for EHR use, and multitask between communicating with patients and using the EHR. DISCUSSION AND CONCLUSION: This study has uncovered the challenges that primary care providers face in integrating the EHR into their work practice, and the strategies they use to overcome these challenges in order to maintain patient-centered care. These findings illuminate the importance of developing "best" practices to improve patient-centered care in today's highly "wired" health environment. These findings also show that more user-centered EHR design is needed to improve system usability.

EHR use and patient satisfaction: What we learned.

PURPOSE: Few studies have quantitatively examined the degree to which the use of the computer affects patients' satisfaction with the clinician and the quality of the visit. We conducted a study to examine this association. METHODS: Twenty-three clinicians (21 internal medicine physicians, 2 nurse practitioners) were recruited from 4 Veteran Affairs Medical Center (VAMC) clinics located in San Diego, Calif. Five to 6 patients for most clinicians (one patient each for 2 of the clinicians) were recruited to participate in a study of patient-physician communication. The clinicians' computer use and the patient-clinician interactions in the exam room were captured in real time via video recordings of the interactions and the computer screen, and through the use of the Morae usability testing software system, which recorded clinician clicks and scrolls on the computer. After the visit, patients were asked to complete a satisfaction survey. RESULTS: The final sample consisted of 126 consultations. Total patient satisfaction (beta=0.014; P=.027) and patient satisfaction with patient-centered communication (beta=0.02; P=.02) were significantly associated with higher clinician "gaze time" at the patient. A higher percentage of gaze time during a visit (controlling for the length of the visit) was significantly associated with greater satisfaction with patient-centered communication (beta=0.628; P=.033). CONCLUSIONS: Higher clinician gaze time at the patient predicted greater patient satisfaction. This suggests that clinicians would be well served to refine their multitasking skills so that they communicate in a patient-centered manner while performing necessary computer-related tasks. These findings also have important implications for clinical training with respect to using an electronic health record (EHR) system in ways that do not impede the one-on-one conversation between clinician and patient.

Sustained Reduction of Ventilator-Associated Pneumonia Rates Using Real-Time Course Correction With a Ventilator Bundle Compliance Dashboard.

BACKGROUND: The effectiveness of practice bundles on reducing ventilator-associated pneumonia (VAP) has been questioned. OBJECTIVE: To implement a comprehensive program that included a real-time bundle compliance dashboard to improve compliance and reduce ventilator-associated complications. DESIGN Before-and-after quasi-experimental study with interrupted time-series analysis. SETTING Academic medical center. METHODS: In 2007 a comprehensive institutional ventilator bundle program was developed. To assess bundle compliance and stimulate instant course correction of noncompliant parameters, a real-time computerized dashboard was developed. Program impact in 6 adult intensive care units (ICUs) was assessed. Bundle compliance was noted as an overall cumulative bundle adherence assessment, reflecting the percentage of time all elements were concurrently in compliance for all patients. RESULTS: The VAP rate in all ICUs combined decreased from 19.5 to 9.2 VAPs per 1,000 ventilator-days following program implementation (P<.001). Bundle compliance significantly increased (Z100 score of 23% in August 2007 to 83% in June 2011 [P<.001]). The implementation resulted in a significant monthly decrease in the overall ICU VAP rate of 3.28/1,000 ventilator-days (95% CI, 2.64-3.92/1,000 ventilator-days). Following the intervention, the VAP rate decreased significantly at a rate of 0.20/1,000 ventilator-days per month (95% CI, 0.14-0.30/1,000 ventilator-days per month). Among all adult ICUs combined, improved bundle compliance was moderately correlated with monthly VAP rate reductions (Pearson correlation coefficient, -0.32). CONCLUSION: A prevention program using a real-time bundle adherence dashboard was associated with significant sustained decreases in VAP rates and an increase in bundle compliance among adult ICU patients.

Suicide risk assessment in high-risk adolescents.

A significant number of adolescents experience depression and other mental health disorders that may put them at risk for suicide. Mental health assessment is an important component of primary healthcare. Depression and suicide risk screening can assist healthcare providers in preventing suicides.

Provider interaction with the electronic health record: the effects on patient-centered communication in medical encounters.

OBJECTIVE: The computer with the electronic health record (EHR) is an additional 'interactant' in the medical consultation, as clinicians must simultaneously or in alternation engage patient and computer to provide medical care. Few studies have examined how clinicians' EHR workflow (e.g., gaze, keyboard activity, and silence) influences the quality of their communication, the patient's involvement in the encounter, and conversational control of the visit. METHODS: Twenty-three primary care providers (PCPs) from USA Veterans Administration (VA) primary care clinics participated in the study. Up to 6 patients per PCP were recruited. The proportion of time PCPs spent gazing at the computer was captured in real time via video-recording. Mouse click/scrolling activity was captured through Morae, a usability software that logs mouse clicks and scrolling activity. Conversational silence was coded as the proportion of time in the visit when PCP and patient were not talking. After the visit, patients completed patient satisfaction measures. Trained coders independently viewed videos of the interactions and rated the degree to which PCPs were patient-centered (informative, supportive, partnering) and patients were involved in the consultation. Conversational control was measured as the proportion of time the PCP held the floor compared to the patient. RESULTS: The final sample included 125 consultations. PCPs who spent more time in the consultation gazing at the computer and whose visits had more conversational silence were rated lower in patient-centeredness. PCPs controlled more of the talk time in the visits that also had longer periods of mutual silence. CONCLUSIONS: PCPs were rated as having less effective communication when they spent more time looking at the computer and when there was more periods of silence in the consultation. Because PCPs increasingly are using the EHR in their consultations, more research is needed to determine effective ways that they can verbally engage patients while simultaneously managing data in the EHR. PRACTICE IMPLICATIONS: EHR activity consumes an increasing proportion of clinicians' time during consultations. To ensure effective communication with their patients, clinicians may benefit from using communication strategies that maintain the flow of conversation when working with the computer, as well as from learning EHR management skills that prevent extended periods of gaze at computer and long periods of silence. Next-generation EHR design must address better usability and clinical workflow integration, including facilitating patient-clinician communication.

The Asian American family and mental health: implications for child health professionals.

The Asian American community has grown significantly in the United States during recent decades. The culture of their countries of origin as well as the society in which they currently live plays a pivotal role in their reaction to mental health and illness. Mental health issues are increasingly evident in Asian American communities. The need for the delivery of culturally competent health care and mental health services is paramount. A culturally competent framework that includes the use of a cultural competence model for practice can guide the health care provider in the recognition of problems, particularly in the children of Asian American families.

The private partners of public health: public-private alliances for public good.

OBJECTIVE: We sought to convey lessons learned by the Centers for Disease Control and Prevention's (CDC's) Prevention Research Centers (PRCs) about the value and challenges of private-sector alliances resulting in innovative health promotion strategies. Several PRCs based in a variety of workplace and community settings contributed. METHODS: We conducted interviews with principal investigators, a literature review, and a review of case studies of private-sector alliances in a microbusiness model, a macrobusiness model, and as multiparty partnerships supporting public health research, implementation, and human resource services. RESULTS: Private-sector alliances provide many advantages, particularly access to specialized skills generally beyond the expertise of public health entities. These skills include manufacturing, distribution, marketing, business planning, and development. Alliances also allow ready access to employee populations. Public health entities can offer private-sector partners funding opportunities through special grants, data gathering and analysis skills, and enhanced project credibility and trust. Challenges to successful partnerships include time and resource availability and negotiating the cultural divide between public health and the private sector. Critical to success are knowledge of organizational culture, values, mission, currency, and methods of operation; an understanding of and ability to articulate the benefits of the alliance for each partner; and the ability and time to respond to unexpected changes and opportunities. CONCLUSION: Private-public health alliances are challenging, and developing them takes time and resources, but aspects of these alliances can capitalize on partners' strengths, counteract weaknesses, and build collaborations that produce better outcomes than otherwise possible. Private partners may be necessary for program initiation or success. CDC guidelines and support materials may help nurture these alliances.

Community engagement in Prevention Research: The Centers for Disease Control and Prevention's Prevention Research Centers' National Community Committee.

The Prevention Research Centers (PRC) Program of the Centers for Disease Control and Prevention (CDC) supports prevention research using community-based participatory research (CBPR) and other community engagement approaches. This paper describes the development of the PRC's National Community Committee (NCC), how the committee strengthened the national program's commitment to CBPR, the impact the committee's activities have had on national initiatives, and the lessons learned from supporting a national community approach in a prevention research program. Community representatives from each PRC's community committee were invited to share and exchange resources, knowledge, and skills to guide the national program. As a result, the NCC was developed. By embracing diversity, building capacity among members, and offering co-learning opportunities, the NCC helped to strengthen the practice of CBPR. The committee's activities helped to ensure community participation at the program's national level and led to involvement in other prevention research initiatives external to the PRC program. Program and committee leaders maintained a shared vision and increased community members' skills. The PRC NCC has taken the concept of community partnership to a national level and has changed the way some community members understand their role in research.

Enhancing transdisciplinary research through collaborative leadership.

Transcending the well-established and familiar boundaries of disciplinary silos poses challenges for even the most interpersonally competent scientists. This paper explores the challenges inherent in leading transdisciplinary projects, detailing the critical roles that leaders play in shepherding transdisciplinary scientific endeavors. Three types of leadership tasks are considered: cognitive, structural, and processual. Distinctions are made between leading small, co-located projects and large, dispersed ones. Finally, social-network analysis is proposed as a useful tool for conducting research on leadership, and, in particular, on the role of brokers, on complex transdisciplinary teams.

Community-based participatory research: necessary next steps.

Community-based participatory research (CBPR) is gaining increasing credence among public health researchers and practitioners. However, there is no standardization in assessing the quality of research methods, the effectiveness of the interventions, and the reporting requirements in the literature. The absence of standardization precludes meaningful comparisons of CBPR studies. Several authors have proposed a broad set of competencies required for CBPR research for both individuals and organizations, but the discussion remains fragmented. The Prevention Research Centers (PRC) Program recently began a qualitative assessment of its national efforts, including an evaluation of how PRCs implement CBPR studies. Topics of interest include types of community partnerships; community capacity for research, evaluation, and training; and factors that help and hinder partner relationships. The assessment will likely contribute to the development of a standard set of competencies and resources required for effective CBPR.

Assessing prevention research impact: a bibliometric analysis.

BACKGROUND: This study was undertaken to explore a bibliometric approach to assessing the impact of selected prevention research center (PRC) peer-reviewed publications. METHODS: The 25 eligible PRCs were asked to submit 15 papers that they considered the most important to be published in the decade 1994-2004. Journal articles (n=227) were verified in 2004 and categorized: 73% were research reports, 10% discussion articles, 9% dissemination articles, and 7% review articles. RESULTS: Only 189 articles (83%) were searchable via the Institute of Scientific Information (ISI) Web of Science databases for citation tracking in 2004. These 189 articles were published in 76 distinct journals and subsequently cited 4628 times (range 0 to 1523) in 1013 journals. Articles published before 2001 were cited a median of 14 times each. Publishing journals had a median ISI impact factor of 2.6, and ISI half-life of 7.2. No suitable benchmarks were available for comparison. The PRC influence factor (number of PRCs that considered a journal highly influential) was only weakly correlated with the ISI impact factor and was not correlated with half-life. CONCLUSIONS: Conventional bibliometric analysis to assess the scientific impact of public health prevention research is feasible, but of limited utility because of omissions from ISI's databases, and because citation benchmarks for prevention research have not been established: these problems can and should be addressed. Assessment of impact on public health practice, policy, or on the health of populations, will require more than a bibliometric approach.