Impact of Longitudinal Electronic Health Record Training for Residents Preparing for Practice in Patient-Centered Medical Homes.

INTRODUCTION: Competence in using an electronic health record (EHR) is considered a critical skill for physicians practicing in patient-centered medical homes (PCMHs), but few studies have examined the impact of EHR training for residents preparing to practice in PCMHs. This study explored the educational outcomes associated with comprehensive EHR training for family medicine residents. METHODS: The PCMH EHR training consisted of case-based routine clinic visits delivered to 3 resident cohorts (N = 18). Participants completed an EHR competency self-assessment between 2011 and 2016 (N = 127), examining 6 EHR/PCMH core skills. We compared baseline characteristics for residents by low vs high exposure to EHR training. Multivariate regression estimated whether self-reported competencies improved over time and whether high PCMH EHR training exposure was associated with incremental improvement in self-reported competencies over time. RESULTS: Residents completed an average of 8.2 sessions: low-exposure residents averaged 5.3 sessions (standard deviation = 1.5), and high-exposure residents averaged 9.0 sessions (standard deviation = 0.9). High-exposed residents had higher posttest scores at training completion (84.4 vs 70.7). Over time, adjusted mean scores (confidence interval) for both groups improved (p < 0.001) from 12.2 (9.6-14.8), with low-exposed residents having greater score improvement (p < 0.001) because of their much lower baseline scores. CONCLUSION: Comprehensive training designed to improve EHR competencies among residents practicing in a PCMH resulted in improved assessment scores. Our findings indicate EHR training as part of resident exposure to the PCMH measurably improves self-assessed competencies, even among residents less engaged in EHR training.

Teaching Today in the Practice Setting of the Future: Implementing Innovations in Graduate Medical Education.

PROBLEM: Implementing an innovation, such as offering new types of patient-physician encounters through the patient-centered medical home (PCMH) model while maintaining Accreditation Council for Graduate Medical Education (ACGME) accreditation standards (e.g., patient encounter minimums for trainees), is challenging. APPROACH: In 2009, the Group Health Family Medicine Residency (GHFMR) received an ACGME Program Experimentation and Innovation Project (PEIP) exception that redefined the minimum Family Medicine Resident Review Committee requirement to 1,400 face-to-face visits and 250 electronic visits (1 electronic visit defined as 3 secure message or telephone encounters). The authors report GHFMR residents' continuity clinic encounters, specifically volume, from 2006 through 2013 via pre- and post-PCMH implementation. They discuss the implications for leaders of high-performing practices who desire to innovate while maintaining accreditation. OUTCOMES: Post-PCMH residents had 20% more overall patient contact. The largest change in care delivery method included a large increase in secure messages between patients and residents. Pre-PCMH residents had more face-to-face encounters; however, post-PCMH residents had more contact for all types of patient care encounters (face-to-face, secure messaging, and telephone) per hour of clinic time. NEXT STEPS: The ACGME PEIP exception, allowing the incorporation of the PCMH, facilitated an increase in patient access and immersed residents in primary care innovation (namely, practicing in a PCMH model during graduate medical education training). The next steps are to assess the effect of the PCMH on resident learning and clinical outcomes and to continue residents' access to training that keeps pace with today's health care delivery needs.

The Generation in Between: A Perspective from the Keystone IV Conference.

Keystone IV affirmed the value of relationships in family medicine, but each generation of family physicians took away different impressions and lessons. "Generation III," between the Baby Boomers and Millennials, reported conflict between their professional ideal of family medicine and the realities of current practice. But the Keystone conference also helped them appreciate core values of family medicine, their shared experience, and new opportunities for leadership.

A Tool to Assess Family Medicine Residents' Patient Encounters Using Secure Messaging.

BACKGROUND: Secure messages exchanged between patients and family medicine residents via an electronic health record (EHR) could be used to assess residents' clinical and communication skills, but the mechanism is not well understood. OBJECTIVE: To design and test a secure messaging competency assessment for family medicine residents in a patient-centered medical home (PCMH). METHODS: Using the existing literature and evidence-based guidelines, we designed an assessment tool to evaluate secure messaging competency for family medicine residents training in a PCMH. Core faculty performed 2-stage validity and reliability testing (n = 2 and n = 9, respectively). A series of randomly selected EHR secure messages (n = 45) were assessed from a sample of 10 residents across all years of training. RESULTS: The secure message assessment tool provided data on a set of competencies and a framework for resident feedback. Assessment showed 10% (n = 2) of residents at the novice level, 50% (n = 10) as progressing, and 40% (n = 8) as proficient. The most common deficiencies for residents' secure messages related to communication rather than clinical competencies (n = 37 [90%] versus n = 4 [10%]). Interrater reliability testing ranged from 60% to 78% agreement and 20% to 44% disagreement. Disagreement centered on interpersonal communication factors. After 2 stages of testing, the assessment using residents' secure messages was incorporated into our existing evaluation process. CONCLUSIONS: Assessing family medicine residents' secure messaging for patient encounters closed an evaluation gap in our family medicine program, and offered residents feedback on their clinical and communication skills in a PCMH.

Family medicine residency training in community health centers: a national survey.

PURPOSE: For more than 25 years, family medicine residencies (FMRs) have worked with community health centers (CHCs) to train family physicians. In light of the long history and current policy focus on this training model, the authors sought to evaluate comprehensively the scope and extent of family physician training occurring in CHCs. METHOD: The authors conducted a cross-sectional survey of 439 U.S. FMR directors in 2007. FMR directors were asked to provide information regarding the number, type, location, and length of any CHC training affiliations and to rate their satisfaction with such affiliations. RESULTS: Of 354 respondents (80% response rate), 83 FMRs (23.4%) provided some type of CHC training experience; 32 (9%) had their main residency continuity training site in a CHC. Respondents reported that 10.5% (788) of family medicine residents were trained in a CHC continuity clinic. The average length of affiliation was 10.2 years. Residency directors reported high satisfaction with CHC training affiliations. CONCLUSIONS: Almost one-quarter of FMRs in 2007 provided some training in CHCs. However, the proportion of residencies providing continuity training in CHCs--the type of training associated with enhanced recruitment and retention of family medicine graduates in underserved areas--was limited and relatively unchanged since 1992.

Barriers to training family medicine residents in community health centers.

BACKGROUND AND OBJECTIVES: Training partnerships between family medicine residencies (FMRs) and community health centers (CHCs) are a potential solution to the chronic problem of health workforce shortages in CHCs. We conducted a national survey to identify the barriers to training family medicine residents in CHCs. METHODS: We asked US family medicine residency directors to identify barriers to training residents in CHCs. Using grounded theory, three coders grouped responses by theme. We examined differences in barriers between residency programs that currently train in CHCs with programs that do not currently train in CHCs. RESULTS: A total of 51% (226/439) of residency program directors responded. Of these, 29% cited governance as a barrier to affiliation, 26% cited administrative complexity, 24% cited financial considerations, 21% cited leadership, and 18% cited access. Programs that trained in CHCs were more likely to cite financial considerations and administrative complexity than programs that did not train in CHCs. CONCLUSIONS: Governance and administrative complexity are the most commonly cited barriers to effective CHC-FMR partnerships. Financial consideration and leadership issues are also common barriers.

Training residents in community health centers: facilitators and barriers.

PURPOSE: Training family medicine residents in underserved settings, such as community health centers (CHCs), may provide a solution to the primary care workforce shortage. We sought to describe the facilitators and barriers to creating partnerships between CHCs and family medicine residencies (FMRs). METHODS: We conducted 19 key informant interviews and 3 focus groups to identify the key factors in the CHC-FMR relationship. Audiotapes and transcripts were analyzed to identify major themes. Key informant results were validated and expanded in the focus group discussions. RESULTS: Four major themes describe the CHC-FMR training partnership: mission, money, quality, and administrative/governance complexity. The CHC-FMR training affiliation is a complex relationship drawn together by a shared mission of service to the underserved, enhanced financial stability, workforce improvement, and greater educational and clinical quality. The relationship is hindered by competing primary missions, chronic underfunding, complex governing institutional regulations, and administrative challenges. In addition, the focus groups offered several policy solutions to address the barriers to CHC-FMR affiliation. CONCLUSIONS: A successful CHC-FMR training partnership relies upon the development of a shared mission of education and service, as well as innovation and flexibility by the organizations that govern them.

Training family physicians in community health centers: a health workforce solution.

PURPOSE: For more than 25 years, family medicine residencies (FMRs) have worked with community health centers (CHCs) to train family physicians. Despite the long history of this affiliation, little research has been done to understand the effects of training residents in this underserved community setting. This study compares CHC and non-CHC-trained family physicians regarding practice location, job and training satisfaction, and recruitment and retention to underserved areas. METHODS: We conducted a cross-sectional survey of a cohort of the 838 graduates from the WAMI (Washington, Alaska, Montana, and Idaho) Family Medicine Residency Network from 1986-2002. RESULTS: CHC-trained family physicians were almost twice as likely to work in underserved settings than their non-CHC-trained counterparts (64% versus 37%). When controlling for gender, percent full-time equivalent, and years from graduation, CHC-trained family physicians were 2.7 times more likely to work in underserved settings than non-CHC-trained family physicians. CHC and non-CHC-trained family physicians report similar job and training satisfaction and scope of practice. CONCLUSIONS: Training family physicians in CHCs meets the health workforce needs of the underserved, enhances the recruitment of family physicians to CHCs, and prepares family physicians similarly to their non-CHC trained counterparts.

PDA usage and training: targeting curriculum for residents and faculty.

BACKGROUND AND OBJECTIVES: Utilization of personal digital assistants (PDAs) in residency education is common, but information about their use and how residents are trained to use them is limited. Better understanding of resident and faculty PDA use and training is needed. METHODS: We used a cross-sectional survey of 598 residents and faculty from the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) Family Medicine Residency Network regarding PDA usage and training. RESULTS: Use of PDAs is common among residents (94%) and faculty (79%). Ninety-six percent of faculty and residents report stable or increasing frequency of use over time. The common barriers to PDA use relate to lack of time, knowledge, and formal education. Approximately half of PDA users (52%) have received some formal training; however, the majority of users report being self-taught. Faculty and residents prefer either small-group or one-on-one settings with hands-on, self-directed, interactive formats for PDA training. Large-group settings in lecture, written, or computer program formats were considered less helpful or desirable. CONCLUSIONS: PDAs have become a commonly used clinical tool. Lack of time and adequate training present a barrier to optimal application of PDAs in family medicine residency education.