Simulating Telemedicine, Medication Reconciliation, and Social Determinants: A Novel Instructional Approach to Health Systems Competencies.

While medication reconciliation is necessary to reduce errors, it is often challenging to gather an accurate history in the clinic. Telemedicine offers a relative advantage over clinic and hospital-based interviews by enabling the clinician to inspect the home environment, review pill bottles, and identify social determinants affecting adherence, such as financial instability. To be effective, however, clinicians must be trained in best-practice interview methods and the proper use of telemedicine. There is very little information in the literature describing the best strategies for teaching students or measuring competencies in telemedicine. Therefore, we created an educational module with a telemedicine simulation and an evaluation rubric. We piloted this module with 48 medical and physician assistant students. Most students could complete a virtual interview and gather a medication history. However, only half identified an over-the-counter medication missing from the list. Most students were either entrustable or approaching entrustment in the six telemedicine competencies measured in this simulation. This simulation is valuable for teaching students about medication reconciliation, using telemedicine to close gaps in access to care, and identifying health-related social needs affecting medication adherence.

Identifying Failure Modes in Telemedicine: An Instructional Needs Assessment.

Technology failures in telehealth are common, and clinicians need the skills to diagnose and manage them at the point of care. However, there are issues beyond technology failures mediating the effective use of telehealth. We must teach best-practice procedures for conducting telemedicine visits and include in instructional simulations commonly encountered failure modes so students can build their skills. To this end, we recruited medical students to conduct a Healthcare Failure Modes and Effects Analysis (HFMEA) to predict failures in telemedicine, their potential causes, and the consequences to develop and teach prevention strategies. Sixteen students observed telehealth appointments independently. Based on their observations, we identified four categories of failures in telemedicine: technical issues, patient safety, communication, and social and structural determinants. We proposed a normalized workflow that included management and prevention strategies. Our findings can inform the creation of new curricula.

Using Simulations to Train Medical Students for Unanticipated Technology Failures in Telemedicine.

Simulations offer a safe environment for health professional training and the opportunity to predictably and consistently introduce events or variables that may be rare or dangerous in a live setting. Exposing trainees to unanticipated events during simulations can improve their ability to adapt and improvise. The COVID-19 pandemic accelerated the adoption of telehealth worldwide and highlighted the need for better training in health professional schools. In the United States, the Association of American Medical Colleges (AAMC) published new telehealth competency standards in 2021. The AAMC stated that health care providers should be aware of the risks of technology failures, capable of troubleshooting them, and lead systems interventions to improve safety. However, the AAMC does not provide guidance on the specific failures or solutions. In this study, we developed a set of technology failures that can be simulated in a telehealth curriculum. We incorporated one technology failure into a simulated telehealth encounter and gathered students' (N = 53) feedback on the exercise. Students' feedback was overwhelmingly positive. They agreed that integrating technology failures into telehealth simulations provides important practice managing these events during clinical encounters. While telehealth is an important healthcare delivery modality that can improve access-to-care, it is imperative to train medical students to navigate technology failures so that can adeptly manage these issues in clinical practice.

Teaching Teledermatology: A Simulation Pilot for Health Professional Students.

We developed a teledermatology simulation to give medical and physician assistant students practice with live videoconferencing and store-and-forward workflows. The simulation included (1) pre-session reading; (2) a brief teledermatology didactic; (3) a simulated encounter with a standardized patient; and (4) faculty-led debriefs. The faculty observed students during the simulation and distributed a post-session learner satisfaction survey. Although students had mixed feelings about the simulation, 88% said the workshop met or exceeded expectations.

A Telepsychiatry Simulation for Suicide Assessment: Teaching Telemedicine Safety Competencies.

Educators must provide controlled scenarios for health professional students to develop patient safety competencies related to telemedicine, including when and how to escalate care. We developed a telepsychiatry workshop to give students experience with a high-stakes mental health condition. The workshop included (1) pre-session readings; (2) didactics on mood disorders and telepsychiatry; (3) a motivational interviewing exercise; (4) a simulated telemedicine encounter; and (5) a faculty-led group debrief. We evaluated teaching effectiveness using a competency assessment with three scales: (1) medical knowledge; (2) interpersonal and communication skills; and (3) telemedicine competencies. Between 0 and 59% of students were entrustable for each telemedicine competency. Our workshop demonstrates how to teach students about the safe use of telehealth technology and provides practice triaging mental health conditions commonly encountered in primary care and mental health telemedicine clinics.

An evaluation of a simulation and video-based training program to address adverse childhood experiences.

Adverse Childhood Experiences (ACEs) are multiple sources of maltreatment and household dysfunction with tremendous impact on health. A trauma-informed (TI) approach is preferred when working with patients with ACEs. The Professional ACEs-Informed Training for Health© (PATH©) educational program and simulation experience using standardized patients (SP) was developed to help healthcare professionals address ACEs with adults. PATH© is a 3-4 hour curriculum comprised of lecture and discussion, video-based demonstration, simulation experience, and debriefing. It was first developed for primary care (PC) residents in family medicine and internal medicine, and subsequently modified for occupational therapy (OT) and physical therapy (PT) students. This study evaluates a preliminary dataset focusing on PATH© skills of PC residents and OT and PT students during simulation. Recordings of 53 learner-SP encounters from 15 OT and PT students and 38 PC residents were coded using standardized behavioral codes. A subset of ten recordings of PC residents who participated in simulations in the first and fourth year of the training program allowed for evaluation of training outcomes over time. Results showed that medical residents and OT and PT students demonstrated skills during SP encounters congruent with TI training on addressing ACEs with adults, particularly in explaining ACEs, demonstrating empathy, collaborative treatment planning, and stigma reduction. PC residents showed both positive and negative changes in PATH©-specific skills from year 1 to 4 of the training program. This study supports the PATH© model and simulation-based training in preparing clinicians to address ACEs with adults and provides insight into further curriculum improvement.

Using Social Simulation to Teach Rehabilitation Science Students About Adverse Childhood Experiences and Trauma Informed Care.

Recent research has identified the relationships between adverse childhood experiences (ACEs) and adult adoption of health risk behaviors, negative health outcomes, and measures of well-being. Given these findings, it is important to consider training models that educate allied health students about the relevance of ACEs to adult health across a myriad of practice settings and equip them with the skills necessary to help patients with a history of ACEs. Physical therapy (PT) and occupational therapy (OT) are key members of the health care team, well positioned to address ACEs with their patients. This study reports on the evaluation of an innovative simulation-based training program, Professional ACE-Informed Training for Health Professionals (PATH), conducted with 26 second-year PT and OT students. Pre- and post-training measures consisted of the General Self-Efficacy Scale, Adult Hope Scale, and a test of knowledge and familiarity with ACEs and trauma-informed care (TIC). Results indicate that self-efficacy, hope, and knowledge of ACEs and TIC increased from pre- to post-tests for both PT and OT students. Qualitative results demonstrate that PT and OT students appreciated participating in the training model and learned a great deal from their experiences; however, they would like even more information and instruction on how to work effectively with patients who have a history of ACEs. Implications of this study and a discussion of the importance of continuing and expanding such training in rehabilitation sciences education and training are provided.

Adverse Childhood Experiences, Other Psychosocial Sources of Adversity, and Quality of Life in Vulnerable Primary Care Patients.

INTRODUCTION: Adults who had adverse childhood experiences (ACEs) have increased risk of negative health outcomes. Despite the prevalence of ACEs, literature is scarce on quality of life (QOL) and ACEs in disadvantaged primary care populations. OBJECTIVE: To examine the prevalence of ACEs and association with chronic health problems and QOL in disadvantaged primary care patients in Oklahoma. METHODS: During a primary care visit, adults completed a questionnaire measuring demographics, ACEs, current health status and well-being, sources of support and adversity, and QOL. A physician investigator reviewed participants' health records, recording the incidence of 32 diagnoses commonly associated with chronic health problems. RESULTS: The survey was completed by 354 patients. Forty-three percent received disability benefits and 71% were unemployed. More than 37% reported 4 or more ACEs, and 35.5% had 0 or 1 ACE.The amount of health problems ranged from 0 to 11 and increased with the number of reported ACEs. The mean number of health problems for each ACE level was as follows: ACEs 0 to 1 had 3.01 problems (95% confidence interval = 2.96-3.88), ACEs 2 to 3 had 3.42 problems (95% confidence interval = 2.96-3.88), and ACEs 4 and above had 4.18 problems (95% confidence interval = 3.72-4.64). ACEs were significantly related to QOL. CONCLUSION: This disadvantaged primary care population had high numbers of ACEs. ACEs correlated with increasing numbers of health problems and worse QOL. Enhanced awareness and action are needed to reduce health disparities and improve outcomes in similar populations.

Variation and Change Over Time in PROMIS-29 Survey Results Among Primary Care Patients With Type 2 Diabetes.

PURPOSE: We sought to describe results of patient-reported outcome measures implemented among primary care patients with diabetes and explore factors associated with changes in scores over time. METHODS: Two organizations serving diverse patient populations collected the PROMIS-29 survey at baseline and 3-month follow-up for patients with type 2 diabetes. Bayesian regression analysis was used to examine the relationship between patient characteristics and changes in PROMIS-29 scores. Exploratory analyses assessed relationships between goal-setting and changes in scores. RESULTS: The study population reported substantially more problems with physical functioning (mean: 42.5 at Site 1 and 38.9 at Site 2) and pain interference (mean: 58.0 at Site 1 and 61.1 at Site 2) compared to the general population (mean: 50; standard deviation: 10). At least 33% of patients had a clinically meaningful change (ie, at least half the standard deviation, or 5 points) in each PROMIS domain. For pain interference, 55% had no change, 22% improved by 5 or more points, and 23% worsened by 5 or more points. Bayesian regression analyses suggest that chronic conditions, insurance status, and Hispanic ethnicity are likely associated with decreased functioning over time. Exploratory analyses found that setting a mental health goal did not appear to be associated with improvement for anxiety or depression. CONCLUSIONS: Use of patient-reported outcome measures in routine clinical care identified areas of functional limitations among people with diabetes. However, changes in participants' PROMIS-29 scores over time were minimal. Research is needed to understand patterns of change in global and domain-specific functioning, particularly among racial/ethnic minorities.

Implementation of the PROMIS-29 in Routine Care for People With Diabetes: Challenges and Opportunities.

Using patient-reported outcome measures (PROMs) in care planning has the potential to improve care, but information about routine implementation in settings serving disadvantaged groups is needed. Two primary care clinics serving populations predominantly eligible for Medicaid and diverse in race/ethnicity implemented the PROMIS-29 as part of clinical care planning. Of the target population with diabetes, 26% (n = 490) completed the PROMs; the proportion that set a goal based on the PROMs differed by site. This report describes factors influencing the PROMs process and the results of interviews with patients and members of the care team about PROMs' implementation and impact.

A simulation and video-based training program to address adverse childhood experiences.

Adverse childhood experiences (ACEs) are 10 categories of childhood abuse and maltreatment, which have a dose-response relationship with common adult health concerns seen in primary care including health risk behaviors, chronic disease, and mental illness. Many of the ACEs-associated biopsychosocial risk factors are modifiable. However, physicians may not address these issues for fear of opening "Pandora's Box", that is, a source of extensive problems for which they are not sufficiently prepared with training, resources, or time. Residents need training in how to conduct trauma-focused conversations within the limited scope of an office visit. To address this need, a 4-hour simulation and video-based training program was developed for primary care residents about how to conduct brief interventions connecting their patients' current health concerns with their experiences of ACEs. Resident participants have evaluated this program as preparatory for real-life encounters and as being designed to allow for educational mastery. This article describes a workshop presenting this training program which was given at the 37th Annual Behavioral Science Forum in Family Medicine. Five skills targeted in the program were presented and a demonstration was made of the components, that is, didactics, provider and patient videos, simulated patient encounters, trainee feedback, and facilitated discussion that encompasses targeted skills, clinical implementation, and self-care. Companion tools were shared, including the syllabus, evaluation rubric, and provider and patient resources. Participants practiced trainee feedback and discussed the challenges in implementation.

Opioid Addiction Treatment Using Buprenorphine-Naloxone In A Community-Based Internal Medicine Practice.

BACKGROUND: Opioid dependency currently affects over 2.5 million patients in the United States and is increasing in incidence. Office-based opioid therapy with buprenorphine-naloxone provides greater patient access to treatment and has significantly improved therapeutic outcomes. METHODS: We conducted a study of 100 consecutive patients treated for opioid dependence with buprenorphine-naloxone in a single provider's community-based internal medicine practice. The primary outcome measures were retention in therapy, wellness, and abstinence from ongoing drug use. Data were obtained from frequent physical examinations, self-report data, and periodic urine drug screening. RESULTS: The retention rate in therapy was 75%. A multidimensional evaluation of wellness improved in 75% of the patients. Eighty-five percent reported no opiate relapse during therapy. CONCLUSION: Office-based opioid therapy with buprenorphine-naloxone has provided greater access to therapy with improved therapeutic outcomes. Our findings support the mounting literature that more patients should be offered office-based opioid therapy for opioid dependency.