Goal-Oriented Prevention: How to Fit a Square Peg into a Round Hole.

Prevention does not fit well within our problem-oriented medical paradigm in which the focus is on curing or ameliorating existing diseases. It is easier and more satisfying to solve existing problems than it is to advise and motivate patients to implement measures to prevent future problems that may or may not occur. Clinician motivation is further diminished by the time required to help people make lifestyle changes, the low reimbursement rate, and the fact that the benefits, if any, are often not apparent for years. Typical patient panel sizes make it difficult to provide all of the recommended disease-oriented preventive services and to also address the social and lifestyle factors that can impact future health problems. One solution to this square peg-round hole mismatch is to focus on the goals, life extension and prevention of future disabilities.

How Patient-Centered Medical Homes Can Bring Meaning to Health Care: A Call for Person-Centered Care.

The development of patient-centered medical homes in the United States was, among other things, an attempt to improve patients' experiences of care. This and other improvement strategies, however, have failed to confront a major barrier, our disease-oriented medical model. Focusing on diseases has contributed to subspecialization and reductionism, which, for patients, has increased medical complexity and made it more difficult to engage in collaborative decision making. The progressive uncoupling of disease prevention and management from other outcomes that may matter more to patients has contributed to the dehumanization of care. An alternative approach, person-centered care, focuses clinical care directly on the aspirations of those seeking assistance, rather than assuming that these aspirations will be achieved if the person's medical problems can be resolved. We recommend the adoption of 2 complementary person-centered approaches, narrative medicine and goal-oriented care, both of which view health problems as obstacles, challenges, and often opportunities for a longer, more fulfilling life. The transformation of primary care practices into patient-centered medical homes has been an important step forward. The next step will require those patient-centered medical homes to become person centered.

Considerations Before Selecting a Stepped-Wedge Cluster Randomized Trial Design for a Practice Improvement Study.

PURPOSE: Despite the growing popularity of stepped-wedge cluster randomized trials (SW-CRTs) for practice-based research, the design's advantages and challenges are not well documented. The objective of this study was to identify the advantages and challenges of the SW-CRT design for large-scale intervention implementations in primary care settings. METHODS: The EvidenceNOW: Advancing Heart Health initiative, funded by the Agency for Healthcare Research and Quality, included a large collection of SW-CRTs. We conducted qualitative interviews with 17 key informants from EvidenceNOW grantees to identify the advantages and challenges of using SW-CRT design. RESULTS: All interviewees reported that SW-CRT can be an effective study design for large-scale intervention implementations. Advantages included (1) incentivized recruitment, (2) staggered resource allocation, and (3) statistical power. Challenges included (1) time-sensitive recruitment, (2) retention, (3) randomization requirements and practice preferences, (4) achieving treatment schedule fidelity, (5) intensive data collection, (6) the Hawthorne effect, and (7) temporal trends. CONCLUSIONS: The challenges experienced by EvidenceNOW grantees suggest that certain favorable real-world conditions constitute a context that increases the odds of a successful SW-CRT. An existing infrastructure can support the recruitment of many practices. Strong retention plans are needed to continue to engage sites waiting to start the intervention. Finally, study outcomes should be ones already captured in routine practice; otherwise, funders and investigators should assess the feasibility and cost of data collection.VISUAL ABSTRACT.

Validity of Medical Record Abstraction and Electronic Health Record-Generated Reports to Assess Performance on Cardiovascular Quality Measures in Primary Care.

Importance: Cardiovascular disease is the leading cause of death in the United States. To improve cardiovascular outcomes, primary care must have valid methods of assessing performance on cardiovascular clinical quality measures, including aspirin use (aspirin measure), blood pressure control (BP measure), and smoking cessation counseling and intervention (smoking measure). Objective: To compare observed performance scores measured using 2 imperfect reference standard data sources (medical record abstraction [MRA] and electronic health record [EHR]-generated reports) with misclassification-adjusted performance scores obtained using bayesian latent class analysis. Design, Setting, and Participants: This cross-sectional study used a subset of the 2016 aspirin, BP, and smoking performance data from the Healthy Hearts for Oklahoma Project. Each clinical quality measure was calculated for a subset of a practice's patient population who can benefit from recommended care (ie, the eligible population). A random sample of 380 eligible patients were included for the aspirin measure; 126, for the BP measure; and 115, for the smoking measure. Data were collected from 21 primary care practices belonging to a single large health care system from January 1 to December 31, 2018, and analyzed from February 21 to April 17, 2019. Main Outcomes and Measures: The main outcomes include performance scores for the aspirin, BP, and smoking measures using imperfect MRA and EHRs and estimated through bayesian latent class models. Results: A total of 621 eligible patients were included in the analysis. Based on MRA and EHR data, observed aspirin performance scores were 76.0% (95% bayesian credible interval [BCI], 71.5%-80.1%) and 74.9% (95% BCI, 70.4%-79.1%), respectively; observed BP performance scores, 80.6% (95% BCI, 73.2%-86.9%) and 75.1% (95% BCI, 67.2%-82.1%), respectively; and observed smoking performance scores, 85.7% (95% BCI, 78.6%-91.2%) and 75.4% (95% BCI, 67.0%-82.6%), respectively. Misclassification-adjusted estimates were 74.9% (95% BCI, 70.5%-79.1%) for the aspirin performance score, 75.0% (95% BCI, 66.6%-82.5%) for the BP performance score, and 83.0% (95% BCI, 74.4%-89.8%) for the smoking performance score. Conclusions and Relevance: Ensuring valid performance measurement is critical for value-based payment models and quality improvement activities in primary care. This study found that extracting information for the same individuals using different data sources generated different performance score estimates. Further research is required to identify the sources of these differences.

The Role of Health Extension in Practice Transformation and Community Health Improvement: Lessons From 5 Case Studies.

Passage of the Patient Protection and Affordable Care Act triggered 2 successive grant initiatives from the Agency for Healthcare Research and Quality, allowing for the evolution of health extension models among 20 states, not limited to support for in-clinic primary care practice transformation, but also including a broader concept incorporating technical assistance for practices and their communities to address social determinants of health. Five states stand out in stretching the boundaries of health extension: New Mexico, Oklahoma, Oregon, Colorado, and Washington. Their stories reveal lessons learned regarding the successes and challenges, including the importance of building sustained relationships with practices and community coalitions; of documenting success in broad terms as well as achieving diverse outcomes of meaning to different stakeholders; of understanding that health extension is a function that can be carried out by an individual or group depending on resources; and of being prepared for political struggles over "turf" and ownership of extension. All states saw the need for long-term, sustained fundraising beyond grants in an environment expecting a short-term return on investment, and they were challenged operating in a shifting health system landscape where the creativity and personal relationships built with small primary care practices was hindered when these practices were purchased by larger health delivery systems.

Primary Care Practices' Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement.

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports-but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures.

Changing the culture of a medical school by orienting students and faculty toward community medicine.

Oklahoma's health status has been ranked among the worst in the country. In 1972, the University of Oklahoma established the Tulsa branch of its College of Medicine (COM) to expand the physician workforce for northeastern Oklahoma and to provide care for the uninsured patients of the area. In 2008, the Tulsa branch launched a distinct educational track, the University of Oklahoma COM's School of Community Medicine (SCM), to prepare providers equipped and committed to addressing prevalent health disparities.The authors describe the Tulsa branch's Summer Institute (SI), a signature program of the SCM, and how it is part of SCM's process of institutional transformation to align its education, service, and research missions toward improving the health status of the entire region. The SI is a weeklong, prematriculation immersion experience in community medicine. It brings entering medical and physician assistant students together with students and faculty from other disciplines to develop a shared culture of community medicine. The SI uses an unconventional curriculum, based on Scharmer's Theory U, which emphasizes appreciative inquiry, critical thinking, and collaborative problem solving. Also, the curriculum includes Professional Meaning conversations, small-group sessions to facilitate the integration of students' observations into their professional identities and commitments. Development of prototypes of a better health care system enables participants to learn by doing and to bring community medicine to life.The authors describe these and other curricular elements of the SI, present early evaluation data, and discuss the curriculum's incremental evolution. A longitudinal outcomes evaluation is under way.

Going "all in" to transform the Tulsa community's health and health care workforce.

Oklahoma's health status ranks among the lowest of the states', yet many Oklahomans oppose the best-known aspects of federal health reform legislation. To address this situation, the University of Oklahoma College of Medicine's School of Community Medicine in Tulsa adopted an "all-in," fully committed approach to transform the Tulsa region's health care delivery system and health care workforce teaching environment by leading community-wide initiatives that took advantage of lesser-known health reform provisions. Medical school leaders shared a vision of improved health for the region with a focus on equity in care for underserved populations. They engaged Tulsa stakeholders to implement health system changes to improve care access, quality, and efficiency. A partnership between payers, providers, and health systems transformed primary care practices into patient-centered medical homes (PCMHs) and instituted both community-wide care coordination and a regional health information exchange. To emphasize the importance of these new approaches to improving the health of an entire community, the medical school began to transform the teaching environment by adding several interdependent experiences. These included an annual interdisciplinary summer institute in which students and faculty from across the university could explore firsthand the social determinants of health as well as student-run PCMH clinics for the uninsured to teach systems-based practice, team-based learning, and health system improvement. The authors share lessons learned from these collaborations. They conclude that working across competitive boundaries and going all in are necessary to improve the health of a community.

An experiential community orientation to improve knowledge and assess resident attitudes toward poor patients.

BACKGROUND: Future physicians may not be prepared for the challenges of caring for the growing population of poor patients in this country. Given the potential for a socioeconomic "gulf" between physicians and patients and the lack of curricula that address the specific needs of poor patients, resident knowledge about caring for this underserved population is low. INTERVENTION: We created a 2-day Resident Academy orientation, before the start of residency training, to improve community knowledge and address resident attitudes toward poor patients through team-based experiential activities. We collected demographic and satisfaction data through anonymous presurvey and postsurvey t tests, and descriptive analysis of the quantitative data were conducted. Qualitative comments from open-ended questions were reviewed, coded, and divided into themes. We also offer information on the cost and replicability of the Academy. RESULTS: Residents rated most components of the Academy as "very good" or "excellent." Satisfaction scores were higher among residents in primary care training programs than among residents in nonprimary care programs for most Academy elements. Qualitative data demonstrated an overall positive effect on resident knowledge and attitudes about community resource availability for underserved patients, and the challenges of poor patients to access high-quality health care. CONCLUSIONS: The Resident Academy orientation improved knowledge and attitudes of new residents before the start of residency, and residents were satisfied with the experience. The commitment of institutional leaders is essential for success.

Ambulatory office organization for internal medicine resident medical education.

PURPOSE: Residents will most effectively learn about ambulatory, systems-based practice by working in highly functional ambulatory practices; however, systems experiences in ambulatory training are thought to be highly variable. The authors sought to determine the prevalence of functional-practice characteristics at clinics where residents learn. METHOD: In 2007, the authors conducted a national survey of medical directors of resident continuity clinics using a comprehensive, Web-based instrument that included both a residency clinic assessment and a practice system assessment (PSA). The authors designed the PSA to estimate the Physician Practice Connections (PPC) score, indicating the readiness of a practice to function as a patient-centered medical home (PCMH). RESULTS: Of 356 clinic directors or physician representatives responding to an initial inquiry, 221 completed the survey (62%)--representing 185 programs (49% of accredited programs). The majority of clinics were hospital based (139/220; 63%) or hospital supported (41/220; 19%) and were located in urban settings (151/217; 70%). Estimated payer mix categories included Medicare or managed Medicare (169; 29%), Medicaid or managed Medicaid (161; 34%), and self-pay (156; 25%). The mean estimated PPC score was 53 points (of 100; SD = 17.6). Suburban and rural clinics, Veterans Affairs' clinics, federally qualified health centers, and clinics with a higher proportion of patients with commercial insurance or managed Medicare earned higher scores. CONCLUSIONS: A substantial portion of residency clinics have elements needed for PCMH recognition. However, clinics struggled with connecting these elements with coordination-of-care processes, suggesting areas for improvement to support better functioning of ambulatory training practices.

Commentary: training internists for practice focused on meeting patient needs.

The author describes the evolution of practice within the broad specialty of internal medicine. This evolution is driven by scientific discovery, emergent patient needs, and market forces. Four ages describe the evolution: the age of the Oslerian diagnostic consultant, the age of the subspecialist, the age of the primary care internist, and the emerging age of focused general internal medicine practice. The author suggests that competence in practice-based learning and improvement linked with evaluation of practice performance throughout a career permits the professions to abandon the notion that valid learning for medical practice occurs only by completing a designated number of months of residency or fellowship training. By applying competency-based standards for specialty certification and maintaining its validity for current practice, boards can provide trainees and practitioners a tool for professional accountability for initial and continuous professional competence. The lifelong learning and evaluation process permits the timely recognition of proficiency acquired in practice. This process engages internists in ongoing guided reflection on measures of performance and provides evidence that they have incorporated new knowledge, technology, skills, and attitudes that align their practice with patient needs. As dialogue with internal medicine stakeholders and customers continues, the author describes how the training standards for certification might adapt to the evolving demands for the specialty practice and how the evaluation of continuous professional development through the maintenance of certification provides an instrument for identifying and recognizing proficiency in providing focused care within the broad discipline of internal medicine.

Variation in internal medicine residency clinic practices: assessing practice environments and quality of care.

BACKGROUND: Few studies have systematically and rigorously examined the quality of care provided in educational practice sites. OBJECTIVE: The objectives of this study were to (1) describe the patient population cared for by trainees in internal medicine residency clinics; (2) assess the quality of preventive cardiology care provided to these patients; (3) characterize the practice-based systems that currently exist in internal medicine residency clinics; and (4) examine the relationships between quality, practice-based systems, and features of the program: size, type of program, and presence of an electronic medical record. DESIGN: This is a cross-sectional observational study. SETTING: This study was conducted in 15 Internal Medicine residency programs (23 sites) throughout the USA. PARTICIPANTS: The participants included site champions at residency programs and 709 residents. MEASUREMENTS: Abstracted charts provided data about patient demographics, coronary heart disease risk factors, processes of care, and clinical outcomes. Patients completed surveys regarding satisfaction. Site teams completed a practice systems survey. RESULTS: Chart abstraction of 4,783 patients showed substantial variability across sites. On average, patients had between 3 and 4 of the 9 potential risk factors for coronary heart disease, and approximately 21% had at least 1 important barrier of care. Patients received an average of 57% (range, 30-77%) of the appropriate interventions. Reported satisfaction with care was high. Sites with an electronic medical record showed better overall information management (81% vs 27%) and better modes of communication (79% vs 43%). CONCLUSIONS: This study has provided insight into the current state of practice in residency sites including aspects of the practice environment and quality of preventive cardiology care delivered. Substantial heterogeneity among the training sites exists. Continuous measurement of the quality of care provided and a better understanding of the training environment in which this care is delivered are important goals for delivering high quality patient care.

Self-assessment of practice performance: development of the ABIM Practice Improvement Module (PIM).

BACKGROUND: Quality measurement and improvement in practice are requirements for Maintenance of Certification by the American Board of Medical Specialties boards and a component of many pay for performance programs. OBJECTIVE: To describe the development of the American Board of Internal Medicine (ABIM) Practice Improvement Module (PIM) and the average performance of ABIM diplomates who have completed the Preventive Cardiology PIM. DESIGN: Observational study of self-administered practice quality improvement. SETTING: Office practices through the United States. PARTICIPANTS: A total of 179 cardiologists and general internists completing requirements for ABIM Maintenance of Certification from 2004 through 2005. MEASUREMENTS: Physicians self-audited at least 25 charts to obtain performance measures, patient demographics, and coronary heart disease risk factors. At least 25 patients completed surveys regarding their experience of care in the physician's practice. Physicians completed a self-assessment survey detailing the presence of various practice systems. RESULTS: The mean rate for systolic blood pressure control was 48%, for diastolic blood pressure 84%, and for low-density lipoprotein (LDL) cholesterol at goal 65%. Of patients 61% rated the quality of care as excellent and 58% rated the practices excellent at encouraging questions and answering them clearly. More than 85% of patients reported "no problem" obtaining a prescription refill, scheduling an appointment, reaching someone in the practice with a question, or obtaining lab results. Targets for improvement were increasing the rates for LDL cholesterol or systolic blood pressure at goal, improving patients' physical activity, patient education, and accuracy of risk assessment. Improvement strategies included implementing chart forms, patient education, or care management processes. LIMITATIONS: Patients and charts were selected by physicians reporting their performance for the purpose of MOC. CONCLUSIONS: The Preventive Cardiology PIM successfully provides a self-assessment of practice performance and provides guidance in helping physicians initiate a cycle of quality improvement in their practices.

Improving the quality of care via maintenance of certification and the Web: an early status report.

Few question the need for continuous professional development throughout a physician's career, but rapid changes in health care are creating demand for physicians to acquire new knowledge, skills, and attitudes to implement quality improvement in clinical practice. The Internet and World Wide Web are technologies that have the potential to facilitate deep change in physician practice and lifelong learning. This paper describes how the American Board of Internal Medicine (ABIM) has utilized the Web and the Internet to engage physicians in the competencies of practice-based learning and improvement and systems-based practice. Specifically, we describe how the ABIM developed and implemented Web-based practice improvement modules (PIMs) to help physicians measure and improve their clinical practice.

Redesigning residency training in internal medicine: the consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force.

Because of numerous criticisms of the content and structure of residency training, redesigning graduate medical education (GME) has become a high priority for the internal medicine community. From 2005 to 2007, the leadership of the internal medicine community, working under the auspices of the Alliance for Academic Internal Medicine Education Redesign Task Force, developed six recommendations it will pursue to improve residency education: (1) focus education around a "core" of internal medicine, which provides the framework for both the structure and content of residents' educational experiences, (2) fully adopt competency-based evaluation and advancement, which will enhance training by focusing on individual learners' needs, (3) allow for increased, resident-centered education beyond the internal medicine core, because different types of practice require customized knowledge and skills, (4) improve ambulatory training by providing patient-centered longitudinal care that addresses the conflict between inpatient and outpatient responsibilities, (5) use new faculty models that emphasize the creation of a core faculty, and (6) align institutional and programmatic resources with the goals of redesign, balancing the clinical mission of the institution with the educational goals of residency training. Adoption of these recommendations will require significant efforts, including pilot projects, faculty development, changes in accreditation requirements, and modifications of GME funding systems. Opportunities are ample for individual programs to develop creative approaches based on the framework for educational redesign outlined in this article, and for these educational and clinical redesign initiatives to work hand-in-hand for the benefit of patients, faculty, trainees, and institutions.

A three-part model for measuring diabetes care in physician practice.

BACKGROUND: To assess the psychometric properties of the three components of the Diabetes Practice Improvement Module, to compare reliabilities of composites to individual measures, and to identify associations among practice-based and patient-based measures. METHOD: Data include practice systems surveys of 626 physicians, 13,965 chart audits, and 12,927 patient surveys. Quality composites were identified using factor analysis. Means with reliabilities (intraclass correlation coefficient [ICC] and Cronbach's alpha) are reported. Associations among patient-based quality measures and practice measures with case-mix adjustments were estimated via hierarchical models. RESULTS: Composite ICCs range from 0.11 to 0.54, and single items range from 0.05 to 0.49. Staff communication, efficiency, care access, and patient knowledge correlate with patient satisfaction (P < .001). Clinical outcomes are associated with clinical processes (e.g., annual foot exam) and appropriate treatment (P < .001). Patient adjusters (e.g., overall health or factors limiting self-care) are important for the models; physician characteristics used (e.g., age, practice size) seem less important. CONCLUSIONS: Composites require smaller patient sample sizes and result in more reliable measures than do individual items. Additionally, the data show meaningful relationships between composites; physician-directed components (i.e., clinical processes and treatments) are related to clinical outcomes, and patients are clearly more satisfied with care if it is easily accessible and if communication about care is good.