Impact of virtual visits on primary care physician work flows.

OBJECTIVE: To understand the impact of virtual visits on primary care physician (PCP) work flows. DESIGN: Qualitative semistructured interviews. SETTING: Primary care practices within 5 regions in southern Ontario. PARTICIPANTS: Physicians representing primary care practices of various sizes and remuneration models (eg, capitation and fee-for-service models). METHODS: Interviews were conducted with PCPs involved in a large-scale pilot project implementing virtual visits (via a Web-based application) into clinical practices. Convenience and purposive sampling were used to recruit PCPs between January 2018 and March 2019. To obtain a representative sample, participants were sought from a variety of practice types and geographic regions. High and low users of virtual visits were included. Interviews were audiorecorded and transcribed. An inductive thematic analysis was used to identify prominent themes and subthemes. MAIN FINDINGS: Twenty-six physicians were interviewed (n=15 using convenience sampling and n=11 through purposive sampling). Four themes were identified: PCPs employ diverse approaches to integrate virtual care into their work flow; PCPs recognize that implementing virtual visits requires upfront time and effort but have variable perceptions regarding long-term impact of virtual care on processes; asynchronous messaging is preferable to synchronous audio or video visits; and strategies were identified to improve the integration of virtual visits. CONCLUSION: The potential of virtual care to improve work flow is dependent on the way these visits are implemented and used. Dedicated time for implementation, emphasis on using asynchronous secure messaging, and access to clinical champions and structured change management support were associated with more seamless integration of virtual visits.

Redesigning primary care: Provider perspectives on the clinical utility of virtual visits.

OBJECTIVE: To explore primary care physician (PCP) perspectives on the clinical utility of virtual visits. DESIGN: Qualitative design involving semistructured interviews. SETTING: Primary care practices within 5 regions in southern Ontario. PARTICIPANTS: Primary care physicians representing different practice sizes and remuneration models. METHODS: Interviews were conducted with PCPs who were involved in a large-scale pilot implementation of virtual visits (patient-provider asynchronous messaging, or synchronous audio or video communication). The first phase involved a convenience sample of users in the first 2 regions where the pilot was initiated; after implementation in all 5 regions, purposive sampling was used to ensure diversity within the sample (eg, physicians representing different use frequencies of virtual visits, regions, and remuneration models). Interviews were audiorecorded and transcribed. An inductive thematic analysis was used to identify prominent themes and subthemes. MAIN FINDINGS: Twenty-six physicians were interviewed. Fifteen were recruited using convenience sampling and 11 through purposive sampling. Four themes regarding the clinical utility of virtual visits were identified: virtual visits can effectively resolve many patient concerns, with some variation in PCP comfort using virtual visits for specific conditions; virtual visits are beneficial for a range of patients but some patients might overuse or inappropriately use them; PCPs prefer to use asynchronous messaging (eg, text or online messaging) because of its convenience and flexibility; and virtual visits can provide value at the patient, provider, and health system levels. CONCLUSION: While participants believed that virtual visits can be appropriately used to resolve a variety of clinical concerns, they found in practice that virtual visits are fundamentally different from face-to-face encounters. Professional guidelines on appropriate use cases should be established to develop a standard framework for virtual care.

Catalyzing Digital Health Innovation in Ontario: The Role of an Academic Medical Centre.

Overcoming barriers to health system innovation is an ongoing challenge in Canada. A total of 51 participants attended a digital health symposium in October 2017 to discuss the role of an academic medical centre (AMC) in advancing innovation. The conversation centred around (i) the current state of innovation in healthcare; (ii) the need for an innovation catalyst; and (iii) the roadmap for an AMC to drive change. AMCs can address the barriers to digital health innovation in Canada by providing a centralized network and infrastructure that supports innovation throughout its journey from "bench to bedside" as well as supporting educational reform.

Barriers to Creating Scalable Business Models for Digital Health Innovation in Public Systems: Qualitative Case Study.

BACKGROUND: Health systems are increasingly looking toward the private sector to provide digital solutions to address health care demands. Innovation in digital health is largely driven by small- and medium-sized enterprises (SMEs), yet these companies experience significant barriers to entry, especially in public health systems. Complex and fragmented care models, alongside a myriad of relevant stakeholders (eg, purchasers, providers, and producers of health care products), make developing value propositions for digital solutions highly challenging. OBJECTIVE: This study aims to identify areas for health system improvement to promote the integration of innovative digital health technologies developed by SMEs. METHODS: This paper qualitatively analyzes a series of case studies to identify health system barriers faced by SMEs developing digital health technologies in Canada and proposed solutions to encourage a more innovative ecosystem. The Women's College Hospital Institute for Health System Solutions and Virtual Care established a consultation program for SMEs to help them increase their innovation capacity and take their ideas to market. The consultation involved the SME filling out an onboarding form and review of this information by an expert advisory committee using guided considerations, leading to a recommendation report provided to the SME. This paper reports on the characteristics of 25 SMEs who completed the program and qualitatively analyzed their recommendation reports to identify common barriers to digital health innovation. RESULTS: A total of 2 central themes were identified, each with 3 subthemes. First, a common barrier to system integration was the lack of formal evaluation, with SMEs having limited resources and opportunities to conduct such an evaluation. Second, the health system's current structure does not create incentives for clinicians to use digital technologies, which threatens the sustainability of SMEs' business models. SMEs faced significant challenges in engaging users and payers from the public system due to perverse economic incentives. Physicians are compensated by in-person visits, which actively works against the goals of many digital health solutions of keeping patients out of clinics and hospitals. CONCLUSIONS: There is a significant disconnect between the economic incentives that drive clinical behaviors and the use of digital technologies that would benefit patients' well-being. To encourage the use of digital health technologies, publicly funded health systems need to dedicate funding for the evaluation of digital solutions and streamlined pathways for clinical integration.

Uptake and patient and provider communication modality preferences of virtual visits in primary care: a retrospective cohort study in Canada.

OBJECTIVES: To evaluate the uptake of a platform for virtual visits in primary care, examine patient and physician preferences for virtual communication methods and report on characteristics of visits and patients experience of care. DESIGN: A retrospective cohort study. SETTING: Primary care practices within five regions in Ontario, Canada after 18 months of access to virtual care services. PARTICIPANTS: 326 primary care providers and 14 291 registered patients. INTERVENTIONS: Providers used a platform that allowed them to connect with their patients through synchronous (audio/video) and/or asynchronous (secure messaging) communication. MAIN OUTCOME MEASURES: User-level data from the platforms including patient demographics, practice characteristics, communication modality used, visit characteristics and patients' satisfaction. RESULTS: Among the participants, 44% of registered patients and 60% of registered providers used the platform at least once. Among patient users, 51% completed at least one virtual visit. The majority of virtual visits (94%) involved secure messaging. The most common patient requests were for medication prescriptions (24%) and follow-up from previous appointment (22%). The most common provider request was to follow-up on test results (59%). Providers indicated that 81% of virtual visits required no follow-up for that issue and 99% of patients reported that they would use virtual care services again. CONCLUSIONS: While there are a growing number of primary care video visit services, our study found that both patients and providers in rostered practices prefer secure messaging over video. Despite fears that virtual visits would be overused by patients, when patients connected with their own primary care provider, many virtual visits appeared to replace in-person visits, and patients did not overwhelm physicians with requests. This approach may improve access and continuity in primary care.

Continuing Professional Development for Primary Care Providers in Palliative and End-of-Life Care: A Systematic Review.

Background and Objective: This review updates and expands on previous reviews of educational interventions for primary care providers (PCPs) involved in palliative and end-of-life care (PEoLC) and is the first to include early studies related to medical assistance in dying (MAiD). Methods: A comprehensive search strategy was conducted across five electronic databases to locate published interventional studies related to ongoing PEoLC and/or MAiD education for primary care professionals. A descriptive summary of results and a narrative discussion of common themes and comparisons are provided. Results: Thirty-seven studies met the inclusion criteria. The researchers found a myriad of interventions, including courses based, practical experience, mentoring, and workshops. The researchers categorized results by four domains: attitude, confidence, knowledge, and skills. Across domains, seven educational topics emerged: general care, interprofessional collaboration, nutrition, pain and symptom management, patient communication, and professional coping. Overall, studies employed various methodologies, but often relied on cross-sectionally measured self-assessment. Two articles were found that measured the impact of MAiD education. Conclusion: These findings suggest that PEoLC education can improve PCPs' perceived attitudes, confidence, knowledge, and skills across multiple areas of palliative care practice. While PCPs across studies valued educational interventions, the findings relating to the impact of PEoLC education on PCP's provision of effective PEoLC were unclear. However, most interventions resulted in enhanced confidence and knowledge. To date, there are only two studies that have examined MAiD educational programs. There is a need for studies of higher rigor with more emphasis on follow-up to clarify the impact training has on those involved in PEoLC and MAiD.

A case for feedback and monitoring assessment in competency-based medical education.

PURPOSE: Within competency-based medical education, self-regulated learning (SRL) requires residents to leverage self-assessment and faculty feedback. We sought to investigate the potential for competency-based assessments to foster SRL by quantifying the relationship between faculty feedback and entrustment ratings as well as the congruence between faculty assessment and resident self-assessment. MATERIALS AND METHODS: We collected comments in (a) an emergency medicine objective structured clinical examination group (objective structured clinical examinations [OSCE] and emergency medicine OSCE group [EMOG]) and (b) a first-year resident multidisciplinary resuscitation "Nightmares" course assessment group (NCAG) and OSCE group (NOG). We assessed comments across five domains including Initial Assessment (IA), Diagnostic Action (DA), Therapeutic Action (TA), Communication (COM), and entrustment. Analyses included structured qualitative coding and (non)parametric and descriptive analyses. RESULTS: In the EMOG, faculty's positive comments in the entrustment domain corresponded to lower entrustment score Mean Ranks (MRs) for IA (<11.1), DA (<11.2), and entrustment (<11.6). In NOG, faculty's negative comments resulted in lower entrustment score MRs for TA (<11.8 and <10) and DA (<12.4), and positive comments resulted in higher entrustment score MRs for IA (>15.4) and COM (>17.6). In the NCAG, faculty's positive IA comments were negatively correlated with entrustment scores (ρ = -.27, P = .04). Across programs, faculty and residents made similar domain-specific comments 13% of the time. CONCLUSIONS: Minimal and inconsistent associations were found between narrative and numerical feedback. Performance monitoring accuracy and feedback should be included in assessment validation.

Ontario and New Zealand Pharmaceuticals: Cost and Coverage.

Ontario is a strong candidate for a comprehensive pharmacare program, given that it has a pre-existing public drug benefit program (the Ontario Drug Benefit Program [ODBP]). This paper outlines strategies from New Zealand's national pharmacare program (the Pharmaceutical Management Agency [PHARMAC]) and compares these strategies to other international examples. It is recommended that the ODBP engage in three strategies currently utilized by the PHARMAC to achieve significant cost savings and create potential to increase their insurance coverage: (i) strict budgeting; (ii) tendering and negotiating; and (iii) reference pricing.

Decision-making frameworks and considerations for informing coverage decisions for healthcare interventions: a critical interpretive synthesis.

OBJECTIVE: To guide decision-making about whether or not to pay for a new healthcare intervention, a number of existing frameworks systematically weigh scientific evidence, cost, and social and ethical values. Each framework has strengths and limitations. This study aims to review and summarize available frameworks and generate an integrated framework, if and where applicable, highlighting particular issues faced with expensive but effective and desirable healthcare interventions. STUDY DESIGN AND SETTING: We conducted a critical interpretive synthesis to inform decision-making about healthcare interventions. We updated prior systematic reviews on decision-making frameworks through 2015. Purposive sampling identified relevant constructs and considerations to facilitate decision-making. RESULTS: Of 2,980 references, we purposively sampled 19 frameworks. The new framework, which built on the GRADE Evidence to Decision framework, included burden of disease, benefits and harms, values and preferences, resource use, equity, acceptability, and feasibility. Modifications to the Evidence to Decision framework included adding limitations of alternative technologies considerations in use (expanding benefits and harms) and broadening acceptability and feasibility constructs to include political and health system factors. No modifications appeared necessary to address the situation of effective but expensive and desirable interventions. CONCLUSION: Guideline developers, health technology assessment producers, and decision-makers can use our integrated framework to inform decision-making about healthcare interventions.

Tracer agents for the detection of sentinel lymph nodes in breast cancer: current concerns and directions for the future.

Tracer agents play a central role in axillary lymphatic mapping for sentinel node identification during breast cancer surgery. This article reviews the data concerning safety, efficacy, and availability of tracers currently in use. Alternate tracer materials are introduced, with review of the current literature.

Analyzing the risk of recurrence after mastectomy for DCIS: a new use for the USC/Van Nuys Prognostic Index.

BACKGROUND: Patients with ductal carcinoma in situ (DCIS) who are treated with mastectomy seldom recur locally or with metastatic disease. When patients with DCIS recur with invasive cancer, they are upstaged and their lives are threatened. We questioned whether histopathologic data could be used to predict these infrequent events. METHODS: We reviewed a prospective database of 1,472 patients with pure DCIS. All patients were scored from 4 to 12 using the USC Van Nuys Prognostic Index, an algorithm based on DCIS size, nuclear grade, necrosis, margin width, and patient age. Probabilities of recurrence and death were calculated using the Kaplan-Meier method. RESULTS: A total of 496 patients with pure DCIS were treated with mastectomy. None received any form of postmastectomy adjuvant treatment. Average follow-up was 83 months. Eleven patients developed recurrences, all of whom scored 10-12 using the USC/VNPI. No patient who scored 4-9 recurred. All 11 patients who recurred had multifocal disease and comedo-type necrosis. The probability of disease recurrence after mastectomy for patients scoring 10-12 was 9.6% at 12 years, compared with 0% for those scoring 4-9. There was no difference in overall survival. CONCLUSIONS: There were no recurrences among mastectomy patients who scored 4-9 using the USC/VNPI. Patients scoring 10-12 were significantly more likely to develop recurrence after mastectomy. At risk were young patients with large, high-grade, and multifocal or multicentric tumors. For every 100 patients with USC/VNPI scores of 10-12, 10 patients will recur by 12 years and 2-3 will develop metastatic disease.

A critical intervention in lesbian, gay, bisexual, and transgender health: knowledge and attitude outcomes among second-year medical students.

BACKGROUND: Lesbian, gay, bisexual, and transgender (LGBT) persons represent an underserved population susceptible to health care disparities. DESCRIPTION: In February 2004, we implemented an LGBT health curriculum for students at the University of California at San Francisco. Confidential matched questionnaires elicited students' knowledge, attitudes, and beliefs about LGBT health issues before and after the intervention. EVALUATION: The surveyed population (52% response rate) was demographically similar to the entire class. There was statistically significant change in the responses to 4 of 16 questionnaire items (p