Utilization Outcomes of a Pilot Primary Care Team Redesign.

OBJECTIVES: To evaluate the effect of a team-based primary care redesign on primary care, emergency department (ED) and urgent care (UC) utilization, and new patient access to primary care. STUDY DESIGN: A retrospective pre-post difference-in-differences analysis of utilization outcomes for patients on a redesigned primary care team compared to a standard primary care group. METHODS: Within a patient-centered medical home, a pilot team was developed comprising 2 colocated "teamlets" of 1 physician, 1 nurse practitioner (NP), 1 registered nurse (RN), and 2 licensed practical nurses (LPNs). The redesigned team utilized physician-NP comanagement, expanded roles for RNs and LPNs, and dedicated provider time for telephone and e-mail medicine. We compared changes in number of office, ED, and UC visits during the implementation year for patients on the redesigned team compared to patients receiving the standard of care in the same clinic. Proportion of new patient visits was also compared between the pilot and the control groups. RESULTS: There were no differences between the redesign group and control group in per-patient mean change in office visits (Δ = -0.04 visits vs Δ = -0.07; P = .98), ED visits (Δ = 0.00 vs Δ = 0.01; P = .25), or UC visits (Δ = 0.00 vs Δ = 0.05; P = .08). Proportion of new patient visits was higher in the pilot group during the intervention year compared to the control group (6.6% vs 3.9%; P < .0001). CONCLUSIONS: The redesign did not significantly impact ED, UC, or primary care utilization within 1 year of follow-up. It did improve access for new patients.

Electronic Health Record's Effects on the Outpatient Office Visit and Clinical Education.

BACKGROUND: During an office visit, the provider has the important cognitive task of attending to the patient while actively using the electronic health record (EHR).  Prior literature suggests that EHR may have a positive effect on simple tasks, but a negative effect on tasks that require complex cognitive processes.  No study has examined the provider's perception of EHR on multiple distinct aspects of the office visit. METHODS: We surveyed providers/preceptors regarding their perception of EHR on multiple aspects of the office visit.  We summarized their EHR utilization history and their perceptions of the EHR during the visit using descriptive statistics.  We tested for associations between time spent using the EHR and distinct aspects of the visit using Chi-square tests of association. RESULTS: In total, 83 providers/preceptors reported use of EHR (response rate 52%). Provider/preceptors reported an overall negative effect of EHR on the patient-provider connection, but an overall positive effect on the review of medications/medical records, communication between providers, review of results with patients and review of follow-up to testing results with patients. The effect of EHR on history taking and teaching students was neutral.  We observed no correlation between the provider's time spent using the EHR and their perception of its effectiveness. CONCLUSIONS: Providers reported a positive perception of EHR on aspects of the office visit that involved a single cognitive task.  However, providers reported a negative perception of EHR on patient-provider connection, which involves a high degree of cognitive processing.