Faculty Bibliography

BACKGROUND: Little has been written about physician stress that may be associated with electronic medical records (EMR). OBJECTIVE: We assessed relationships between the number of EMR functions, primary care work conditions, and physician satisfaction, stress and burnout. DESIGN AND PARTICIPANTS: 379 primary care physicians and 92 managers at 92 clinics from New York City and the upper Midwest participating in the 2001-5 Minimizing Error, Maximizing Outcome (MEMO) Study. A latent class analysis identified clusters of physicians within clinics with low, medium and high EMR functions. MAIN MEASURES: We assessed physician-reported stress, burnout, satisfaction, and intent to leave the practice, and predictors including time pressure during visits. We used a two-level regression model to estimate the mean response for each physician cluster to each outcome, adjusting for physician age, sex, specialty, work hours and years using the EMR. Effect sizes (ES) of these relationships were considered small (0.14), moderate (0.39), and large (0.61). KEY RESULTS: Compared to the low EMR cluster, physicians in the moderate EMR cluster reported more stress (ES 0.35, p=0.03) and lower satisfaction (ES -0.45, p=0.006). Physicians in the high EMR cluster indicated lower satisfaction than low EMR cluster physicians (ES -0.39, p=0.01). Time pressure was associated with significantly more burnout, dissatisfaction and intent to leave only within the high EMR cluster. CONCLUSIONS: Stress may rise for physicians with a moderate number of EMR functions. Time pressure was associated with poor physician outcomes mainly in the high EMR cluster. Work redesign may address these stressors.

Challenges persist on how to effectively integrate the electronic health record (EHR) into patient visits and clinical workflow, while maintaining patient-centered care. Our goal was to identify variations in, barriers to, and facilitators of the use of the US Department of Veterans Affairs (VA) EHR in ambulatory care workflow in order better to understand how to integrate the EHR into clinical work. We observed and interviewed 20 ambulatory care providers across three geographically distinct VA medical centers. Analysis revealed several variations in, associated barriers to, and facilitators of EHR use corresponding to different units of analysis: computer interface, team coordination/workflow, and organizational. We discuss our findings in the context of different units of analysis and connect variations in EHR use to various barriers and facilitators. Findings from this study may help inform the design of the next generation of EHRs for the VA and other healthcare systems.

Objectives To examine the associations between racial/ethnic concordance and blood pressure (BP) control, and to determine whether patient trust and medication adherence mediate these associations. Design Cross-sectional study of 723 hypertensive African-American and white patients receiving care from 205 white and African-American providers at 119 primary care clinics, from 2001 to 2005. Racial/ethnic concordance was characterized as dyads where both the patient and physician were of the same race/ethnicity; discordance occurred in dyads where the patient was African-American and the physician was white. Patient perceptions of trust and medication adherence were assessed with self-report measures. The BP readings were abstracted from patients' medical charts using standardized procedures. Results Six hundred thirty-seven patients were in race/ethnic-concordant relationships; 86 were in race/ethnic-discordant relationships. Concordance had no association with BP control. White patients in race/ethnic-concordant relationships were more likely to report better adherence than African-American patients in race/ethnic-discordant relationships (OR: 1.27, 95% CI: 1.01, 1.61, p = 0.04). Little difference in adherence was found for African-American patients in race/ethnic-concordant vs. discordant relationships. Increasing trust was associated with significantly better adherence (OR: 1.17, 95% CI: 1.04, 1.31, p < 0.01) and a trend toward better BP control among all patients (OR: 1.26, 95% CI: 0.97, 1.63, p = 0.07). Conclusions Patient trust may influence medication adherence and BP control regardless of patient-physician racial/ethnic composition.

BACKGROUND: As primary care practices evolve into medical homes, there is an increasing need for effective models to shift from visit-based to population-based strategies for care. However, most medical teams lack tools and training to manage panels of patients. As part of a study comparing different approaches to panel management at the Manhattan and Brooklyn campuses of the VA New York Harbor Healthcare System, we created a toolkit of strategies that non-clinician panel management assistants (PMAs) can use to enhance panel-wide outcomes in smoking cessation and hypertension. METHODS: We created the toolkit using: 1) literature review and consultation with outside experts, 2) key informant interviews with staff identified using snowball sampling, 3) pilot testing for feasibility and acceptability, and 4) further revision based on a survey of primary care providers and nurses. These steps resulted in progressively refined strategies for the PMAs to support the primary care team. RESULTS: Literature review and expert consultation resulted in an extensive list of potentially useful strategies. Key informant interviews and staff surveys identified several areas of need for assistance, including help to manage the most challenging patients, providing care outside of the visit, connecting patients with existing resources, and providing additional patient education. The strategies identified were then grouped into 5 areas -- continuous connection to care, education and connection to clinical resources, targeted behavior change counseling, adherence support, and patients with special needs. CONCLUSIONS: Although panel management is a central aspect of patient-centered medical homes, providers and health care systems have little guidance or evidence as to how teams should accomplish this objective. We created a toolkit to help PMAs support the clinical care team for patients with hypertension or tobacco use. This toolkit development process could readily be adapted to other behaviors or conditions. Trial registration: NCT01677533 (www.clinicaltrials.gov).