Elizabeth G. Baxley

Use of ED diagnosis to determine medical necessity of EMS transports

Objective. To examine interrater agreement for classifying emergency medical services transports as medically unnecessary using emergency department diagnosis as the sole determining factor. Methods. Three emergency physicians andtwo family medicine physicians classified 913 International Classification of Diseases, Ninth Revision (ICD-9) codes as medically necessary, unnecessary, or uncertain. Overall agreement, interrater agreement, andagreement within 17 major disease categories were measured using κ statistics in SAS. Results. Physicians rated between 25% and65% of diagnoses codes as medically unnecessary. Overall agreement was fair (κ = 0.31). Agreement within specialties was higher among family medicine–trained physicians than among emergency physicians (κ = 0.52 andκ = 0.22, respectively). Agreement across all raters was highest for diseases classified as symptoms, signs, andill-defined conditions (κ = 0.40) andlowest for diseases of the blood andblood-forming organs (κ = −0.17). Agreement was observably better between physicians with more experience. Conclusions. Considerable doubts about the utility of emergency department diagnosis as a criterion are raised from study findings. Further development of Neely Conference criteria is needed. Priority should be given to testing andvalidation of criteria as well as exploration of differences in judgment between specialists representative of the medical director profession.

Medically Unnecessary Emergency Medical Services (EMS) Transports Among Children Ages 0 to 17 Years

Objectives: Estimate the prevalence of medically unnecessary Emergency Medical Services (EMS) transports among children. Methods: We linked EMS and emergency department (ED) billing records for all EMS-to-hospital transports of children originating in three counties in South Carolina between January 1, 2001 and March 31, 2003. EMS responses resulting in no transport, transports to destinations other than the ED, or multiple trips for the same child in a single day could not be linked to ED data and were excluded. Medically unnecessary transports were identified with an algorithm using pre-hospital impressions, ED diagnoses and ED procedures. After exclusions, 5,693 transports of children between 0 and 17 years were available for study. Results: Sixteen percent (16.4%) of all transports were medically unnecessary. Among children through age 12, upper respiratory and viral problems were the most common diagnoses associated with medically unnecessary transports; among older children, behavioral problems such as conduct disturbance or drug abuse were common. In multivariable analysis, the odds of an unnecessary transport were higher among younger children, non-white children, rural children, and children insured by Medicaid. Conclusions: The proportion of EMS transports which may be medically unnecessary is relatively modest compared to previous studies. However, many questions remain for future research. Further investigation should include examination of primary care availability and occurrence of unnecessary EMS use, existence of race-based disparities, and transports involving conduct disturbance and other behavioral conditions among children.

Program-Centered Education: A New Model for Faculty Development

Background: We describe a program-focused faculty development model that has been implemented across 7 family medicine residency programs. Description: The South Carolina Faculty Development Initiative (SCFDI) targets residency program faculty as a group. The SCFDI assesses training needs of the target faculty through the use of qualitative and quantitative information obtained from faculty, residents, and staff of each residency. Internal comparisons of faculty, resident and staff views, coupled with comparisons across residencies, are used to develop each programs curriculum. A longitudinal series of faculty development workshops is conducted at the programs facility, with all faculty participating simultaneously. Evaluation: The 34 workshops presented involved 90% of the eligible faculty. Attendees ranked presentations highly for quality, scholarship, applicability to faculty role, as well as usefulness to themselves and their program. Conclusions: A program-specific model of faculty development, wit...

OSTEOPOROSIS RECOGNITION: CORRECTING GEHLBACH ET AL.

Gehlbach et al.1 analyzed 1993–1997 data from the National Ambulatory Medical Care Survey (NAMCS) to determine the degree to which primary care physicians recognized osteoporosis. The authors’ analysis suggested that primary care physicians were underdiagnosing and, in consequence, undertreating this condition. Specifically, Gehlbach et al. reported that fewer than 2% of elderly White women were correctly diagnosed, while the estimated prevalence in this age group was 29%. (The report cited for this prevalence estimate2 excluded women who had ever received hormone therapy, and thus does not provide a population-based estimate.) Gehlbach et al. based their conclusions on the diagnoses associated with the patient’s current office visit. They did not examine a condition-specific checklist included on the NAMCS survey form. In 1993 and 1994, physicians were asked whether patients had any of 5 conditions in addition to the presenting complaint: asthma, diabetes, HIV, obesity, or osteoporosis. We reassessed physicians’ recognition of osteoporosis using this check-off item. Like Gehlbach et al., we obtained NAMCS data sets and limited the analysis to White women aged 60 years and older visiting primary care physicians: family physicians, general practitioners, internists, obstetricians, and gynecologists. We also included geriatricians, which were not explicitly mentioned by Gehlbach et al. but, based on raw visit counts, were included in their analysis. In addition, we corrected a methodological flaw in the analysis of Gehlbach et al. by using weighting procedures appropriate to the NAMCS’s stratified design. In 1993, 13.4% of visits involved women with diagnosed osteoporosis. Age-specific prevalence was 7.3% among women aged 60 through 69 years, 13.8% among women aged 70 through 79 years, and 25.4% among women aged 80 years and older. In 1994, 9.5% of visits involved women with osteoporosis, with a prevalence of 5.8% among women aged 60 through 69 years, 9.05% among women aged 70 through 79 years, and 18.1% among women aged 80 years and older. Gehlbach and colleagues’ characterization of “low rates of recognition and treatment”1 by primary care physicians is not supported by a correct analysis of NAMCS data. Rather, physicians’ recognition of osteoporosis paralleled what one might expect to find in a visit-based group of women.3,4 Although there was room for improvement, the data do not suggest that physicians were failing to recognize osteoporosis in 1993 and 1994. There were no clinical guidelines in place at that time recommending routine or universal screening for osteoporosis. The presence of errors in a report by established investigators reminds us all to be cognizant of definitions and restrictions when analyzing secondary data. Review of data fields, appropriate weighting to reflect the sampling design, and acknowledgement of statistically unreliable estimates are essential. Such care is particularly important for sponsored research.

ELECTRONIC HEALTH RECORDS IN ACADEMIC FAMILY MEDICINE PRACTICES: A TALE OF PROGRESS AND OPPORTUNITY

The Future of Family Medicine report called for an electronic health record (EHR) that assures integration of clinical information; provides decision-support based on evidence-based guidelines; generates chronic disease registries; tracks health maintenance interventions; and supports practice-based research and quality improvement activities. Yet, the substantial organizational, financial, and intellectual challenges of implementing EHRs in academic departments have been previously outlined.1 ADFM recently conducted an all-member electronic survey (response rate 61%) to assess the status of implementation within the context of these challenges. Sixty-two percent of the department clinical practices are owned by their universities and 25% by their sponsoring hospital. The overwhelming majority (89%) include faculty and learners practicing together, highlighting the imperative we have to model effective practice redesign. Nearly all respondents have either implemented EHRs (72%) or plan to within the next 12 months (18%). Use of EHRs is a relatively new experience for departments, with 64% reporting use for 5 years or less. This level of incorporation is likely enabled by the fact that the majority of these systems are owned and upgraded by the university (38%) or health system (34%), with only 12% of departments owning their own EHRs. Clinical information is largely recorded (61%) through a mix of template and free-text entry. Nearly all EHRs (87%) have prescription writer capabilities, and 89% provide drug safety information at the point-of-care. However, only 38% provide drug cost information and fewer than one-half (49%) provide drug information handouts for patients. In nearly two-thirds (65%) of cases, lab studies and other ancillaries flow into the chart electronically, allowing for serial comparisons. Quality improvement capabilities of EHRs are insufficient. Over one-half (53%) report having no built-in point-of-care decision support; though nearly one-third (29%) plan to have such within the year. Only 42% of the time is decision support available for clinical preventive services, while fewer than one-third (31%) of respondents report having chronic disease care reminders. Lack of patient registries is a similar barrier to the provision of high quality disease care, with an astonishing 61% of departments reporting that they do not have a functioning registry within their EHR. A number have addressed this by creating or purchasing their own superimposed registry. Two-thirds (67%) of respondents regularly measure quality indicators for their practice(s) as a whole, and one-half (52%) do so for individual clinicians in the practice. Fewer than one-half (49%) of academic practices have HIPAA-compliant Web access for patients. For those who do, 31% have a Web site for practice information; 26% allow patients to request appointments; and 23% have capability for patients to request prescription refills. Only 15% allow for e-visits with a nurse or clinician, while only 8% allow patients electronic access to portions of their health record. Academic practices face 2 imperatives: providing high quality care to their patients, and effectively demonstrating elements of the patient-centered medical home to students, residents, and our parent health systems. This survey of academic departments suggests that EHRs are quickly becoming a reality in our teaching practices. While we have benefited from the start-up capital and technologic expertise offered by our large, affiliated health science centers, we are also struggling with the challenges of slow implementation and lack of incorporation of important items such as decision support, registry use, quality indicator reporting, and electronic communication that are hallmarks of the Future of Family Medicine report. Our departments must take an active role in the redesign of our teaching practices to be patient-centered medical homes (PC-MH), maximally utilizing available technology to aid in this journey. Our parent health systems may not share this vision, and thus, may not be responsive to our needs and requests. Hiring or training faculty members who are technologically savvy will help develop the internal expertise we need to modify our EHRs for more rapid improvement efforts. We must also be strong advocates for, and demonstrate the effectiveness of, a well-designed ambulatory EHR in helping us provide higher quality care at a lower cost to the patient and the health system. This initially may require creating or purchasing our own “add-ons”, such as disease registries or secure practice Web sites for e-visits. Ultimately, playing a central leadership role in system-wide EHR implementation or revisions will likely to produce substantially better, and more sustainable, results. Much education remains to be done, and there is a compelling need for us to find ways to sell this vision to our health systems, lest we lose the opportunity to truly model patient-centered practice to our learners.

ADVANCED ACCESS IN ACADEMIC SETTINGS: DEFINITIONAL CHALLENGES

Enhanced access to care is a hallmark of the patient-centered medical home. The first standard in National Committee for Quality Assurance (NCQA) criteria for certification as a medical home requires that practices have written standards for patient access and communication, and that they use data

The Teachers of Quality Academy: A Learning Community Approach to Preparing Faculty to Teach Health Systems Science.

Problem Although efforts to integrate health systems science (HSS) topics, such as patient safety, quality improvement (QI), interprofessionalism, and population health, into health professions curricula are increasing, the rate of change has been slow. Approach The Teachers of Quality Academy (TQA), Brody School of Medicine at East Carolina University, was established in January 2014 with the dual goal of preparing faculty to lead frontline clinical transformation while becoming proficient in the pedagogy and curriculum design necessary to prepare students in HSS competencies. The TQA included the completion of the Institute for Healthcare Improvement Open School Basic Certificate in Quality and Safety; participation in six 2-day learning sessions on key HSS topics; completion of a QI project; and participation in three online graduate courses. Outcomes Twenty-seven faculty from four health science programs completed the program. All completed their QI projects. Nineteen (70%) have been formally engaged in the design and delivery of the medical student curriculum in HSS. Early into their training, TQA participants began to apply new knowledge and skills in HSS to the development of educational initiatives beyond the medical student curriculum. Next Steps Important next steps for TQA participants and program planners include further incorporation as faculty advisors and contributors to the full implementation of the longitudinal HSS curriculum; expanded involvement with the Leaders in Innovative Care Scholars student leadership distinction track; continued in-depth evaluation of the impact of TQA participation on patient care, teaching, and role modeling; and the recruitment of the next cohort of TQA participants.

Organized Continuity Panel Reassignment

BACKGROUND Structured continuity clinical experience is required in all primary care residency programs. There is a paucity of data on whether continuity patient panels are routinely used, what the ideal panel composition is, how panels are managed within residency programs across the country, and the outcomes related to this training requirement. METHODS We designed an organized continuity panel reassignment process with the goal of producing balanced resident panels, that is, panels with similar numbers of patients by race/ethnicity, sex, and age group, as well as comparable numbers of patients with diabetes and those with high health care use. This project focused on postgraduate year-1 (PGY-1) panels to use balanced panels for redesign and focus of their initial training experiences on practice-based learning and patient care continuity. RESULTS Findings suggest improved parity in patient care experiences through more evenly distributed panels. Furthermore, the focus on panel review and case management enhanced the curriculum for PGY-1 residents, whose clinical experiences and diabetes clinical quality indicators compared more favorably to residents in earlier classes. CONCLUSIONS Balanced continuity panels provide an enhanced substrate for building clinical curricula. Preliminary data suggest that this process helped contribute to improved quality indicators for patients with diabetes.

The impact of resident physician coverage on emergency department visits in South Carolina.

Background This study examines emergency department (ED) visits to assess the potential impact on rural and minority patients if the practice of resident moonlighting was limited. Methods Billing data from all South Carolina ED visits in 1998 were linked to the physician licensure file. Logistic regression analysis was performed to determine patient characteristics predictive of being seen by a resident physician. Results Resident physicians attended 3.4% of visits for patients residing in rural areas and 1.4% of those from urban areas. The odds of being treated by a resident were higher among persons living in health professional shortage-designated or rural areas, minorities, and persons with government insurance. Conclusion Patients from vulnerable populations have greater odds of being seen by a resident physician for an ED visit. These populations may be placed at risk for reduced access to health care services if limitations on resident physician moonlighting impair the ability of rural hospitals to staff EDs.

A systems-based approach to improving educational quality via community-oriented faculty development.

No abstract available.