Nicole Isaacson

Bridging Primary Care Practices and Communities to Promote Healthy Behaviors

BACKGROUND Primary care practices able to create linkages with community resources may be more successful at helping patients to make and sustain health behavior changes. METHODS Health behavior-change interventions in eight practice-based research networks were examined. Data were collected July 2005-October 2007. A comparative analysis of the data was conducted to identify and understand strategies used for linking primary care practices with community resources. RESULTS Intervention practices developed three strategies to initiate and/or implement linkages with community resources: pre-identified resource options, referral guides, and people external to the practice who offered support and connection to resources. To initiate linkages, practices required the capacity to identify patients, make referrals, and know area resources. Linkage implementation could still be defeated if resources were not available, accessible, affordable, and perceived as valuable. Linkages were facilitated by boundary-spanning strategies that compensated for the lack of infrastructure between practices and resources, and by brokering strategies that identified interested community partners and aided mutually beneficial connections with them. Linkages were stronger when they incorporated practice or resource abilities to motivate the patient, such as brief counseling or postreferral outreach. Further, data suggested that sustaining linkages requires continuous attention and ongoing communication between practices and resources. CONCLUSIONS Creating linkages between primary care practices and community resources has the potential to benefit both patients and clinicians and to lessen the burden on the U.S. healthcare system resulting from poor health behaviors. Infrastructure support and communication systems must be developed to foster sustainable linkages between practices and local resources.

Variation in Electronic Prescribing Implementation Among Twelve Ambulatory Practices

BackgroundElectronic prescribing has been advocated as an important tool for improving the safety and quality of medication use in ambulatory settings. However, widespread adoption of e-prescribing in ambulatory settings has yet to be realized. The determinants of successful implementation and use in these settings are not well understood.ObjectiveTo describe the practice characteristics associated with implementation and use of e-prescribing in ambulatory settings.DesignMulti-method qualitative case study of ambulatory practices before and after e-prescribing implementation.ParticipantsSixteen physicians and 31 staff members working in 12 practices scheduled for implementation of an e-prescribing program and purposively sampled to ensure a mix of practice size and physician specialty.MeasurementsField researchers used observational and interview techniques to collect data on prescription-related clinical workflow, information technology experience, and expectations.ResultsFive practices fully implemented e-prescribing, 3 installed but with only some prescribers or staff members using the program, 2 installed and then discontinued use, 2 failed to install. Compared to practice members in other groups, members of successful practices exhibited greater familiarity with the capabilities of health information technologies and had more modest expectations about the benefits likely to accrue from e-prescribing. Members of unsuccessful practices reported limited understanding of e-prescribing capabilities, expected that the program would increase the speed of clinical care and reported difficulties with technical aspects of the implementation and insufficient technical support.ConclusionsPractice leaders should plan implementation carefully, ensuring that practice members prepare for the effective integration of this technology into clinical workflow.

Online Diaries for Qualitative Evaluation: Gaining Real-Time Insights

Interactive online diaries are a novel approach for evaluating project implementation and provide real-time communication between evaluation staff members and those implementing a program. Evaluation teams can guide the lines of inquiry and ensure that data are captured as implementation develops. When used together with conventional evaluation strategies, interactive online diaries allow for an in-depth understanding of project implementation, as well as the challenges program staff members confront and the solutions they develop. Interactive online diaries also can help evaluators address challenges such as self-reporting bias, documenting project evolution, and capturing implementers’ ongoing insights as they develop. These insights might otherwise be lost to the evaluation process. The authors describe the development and use of this online approach in the evaluation of a foundation-sponsored program to improve the provision of preventive care in physicians’ offices. The program included 17 practice-based research networks and their participating primary care practices.

Early Adopters of Electronic Prescribing Struggle to Make Meaningful Use of Formulary Checks and Medication History Documentation

Introduction: Use of electronic prescribing (e-prescribing) can improve safety and reduce costs of care by alerting prescribers to drug-drug interactions, patient nonadherence to therapies, and insurance coverage information. Deriving these benefits will require clinical decision support based on presentation of accurate and complete formulary and benefit (F&B) and medication history (RxH) data to prescribers, but relatively little is known about how this information is used in primary care. Methods: This is a multimethod comparative case study of 8 practices, which were selected to ensure practice size and physician specialty variation, implementing a stand-alone e-prescribing program. Field researchers observed prescription workflow and interviewed physicians and office staff. Results: Before implementation, few prescribers reported using F&B references when making medication choices; all used paper-based methods for tracking medication history. After implementation, some prescribers reported using F&B data to inform medication choices but missing information reduced confidence in these resources. Low confidence in RxH data led to paper-based workarounds. Conclusions: Challenges experienced with formulary checks and RxH documentation led to prescriber distrust and unwillingness to rely on e-prescribing-based information. Greater data accuracy and completeness must be assured if e-prescribing is to meet meaningful use objectives to improve the efficiency and safety of prescribing in primary care settings.

Coordination of Health Behavior Counseling in Primary Care

PURPOSE We wanted to examine how coordinated care is implemented in primary care practices to address patients’ health behavior change needs. METHODS Site visit notes, documents, interviews, and online implementation diaries were collected from July 2005 to September 2007 from practice-based research networks (PBRNs) participating in Prescription for Health: Promoting Healthy Behaviors in Primary Care Research Networks (P4H). An iterative group process was used to conduct a cross-case comparative analysis of 9 interventions. Published patient outcomes reports from P4H interventions were referenced to provide information on intervention effectiveness. RESULTS In-practice health risk assessment (HRA) and brief counseling, coupled with referral and outreach to a valued and known counseling resource, emerged as the best way to consistently coordinate and encourage follow-through for health behavior counseling. Findings from published P4H outcomes suggest that this approach led to improvement in health behaviors. Automated prompts and decision support tools for HRA, brief counseling and referral, training in brief counseling strategies, and co-location of referral with outreach facilitated implementation. Interventions that attempted to minimize practice or clinician burden through telephone and Web-based counseling systems or by expanding the medical assistant role in coordination of health behavior counseling experienced difficulties in implementation and require more study to determine how to optimize integration in practices. CONCLUSIONS Easy-to-use system-level solutions that have point-of-delivery reminders and decision support facilitate coordination of health behavior counseling for primary care patients. Infrastructure is needed if broader integration of health behavior counseling is to be achieved in primary care.

The “fetus-infant”: Changing classifications ofIn Utero development in medical texts

This paper examines several aspects of the changing cultural classifications of reproduction through a close reading of obstetrics textbooks. Through the discursive construction of the fetus in obstetric texts, medical accounts are beginning to classify the fetus as a baby. In investigating this transformation, I focus upon two cognitive processes: the splitting of the fetus apart from the pregnant woman and the concurrent lumping of two distinct mental entities—a fetus and an infant into one new medical category: the fetus-infant. In addition, textual evidence shows a shift in cognitive orientation away from classifying fetuses based on gestational age to an emphasis on what I term functional age. Further, new knowledge enables physicians to affect functional age, making the fetus with mature function in utero conceptually no different from a baby.

The Patient Medication List: Can We Get Patients More Involved in Their Medical Care?

Background: Patient involvement is essential to maintain accurate and updated medication lists, provide quality care, and decrease potential errors. The purpose of this study was to determine the acceptance of medication lists maintained by patients and if their use affected perceptions of patient and physician responsibility and patients’ knowledge of their medical care. Methods: A foldable, wallet-sized medication list card was distributed to a convenience sample of 104 patients ≥40 years of age at an outpatient residency site. They were also given a survey of demographic variables and the Patient Medication Scale, which measures their perceptions of patient responsibility, physician responsibility, and patients’ knowledge of their medical care. They were contacted by phone 4 to 11 months later to ascertain if they were using the medication card and the Patient Medication Scale was readministered. Results: Forty-two of 66 patients contacted after the intervention consented to a full interview. Thirty-eight percent (25 of 66) reported using the card. The patients using the card showed increased scores in perceived patient knowledge and patient responsibility, with no change in their perceptions of physician responsibility. Among the 41 respondents not using the card, approximately half indicated interest in using the card in the future or were using a card of their own. Conclusions: A significant percentage of patients were willing to use the medication list card. Use of the card also seemed to increase their sense of responsibility and perceived knowledge of their medical care.

Examining Role Change in Primary Care Practice

Purpose: While experts suggest that primary care needs far-reaching transformation that includes adding or reconfiguring roles to improve patient care, little is known about how role change occurs in practice settings. Methods This was a cross-case comparative analysis of 3 projects designed to improve health behavior counseling in primary care practices by adding to or changing clinical support staff roles. Qualitative data (site visits notes, grantee reports, interviews with grantees, and online diary entries) were analyzed to examine instances of role change in depth, using role change theory as an organizing framework. Results Practice team members had greater success taking on new roles when patients valued the services provided. Often, it was easier to a hire a new person into a new role rather than have an existing practice member shift responsibilities. This was because new personnel had the structural autonomy, credibility, and organizational support needed to develop new responsibilities and routines. Conclusion: As primary care delivery systems are redesigned in ways that rely on new roles to deliver care, understanding how to effectively add or change staff roles is essential and requires attention to patients’, practice members’, and institutions’ support for new roles.