Rebecca E. Rdesinski

Simulated electronic health record (Sim-EHR) curriculum: teaching EHR skills and use of the EHR for disease management and prevention.

Electronic health records (EHRs) can improve many aspects of patient care, yet few formal EHR curricula exist to teach optimal use to students and other trainees. The Simulated EHR (Sim-EHR) curriculum was introduced in January 2011 at Oregon Health & Science University (OHSU) to provide learners with a safe hands-on environment in which to apply evidence-based guidelines while learning EHR skills. Using an EHR training platform identical to the OHSU EHR system, learners review and correct a simulated medical chart for a complex virtual patient with chronic diseases and years of fragmented care. They write orders and prescriptions, create an evidence-based plan of care for indicated disease prevention and management, and review their work in a small-group setting. Third-year students complete the Sim-EHR curriculum as part of the required family medicine clerkship; their chart work is assessed using a rubric tied to the curriculum’s general and specific objectives. As of January 2014, 406 third-year OHSU medical students, on campus or at remote clerkship sites, and 21 OHSU internal medicine interns had completed simulated charts. In this article, the authors describe the development and implementation of the Sim-EHR curriculum, with a focus on use of the curriculum in the family medicine clerkship. They also share preliminary findings and lessons learned. They suggest that the Sim-EHR curriculum is an effective, interactive method for providing learners with EHR skills education while demonstrating how a well-organized chart helps ensure safe, efficient, and quality patient care.

The costs of recruitment and retention of women from community-based programs into a randomized controlled contraceptive study.

Study aim. Assessing recruitment and retention activities needed to enroll women identified through community-based programs (such as the Women, Infants, and Children (WIC) program) into a randomized controlled clinical trial on nurse-delivered contraceptives in the home. The majority of women in this study had low socioeconomic status indicators and low levels of education, and the majority were young. Methods. Recruitment sources and number of contact-attempts were collected and analyzed. Full time equivalents needed to undertake these activities were estimated. Results. Two hundred and forty five women were identified in recruiting and enrolling 103 study participants involving 1,232 contact-attempts. Self-referral had the highest ratio of referrals to enrollees (55.6%), while this ratio was the lowest for community outreach (33.3%). Retention activities succeeded in maintaining over 90% of the sample. Ninety-two percent of English-speaking participants completed the study versus 79% of Spanish-speaking participants. The time expenditure per enrollee was 10.4 hours for recruitment and 1.2 hours for retention, with an estimated cost per enrollee of

The influence of nurse home visits, including provision of 3 months of contraceptives and contraceptive counseling, on perceived barriers to contraceptive use and contraceptive use self-efficacy.

324.03 for recruitment and

Access assured: a pilot program to finance primary care for uninsured patients using a monthly enrollment fee.

39.14 for retention. More retention activities were required to maintain women in the comparison group than in the intervention group.

Patient-Provider Communication: Does Electronic Messaging Reduce Incoming Telephone Calls?

OBJECTIVE To identify the influence of a community health nurse (CHN) home visit on perceived barriers to contraceptive access and contraceptive use self-efficacy. METHODS We enrolled 103 women into two groups in a randomized trial evaluating the influence of contraceptive dispensing and family planning counseling during home visits on perceived barriers to accessing contraceptives and contraceptive use self-efficacy. Both groups received counseling by a CHN about sexually transmitted disease and pregnancy prevention, and a resource card listing phone numbers of family planning clinics. After randomization, the CHN dispensed three months of hormonal contraception to the intensive intervention group and advised the minimal intervention group to schedule an appointment at a family planning clinic. Data collection at baseline and 12 months included demographic, reproductive and other health-related information as well as quantitative assessments of information on perceived barriers to contraceptive access and contraceptive use self-efficacy. RESULTS The mean age of participants was 24.7 years. Three-fourths had household incomes under

The association of family continuity with infant health service use.

25,000. We found significant reductions in three perceived barriers to contraceptive access for both groups, as well as significant increases in two measures of contraceptive use self-efficacy at twelve months compared to baseline. CONCLUSION Nurse home visits involving family planning counseling might be effective in reducing perceived barriers to contraceptive access and increasing contraceptive use self-efficacy.

Surgery clerkship evaluations drive improved professionalism

Background: Access Assured is an experimental program being used by 2 academic family medicine practices to deliver primary care to an uninsured patient population using a monthly retainer payment system in addition to a sliding fee schedule for office visits. This prospective cohort study was designed to determine whether patients would join such a program, to describe the population of people who did so, and to assess the programs financial viability. Methods: We used data abstracted from our electronic medical record system to describe the demographic characteristics and care utilization patterns of those patients enrolling during the first year of the study, between February 1, 2008, and January 31, 2009. We also compared 2 subpopulations of enrollees defined by their eligibility for office fee discounts based on income. Results: A total of 600 Access Assured members made 1943 office visits during the study period, receiving a total of 4538.22 relative value units of service. Based on the membership fee, office visit fee collections, and remaining accounts receivable, this resulted in an expected reimbursement rate of

Personal characteristics associated with the effect of childhood trauma on health

42.88 per relative value units. Three hundred one of the 600 (50.2%) patients had incomes above 400% of the federal poverty level (FPL) at the time of each of their office visits and were therefore not eligible for any visit fee discount. Another 156 patients (26.0%) were eligible for a 100% discount of all visit fees based on their income below 200% of the FPL. Using a multivariable Poisson regression analysis of these 2 groups, we determined that age was a significant determinant of return visit rate, with a 0.7% increase in return visit rate for each additional year of age (P = .006). Women had a 26% higher return visit rate than men (P = .001). After accounting for age, sex, and clinic site, fee discount level based on income was not a significant independent determinant of return visit rate (P = .118). Conclusions: A retainer-based program to enroll uninsured patients being used in 2 academic family medicine clinics attracted 600 patients during its first year. The program was financially viable and resulted in an expansion of our service to uninsured patients. More than half of the patients had incomes above 400% of the FPL, suggesting that the population of uninsured Oregonians may be economically more diverse than suspected.

Response: Re: patient-provider communication: Does electronic messaging reduce incoming telephone calls?

Purpose: Internet-based patient portals are increasingly being implemented throughout health care organizations to enhance health and optimize communication between patients and health professionals. The decision to adopt a patient portal requires careful examination of the advantages and disadvantages of implementation. This study aims to investigate 1 proposed advantage of implementation: alleviating some of the clinical workload faced by employees. Methods: A retrospective time-series analysis of the correlation between the rate of electronic patient-to-provider messages—a common attribute of Internet-based patient portals—and incoming telephone calls. The rate of electronic messages and incoming telephone calls were monitored from February 2009 to June 2014 at 4 economically diverse clinics (a federally qualified health center, a rural health clinic, a community-based clinic, and a university-based clinic) related to 1 university hospital. Results: All 4 clinics showed an increase in the rate of portal use as measured by electronic patient-to-provider messaging during the study period. Electronic patient-to-provider messaging was significantly positively correlated with incoming telephone calls at 2 of the clinics (r = 0.546, P < .001 and r = 0.543, P < .001). The remaining clinics were not significantly correlated but demonstrated a weak positive correlation (r = 0.098, P = .560 and r = 0.069, P = .671). Conclusions: Implementation and increased use of electronic patient-to-provider messaging was associated with increased use of telephone calls in 2 of the study clinics. While practices are increasingly making the decision of whether to implement a patient portal as part of their system of care, it is important that the motivation behind such a change not be based on the idea that it will alleviate clinical workload.

Randomized Controlled Trial of Home‐Based Hormonal Contraceptive Dispensing for Women At Risk of Unintended Pregnancy

Purpose: Continuity of care is a fundamental component of family medicine that has been shown to improve health care quality. Family continuity, when different family members are seen by the same clinician or practice, has not been well studied. Methods: We performed a retrospective cohort study of Medicaid enrollees in Oregon using administrative data. Infants were determined to have family continuity if they received well-baby care at the same clinic as that in which their mothers received prenatal care. Results: Of the 1591 infants identified for participation in this study, 749 (47.1%) had family continuity. Infants had a mean of 4.55 well-child visits, 1.23 emergency department visits, and 0.17 hospitalizations in the first 13 months of life. Multivariate analyses found that infants with family continuity had increased numbers of well-child visits (relative risk, 1.05; P = .041), increased numbers of emergency department visits (relative risk, 1.36; P < .0001), and no difference in the number of hospitalizations (relative risk, 0.85; P = .282) when compared with infants without family continuity. Conclusions: Family continuity, when measured at the clinic level, is associated with a variable effect on infant health service use. This finding suggests that clinic-level continuity is not sufficient for achieving all the benefits of continuity.