September/October 2017 Annals of Family Medicine

By a News Reporter-Staff News Editor at Insurance Weekly News -- Primary care physicians spend more than one-half of their workday interacting with the electronic health record during and after clinic hours. Based on data from EHR event logs (an automated tracking feature) and confirmed by direct observation data, researchers from the University of Wisconsin and the American Medical Association found that physicians spent 355 minutes (5.9 hours) of an 11.4 hour workday in the EHR, including 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after hours. Almost half of their total EHR time per day (44 percent) was devoted to clerical tasks and an additional 84 minutes per day (24 percent) was spent managing the inbox. Time spent on EHR activities differed by time of day on weekdays and weekends, with weekend EHR work peaking around 10:00 am and 10:00 pm. A number of factors contribute to physician burnout and increased workload related to the EHR, the authors explain. This includes the amount of time required for documentation (84 minutes) and order entry (43 minutes), as well as the inefficiency and distraction of communicating with team members through the EHR instead of verbally. The authors contend that solutions for common problems in primary care, such as proactive planned care, team-based care, and sharing of clerical tasks, require thoughtful EHR system applications.

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations Brian G. Arndt, MD, et al University of Wisconsin, Madison, Wisconsin

http://www.annfammed.org/content/15/5/419.full

Scribes Significantly Improve Physician Satisfaction With No Negative Effects on Patient Satisfaction

The first randomized controlled trial of scribes finds that they produce significant improvements in physician satisfaction without detracting from patient satisfaction. The use of scribes--team members who document patient encounters in real time under physician supervision--has gained considerable popularity as a strategy to decrease physicians' clerical burden, although high-quality evidence of their effects has been lacking. In this study, over the course of one year, family physicians were randomized to one week in which scribes drafted all relevant documentation, which was reviewed and signed by the physician, followed by one week without a scribe in which physicians performed all charting duties. Scribes improved all aspects of physician satisfaction, including overall satisfaction (OR 10.75) and satisfaction with length of time with patients (OR 3.71), time spent charting (OR 86.09), chart quality (OR 7.25), and chart accuracy (OR 4.61). Scribes had no effect on patient satisfaction and increased the proportion of charts that were completed within 48 hours (OR 1.18, P =.028). Physicians were more satisfied with scribed charts than with their own. Spending less time on documentation, the authors note, frees up physicians to pursue direct clinical care, care coordination, and teaching activities, which they suggest is likely to help prevent physician burnout. Scribes could complement a high-functioning electronic health record and, until electronic records are redesigned for improved functionality, could provide an immediate solution to the clerical burden they entail.

Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial Risha Gidwani, DrPH, et al Stanford University School of Medicine, Stanford, California

http://www.annfammed.org/content/15/5/427.full

Cancer Patients Receive Less Support to Quit Smoking Than Patients With Heart Disease

Although a cancer diagnosis can motivate people to try to quit smoking, a study of British general practitioners finds that physicians are more likely to support smoking cessation in primary care patients with coronary heart disease than those with cancer, and patients with cancer are less likely to stop smoking. Using electronic primary care records, 12,393 incident cases of lung, bladder and upper aerodigestive tract cancers diagnosed between 1999-2013 were matched 1:1 with incident coronary heart disease cases. At diagnosis, 32 percent of patients with cancer and 18 percent of patients with coronary heart disease smoked. In a retrospective cohort study, researchers found that people with cancer were less likely than controls to have smoking status recorded by their GP (37 percent versus 78 percent), be given advice to quit smoking (23 percent versus 45 percent), or be prescribed smoking cessation medication (12 percent versus 21 percent). Of the 3,706 cancer/heart disease patients who smoked at diagnosis and had at least one smoking status update in the year following diagnosis, 1,359 (37 percent) of patients with cancer and 1,645 (44 percent) of patients with heart disease stopped smoking. Confining the analysis to patients who smoked at the time of diagnosis and to those with a better prognosis did not change these findings except that the difference in prescription of pharmacotherapy was no longer apparent. The frequency of recording of smoking status, advice and pharmacotherapy increased after introduction of incentive payments for GPs to manage smoking but there were no differences in the rates of quitting. The authors call for improvements in the management of smoking cessation by GPs for patients with cancer.

Physician Support of Smoking Cessation After Diagnosis of Lung, Bladder or Upper Aerodigestive Tract Cancer Amanda Farley PhD, et al University of Birmingham, Edgbaston, Birmingham,United Kingdom

http://www.annfammed.org/content/15/5/443.full

Affordable Care Act is Expanding Health Insurance Coverage to More Patients, Although Differences Remain

Expansion of Medicaid coverage under the Affordable Care Act has contributed to sizeable decreases in medical visits in which people were uninsured. This is true across all racial and ethnic groups, although disparities remain. Using electronic health record data from 10 states that expanded Medicaid and six states that did not, a new study examined 359 community health centers and 870,319 patients with more than four million visits. Rates of Medicaid-insured visits increased in expansion states for all racial/ethnic groups immediately following ACA Medicaid expansion, whereas no significant change was observed for Medicaid-insured visits for any racial/ethnic group in non-expansion states. Rates of uninsured visits decreased for all racial/ethnic groups in both expansion and non-expansion states, but the declines were more immediate and pronounced in expansion states. Specifically, rates of Medicaid-insured visits in expansion states increased 60 percent from before the ACA to after its implementation among non-Hispanic whites (rate ratio [RR]=1.60; 95 percent confidence interval, 1.44-1.78), 77 percent for Hispanics (RR=1.77; 95 percent CI, 1.56-2.02), and 40 percent for non-Hispanic blacks (RR=1.40; 95percent CI, 1.23-1.61). The most notable changes in non-expansion states were in private insurance visit rates: all racial/ethnic groups increased significantly in the post-implementation period, with Hispanics utilizing community health centers with private coverage at 3.6 times their rate prior to the ACA. This suggests that fewer Hispanic patients were eligible for Medicaid and therefore sought private coverage to comply with the ACA's individual mandate. In spite of these improvements, disparities remain. For example, Hispanic patients had the highest uninsured visit rates before Medicaid expansion and, after Medicaid expansion, a significantly smaller decline in rates of uninsured visits than non-Hispanic whites and non-Hispanic blacks. Thus, gaps in Medicaid coverage appear to have continued for Hispanic patients while disparities have been reduced for non-Hispanic blacks. These findings suggest the need for continued and more equitable insurance expansion efforts to eliminate health insurance disparities.

Uninsured Primary Care Visit Disparities Under the Affordable Care Act Heather Angier, MPH, et al Oregon Health & Science University, Portland, Oregon

http://www.annfammed.org/content/15/5/434.full

Trustworthiness and Public Investment in Clinical Practice Guidelines

Although clinical practice guidelines should be based on high quality research and practice experience, they vary in their relevance to practice, use of evidence, and other factors. Researchers have now developed the Guideline Trustworthiness, Relevance, and Utility Scoring Tool (G-TRUST), a tool for clinicians to identify useful practice guidelines. Twenty-two experts in evidence-based medicine, 17 developers of high-quality guidelines, and one consumer representative participated in a modified Delphi process to obtain consensus on a checklist of items and their relative impact on guideline quality. More than 75 percent of experts found three of the eight checklist items to be major indicators of guideline usefulness and, in comparison to a reference standard (the AGREE tool), a scoring system was developed identifying guidelines as "useful," "may not be useful," and "not useful." The eight-item checklist identified 92 percent of low-quality guidelines and disqualified many high quality guidelines because of a stricter definition of trustworthiness, including more stringent conflict of interest requirements. With the proliferation of practice guidelines, numbering in the thousands, the authors call for research to determine the reliability of G-TRUST and to examine how the tool might interact with technology, such as smart phone applications.

Keywords for this news article include: Cancer, Medicaid, Oncology, Cardiology, Health Policy, Pharmacotherapy, Community Health, Health Insurance, Clinical Research, Affordable Care Act, Information Technology, Electronic Medical Records, Clinical Trials and Studies, American Academy of Family Physicians, Cardiovascular Diseases and Conditions.

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