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Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as <140/90 mm Hg, improved from 31.8% in 1999–2000 to 48.5% in 2007–2008, it remained stable through 2013–2014 and declined to 43.7% in 2017–2018. To address the rapid decline in hypertension control, the National Heart, Lung, and Blood Institute and the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention convened a virtual workshop with multidisciplinary national experts. Also, the group sought to identify opportunities to reverse the adverse trend and further improve hypertension control. The workshop immediately preceded the Surgeon General's Call to Action to Control Hypertension, which recognized a stagnation in progress with hypertension control. The presentations and discussions included potential reasons for the decline and challenges in hypertension control, possible "big ideas," and multisector approaches that could reverse the current trend while addressing knowledge gaps and research priorities. The broad set of "big ideas" was comprised of various activities that may improve hypertension control, including: interventions to engage patients, promotion of self-measured BP monitoring with clinical support, supporting team-based care, implementing telehealth, enhancing community–clinical linkages, advancing precision population health, developing tailored public health messaging, simplifying hypertension treatment, using process and outcomes quality metrics to foster accountability and efficiency, improving access to high-quality health care, addressing social determinants of health, supporting cardiovascular public health and research, and lowering financial barriers to hypertension control. [ABSTRACT FROM AUTHOR]

Objectives: To identify the unmet information needs of clinical teams delivering care to patients with complex medical, social, and economic needs; and to propose principles for redesigning electronic health records (EHR) to address these needs.Materials and Methods: In this observational study, we interviewed and observed care teams in 9 community health centers in Oregon and Washington to understand their use of the EHR when caring for patients with complex medical and socioeconomic needs. Data were analyzed using a comparative approach to identify EHR users' information needs, which were then used to produce EHR design principles.Results: Analyses of > 300 hours of observations and 51 interviews identified 4 major categories of information needs related to: consistency of social determinants of health (SDH) documentation; SDH information prioritization and changes to this prioritization; initiation and follow-up of community resource referrals; and timely communication of SDH information. Within these categories were 10 unmet information needs to be addressed by EHR designers. We propose the following EHR design principles to address these needs: enhance the flexibility of EHR documentation workflows; expand the ability to exchange information within teams and between systems; balance innovation and standardization of health information technology systems; organize and simplify information displays; and prioritize and reduce information.Conclusion: Developing EHR tools that are simple, accessible, easy to use, and able to be updated by a range of professionals is critical. The identified information needs and design principles should inform developers and implementers working in community health centers and other settings where complex patients receive care. [ABSTRACT FROM AUTHOR]

Integrated behavioral health and primary care is a patient-centered approach designed to address a person's physical, emotional, and social healthcare needs. Increasingly, practices are integrating care to help achieve the Quadruple Aim, yet no studies have examined, using qualitative methods, patients' experiences of care in integrated settings. The purpose of this study was to examine patients' experiences of care in community- based settings integrating behavioral health and primary care. This is a qualitative study of 24 patients receiving care across five practices participating in Advancing Care Together (ACT). ACT was a 4-year demonstration project (2010-2014) of primary care and community mental health centers (CMHCs) integrating care. We conducted in-depth interviews in 2014 and a multidisciplinary team analyzed data using an inductive qualitative descriptive approach. Nineteen patients described receiving integrated care. Both primary care and CMHC patients felt cared for when the full spectrum of their needs, including physical, emotional, and social circumstances, were addressed. Patients perceived personal, interpersonal, and organizational benefits from integrated care. Interactions with integrated team members helped patients develop and/or improve coping skills; patients shared lessons learned with family and friends. Service proximity, provider continuity and trust, and a number of free initial behavioral health appointments supported patient access to, and engagement with, integrated care. In contrast, patients' prior experience, provider "mismatch," clinician turnover, and restrictive insurance coverage presented barriers in accessing and sustaining care. Patients in both primary care and CMHCs perceived similar benefits from integrated care related to personal growth, improved quality, and access to care. Policy makers and practice leadership should attend to proximity, continuity, trust, and cost/coverage as factors that can impede or facilitate engagement with integrated care. [ABSTRACT FROM AUTHOR]

Objective: The federal meaningful use (MU) program was aimed at improving adoption and use of electronic health records, but practicing physicians have criticized it. This study was aimed at quantifying the benefits (ie, usefulness) and burdens (ie, workload) of the MU program for practicing family physicians.Materials and Methods: An interdisciplinary national panel of experts (physicians and engineers) identified the work associated with MU criteria during patient encounters. They conducted a national survey to assess each criterion's level of patient benefit and compliance burden.Results: In 2015, 480 US family physicians responded to the survey. Their demographics were comparable to US norms. Eighteen of 31 MU criteria were perceived as useful for more than half of patient encounters, with 13 of those being useful for more than two-thirds. Thirteen criteria were useful for less than half of patient encounters. Four useful criteria were reported as having a high compliance burden.Discussion: There was high variability in physicians' perceived benefits and burdens of MU criteria. MU Stage 1 criteria, which are more related to basic/routine care, were perceived as beneficial by most physicians. Stage 2 criteria, which are more related to complex and population care, were perceived as less beneficial and more burdensome to comply with.Conclusion: MU was discontinued, but the merit-based incentive payment system within the Medicare Access and CHIP Reauthorization Act of 2015 adopted its criteria. For many physicians, MU created a significant practice burden without clear benefits to patient care. This study suggests that policymakers should not assess MU in aggregate, but as individual criteria for open discussion. [ABSTRACT FROM AUTHOR]

Objectives. Little is known about clinicians' use of prescription drug monitoring program (PDMP) profiles in decision-making. The objective of this qualitative study was to understand how clinicians use, interpret, and integrate PDMP profiles with other information in making clinical decisions. Design. Qualitative interviews of clinician PDMP users. Setting. Oregon registrants in the state's PDMP. Subjects. Thirty-three clinicians practicing in primary care, emergency medicine, pain management, psychiatry, dentistry, and surgery. Methods. We conducted semistructured telephone interviews with PDMP users. A multidisciplinary team used a grounded theory approach to identify patterns of PDMP use and how PDMP profiles influence clinical decisions. Results. PDMP use varied from consistent monitoring to checking the PDMP only on suspicion of misuse, with inconsistent use reported particularly among short-term prescribers. Primary care clinicians reported less routine use with existing pain patients than with new patients. In response to worrisome PDMP profiles with new patients, participants reported declining to prescribe, except in the case of acute, verifiable conditions. Long-term prescribers reported sometimes continuing prescriptions for existing patients depending on perceived patient intent, honesty, and opioid misuse risk. Some long-term prescribers reported discharging patients from their practices due to worrisome PDMP profiles; others expressed strong ethical grounds for retaining patients but discontinuing controlled substances. Conclusion. Greater consistency is needed in use of PDMP in monitoring existing patients and in conformity to guidelines against discharging patients from practice. Research is needed to determine optimal approaches to interpreting PDMP profiles in relation to clinical judgment, patient screeners, and other information. [ABSTRACT FROM AUTHOR]

Objectives. Clinician communication with patients regarding worrisome findings in Prescription Drug Monitoring Programs (PDMPs) may influence patient responses and subsequent care. The authors studied the range of approaches clinicians report when communicating with patients in this situation and how practice policies and procedures may influence this communication. Design. Qualitative interviews of clinician PDMP users. Setting: Oregon registrants in the state's PDMP. Subjects. Thirty-three clinicians practicing in pain management, emergency medicine, primary care, psychiatry, dentistry, and surgery. Methods. The authors conducted semi-structured interviews via telephone with clinicians who routinely used the PDMP. A multidisciplinary team used a grounded theory approach to identify ways clinicians reported using information from the PDMP when communicating with patients, and policies that influenced that communication. Results. Clinicians reported using a range of approaches for communicating about PDMP results, from openly sharing, to questioning patients without disclosing access to the PDMP, to avoiding the conversation. Clinicians also reported practice policies and procedures that influenced communication with their patients about prescribing and ongoing care, including policies that normalized use of the PDMP with all patients and those that facilitated difficult conversations by providing a rationale not to prescribe in certain circumstances. Conclusion. Clinicians' self-reported approaches to sharing PDMP findings and communicating prescribing decisions with patients vary and may be facilitated by appropriate practice policies. Such communication may have implications for patient engagement and alliance building. More research is needed to identify best practices and potential guidelines for effectively communicating about PDMP findings, as this may enhance health outcomes. [ABSTRACT FROM AUTHOR]

Objectives Prescription drug monitoring programs ( PDMPs) are now active in most states to assist clinicians in identifying potential controlled drug misuse, diversion, or excessive prescribing. Little is still known about the ways in which they are incorporated into workflow and clinical decision making, what barriers continue to exist, and how clinicians are sharing PDMP results with their patients. Design Qualitative data were collected through online focus groups and telephone interviews. Setting Clinicians from pain management, emergency and family medicine, psychiatry/behavioral health, rehabilitation medicine, internal medicine and dentistry participated. Patients Thirty-five clinicians from nine states participated. Methods We conducted two online focus groups and seven telephone interviews. A multidisciplinary team then used a grounded theory approach coupled with an immersion-crystallization strategy for identifying key themes in the resulting transcripts. Results Some participants, mainly from pain clinics, reported checking the PDMP with every patient, every time. Others checked only for new patients, for new opioid prescriptions, or for patients for whom they suspected abuse. Participants described varied approaches to sharing PDMP information with patients, including openly discussing potential addiction or safety concerns, avoiding discussion altogether, and approaching discussion confrontationally. Participants described patient anger or denial as a common response and noted the role of patient satisfaction surveys as an influence on prescribing. Conclusion Routines for accessing PDMP data and how clinicians respond to it vary widely. As PDMP use becomes more widespread, it will be important to understand what approaches are most effective for identifying and addressing unsafe medication use. [ABSTRACT FROM AUTHOR]

Objective Electronic health record (EHR) use in ambulatory care can improve safety and quality; however, problems with design, implementation, and poor interface with other systems lead users to develop 'workarounds', or behaviors users adopt to overcome perceived limitations in a technical system. We documented workarounds used in independent, community-based primary care practices, and developed a typology of their key features. Materials and methods Comparative case study of EHR use in seven independent primary care practices. Field researchers spent approximately 1 month in each practice to observe EHR use, conduct patient pathways, and interview clinicians and staff. Results We observed workarounds addressing a wide range of EHR-related problems, including: user interface issues (eg, insufficient data fields, limited templates), barriers to electronic health information exchange with external organizations, and struggles incorporating new technologies into existing office space. We analyzed the observed workarounds inductively to develop a typology that cuts across specific clinical or administrative processes to highlight the following key formal features of workarounds in general: temporary/routinized, which captures whether the workaround is taken for granted as part of daily workflow or is understood as a short-term solution; avoidable/unavoidable, referring to the extent to which the workaround is within the practice's power to eliminate; and deliberately chosen/unplanned, which differentiates strategically chosen adaptations from less thoughtful workarounds. Conclusions This workaround typology provides a framework for EHR users to identify and address workarounds in their own practices, and for researchers to examine the effect of different types of EHR workarounds on patient safety, care quality, and efficiency. [ABSTRACT FROM AUTHOR]