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Background: Patients with opioid use disorder (OUD) experience various forms of stigma at the individual, public, and structural levels that can affect how they access and engage with healthcare, particularly with medications for OUD treatment. Telehealth is a relatively new form of care delivery for OUD treatment. As reducing stigma surrounding OUD treatment is critical to address ongoing gaps in care, the aim of this study was to explore how telehealth impacts patient experiences of stigma. Methods: In this qualitative study, we interviewed patients with OUD at a single urban academic medical center consisting of multiple primary care and addiction clinics in Oregon, USA. Participants were eligible if they had (1) at least one virtual visit for OUD between March 2020 and December 2021, and (2) a prescription for buprenorphine not exclusively used for chronic pain. We conducted phone interviews between October and December 2022, then recorded, transcribed, dual-coded, and analyzed using reflexive thematic analysis. Results: The mean age of participants (n = 30) was 40.5 years (range 20–63); 14 were women, 15 were men, and two were transgender, non-binary, or gender-diverse. Participants were 77% white, and 33% had experienced homelessness in the prior six months. We identified four themes regarding how telehealth for OUD treatment shaped patient perceptions of and experiences with stigma at the individual (1), public (2–3), and structural levels (4): (1) Telehealth offers wanted space and improved control over treatment setting; (2) Public stigma and privacy concerns can impact both telehealth and in-person encounters, depending on clinical and personal circumstances; (3) The social distance of telehealth could mitigate or exacerbate perceptions of clinician stigma, depending on both patient and clinician expectations; (4) The increased flexibility of telehealth translated to perceptions of increased clinician trust and respect. Conclusions: The forms of stigma experienced by individuals with OUD are complex and multifaceted, as are the ways in which those experiences interact with telehealth-based care. The mixed results of this study support policies allowing for a more individualized, patient-centered approach to care delivery that allows patients a choice over how they receive OUD treatment services. [ABSTRACT FROM AUTHOR]

Purpose: We undertook a study to assess whether implementing 7 evidence-based strategies to build improvement capacity within smaller primary care practices was associated with changes in performance on clinical quality measures (CQMs) for cardiovascular disease.Methods: A total of 209 practices across Washington, Oregon, and Idaho participated in a pragmatic clinical trial that focused on building quality improvement capacity as measured by a validated questionnaire, the 12-point Quality Improvement Capacity Assessment (QICA). Clinics reported performance on 3 cardiovascular CQMs-appropriate aspirin use, blood pressure (BP) control (<140/90 mm Hg), and smoking screening/cessation counseling-at baseline (2015) and follow-up (2017). Regression analyses with change in CQM as the dependent variable allowed for clustering by practice facilitator and adjusted for baseline CQM performance.Results: Practices improved QICA scores by 1.44 points (95% CI, 1.20-1.68; P <.001) from an average baseline of 6.45. All 3 CQMs also improved: aspirin use by 3.98% (average baseline = 66.8%; 95% CI for change, 1.17%-6.79%; P = .006); BP control by 3.36% (average baseline = 61.5%; 95% CI for change, 1.44%-5.27%; P = .001); and tobacco screening/cessation counseling by 7.49% (average baseline = 73.8%; 95% CI for change, 4.21%-10.77%; P <.001). Each 1-point increase in QICA score was associated with a 1.25% (95% CI, 0.41%-2.09%, P = .003) improvement in BP control; the estimated likelihood of reaching a 70% BP control performance goal was 1.24 times higher (95% CI, 1.09-1.40; P <.001) for each 1-point increase in QICA.Conclusion: Improvements in clinic-level performance on BP control may be attributed to implementation of 7 evidence-based strategies to build quality improvement capacity. These strategies were feasible to implement in small practices over 15 months. [ABSTRACT FROM AUTHOR]

Purpose: We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance.Methods: Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach.Results: Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76).Conclusions: Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation. [ABSTRACT FROM AUTHOR]

Background: Little attention has been paid to quality improvement (QI) capacity within smaller primary care practices which comprise nearly half of all primary care settings. Strategies for external support to build such capacity include practice facilitation (PF), shared learning opportunities, and educational outreach. Although PF has proven effectiveness, little is known about the comparative effectiveness of combining these strategies. Here, we describe the protocol of the "Healthy Hearts Northwest" (H2N) study, a randomized trial designed to address these questions while improving risk factors for cardiovascular disease.Methods/design: The targeted enrollment is 250 smaller primary care practices across Washington, Oregon, and Idaho. The study is utilizing a two-by-two factorial design to assess four different combinations of practice support: PF alone, PF with educational outreach, PF with shared learning opportunities, or PF with both. A mixed methods approach is being used for evaluation and will include data from (1) baseline and follow-up practice and staff surveys; (2) baseline and quarterly clinical performance measurement from each practice on four cardiovascular risk factors: appropriate aspirin use, blood pressure control, lipid management and smoking cessation support; and (3) a quality improvement capacity assessment (QICA) survey used by external practice facilitators to guide improvement efforts.Discussion: Results from this study will inform future large-scale practice improvement initiatives by providing comparisons of promising external practice support strategies and advance our understanding of how to build QI capacity in primary care.Trial Registration: ClinicalTrials.gov, NCT02839382. [ABSTRACT FROM AUTHOR]

Background: Red blood cell transfusion is the most common procedure in hospitalized patients in the US. Growing evidence suggests that a sizeable percentage of these transfusions are inappropriate, putting patients at significant risk and increasing costs to the health care system.Methods: We performed a retrospective quasi-experimental study from November 2008 until November 2014 in a 576-bed tertiary care hospital. The intervention consisted of an interruptive clinical decision support alert shown to a provider when a red blood cell transfusion was ordered in a patient whose most recent hematocrit was ≥21%. We used interrupted time series analysis to determine whether our primary outcome of interest, rate of red blood cell transfusion in patients with hematocrit ≥21% per 100 patient (pt) days, was reduced by the implementation of the clinical decision support tool. The rate of platelet transfusions was used as a nonequivalent dependent control variable.Results: A total of 143,000 hospital admissions were included in our analysis. Red blood cell transfusions decreased from 9.4 to 7.8 per 100 pt days after the clinical decision support intervention was implemented. Interrupted time series analysis showed that significant decline of 0.05 (95% confidence interval [CI], 0.03-0.07; P < .001) units of red blood cells transfused per 100 pt days per month was already underway in the preintervention period. This trend accelerated to 0.1 (95% CI, 0.09-0.12; P < .001) units of red blood cells transfused per 100 pt days per month following the implementation of the clinical decision support tool. There was no statistical change in the rate of platelet transfusion resulting from the intervention.Conclusions: The implementation of an evidence-based clinical decision support tool was associated with a significant decline in the overuse of red blood cell transfusion. We believe this intervention could be easily replicated in other hospitals using commercial electronic health records and a similar reduction in overuse of red blood cell transfusions achieved. [ABSTRACT FROM AUTHOR]

Introduction: Primary care risk stratification (RS) has been shown to help practices better understand their patient populations' needs and may improve health outcomes and reduce expenditures by targeting and tailoring care to high-need patients. This study aims to understand key considerations practices faced and practice experiences as they began to implement RS models., Methods: We conducted semistructured interviews about experiences in RS with 34 stakeholders from 15 primary care practices in Oregon and Colorado and qualitatively analyzed the data., Results: Three decisions were important in shaping practices' experiences with RS: choosing established versus self-created algorithms or heuristics, clinical intuition, or a combination; selecting mechanisms for assigning risk scores; determining how to integrate RS approaches into care delivery. Practices using clinical intuition found stratification time-consuming and difficult to incorporate into existing workflows, but trusted risk scores more than those using algorithms. Trust in risk scores was influenced by data extraction capabilities; practices often lacked sufficient data to calculate their perceived optimal risk score. Displaying the scores to the care team was a major issue. Finally, obtaining buy-in from care team members was challenging, requiring repeated cycles of improvement and workflow integration., Discussion: Practices used iterative approaches to RS implementation. As a result, procedural and algorithmic changes were introduced and were influenced by practices' health IT, staffing, and resource capacities. Practices were most successful when able to make iterative changes to their approaches, incorporated both automation and human process in RS, educated staff on the importance of RS, and had readily accessible risk scores., Competing Interests: Conflict of interest: none declared., (© Copyright 2019 by the American Board of Family Medicine.)

Objective: The patient-centered medical home (PCMH) is emerging as a key strategy to improve health outcomes, reduce total costs, and strengthen primary care, but a myriad of operational measures of the PCMH have emerged. In 2009, the state of Oregon convened a public, legislatively mandated committee charged with developing PCMH measures. We report on the process of, outcomes of, and lessons learned by this committee., Methods: The Oregon PCMH advisory committee was appointed by the director of the Oregon Department of Human Services and held 7 public meetings between October 2009 and February 2010. The committee engaged a diverse group of Oregon stakeholders, including a variety of practicing primary care physicians., Results: The committee developed a PCMH measurement framework, including 6 core attributes, 15 standards, and 27 individual measures. Key successes of the committee's work were to describe PCMH core attributes and functions in patient-centered language and to achieve consensus among a diverse group of stakeholders., Conclusions: Oregon's PCMH advisory committee engaged local stakeholders in a process that resulted in a shared PCMH measurement framework and addressed stakeholders' concerns. The state of Oregon now has implemented a PCMH program using the framework developed by the PCMH advisory committee. The Oregon experience demonstrates that a brief public process can be successful in producing meaningful consensus on PCMH roles and functions and advancing PCMH policy.

This study sought to understand the acceptability and feasibility of office-based nurse care management in medium to large rural primary care practices. A qualitative assessment of Care Management Plus (a focused medical home model for complex patients) implementation was conducted using semistructured interviews with 4 staff cohorts. Cohorts included clinician champions, clinician partners, practice administrators, and nurse care managers. Seven key implementation attributes were: a proven care coordination program; adequate staffing; practice buy-in; adequate time; measurement; practice facilitation; and functional information technology. Although staff was positive about the care coordination concept, model acceptability was varied and additional study is required to determine sustainability.

Background: Although medication reconciliation (MR) can reduce medication discrepancies, it is challenging to operationalise. Consequently, we developed a health information technology (HIT) to collect a patient medication history and make it available to the primary care (PC) provider. We deployed a self-service kiosk in a PC clinic that permits patients to indicate a medication adherence history. Patient responses are immediately viewable in the legacy electronic health record. This paper describes a survey developed to assess PC provider perceptions of our HIT and HIT implementation effectiveness., Methods: We developed and administered a survey to all PC providers to assess technology implementation effectiveness. The survey included scales measuring (1) user attitudes towards MR, (2) perceptions of our HIT and (3) the local organisational climate for implementation. We also assessed the consistency and quality of tool use., Results: Nearly 90% of PC providers responded to the survey and 58% indicated that they were familiar with the technology and had seen the tool output. Most providers believed that MR represented an important safety intervention, although 43% did not believe that they had the necessary resources to manage discrepancies. Composite scale scores for the 58% of respondents familiar with the HIT indicate that the majority favoured our tool over usual care. However, composite scale scores suggest that the climate for implementation at our facility was suboptimal. Overall, the quality and consistency of tool use among providers was very heterogeneous., Conclusions: A patient self-service kiosk offers an efficient mechanism to collect a medication adherence history; provider survey responses indicate that they appreciated and used the MR kiosk output. Nonetheless, opportunities exist to improve data displays and embed decision support to facilitate discrepancy management.

We present the User Need Analysis process for the Integrated Care Coordination Information System (ICCIS) research project at Oregon Health & Science University (OHSU). The primary goal of the process was to select a mix of methodologies to perform user need analysis which would lead to generation of system requirements. The ICCIS Team developers would use these prioritized requirements to build the next generation of the ICCIS software that would help meet the overall goals of the care model. First, semi-structured User Discussion Guides and structured questioners were used to collect raw needs from Physicians, Nurses, IT and Administrative personal. Later Conjoint Analysis (CA) and Dimensional Analysis (DA) were used to generate emerging concepts and priorities from the discussions with the end-user community.

Background: Discrepancies in medication documentation most often occur at handoffs or transition points in care. A process improvement team at the Portland Department of Veterans Affairs developed a standardized medication reconciliation process for the Portland chemotherapy administration unit, a physically self-contained clinic with a standard intake process and a uniform patient traffic pattern., Methods: The team developed the automated patient history intake device (APHID), a reconciliation software program accessed by the patient using a computer terminal kiosk in the clinic lobby. The program simultaneously checks in patients for an appointment and gathers a medication-adherence history by retrieving medication lists from all Veterans Affairs facilities and pairing each medication with a pill picture. Installation of the APHID kiosk included an initial two-week roll-in period beginning in February 2008., Results: During the roll-in period, 91 (82.0%) of 111 patients completed check-in and performed medication reconciliation using the kiosk. Medication lists gathered at the kiosk were compared with existing health record documentation and clinician interviews. For each patient encounter, the process demonstrated an average of 4.59 discrepancies and an average of 1.61 clinically significant or potentially lethal discrepancies. The new process saved approximately 0.24 full-time equivalents of nursing time in the chemotherapy clinic-a nearly 50% reduction in nursing time dedicated to reconciliation activities without an apparent loss in data accuracy., Discussion: A patient-centered reconciliation model using consumer-based kiosk technology helped providers efficiently retrieve a comprehensive list of medications across a geographically diverse area and improve patient medication recall using visual cues including medication pictures.