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Administrative burden is one of many potential root causes of physician burnout. Scribe documentation assistance can reduce this burden. However, traditional in-person scribe services are challenged by consistent staffing because the model requires the physical presence of a scribe and limits the team to a single individual. In addition, in-person scribes cannot provide the flexible support required for virtual care encounters, which can now pivot geographically and temporally. To respond to these challenges, our health network implemented an asynchronous virtual scribe model and evaluated the program's impact on clinician perceptions of burnout across multiple outpatient specialties.Using a mixed-methods, pre-/postdesign, this evaluation measured the impact of an asynchronous virtual scribe program on physician burnout. Physicians were given the Professional Fulfillment Index tool (to self-assess their mental state) and free-text comment surveys before virtual scribe initiation and again at 3-, 6-, and 12-month intervals after program implementation. Descriptive statistics of survey results and qualitative review of free-text entries were analyzed for themes of facilitation and barriers to virtual scribe use.Of 50 physician participants in this study, 42 (84%) completed the preintervention survey and 15 (36%) completed all 4 surveys; 25 participants (50%) discontinued scribe use after 12 months. Burnout levels-as defined by dread, exhaustion, lack of enthusiasm, decrease in empathy, and decrease in colleague connection-all trended toward improvement during this study. Importantly, quality, time savings, burnout, and productivity moved in positive directions as well.The cost burden to physicians and the COVID-19 pandemic inhibited the continued use of asynchronous virtual medical scribes. Nevertheless, those who continued in the program have reported positive outcomes, which indicates that the service can be a viable and effective tool to reduce physician burnout.

Adult vaccination rates are low in the United States, despite clear benefits for reducing morbidity and mortality. Vaccine science is evolving rapidly, and family physicians must maintain familiarity with the most recent guidelines. The recommended adult immunization schedule is updated annually by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. All eligible patients should receive SARS-CoV-2 vaccines according to the current guidelines. Adults without contraindications should also receive an annual influenza vaccine. Hepatitis A vaccine is recommended for adults with specific risk factors. All pregnant patients, adults younger than 60 years, and those 60 years and older who have risk factors should receive a hepatitis B vaccine. A 15- or 20-valent pneumococcal conjugate vaccine is recommended for all patients who are 65 years and older. Patients who receive 15-valent pneumococcal conjugate vaccine should receive a dose of 23-valent pneumococcal polysaccharide vaccine one year later. Adults 19 to 64 years of age should receive a pneumococcal vaccination if they have medical risk factors. A single dose of measles, mumps, and rubella vaccine is recommended for adults without presumptive immunity, and additional doses are recommended for patients with HIV and postdelivery for pregnant patients who are not immune to rubella. A tetanus and diphtheria toxoids booster is recommended every 10 years. For pregnant patients and those in close contact with young infants, a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine should be administered. The human papillomavirus vaccine is recommended for all people through 26 years of age. Herpes zoster vaccine is indicated for all adults 50 years and older. .

Asynchronous telehealth provides a viable option for improving access in a convenient and timely manner to patients seeking care as well as for physicians seeking subspecialty consultation. Access to technology, clear guidelines, standards, and expectations is required for this innovation to function well. Limitations in access due to patient and technology factors is an area that requires attention. Positive impact on access and quality has been demonstrated. Rapid development continues and was enhanced with the Sars-CoV-2 pandemic.

This review, and the at-a-glance tables that follow, detail indications and strategies for the treatment of adults with hypertriglyceridemia.

This article illustrates quality improvement (QI) methodology using an example intended to improve chlamydia screening in women. QI projects in healthcare provide great opportunities to improve patient quality and safety in a real-world healthcare setting, yet many academic centres lack training programmes on how to conduct QI projects. The choice of chlamydia screening was based on the significant health burden chlamydia poses despite simple ways to screen and treat. At the University of Michigan, we implemented a multidepartment process to improve the chlamydia screening rates using the plan-do-check-act model. Steps to guide QI projects include the following: (1) assemble a motivated team of stakeholders and leaders; (2) identify the problem that is considered a high priority; (3) prepare for the project including support and resources; (4) set a goal and ways to evaluate outcomes; (5) identify the root cause(s) of the problem and prioritise based on impact and effort to address; (6) develop a countermeasure that addresses the selected root cause effectively; (7) pilot a small-scale project to assess for possible modifications; (8) large-scale roll-out including education on how to implement the project; and (9) assess and modify the process with a feedback mechanism. Using this nine-step process, chlamydia screening rates increased from 29% to 60%. QI projects differ from most clinical research projects by allowing clinicians to directly improve patients’ health while contributing to the medical science body. This may interest clinicians wishing to conduct relevant research that can be disseminated through academic channels.

A key strategy for improving healthcare outcomes is the development of a sufficient number of health care professionals at both the front line and in leadership positions who partner with human factors experts to promulgate the lessons of patient safety and quality improvement (PS/QI). The complexity of healthcare systems necessitates effective collaboration to achieve gains in PS/QI. A “Patient Safety and Quality Leadership” (PASQUAL) Scholars program was developed at the University of Michigan to provide clinicians with a theoretical and practical underpinning of human factors, QI, and PS knowledge. The scholars program's curriculum has been developed and refined to create clinical leaders who can work together with human factors professionals to have a significant impact on healthcare outcomes. The PASQUAL Scholars curriculum provides a concrete, time-tested blueprint for a successful program to improve safety and quality, and provide a human infrastructure of partners in human factors efforts.

SummaryObjectives To understand the attitudes and perceptions of ophthalmologists toward an electronic health record (EHR) system, before and after its clinical implementation.Methods Ophthalmologists at a single large academic ophthalmology department were surveyed longitudinally before and after implementation of a new EHR system. The survey measured ophthalmologists’ attitudes toward implementation of a new EHR. Questions focused on satisfaction, efficiency, and documentation. All attending physicians (between 56 and 61 at various time points) in the University of Michigan Department of Ophthalmology and Visual Sciences were surveyed. We plotted positive responses to survey questions and assessed whether perceptions followed a J-curve with an initial decrease followed by an increase surpassing pre-implementation levels.Results Survey responses were received from 32 (52%) ophthalmologists pre-implementation, and 28 (46%) at 3 months, 35 (57%) at 7 months, 40 (71%) at 13 months and 39 (67%) at 24 months post-implementation. After EHR implementation respondents were more likely to express concerns about their ability to create high-quality documentation (pConclusions As ophthalmology practices continue to transition to EHRs, adapting them to their specific culture and needs is important to maintain efficiency and user satisfaction. This study identifies areas of concern to ophthalmologists that may be addressed through education of physicians and customization of software as other practices move forward with EHR implementation.Citation: Ehrlich JR, Michelotti M, Blachley TS, Zheng K, Couper MP, Greenberg GM, Kileny S, Branford GL, Hanauer DA, Weizer JS. A two-year longitudinal assessment of ophthalmologists’ perceptions after implementing an electronic health record system.

The authors developed advance consent in Japanese for epidural anesthesia for pregnant Japanese-speaking women. Their explanatory, sequential mixed methods design involved a survey (QUAN) and telephone interviews with Japanese women (QUAL). An e-mail survey of health professionals (quan/ qual) was conducted concurrently to the QUAL arm. Japanese women and health professionals found advance consent as helpful, though minor problems were identified. Advance consent helped lower communication barriers, and the women wanted more information about pain control. This mixed methods study of Japanese women suggests that bilingual advance consent offers an innovative tool to help overcome the language barrier for non-English-proficient women who predictably needed interventions (e.g., epidurals) under unpredictable circumstances.

This report describes a two-year, prospective, longitudinal survey of attending physicians in three clinical areas (family medicine, general pediatrics, internal medicine) who experienced a transition from a homegrown electronic health record (EHR) to a vendor EHR. Participants were already highly familiar with using EHRs. Data were collected 1 month before as well as 3, 6, 13, and 25 months post-implementation. Our primary goal was determining if perceptions followed a J-curve pattern in which perceptions initially dropped but eventually surpassed baseline measures. A J-curve was not found for any measures including Workflow, Safety, Communication, and Satisfaction. Only the Reminders and Alerts measure dropped and then returned to baseline (U-curve); a few remained flat-lined. Most dropped and remained below baseline (L-curve). The only measure that remained above baseline was documenting in the exam room with the patient. This study adds to the literature about current controversies surrounding EHR adoptions and physician satisfaction.

Objectives. We examined how family medicine clinic physicians and staff worked in collaborative teams to implement an automated clinical reminder to improve tetanus, diphtheria, and acellular pertussis (Tdap) booster vaccine administration and documentation. Methods. A clinical reminder was developed at 5 University of Michigan family medicine clinics to identify patients 11 to 64 years old who were in need of the Tdap booster vaccine. Quality improvement cycles were used to improve clinic care processes. Immunization rates from 2008 to 2011 were compared with rates at 4 primary care control clinics. Results. Vaccination rates among eligible patients increased from 15.5% to 47.3% within the family medicine clinics and from 14.1% to 30.2% within the control clinics. After adjustment for covariates, family medicine patients had a higher probability of vaccination than control patients during each measurement period (0.17 vs 0.15 at baseline, 0.53 vs 0.22 during year 1, and 0.50 vs 0.30 during year 2). Conclusions. Automated clinical reminders, when designed and implemented via a consensus-based framework that addresses the process of care, can dramatically improve provision of preventive health care.

Contraceptive agents provide both irreversible and nonreversible methods of protection from unwanted pregnancy. Decisions about the selection of methods affecting human sexuality must be made with full informed consent with a respect for each individual’s personal sexual practices and beliefs. Although no method or agent provides absolute protection, current agents offer high effectiveness, minimal side effects, and convenience. It is necessary to balance these components with cost data. Trussell et al. developed an economic model to compare the effectiveness and costs per person of 15 contraceptive methods and found that the up-front acquisition costs of contraceptives are inaccurate predictors of the economic value of competing contraceptive methods, and that investments in contraception provide substantial economic savings and societal benefits.1 Regardless of payment mechanism, contraception saves money by preventing unwanted pregnancy, and improved cost savings can be achieved by optimizing appropriate and consistent use.