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PURPOSE The purpose of this study is to evaluate recent trends in primary care physician (PCP) electronic health record (EHR) workload. METHODS This longitudinal study observed the EHR use of 141 academic PCPs over 4 years (May 2019 to March 2023). Ambulatory full-time equivalency (aFTE), visit volume, and panel size were evaluated. Electronic health record time and inbox message volume were measured per 8 hours of scheduled clinic appointments. RESULTS From the pre-COVID-19 pandemic year (May 2019 to February 2020) to the most recent study year (April 2022 to March 2023), the average time PCPs spent in the EHR per 8 hours of scheduled clinic appointments increased (+ 28.4 minutes, 7.8%), as did time in orders (+ 23.1 minutes, 58.9%), inbox (+14.0 minutes, 24.4%), chart review (+ 7.2 minutes, 13.0%), notes (+2.9 minutes, 2.3%), outside scheduled hours on days with scheduled appointments (+6.4 minutes, 8.2%), and on unscheduled days (+13.6 minutes, 19.9%). Primary care physicians received more patient medical advice requests (+5.4 messages, 55.5%) and prescription messages (+2.3, 19.5%) per 8 hours of scheduled clinic appointments, but fewer patient calls (-2.8, -10.5%) and results messages (-0.3, -2.7%). While total time in the EHR continued to increase in the final study year (+ 7.7 minutes, 2.0%), inbox time decreased slightly from the year prior (-2.2 minutes, -3.0%). Primary care physicians' average aFTE decreased 5.2% from 0.66 to 0.63 over 4 years. CONCLUSIONS Primary care physicians' time in the EHR continues to grow. While PCPs' inbox time may be stabilizing, it is still substantially higher than pre- pandemic levels. It is imperative health systems develop strategies to change the EHR workload trajectory to minimize PCPs' occupational stress and mitigate unnecessary reductions in effective physician workforce resulting from the increased EHR burden. Key words: electronic health records (EHR); workload; burnout; practice of primary care; patient portal, INTRODUCTION There are not enough hours in the day for primary care physicians (PCPs) to do all that is expected of them. It would take nearly 27 hours per day [...]

Accurately quantifying clinician time spent on electronic health record (EHR) activities outside the time scheduled with patients is critical for understanding occupational stress associated with ambulatory clinic environments. We make 3 recommendations regarding EHR workload measures that are intended to capture time working in the EHR outside time scheduled with patients, formally defined as work outside of work (WOW): (1) separate all time working in the EHR outside of time scheduled with patients from time working in the EHR during time scheduled with patients, (2) do not exclude any time before or after scheduled time with patients, and (3) encourage the EHR vendor and research communities to develop and standardize validated, vendor-agnostic methods for measuring active EHR use. Attributing all EHR work outside time scheduled with patients to WOW, regardless of when it occurs, will produce an objective and standardized measure better suited for use in efforts to reduce burnout, set policy, and facilitate research. Key words: electronic health records; health information technology; time and motion studies; ambulatory care; workload; burnout; job stress; after hours; work outside of work; metrics; schedules; efficiency, organizational; professional practice; organizational change https://doi.org/10.1370/afm.2960, INTRODUCTION The occupational stress clinicians experience from electronic health record (EHR) workload in ambulatory settings is increasing, partly because of the volume and complexity of work demands that occur outside [...]

PURPOSE Most patients are escorted to exam rooms (escorted rooming) although patients directing themselves to their exam room (self-rooming) saves patient and staff time while increasing patient satisfaction. This study assesses patient and staff perceptions after pragmatic implementation of self-rooming. METHODS In October-December 2020, we surveyed patients and staff in 25 primary care clinics after our institution expanded self-rooming from 4 specially built clinics during the COVID-19 pandemic. Semi-structured surveys asked about rooming process used, rooming process preferred, and perceptions of self-rooming compared with escorted rooming. RESULTS Most patients (n = 1,561) preferred self-rooming (86%), especially among patients aged Over one-half of staff (n = 241; 180 clinical, 61 nonclinical) preferred self- rooming (59%) and thought most patients liked self-rooming (65.8%), especially among clinical staff and in early adopter clinics ([less than or equal to] 2016). Few staff reported worse waiting times for patients (12.4%), medical assistants (MAs) (15.9%), and clinicians (16.4%) or worse crowding in waiting areas (1.7%) and hallways (10.1%). Unlike patient-reported confusion (7.6%), most staff thought self-rooming led to more patient confusion (63.8%), except in early-adopter clinics (44.4%). CONCLUSIONS Self-rooming is a patient-centered innovation that is also acceptable to staff. We demonstrated that pragmatic implementation is feasible across primary care without expensive technology or specially designed buildings. Key words: primary care; self-rooming; organizational innovation; patientcentered care, INTRODUCTION Self-rooming is a relatively new process where patients direct themselves to an assigned exam room immediately after checking in, bypassing the traditional experience in which a staff member would [...]

Problem In Mozambique, pulmonary tuberculosis is primarily diagnosed with sputum smear microscopy. However this method has low sensitivity, especially in people infected with human immunodeficiency virus (HIV). Patients are seldom tested for drug-resistant tuberculosis. Approach The national tuberculosis programme and Health Alliance International introduced rapid testing of smear- negative sputum samples. Samples were tested using a polymerase-chain-reaction-based assay that detects Mycobacterium tuberculosis deoxyribonucleic acid and a mutation indicating rifampicin resistance; Xpert[R] MTB/RIF (Xpert[R]). Four machines were deployed in four public hospitals along with a sputum transportation system to transfer samples from selected health centres. Laboratory technicians were trained to operate the machines and clinicians taught to interpret the results. Local setting In 2012, Mozambique had an estimated 140000 new tuberculosis cases, only 34% of which were diagnosed and treated. Of tuberculosis patients, 58% are HIV-infected. Relevant changes From 2012-2013, 1558 people were newly diagnosed with tuberculosis using sputum smears at intervention sites. Xpert[R] detected M. tuberculosis in an additional 1081 sputum smear-negative individuals, an increase of 69%. Rifampicin resistance was detected in 58/1081 (5%) of the samples. However, treatment was started in only 82% of patients diagnosed by microscopy and 67% of patients diagnosed with the rapid test. Twelve of 16 Xpert[R] modules failed calibration within 15 months of implementation. Lessons learnt Using rapid tests to diagnose tuberculosis is promising but logistically challenging. More affordable and durable platforms are needed. All patients diagnosed with tuberculosis need to start and complete treatment, including those who have drug resistant strains. [TEXT NOT REPRODUCIBLE IN ASCII] [TEXT NOT REPRODUCIBLE IN ASCII] Probleme Au Mozambique, la tuberculose pulmonaire est principalement diagnostiquee en examinant des frottis d'expectoration au microscope. Cependant, cette methode est peu sensible, en particulier chez les personnes infectees par le virus de l'immunodefidence humaine (VIH). Les patients sont rarement testes pour la tuberculose resistante aux medicaments. Approche Le programme national de lutte contre la tuberculose et Health Alliance International ont introduit le depistage rapide sur les echantillons de frottis d'expectoration negatifs. Les echantillonsontete testes a l'aide d'un test base sur l'amplification en chatne par polymerase, qui detecte l'acide desoxyribonucleique de la bacterie Mycobacterium tuberculosis et une mutation indiquant la resistance a la rifampicine: Xpert[R] MTB/RIF (Xpert[R]). Quatre machines ont ete deployees dans quatre hopitaux publics avec un systeme de transport des frottis d'expectoration pour transferer les echantillons depuis les centres de sante selectionnes. Les techniciens de laboratoire ont ete formes a utiliser les machines et les cliniciens ont appris a interpreter les resultats. Environnement local En 2012, le nombre de nouveaux cas de tuberculose au Mozambique etait estime a 140 000, dont seuls 34% etaient diagnostiques et traites. Des patients atteints de tuberculose, 58% etaient infectes par le VIH. Changements significatifs Depuis 2012-2013, 1558 personnes ont ete nouvellement diagnostiquees comme tuberculeuses par examen des frottis d'expectoration dans les sites d'intervention. Xpert[R] a detecte M. tuberculosis dans 1081 echantillons supplementaires, soit une augmentation de 69%. La resistance a Ia rifampicine a ete detectee dans 58 des 1 081 echantillons (5%). Cependant, le traitement avait commence chez seulement 82% des patients diagnostiques par microscopie et 67% des patients diagnostiques par le test de depistage rapide. Parmi les 16 modules Xpert[R], 12 dentre eux n'avaient pas reussi 1'etalonnage au cours des 15 mois de la mise en oeuvre. Lecons tirees L'utilisation de tests de depistage rapide pour diagnostiquer la tuberculose est prometteuse, mais reste difficile sur le plan logistique. Des plateformes plus abordables et durables sont necessaires. Tous les patients diagnostiques comme tuberculeux doivent commencer et terminer leur traitement, y compris ceux avec des souches resistantes aux medicaments. [TEXT NOT REPRODUCIBLE IN ASCII] Situacion En Mozambique, la tuberculosis pulmonar se diagnostica principalmente mediante la baciloscopia del esputo. No obstante, Ia sensibilidad de este metodo es insuficiente, especialmente en las personas infectadas con el virus de la inmunodeficiencia humana (VIH). Pocas veces se somete a los pacientes a pruebas para la tuberculosis resistente a medicamentos. Enfoque El programa nacional contra la tuberculosis y Health Alliance International han introducido la prueba rapida de muestras de esputo de frotis negativo. Se analizaron las muestras mediante un analisis basado en la reaccion en cadena de la polimerasa que detecta el acido desoxirribonucleico de la Mycobacterium tuberculosis y una mutacion que indica resistencia a la rifampicina; Xpert[R] MTB/RIF (Xpert[R]). Se instalaron cuatro maquinas en cuatro hospitales publicos junto con un sistema de transporte de esputo para transferir Ias muestras de los centros de salud seleccionados. Se capacito a los tecnicos de laboratorio para operar Ias maquinas y a los medicos se les enseno a interpretar los resultados. Marco regional En 2012, Mozambique presenter aproximadamente 140 000 casos nuevos de tuberculosis, de los cuales solo se diagnostico y trato el 34 %. De los enfermos de tuberculosis, 58% esta infectado por el VIH. Cambios importantes Entre 2012 y 2013, se diagnosticaron 1558 afectados nuevos por tuberculosis por medio dei frotis de esputo en los centros de intervencion. Xpert[R] detecto la M. tuberculosis en 1081 muestras adicionales, Io que representa un aumento dei 69 %. Se detecto resistencia a Ia rifampicina en 58 de Ias 1081 muestras (5 %). Sin embargo, el tratamiento solo se inicio en el 82 % de los pacientes diagnosticados por baciloscopia y en el 67 % de los pacientes diagnosticados mediante Ia prueba rapida. Hubo fallos de calibracion en doce de los 16 modulos de Xpert[R] a los 15 meses de Ia aplicacion. Lecciones aprendidas El uso de pruebas rapidas para diagnosticar la tuberculosis resulta prometedor, pero es dificil desde el punto de vista. Se requieren plataformas mas asequibles y duraderas. Todos los pacientes diagnosticados con tuberculosis deben iniciary completar un tratamiento, incluidos aquellos con cepas resistentes a medicamentos., Introduction People infected with human immunodeficiency virus (HIV) are susceptible to tuberculosis. This has led to an HIV-driven tuberculosis epidemic in sub-Saharan Africa over the past two decades. (1) Diagnosing [...]

Introduction: In 2004, Mozambique, supported by large increases in international disease‐specific funding, initiated a national rapid scale‐up of antiretroviral treatment (ART) and HIV care through a vertical “Day Hospital” approach. Though this model showed substantial increases in people receiving treatment, it diverted scarce resources away from the primary health care (PHC) system. In 2005, the Ministry of Health (MOH) began an effort to use HIV/AIDS treatment and care resources as a means to strengthen their PHC system. The MOH worked closely with a number of NGOs to integrate HIV programs more effectively into existing public‐sector PHC services. Case Description: In 2005, the Ministry of Health and Health Alliance International initiated an effort in two provinces to integrate ART into the existing primary health care system through health units distributed across 23 districts. Integration included: a) placing ART services in existing units; b) retraining existing workers; c) strengthening laboratories, testing, and referral linkages; e) expanding testing in TB wards; f) integrating HIV and antenatal services; and g) improving district‐level management. Discussion: By 2008, treatment was available in nearly 67 health facilities in 23 districts. Nearly 30,000 adults were on ART. Over 80,000 enrolled in the HIV/AIDS program. Loss to follow‐up from antenatal and TB testing to ART services has declined from 70% to less than 10% in many integrated sites. Average time from HIV testing to ART initiation is significantly faster and adherence to ART is better in smaller peripheral clinics than in vertical day hospitals. Integration has also improved other non‐HIV aspects of primary health care. Conclusion: The integration approach enables the public sector PHC system to test more patients for HIV, place more patients on ART more quickly and efficiently, reduce loss‐to‐follow‐up, and achieve greater geographic HIV care coverage compared to the vertical model. Through the integration process, HIV resources have been used to rehabilitate PHC infrastructure (including laboratories and pharmacies), strengthen supervision, fill workforce gaps, and improve patient flow between services and facilities in ways that can benefit all programs. Using aid resources to integrate and better link HIV care with existing services can strengthen wider PHC systems., Introduction The rapid scale up of antiretroviral treatment (ART) and HIV care across Africa over the past five years has provoked an important and lively debate about the impact of [...]

We performed a cross-sectional, community-based survey, supplemented by interviews with community leaders in Chiapas, Mexico, to examine the prevalence and predictors of child malnutrition in regions affected by the Zapatista conflict. The prevalence rates of stunting, wasting, and underweight were 54.1%, 2.9%, and 20.3%, respectively, in 2666 children aged younger than 5 years. Stunting was associated with indigenous ethnicity, poverty, region of residence, and intracommunity division. The results indicate that malnutrition is a serious public health problem in the studied regions. Am J Public Health. 2007;97:229-232. doi: 10.2105/AJPH.2005.070409)

A mixed-methods approach was used to describe the process of implementing modified directly observed therapy (mDOT) for an ongoing randomized control trial (RCT) in Beira, Mozambique. The observations suggest that trained and supervised peers could be effective for observing treatment, educating and counseling patients, and strengthening relationships between patients and their health clinics and communities.

The Zapatista armed conflict began in the state of Chiapas, Mexico, in 1994, and overlaps pre-existing local disputes about land, religion, and other issues. Related disruptions in access to and utilization of health services have been alleged to have compromised local health status, particularly in vulnerable subgroups such as indigenous women and infants. The study objective was to measure maternal and perinatal mortality ratios and utilization of pregnancy-related health services in the region affected by the Zapatista conflict, and to describe associations between these primary outcome measures, socioeconomic and demographic factors, and factors associated with inter-party and intra-community conflict. A cross-sectional, population-based survey was conducted in 46 communities in three regions. The study subjects were 1227 women, 13-49 years old, who had been pregnant during the preceding 2 years (1999-2001). Principal outcome measures were maternal and perinatal mortality, and site of delivery. Secondary analyses explored associations between primary outcomes and socioeconomic, demographic, and conflict-related factors. Most births (87.1%) occurred at home. The crude observed maternal and perinatal mortality ratios were 607/100,000 and 23.5/1000 live births, respectively. Those who died had difficulty accessing emergency obstetrical care. Both home birth and mortality were associated with descriptors of intra-community conflict. Observed maternal and perinatal mortality ratios were substantially higher than those officially reported for Mexico or Chiapas. Reduction of high reproductive mortality ratios will require attention to socioeconomic and conflict-related problems, in addition to improved access to emergency obstetrical services. Keywords: Maternal mortality; Perinatal mortality; Chiapas; Mexico; War

Abstract Background Since the rapid scale-up of antiretroviral therapy (ART) programs in sub-Saharan Africa, electronic patient tracking systems (EPTS) have been deployed to respond to the growing demand for program monitoring, evaluation and reporting to governments and donors. These routinely collected data are often used in epidemiologic and operations research studies intended to improve programs. To ensure accurate reporting and good quality for research, the reliability and completeness of data systems need to be assessed and reported. We assessed the completeness and reliability of EPTS used in 16 HIV care and treatment clinics in Manica and Sofala provinces of Mozambique. Methods We conducted a cross-sectional study to assess the completeness and reliability of key variables in the electronic data system for patients enrolling in 16 public sector HIV treatment clinics between 1 July 2004 and 30 June 2008. Data from the electronic database was compared with data abstracted from a stratified random sample of 520 patient charts. Percent agreement, kappa scores and concordance correlation coefficients were calculated for specified variables. Percentile bootstrap confidence intervals were calculated to account for the stratified nature of our sampling. Results A total of 16,149 patients with a median age of 33 years and a median CD4 count of 151 enrolled in these 16 clinics between 1 July 2004 and 30 June 2008. The level of completeness was high for most variables with height (18.6%) and weight (11.5%) having the highest amount of missing data. The level of agreement for available data was also high with reliability statistics of 0.95 (95% CI: 0.92-0.98) for gender, 0.91 (95% CI: 0.80-1.00) for pre-ART CD4 value and 0.97 (95% CI: 0.95-0.99) for patient retention. Conclusions Electronic patient tracking systems have been deployed to respond to the growing monitoring, evaluation and reporting requirements. In our cross-sectional study of clinics in Manica and Sofala provinces of Mozambique, we found high levels of completeness and reliability for key variables indicating that these electronic databases provided adequate data not only for monitoring and evaluation but also for research. Routine evaluations of the completeness and reliability of these databases need to occur to ensure high quality data are being used for reporting and research.

Abstract Background Primary health care is recognized as a main driver of equitable health service delivery. For it to function optimally, routine health information systems (HIS) are necessary to ensure adequate provision of health care and the development of appropriate health policies. Concerns about the quality of routine administrative data have undermined their use in resource-limited settings. This evaluation was designed to describe the availability, reliability, and validity of a sample of primary health care HIS data from nine health facilities across three districts in Sofala Province, Mozambique. HIS data were also compared with results from large community-based surveys. Methodology We used a methodology similar to the Global Fund to Fight AIDS, Tuberculosis and Malaria data verification bottom-up audit to assess primary health care HIS data availability and reliability. The quality of HIS data was validated by comparing three key indicators (antenatal care, institutional birth, and third diptheria, pertussis, and tetanus [DPT] immunization) with population-level surveys over time. Results and discussion The data concordance from facility clinical registries to monthly facility reports on five key indicators--the number of first antenatal care visits, institutional births, third DPT immunization, HIV testing, and outpatient consults--was good (80%). When two sites were excluded from the analysis, the concordance was markedly better (92%). Of monthly facility reports for immunization and maternity services, 98% were available in paper form at district health departments and 98% of immunization and maternity services monthly facility reports matched the Ministry of Health electronic database. Population-level health survey and HIS data were strongly correlated (R = 0.73), for institutional birth, first antenatal care visit, and third DPT immunization. Conclusions Our results suggest that in this setting, HIS data are both reliable and consistent, supporting their use in primary health care program monitoring and evaluation. Simple, rapid tools can be used to evaluate routine data and facilitate the rapid identification of problem areas.

Abstract Background The growing AIDS epidemic in southern Africa is placing an increased strain on health systems, which are experiencing steadily rising patient loads. Health care systems are tackling the barriers to serving large populations in scaled-up operations. One of the most significant challenges in this effort is securing the health care workforce to deliver care in settings where the manpower is already in short supply. Methods We have produced a demand-driven staffing model using simple spreadsheet technology, based on treatment protocols for HIV-positive patients that adhere to Mozambican guidelines. The model can be adjusted for the volumes of patients at differing stages of their disease, varying provider productivity, proportion who are pregnant, attrition rates, and other variables. Results Our model projects the need for health workers using three different kinds of goals: 1) the number of patients to be placed on anti-retroviral therapy (ART), 2) the number of HIV-positive patients to be enrolled for treatment, and 3) the number of patients to be enrolled in a treatment facility per month. Conclusion We propose three scenarios, depending on numbers of patients enrolled. In the first scenario, we start with 8000 patients on ART and increase that number to 58 000 at the end of three years (those were the goals for the country of Mozambique). This would require thirteen clinicians and just over ten nurses by the end of the first year, and 67 clinicians and 47 nurses at the end of the third year. In a second scenario, we start with 34 000 patients enrolled for care (not all of them on ART), and increase to 94 000 by the end of the third year, requiring a growth in clinician staff from 18 to 28. In a third scenario, we start a new clinic and enrol 200 new patients per month for three years, requiring 1.2 clinicians in year 1 and 2.2 by the end of year 3. Other clinician types in the model include nurses, social workers, pharmacists, phlebotomists, and peer counsellors. This planning tool could lead to more realistic and appropriate estimates of workforce levels required to provide high-quality HIV care in a low-resource settings.

Abstract Background The most pressing challenge to achieving universal access to highly active anti-retroviral therapy (HAART) in sub-Saharan Africa is the shortage of trained personnel to handle the increased service requirements of rapid roll-out. Overcoming the human resource challenge requires developing innovative models of care provision that improve efficiency of service delivery and rationalize use of limited resources. Methods We conducted a time-series intervention trial in two HIV clinics in central Mozambique to discern whether expanding the role of basic-level nurses to stage HIV-positive patients using CD4 counts and WHO-defined criteria would lead to more rapid information on patient status (including identification of HAART eligible patients), increased efficiency in the use of higher-level clinical staff, and increased capacity to start HAART-eligible patients on treatment. Results Overall, 1,880 of the HAART-eligible patients were considered in the study of whom 48.5% started HAART, with a median time of 71 days from their initial blood draw. After adjusting for time, expanding the role of nurses to stage patients was associated with more rational use of higher-level clinical staff at one site (Beira OR 1.9, 95% CI 1.1–3.3; Chimoio OR 0.2, 95% CI 0.1–0.5). In multivariate analyses, the rate of starting HAART in patients with CD4 counts of less than 200/mm3 increased over time (HR = 1.07, 95% CI 1.02–1.13), as did the total number of new patients initiating HAART (β = 7.3, 95% CI 1.3–13.3). However, the intervention was not independently associated with either of these outcomes in multivariate analyses (HR = 0.9, 95% CI 0.7–1.2) for starting HAART in patients with CD4 counts of less than 200/mm3; (β = -5.2, p = 0.75) for the total number of new patients initiating HAART per month. No effect of the intervention was found in these outcomes when stratifying by site. Conclusion The CD4 nurse intervention, when implemented correctly, was associated with a more rational use of higher-level clinical providers, which may improve overall clinic flow and efficient use of the limited supply of human resources. However, this intervention did not lead to an increase in the number of patients starting HAART or a reduction in the time to HAART initiation. Study month appears to play an important role in all outcomes, suggesting that general improvements in clinic efficiency may have overshadowed the effect of the intervention. The lack of observed effect in these outcomes may be due to additional health systems bottlenecks that delay the initiation of treatment in HAART-eligible patients.