Annals of Family Medicine March/April 2024 Tip Sheet

(Press-News.org) Collaboration Between Medical Department Staff and Their IT Colleagues on an EHR Optimization Project Leads to Improved Productivity

Between June and October 2021, members of Marshall University’s Department of Family and Community Health collaborated with their school’s Information Technology (IT) team to conduct a four-month, department-wide optimization project to improve their usage of the Electronic Health Record (EHR) software. The software was implemented across their institution nine months prior. In this paper, they analyze their attempt to enhance EHR usability within their department as well as the impact of their efforts on departmental productivity.

At the outset, eight work groups were created to identify workflow problems. Each work group was related to a specific critical area within the department’s daily workflow: care coordination, communication, front desk, medication, notes, nursing, orders/referrals, and revenue. The groups included a multidisciplinary mix of junior- and senior-level department members. In one-hour monthly meetings, they analyzed the efficiency of problematic tasks and processes, determined best practices for handling them, and created new workflow policies. Each of the 124 EHR-related optimizations that emerged from these groups was tracked under one of four categories: Accommodation (workflow adjusted outside the EHR by the department), Discovery (workflow found inside the EHR by the department), Creation (workflow added to the EHR by IT), and Modification (workflow changed within the EHR by IT). Just over 20% were Creation or Modification optimizations, falling under the domain of IT. Nearly 80% did not require IT fixes, with 43.5% deemed Discovery optimizations, in which solutions were already in the EHR, but users didn’t know the functionality was available. 

What We Know: The majority of health care practices now use an EHR. The large-scale adoption of EHRs was expected to improve communication among clinical and administrative staff and ensure the standardization, quality, and safety of care. However, EHR usage is often associated with problems including increased administrative burdens, negative clinician emotions, attenuated workflow communication, clinician burnout, and medical errors. Physicians and other practice staff may not receive much training in how to engage with the EHR interface during its implementation. 

What This Study Adds: Current literature on EHR optimization is limited and largely details organization-wide initiatives. This is the first study to demonstrate that successful EHR workflow optimization is possible at the departmental level. Ongoing collaboration between EHR users and their IT colleagues is essential to improving user experience. Many EHR difficulties stem from users’ insufficient knowledge of how the interface works. On the technology side, greater understanding of clinicians’ needs could inform upgrades to EHR interfaces and functionality. 

Optimization of Electronic Health Record Usability Through a Department-Led Quality Improvement Process

Adam M. Franks, MD, et al

Department of Family and Community Health, Marshall University, Huntington, West Virginia

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The Future of Independent Primary Care Practices Serving Vulnerable Populations Depends on New Policies That Support Health Equity

In recent years, the U.S. government has invested substantially in Federally Qualified Health Centers (FQHCs), which have become synonymous in policy discussions with primary care for the socially vulnerable. Conversely, no such investment has been made in independent practices serving socially vulnerable patients. As independent practices become less financially viable, this disparity could severely limit primary care options for socially vulnerable patients. This mixed-methods study considers the extent to which independent family physicians in urban communities serve socially vulnerable patients and aims to better understand their practices, challenges, and the structural supports that could better facilitate their patient care.

Quantitative analysis of data from the 2017-2020 American Board of Family Medicine’s (ABFM) Family Medicine Certification Examination questionnaire, a mandatory component of family medicine recertification, showed that 19.3% of family physicians in urban areas, down from 22.6% in 2017, served in independent practices with one to five clinicians. Nearly half of them reported that more than 10% of their patients were socially vulnerable. For the qualitative portion of the study, researchers conducted one-hour semi-structured virtual interviews with 22 physicians who, per their ABFM questionnaires, met the following inclusion criteria: (1) their principal practice site is independently owned; (2) they are its sole or partial owner; (3) their practice has one to five providers; (4) their practice is in an urban area; and (5) more than 50% of their patients are socially vulnerable. The results of the interviews revealed five themes: (1) substantial time is spent addressing access issues and social determinants of health; (2) these practices receive minimal support from health care entities such as independent practice associations and health plans and have insufficient connections with community-based organizations; (3) they face myriad financial challenges; (4) they have serious concerns about their future; and (5) their physicians hold a deep personal commitment to serving socially vulnerable patients in independent practice. The researchers conclude that health equity–focused policies could decrease the burden on these physicians and bolster independent practices so that socially vulnerable patients will continue to have options when seeking primary care.

What We Know: Historically, primary care for socially vulnerable populations has depended on a fragmented “safety net” of public hospitals, health centers, and other health care organizations that provide care regardless of whether patients can pay. In recent years, the federal government has provided substantial funding to large FQHCs to care for the socially vulnerable, though no equivalent investment has been made in independent practices. Consequently, such practices are at risk of closure, even though many physicians and patients still prefer smaller, independent practice settings.

What This Study Adds: This study provides rich insights from independent primary care physicians serving socially vulnerable patients, a perspective that is underrepresented in the literature. While the multidisciplinary research team focused on urban communities, their findings might also be relevant to small independent rural practices. They propose that public policy focused on health equity, new primary care payment models that increase payments to independent practices, and new workforce policies that encourage recruitment and retention of small practice primary care teams could help these practices stay afloat.

Small Independent Primary Care Practices Serving Socially Vulnerable Urban Populations

Diane R. Rittenhouse, MD, MPH, et al

Mathematica, Oakland, California

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Patients With Multimorbidity and Limited Life Expectancy May Undergo Lung Cancer Screening Unaware That it Could Cause Them More Harm Than Good 

This study considers how patients with multimorbidity who would receive marginal benefits from lung cancer screening (LCS) conceptualize their health and make decisions about LCS. Researchers recruited 40 participants with multimorbidity and limited life expectancy (predicted one-year risk of hospitalization or death) to interview from six Veterans Health Administration (VA) health centers. The participants met the following criteria: (1) they met the U.S. Preventive Services Task Force’s age and smoking criteria for LCS eligibility but had not previously undergone VA LCS; (2) were offered VA LCS in the prior six months based on clinician completion of an LCS clinical reminder in the electronic health record; and (3) had marginal anticipated LCS benefit, based on a high care assessment score, suggesting greater health concerns and decreased life expectancy. Interview questions explored LCS decision making within the broader contexts of the participant’s life and their patient-clinician relationship, their perceptions of their own health, their beliefs about screening, and how they perceived the benefits and harms of LCS. Twenty-six participants had agreed to undergo VA LCS after discussing it with their clinician. While 14 Veterans initially declined LCS, several were screened later, either within the VA system or elsewhere.

Study participants largely held positive beliefs about LCS and perceived screening as non-invasive. Thematic analysis of the interviews revealed factors that influenced participants to choose LCS included personal health goals, trust in their clinician and the VA system, and anticipated regret over not getting screened. Factors that did not influence their decisions included their perception of their own health and their perception (or lack of knowledge) of the potential harms. Many participants did not recall discussing potential harms with their clinician, but when informed by the researchers of such risks, many said it would be unlikely that they would pursue further screening. This underscores the importance of patient-clinician discussions and shared decision making to ensure that patients understand the potential harms and benefits of undergoing LCS.

What We Know: Overscreening for various types of cancer occurs frequently. It can be challenging for clinicians and patients to balance benefits and harms when deciding whether to pursue screening. LCS offers less benefit and has a greater potential for causing harm to people with multiple comorbidities and limited life expectancy. However, such individuals are more likely to undergo screening than healthier LCS-eligible people, often without being aware of the possible consequences.

What This Study Adds: This study suggests that patients with multimorbidity and limited life expectancy may be unaware of their risk of harm when accepting LCS. It identifies several motivating factors explaining why people with marginal anticipated LCS benefits are receptive to LCS. It also suggests that, if they had been aware of the potential harms, they may have been less likely to undergo LCS. It appears that neither the electronic health record (EHR) -generated prompt algorithm nor the clinician took into account the potential harms of screening for those with limited life expectancy. Discussions of relative benefits and risks between patients and their clinicians are necessary in order to make informed, shared decisions on whether to pursue screening.

“It Can’t Hurt!”: Why Many Patients Withimited Life Expectancy Decide to Accept Lung Cancer Screening

Eduardo R. Núñez, MD, et al

Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, Massachusetts VA Bedford Healthcare System, Bedford, Massachusetts; The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts; Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts

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The Complexities of Lung Cancer Screening Decisions Among Patients with Comorbidities

Many individuals eligible for lung cancer screening (LCS) also suffer from multiple health issues at the same time, known as comorbid conditions. This study explores how primary care physicians (PCPs) factor comorbidities into their shared decision-making conversations with patients to discuss the harms and benefits of lung cancer screening. Researchers conducted semi-structured interviews with 15 PCPs affiliated with the Mount Sinai Health System in New York City between October 2020 and February 2021. PCPs were asked questions to examine their understanding of how comorbidities influence LCS and explored the presence/extent of shared decision-making discussions in the context of comorbidities. The researchers found that LCS shared decision-making conversations differed substantially with patients with complex comorbidities. The findings indicate three themes: (1) To discuss or not to discuss—PCPs describe making clinical judgments to assess whether the patient is a good candidate for LCS before approaching the patient for a shared decision-making conversation. PCPs made mental assessments which factored in the patient’s current health, life expectancy, quality of life, and access to support systems. (2) Shared decision making is not a simple discussion—when PCPs did initiate LCS discussions, while some felt they could provide objective information, others struggled with personal biases. (3) Ultimately, the decision is up to the patient—patients ultimately made their own decisions, even if the decision conflicted with advice from the PCP.

What We Know: The United States Preventive Services Task Force (USPSTF) guidelines recommend LCS with an annual low-dose computed tomography of the chest for individuals who meet age and smoking history criteria. The USPSTF rates this recommendation as “Grade B,” suggesting that health care clinicians offer or provide LCS to patients as part of their routine care, yet only 5.8% of eligible patients undergo LCS annually. Comorbid conditions add complexity to discussions on the risks and benefits of LCS.

What This Study Adds: The researchers believe this is the first study to characterize how PCPs consider chronic diseases and fitness for LCS in the context of comorbidities. Their findings support the call for continued research to determine the specific impact of comorbidities on LCS benefit and harm, as well as its clinical application. PCPs need more evidence-based information on LCS in cases of complex comorbidities to be able to effectively conduct shared decision-making discussions with these patients. The study calls for future research to include efforts to characterize the benefits and harms of LCS in patients with comorbidities to inform guidelines and clinical application.

Challenges Addressing Lung Cancer Screening forPatients With Multimorbidity in Primary Care: A Qualitative Study

Minal S. Kale, MD, MPH, et al

Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York

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ChatGPT’s Potential and Limits in Summarizing Medical Research for Clinicians 

Large language models (LLMs) are neural network–based computer programs that use a detailed statistical understanding of written language to perform many tasks, including text generation, summarization, software development, and prediction. However, LLMs can produce text that, while may seem correct, is not fact-based. This study investigates whether a popular LLM, ChatGPT-3.5, could produce high-quality, accurate, and bias-free summaries of medical research abstracts and determine the relevance of various journals and their articles to different medical specialties. Ten articles published in 2022 (not yet “seen” by ChatGPT, as ChatGPT was trained on data before 2022) were randomly sampled from each of 14 selected journals. ChatGPT was then prompted to summarize the abstract, “self-reflect” on the quality, accuracy, and bias of its own summaries, and evaluate its performance in classifying articles’ and journals' relevance to various areas of medicine (cardiology, pulmonary medicine, family medicine, internal medicine, public health, primary care, neurology, psychiatry, obstetrics and gynecology, and general surgery). The quality of summaries, relevant classification of journal and article to medical specialty were also assessed by human physicians. The results include a total of 140 abstract summaries across 14 journals. ChatGPT produced summaries that were 70% shorter than the abstracts. The summaries were rated as high quality, high accuracy, and low bias by both ChatGPT and physician reviewers. Serious inaccuracies occurred in only four of the 140 summaries. Minor inaccuracies were noted in 20 of 140 articles and mostly related to the introduction of ambiguity in meaning or summarization of details that would have provided additional content but not completely changed the meaning. ChatGPT was able to classify journals to relevant medical specialties but was much less able to classify specific articles to relevant medical specialties. The summaries were found to have rare—but important—inaccuracies that preclude them from being considered a definitive source of truth.

What We Know: The availability of medical knowledge is increasing. However, due to the demands of their jobs, clinicians have little time to review academic literature, even within their own specialty. Large language models (eg, ChatGPT) could be helpful and save time, but they are not always accurate as they can include bias from their training models and the human feedback which reinforces their learning, and sometimes include information that is not fact-based. 

What This Study Adds: Clinicians are strongly cautioned against solely relying on ChatGPT-based summaries to understand study methods and study results, especially in high-risk situations. Critical medical decisions should—for obvious reasons—remain based on a full evaluation of the full text of articles in context with available evidence from meta-analyses and professional guidelines. However, this study suggests ChatGPT can be useful as a screening tool to help busy clinicians and scientists more rapidly evaluate whether further review of an article is likely to be worthwhile. 

Quality, Accuracy, and Bias in ChatGPT-Based Summarization of Medical Abstracts 

Daniel J. Parente, MD, PhD, et al

Department of Family Medicine and Community Health, University of Kansas Medical Center, Kansas City, Kansas

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Fathers’ Perceptions of Their Teen Sons’ Readiness for Sex Linked to Their Likelihood to Provide Guidance on Condom Use

The purpose of this study was to delve deeper into the link between fathers’ perceptions of their adolescent sons’ preparedness to engage in sexual intercourse, and how likely they were to provide their sons with guidance on using condoms correctly and consistently. Researchers recruited 191 father-son pairs from among Black and Latino residents of the South Bronx in New York City; adolescent participants ranged in age from 15 to 19 years old. Using a sequential mixed-methods explanatory design, all participants completed a confidential survey, after which a random subset of the fathers engaged in two audio-recorded conversations with a ‘father coach.’ Both the survey and conversations were offered in participants’ choice of either English or Spanish. Of note, more than one in three fathers who thought their son already had sex also assessed their sons as “not yet ready to have sex.”

What We Know: Parent-adolescent conversations regarding sexual activity and condom use have important benefits for protecting adolescent sexual health, including conversations between fathers and adolescent sons. However, barriers for fathers to initiate these conversations have been documented. In addition, factors that generally influence a parent’s initiation of these conversations, such as adolescent age and the parent’s perception of whether or not their child is already engaging in sexual activity, remain insufficiently understood for fathers specifically.

What This Study Adds: Currently, published research lacks data about how fathers assess their sons’ readiness for a discussion about sexual activity and correct and consistent condom use. The current research identified three influential factors, including (1) the completion of milestones related to the teens’ life opportunity trajectories; (2) cognitive-social-emotional maturity; and (3) preparedness to have sex safely and avoid negative health and social consequences. These themes emerged as salient for Latino and Black fathers of varying ages. On the basis of these findings, this study provides practical suggestions for engaging fathers in primary care to promote adolescent male correct and consistent condom use.

Paternal Perspectives on Latino and Black Sons’ Readiness for Sex and Condom Guidance: A Mixed Methods Study

Vincent Guilamo-Ramos, PhD, MPH, LCSW, RN, ANP-BC, PMHNP-BC, FAAN, et al

Center for Latino Adolescent and Family Health, Johns Hopkins University, Washington, DC; Institute for Policy Solutions, Johns Hopkins University, Washington, DC; School of Nursing, Johns Hopkins University, Baltimore, Maryland; Presidential Advisory Council on HIV/AIDS, US Department of Health and Human Services, Washington, DC

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Pediatric Health Care Disrupted by COVID-19 Pandemic, Compounded by Existing Barriers Such as Systemic Racism

This study explores the extent to which pediatric health care was interrupted during and as a result of the COVID-19 pandemic. This was measured based on three primary outcomes of interest: foregone care, foregone well-child or vaccination-related visits, and complete absence of well-child or vaccination-related visits. Researchers extracted data from a nationwide longitudinal survey known as CovEx (COVID Experiences Survey) that had been administered in two “waves'' to a cohort of parents of children between five and 12 years of age. Wave 1 took place October 8-November 13, 2020, and Wave 2 took place March 24-May 7, 2021, with an 82% retention rate of participants. Data was examined through the lens of four categories: child-level, parent-level, household-level, and county-level.

Almost one-third (30.1%) of children in the cohort had not had a well-child or vaccination-related visit in over one year, making up the largest percentage among the three primary outcomes of interest. Among the other two measured gaps, 16.3% of children in the cohort had foregone care and 10.9% had foregone well-child or vaccination-related visits. Non-Hispanic White children were at a much lower risk of experiencing any of the three gaps, with the greatest difference seen in their being less than half as likely to have a foregone well-child or vaccination-related visit in comparison to their non-White counterparts. Children who were in school using a completely virtual platform were 1.43 times as likely to forgo care than kids who were in a part-virtual/part-in-person (i.e., hybrid) format or only in-person.

What We Know: Health care barriers such as racism and low socioeconomic status continue to disproportionately affect specific populations. The COVID-19 pandemic only compounded these issues, once again affecting the same populations to disproportionate heights and making access to health care even more difficult. 

What This Study Adds: This study reiterates how, due to the COVID-19 pandemic, pediatric patients missed routine appointments, with racial disparities increasing this risk. Children in counties with fewer primary care doctors per capita were more likely to miss their well-child or vaccination-related visits. Additionally, children with an existing emotional, mental, or developmental behavioral condition had more than twice the risk of foregone care.

Disparities in Unmet Health Care Needs Among US Children During the COVID-19 Pandemic

Sanjana Pampati, MPH, et al

Centers for Disease Control and Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Division of Adolescent and School Health, Atlanta, Georgia, and Emory University, Rollins School of Public Health, Atlanta, Georgia

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CVD-Related Hospitalizations Can  be Prevented by Primary Health Care, Suggests Study in Brazil’s State of Paraná

Researchers analyzed (1) spatiotemporal tendencies of cardiovascular disease-related hospitalizations that could have been prevented by primary health care (PHC-sensitive CVD); and (2) the relationship between social infrastructure development and access to primary health care (PHC). They collected data from the Brazilian state of Paraná’s public records for the years 2014 through 2019, limited to patients between the ages of 50 to 69 years old. They found 193,174 hospitalizations that fit their criteria. 

While annual PHC-sensitive CVD hospitalizations increased overall by approximately 4,000 incidents over the five years, they decreased by seven hospitalizations per 10,000 citizens. However, municipalities with fewer primary care resources, which tended to be the small and medium-sized municipalities, had increases in PHC-sensitive CVD hospitalizations.

What We Know: Primary health care has the power and potential to prevent CVD morbidity and mortality in about 80% of cases. However, this becomes more challenging in resource-poor areas, due to low health literacy, as well as the challenges of accessing both primary health care and preventative lifestyle measures (ie, quality food, safe areas to exercise, etc.).

What This Study Adds: As larger municipalities increase their social development, PHC-sensitive CVD hospitalization rates decrease; however, in small or medium-sized municipalities, PHC-sensitive CVD hospitalization rates did not decrease. The inverse association between social development and PHC-sensitive CVD hospitalizations highlights the need for policy makers to consider health care impacts of social development projects.

Hospitalizations for Cardiovascular Diseases Sensitive to Primary Health Care in Paraná State, Brazil: A Bayesian Spatiotemporal Model

Samile Bonfim, MHS, et al

Postgraduate Program in Health Sciences, Center for Health Sciences, State University of Maringá, Maringá, Paraná, Brazil

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Survey on Genital Tucking Among Transgender and Gender Diverse Individuals: Majority of Respondents Desire Open Conversation With Health Care Providers

Genital tucking is the practice of hiding or minimizing the appearance of one’s genitals and gonads. It is practiced by transgender women and gender diverse individuals who were assigned male at birth. In this study, researchers designed a 27-question survey related to such factors as the length of time individuals spent tucked; how commonly and frequently; and understandings of, concerns for, and positive/negative history of potential adverse effects. Only 23% of the 98 respondents reported discussing tucking with their health care providers, in comparison to the 70% who said they would feel comfortable or very comfortable having this discussion. Those surveyed made several suggestions for providers to facilitate more productive discussion, such as asking permission and communicating empathy; however, the study also brings to light the need for more published data in order to create the evidence-based materials that can properly educate health care providers. 

Genital Tucking Practices in Transgender and Gender Diverse Patients

Nicholas Kidd, MD, et al

University of Virginia Department of Family Medicine, Charlottesville, Virginia

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DEI and Antiracism Curriculum Must Connect the Classroom to the Clinic to Educate Medical Students About Racism in Medicine

There's a growing awareness of the role medicine as an institution has played in creating and perpetuating health inequities facing historically marginalized groups, yet systemic racism and implicit biases continue to shape aspects of clinical practice such as care management decisions and patient communication. 

Addressing medical racism has become an essential part of the medical education curriculum, though most published curricula treat health equity as a lecture topic separate from clinical practice. In this report, authors from the Emory University School of Medicine present a new approach to threading (cohesively incorporating) diversity, equity, and inclusion (DEI) and antiracist concepts throughout all aspects of undergraduate medical education.

The authors set out three phases of the process of threading DEI and antiracist concepts into medical education. Phase one is to establish a framework for DEI curriculum development. A dedicated team of administrators, faculty, and students is assembled to identify gaps and opportunities in the current curriculum, recommend changes toward shaping a DEI-informed curriculum, and create a bias-reporting system. The team also establishes metrics to periodically assess how students and faculty feel about curricular changes and shifts in the campus climate as they pertain to DEI and antiracist initiatives.

The second phase is curriculum content development. The DEI team proposes learning objectives and outcomes that correspond to DEI and antiracism concepts for all courses and clerkships. They encourage faculty development for learning best practices in teaching about DEI topics within their curriculum. The team also determines how best to evaluate learning outcomes to ensure that students attain the appropriate knowledge and skills.

The third phase entails the implementation of the DEI and antiracism medical curriculum, and the ongoing evaluation and refinement of that curriculum thereafter.

The authors acknowledge that the success of a DEI and antiracism curriculum requires dedicated funding for full-time staff and training personnel, clear and cohesive goals, and significant effort, awareness, and support at all levels from students through senior administrators. The approach they outline in this paper is meant to offer actionable guidance for taking steps toward health equity within medical education.

How to Create a Diversity, Equity, and Inclusion Curriculum: More Than Checking a Box

Tracey L. Henry, MD, MPH, MS, et al

Emory University School of Medicine, Department of Medicine, Division of General Internal Medicine, Atlanta, Georgia

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A National Quality Improvement Initiative Provides Insight Into How to Successfully Implement Change in Primary Care Practices

In 2015, the Agency for Healthcare Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health. This three-year initiative, AHRQ’s largest-ever investment in primary care research, was designed to provide external quality improvement support to help small and medium-size primary care practices implement the latest evidence and improve their delivery of cardiovascular care. 

AHRQ awarded grants to primary care practices in seven regions across the U.S. to implement this initiative and to evaluate their own experiences with it, thereby accounting for regional differences in needs and existing resources. Additionally, AHRQ funded a technical assistance center to provide learning and support services to grantees. 

An independent, overarching evaluation of the initiative found that, despite challenges that often accompany quality improvement changes (eg, training staff, adding to their workload), the EvidenceNOW model successfully boosted the capacity of the participating practices to improve quality of care while helping to advance heart health. In AHRQ’s own reflections on the project, three key lessons emerged: 

(1) Change is neither one-size-fits-all nor straightforward. Quality improvement endeavors must be adaptable to suit the needs and resources of different practices. They also must allow for real-time flexibility to address unforeseen challenges. 

(2) Change is a collaborative effort. Its success depends on relationships among practice personnel, their individual well-being, and their capacity for and openness to change.

(3) While policymakers tend to expect immediate results, it can take years for substantive change to take hold in primary care practices and for the effects to become apparent. 

AHRQ believes these lessons make a case for developing a stable, well-funded infrastructure on a national level to provide ongoing external support for primary care practice transformation. Funding is needed to address broader issues with processes and services that most directly affect patient care. Most importantly, funding for practice transformation has to be ongoing, rather than tied to limited projects, in order to sustain and build on improvements.

What AHRQ Learned While Working to Transform Primary Care

Therese Miller, DrPH, et al

Agency for Healthcare Research and Quality, Rockville, Maryland

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Choosing the Best Payment Model to Stay True to Family Medicine’s Mission

Told through the lens of her relationship with a particularly memorable patient, a physician reflects upon how she was able to stay true to the heart of family medicine—ie, giving continuity care on a personal level—in the face of health system structures and payment models. She tells of her own positive transition from the fee-for-service model to the capitated model. She also acknowledges common barriers to care among medically complex patients, such as low literacy and racism. 

Joe’s Story: How a Capitated Payment Model Lets Me Be the Physician I Want to Be

Amy C. Denham, MD, MPH

Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

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The Challenge of Addressing Childhood Obesity in the Face of Unrealistic Guidelines and Resource Shortages

In this essay, a primary care pediatrician raises questions about the practicality of the American Academy of Pediatrics’ obesity management guideline. She discusses why it is unattainable in real-life practice, and identifies what would need to change in order to even begin making an impact. 

Mission Impossible? Managing the American Academy of Pediatrics' Obesity Guideline

Eleanor R. Menzin, MD

Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Cambridge, Massachusetts;  Managing Partner, Longwood Pediatrics, Boston, Massachusetts 

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Offering Bandages to Match a Range of Skin Tones Can Foster a Sense of Inclusivity and Positively Affect Patient Experience

Researchers in the New York City metro area undertook a quality improvement initiative to determine  whether offering bandages in a range of skin tones reflecting a diverse patient population would affect patient experience. Patients at a COVID-19 vaccination site were offered their choice of bandage from among four color options, the conventional beige and three darker tones. They were then asked to take a voluntary anonymous survey about their care experience. Nearly two-thirds of the 44 total participants who took the survey, and nearly 70 percent of non-white participants, said they chose the bandage that best matched their skin tone. A greater percentage of non-white participants than white participants strongly agreed that bandage options positively impacted their view of the clinic and/or its health care workers. The research team concluded that offering bandages in various skin shades is a small but meaningful step toward more inclusive medical care.

Cultivating Inclusivity in Medicine: The Impact of Offering Bandage Options of Various Skin Shades on Patient Experience

Julia Lo Cascio, BS, et al

New York University Grossman Long Island School of Medicine, Mineola, New York

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Encouraging Healthy Toothbrushing Practices for Young Children by Providing Toothbrushing Kits and Educational Materials for Parents/Caregivers during Well-Child Visits

Dental caries is the most common chronic disease of childhood, and twice daily toothbrushing with fluoridated toothpaste is a clinically effective way of reducing dental caries in children. Favorable toothbrushing practices of young children are associated with parental/caregiver support. Physicians at the Cambridge Health Alliance, a non-profit, safety-net health care system in Massachusetts, successfully implemented a pilot program to promote toothbrushing during well-child visits. Toothbrushing kits were offered to parents/caregivers with enclosed instructional materials in their preferred language, including English, Portuguese, Spanish, Haitian Creole, Nepali, and Arabic. The supply of toothbrushing kits lasted 26 weeks, reflecting an uptake of more than 80 percent.

Uptake of a Multilingual Intervention to Promote Toothbrushing in a Safety-Net Health Care System

John Ahern, MB, BCh, BAO, BDentSc, MSc, PhD, et al

Cambridge Health Alliance, Department of Family Medicine, Cambridge, Massachusetts

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Using an EHR Does Not Need to be a Source of Frustration

In 2009, the HITECH Act encouraged health care providers in the U.S. to adopt electronic health records (EHR) through financial incentives. Since then, over 96% of American hospitals have adopted an EHR. Hospitals routinely spend 5-10% of revenue on information technology, yet frustration with using EHRs is a leading cause of clinical staff and clinician burn-out.

The authors of this editorial consider the solutions to the difficulty of using EHRs presented in “Optimization of Electronic Health Record Usability Through a Department-Led Quality Improvement Process,” a paper in this issue by Adam M. Franks and colleagues at Marshall University. The authors believe this study’s results should prompt those in hospital leadership to reflect on their institutions’ relationship to the EHR. While EHR vendors should take steps to improve product usability, Franks et al show that many usability issues stem from the under-training clinical staff on technical skills and under-investment in platforms. The editorialists note that there are many examples of successful technological implementations in industries beyond health care and that even within healthcare, systems like the Department of Veterans Affairs’s VistA system are among the top-rated EHR systems by its users, because it was built “by the VA for the people who use it.”

“Health care systems must undergo a radical shift in their approach to technology,” the editorialists conclude. “Embracing change requires moving beyond viewing technology as a minor secondary competency and reimagining institutions as both clinical and technology organizations, necessitating substantial investment."

Friend or Foe? Helping Health Care Leadership Reimagine a Healthy EHR Relationship

Meylakh Barshay, AB 

The Warren Alpert Medical School of Brown University, Providence, Rhode Island

Caroline R. Richardson, MD

The Warren Alpert Medical School of Brown University, Providence, Rhode Island

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