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Advanced practice providers (APPs) are integral members of the healthcare delivery team. However, there has been a lack of standardization and uniformity in how they are utilized across inpatient, ambulatory, and procedural settings.A multidisciplinary workforce planning committee was formed in March 2021 to evaluate all new and replacement full-time equivalent APP positions at Stanford Health Care (SHC), an academic medical center of more than 600 APPs, to optimize and standardize the role of APPs as per national benchmarks.Six months since the launch of the committee, there has been a 10% increase in the number of visits and procedures performed by APPs providing better access for patients. In addition, there has been a 38.7% improvement in ambulatory APPs meeting their productivity target, 19.4% improvement in ambulatory APPs meeting utilization targets, and 36.8% improvement in ambulatory APPs meeting the 50th percentile and above as per the relative value unit benchmark published by the Medical Group Management Association for Academic Medical Centers. For inpatient APPs, there has been a 38.8% improvement in APPs meeting the average daily census target.APP utilization is an important topic that has not been consistently addressed in the literature. Inappropriate utilization and lack of top of licensure practice have been associated with increased turnover, decreased job satisfaction, and professional development. By developing a multidisciplinary workforce planning committee, full-time employee positions are evaluated with a goal of optimizing and standardizing the role of APPs at SHC.

Objectives Diagnostic programs and second opinion clinics have grown and evolved in the recent years to help patients with rare, puzzling, and complex conditions who often suffer prolonged diagnostic journeys, but there is a paucity of literature on the clinical characteristics of these patients and the efficacy of these diagnostic programs. This study aims to characterize the diagnostic journey, case features, and diagnostic outcomes of patients referred to a team-based second opinion clinic at Stanford. Methods Retrospective chart review was performed for 237 patients evaluated for diagnostic second opinion in the Stanford Consultative Medicine Clinic over a 5 year period. Descriptive case features and diagnostic outcomes were assessed, and correlation between the two was analyzed. Results Sixty-three percent of our patients were women. 49% of patients had a potential precipitating event within about a month prior to the start of their illness, such as medication change, infection, or medical procedure. A single clear diagnosis was determined in 33% of cases, whereas the remaining cases were assessed to have multifactorial contributors/diagnoses (20%) or remained unclear despite extensive evaluation (47%). Shorter duration of illness, fewer prior specialties seen, and single chief symptom were associated with higher likelihood of achieving a single clear diagnosis. Conclusions A single-site academic consultative service can offer additional diagnostic insights for about half of all patients evaluated for puzzling conditions. Better understanding of the clinical patterns and patient experiences gained from this study helps inform strategies to shorten their diagnostic odysseys.

In response to the COVID-19 pandemic, primary care practices across the United States have transitioned from in-person visits to virtual visits. However, there is limited information regarding the facilitators and barriers to the implementation of such a transition. The objective of this study was to evaluate the short-term implications of rapid transition to video visits at Stanford Primary Care through qualitative interviews with key stakeholders., Background: The coronavirus disease 2019 pandemic spurred health systems across the world to quickly shift from in-person visits to safer video visits. Objective: To seek stakeholder perspectives on video visits' acceptability and effect 3 weeks after near-total transition to video visits. Design: Semistructured qualitative interviews. Setting: 6 Stanford general primary care and express care clinics at 6 northern California sites, with 81 providers, 123 staff, and 97 614 patient visits in 2019. Participants: Fifty-three program participants (overlapping roles as medical providers [n = 20], medical assistants [n = 16], nurses [n = 4], technologists [n = 4], and administrators [n = 13]) were interviewed about video visit transition and challenges. Intervention: In 3 weeks, express care and primary care video visits increased from less than 10% to greater than 80% and from less than 10% to greater than 75%, respectively. New video visit providers received video visit training and care quality feedback. New system workflows were created to accommodate the new visit method. Measurements: Nine faculty, trained in qualitative research methods, conducted 53 stakeholder interviews in 4 days using purposeful (administrators and technologists) and convenience (medical assistant, nurses, and providers) sampling. A rapid qualitative analytic approach for thematic analysis was used. Results: The analysis revealed 12 themes, including Pandemic as Catalyst; Joy in Medicine; Safety in Medicine; Slipping Through the Cracks; My Role, Redefined; and The New Normal. Themes were analyzed using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to identify critical issues for continued program utilization. Limitations: Evaluation was done immediately after deployment. Although viewpoints may have evolved later, immediate evaluation allowed for prompt program changes and identified broader issues to address for program sustainability. Conclusion: After pandemic-related systems transformation at Stanford, critical issues to sustain video visit long-term viability were identified. Specifically, technology ease of use must improve and support multiparty videoconferencing. Providers should be able to care for their patients, regardless of geography. Providers need decision-making support with virtual examination training and home-based patient diagnostics. Finally, ongoing video visit reimbursement should be commensurate with value to the patients' health and well-being. Primary Funding Source: Stanford Department of Medicine and Stanford Health Care.

Background: Behavioral health services, integrated into primary care practices, have become increasingly implemented. Although patient satisfaction has been studied, limited information exists about patient preferences for integrated behavioral health in primary care and how perceptions may vary. Objective: To determine patient preferences for integrated behavioral health within primary care and explore differences across patient groups. Methods: A self-report survey was distributed within a quality improvement initiative in an academic health system. A brief 8-item self-report questionnaire of perceptions and preferences for integrated behavioral health was administered to 752 primary care patients presenting before their visits at two primary care clinics. Participation was voluntary, responses were anonymous, and all patients presenting during a three-week timeframe were eligible. Results: In general, patients preferred to have behavioral health concerns addressed within primary care (n = 301; 41%) rather than referral to a specialist (7.5%; n = 55). There was no evidence of variation in preferences by demographic characteristics. Comfort levels to receive behavioral health services ( P

It is old news that we spend more than we get from our health care system. Yet, both history and current headlines demonstrate that crisis is often a prelude to transformation. I read the National Academies of Sciences, Engineering, and Medicine's Rebuilding the Foundations of Health Care report[1][

PURPOSE: Assess effectiveness of Primary Care 2.0: a team-based model that incorporates increased medical assistant (MA) to primary care physician (PCP) ratio, integration of advanced practice clinicians, expanded MA roles, and extended the interprofessional team. METHODS: Prospective, quasi-experimental evaluation of staff/clinician team development and wellness survey data, comparing Primary Care 2.0 to conventional clinics within our academic health care system. We surveyed before the model launch and every 6-9 months up to 24 months post implementation. Secondary outcomes (cost, quality metrics, patient satisfaction) were assessed via routinely collected operational data. RESULTS: Team development significantly increased in the Primary Care 2.0 clinic, sustained across all 3 post implementation time points (+12.2, +8.5, + 10.1 respectively, vs baseline, on the 100-point Team Development Measure) relative to the comparison clinics. Among wellness domains, only “control of work” approached significant gains (+0.5 on a 5-point Likert scale, P = .05), but was not sustained. Burnout did not have statistically significant relative changes; the Primary Care 2.0 site showed a temporal trend of improvement at 9 and 15 months. Reversal of this trend at 2 years corresponded to contextual changes, specifically, reduced MA to PCP staffing ratio. Adjusted models confirmed an inverse relationship between team development and burnout (P

BACKGROUND Hypertension is the most prevalent and important risk factor for cardiovascular disease, affecting nearly 50% of the US adult population; however, only 30% of these patients achieve controlled blood pressure (BP). Incorporating strategies into primary care that take into consideration individual patient needs, such as remote BP monitoring, may improve hypertension management. OBJECTIVE From March 2018 to December 2018, Stanford implemented a precision health pilot called Humanwide, which aimed to leverage high-technology and high-touch medicine to tailor individualized care for conditions such as hypertension. We examined multi-stakeholder perceptions of hypertension management in Humanwide to evaluate the program’s acceptability, appropriateness, feasibility, and sustainability. METHODS We conducted semistructured interviews with 16 patients and 15 health professionals to assess their experiences with hypertension management in Humanwide. We transcribed and analyzed the interviews using a hybrid approach of inductive and deductive analysis to identify common themes around hypertension management and consensus methods to ensure reliability and validity. RESULTS A total of 63% (10/16) of the patients and 40% (6/15) of the health professionals mentioned hypertension in the context of Humanwide. These participants reported that remote BP monitoring improved motivation, BP control, and overall clinic efficiency. The health professionals discussed feasibility challenges, including the time needed to analyze BP data and provide individualized feedback, integration of BP data, technological difficulties with the BP cuff, and decreased patient use of remote BP monitoring over time. CONCLUSIONS Remote BP monitoring for hypertension management in Humanwide was acceptable to patients and health professionals and appropriate for care. Important challenges need to be addressed to improve the feasibility and sustainability of this approach by leveraging team-based care, engaging patients to sustain remote BP monitoring, standardizing electronic medical record integration of BP measurements, and finding more user-friendly BP cuffs.

Background Humanwide was precision health embedded in primary care aiming to leverage high-tech and high-touch medicine to promote wellness, predict and prevent illness, and tailor treatment to individual medical and psychosocial needs. Methods We conducted a study assessing implementation outcomes to inform spread and scale, using mixed methods of semi-structured interviews with diverse stakeholders and chart reviews. Humanwide included: 1) health coaching; 2) four digital health tools for blood-pressure, weight, glucose, and activity; 3) pharmacogenomic testing; and 4) genetic screening/testing. We examined implementation science constructs: reach/penetration, acceptability, feasibility, and sustainability. Chart reviews captured preliminary clinical outcomes. Results Fifty of 69 patients (72%) invited by primary care providers participated in the Humanwide pilot. We performed chart reviews for the 50 participating patients. Participants were diverse overall (50% non-white, 66% female). Over half of the participants were obese and 58% had one or more major cardiovascular risk factor: dyslipidemia, hypertension, diabetes. Reach/penetration of Humanwide components varied: pharmacogenomics testing 94%, health coaching 80%, genetic testing 72%, and digital health 64%. Interview participants (n=27) included patients (n=16), providers (n=9), and the 2 staff who were allocated dedicated time for Humanwide patient intake and orientation. Patients and providers reported Humanwide was acceptable; it engaged patients holistically, supported faster medication titration, and strengthened patient-provider relationships. All patients benefited clinically from at least one Humanwide component. Feasibility challenges included: low provider self-efficacy for interpreting genetics and pharmacogenomics; difficulties with data integration; patient technology challenges; and additional staffing needs. Patient financial burden concerns surfaced with respect to sustainability. Conclusion This is the first report of implementation of a multi-component precision health model embedded in team-based primary care. We found acceptance from both patients and providers; however, feasibility barriers must be overcome to enable broad spread and sustainability. We found that barriers to implementation of precision health in a team-based primary care clinic are mundane and straightforward, though not necessarily easy to overcome. Future implementation endeavors should invest in basics: education, workflow, and reflection/evaluation. Strengthening fundamentals will enable healthcare systems to more nimbly accept the responsibility of meeting patients at the crossroads of innovative science and routinized clinical systems.

Background: Prolonged symptoms after SARS-CoV-2 infection are well-documented. However, which factors influence development of long-term symptoms, how symptoms vary across ethnic groups, and whether long-term symptoms correlate with serologic biomarkers remain elusive. Methods: Adult inpatient and outpatient SARS-CoV-2 RT-PCR positive patients were recruited at Stanford from March 2020 to February 2021. Study participants were seen for in-person visits at diagnosis and every 1-3 months for up to one year after diagnosis; they completed symptom surveys and underwent sampling procedures (blood draw and nasal swab) at each visit. Findings: Our cohort (n=617) ranged from asymptomatic to critical COVID-19 infections. 40% of participants reported at least one symptom associated with COVID-19 six months after diagnosis. Median time from diagnosis to first resolution of all symptoms was 44 days, median time from diagnosis to sustained symptom resolution with no recurring symptoms for one month or longer was 214 days. Serum anti-nucleocapsid IgG level in the first week of infection was predictive of time to symptom resolution. A prior diagnosis of lung disease was associated with longer time to symptom resolution. COVID-19 disease severity, ethnicity, sex, cytomegalovirus (CMV) seropositivity, and remdesivir use did not affect time to sustained symptom resolution. More than 90% of participants had SARS-CoV-2-specific antibody>1000 AU/mL nine months after diagnosis. Interpretation: Our findings showed that all disease severities had a similar risk of developing post-COVID-19 syndrome in an ethnically diverse population. Comorbid lung disease and lower levels of initial IgG response to SARS-CoV-2 nucleocapsid antigen were associated with longer symptom duration. Trial Registration: National clinical trial database NCT04664309. Funding: NIH CTSA grant, U54 NIH Grant, R21 NIEHS, Sean N Parker Center for Allergy and Asthma Research at Stanford University, the Sunshine Foundation, the Crown Foundation, and the Parker Foundation. Declaration of Interest: Dr. Boyd received support for the current manuscript from Meso Scale Discovery and NIH; 418 received consulting fees by Regeneron for expert testimony, has stocks or stock options in 419 AbCellera Biologics; Dr. Chinthrajah reports grants from NIAID, CoFAR, Aimmune, DBV 420 Technologies, Astellas, Regeneron, Stanford Maternal and Child Health Research Institute 421 (MCHRI), and FARE. She is an Advisory Board Member at Alladapt Therapeutics, Novartis, 422 Genentech, Sanofi, Allergenis, and Nutricia; Dr. Manisha Desai received support from Chan 423 Zuckerberg Foundation; Dr. Maecker received grants or contracts from NIH, Bill & Melinda 424 Gates Foundation, Ionis Corporation, Amgen Corporation; Consulting fees from Magarray Corp; 425 payment or honoraria from UCLA, UC Davis; leadership or fiduciary role at Cytek SAB; stocks 426 or stock options at BD Biosciences; Dr. Nadeau reports grants from National Institute of Allergy and Infectious Diseases (NIAID), National Heart, Lung, and Blood Institute (NHLBI), National Institute of Environmental Health Sciences (NIEHS), and Food Allergy Research & Education (FARE); Director of World Allergy Organization (WAO) , Advisor at Cour Pharma, Consultant for Excellergy, Red tree ventures, and Phylaxis, Co-founder of Before Brands, Alladapt, Latitude, and IgGenix; and National Scientific Committee member at Immune Tolerance Network (ITN), and National Institutes of Health (NIH) clinical research centers, outside the submitted work; patents include, “Mixed allergen composition and methods for using the same”, “Granulocyte-based methods for detecting and monitoring immune system disorders”, “Methods and Assays for Detecting and Quantifying Pure Subpopulations of White Blood Cells in Immune System Disorders,” and “Methods of isolating allergen-specific antibodies from humans and uses thereof”; Dr. Benjamin Pinsky received grants or contracts for the present manuscript from MesoScale Diagnostics; Dr. Angele Rogers was a Clinical Trials Advisory Board Member for Merck; Dr. Sindher reports support for the present manuscript from the NIH, Regeneron, DBV Technologies, Aimmune, Novartis, CoFAR, FARE, participated on a DSMB for Astra Zeneca, DBV, and received payment or honorarium from FARE; Neera Ahuja, Maja Artandi, Linda Barman, Catherine Blish, Andra Blomkalns, William Collins, MacKenzie Cox, Linda Geng, Xiaolin Jia, Megan Mahoney, Monali Manohar, Ruth O’hara, Rajan Puri, Katharina Roltgen, Laura Vaughan, Samuel Yang, Shu Cao, Iris Chang, Hena Din, Evan Do, Andrea Fernandez, Alexandra Lee, Natasha Purington, Yael Rosenberg-Hasson, Theo Snow, Daniel Solis, Michelle Verghese, and Yingjie Weng have no conflict of interest. Ethical Approval: This study was reviewed and approved by the Stanford Administrative Panel on Human Subjects in Medical Research.

BACKGROUND The COVID-19 pandemic has created unprecedented challenges for first responders (eg, police, fire, and emergency medical services) and nonmedical essential workers (eg, workers in food, transportation, and other industries). Health systems may be uniquely suited to support these workers given their medical expertise, and mobile apps can reach local communities despite social distancing requirements. Formal evaluation of real-world mobile app–based interventions is lacking. OBJECTIVE We aimed to evaluate the adoption, acceptability, and appropriateness of an academic medical center–sponsored app-based intervention (COVID-19 Guide App) designed to support access of first responders and essential workers to COVID-19 information and testing services. We also sought to better understand the COVID-19–related needs of these workers early in the pandemic. METHODS To understand overall community adoption, views and download data of the COVID-19 Guide App were described. To understand the adoption, appropriateness, and acceptability of the app and the unmet needs of workers, semistructured qualitative interviews were conducted by telephone, by video, and in person with first responders and essential workers in the San Francisco Bay Area who were recruited through purposive, convenience, and snowball sampling. Interview transcripts and field notes were qualitatively analyzed and presented using an implementation outcomes framework. RESULTS From its launch in April 2020 to September 2020, the app received 8262 views from unique devices and 6640 downloads (80.4% conversion rate, 0.61% adoption rate across the Bay Area). App acceptability was mixed among the 17 first responders interviewed and high among the 10 essential workers interviewed. Select themes included the need for personalized and accurate information, access to testing, and securing personal safety. First responders faced additional challenges related to interprofessional coordination and a “culture of heroism” that could both protect against and exacerbate health vulnerability. CONCLUSIONS First responders and essential workers both reported challenges related to obtaining accurate information, testing services, and other resources. A mobile app intervention has the potential to combat these challenges through the provision of disease-specific information and access to testing services but may be most effective if delivered as part of a larger ecosystem of support. Differentiated interventions that acknowledge and address the divergent needs between first responders and non–first responder essential workers may optimize acceptance and adoption.

Background: The COVID-19 pandemic has created unprecedented challenges for first responders (eg, police, fire, and emergency medical services) and nonmedical essential workers (eg, workers in food, transportation, and other industries). Health systems may be uniquely suited to support these workers given their medical expertise, and mobile apps can reach local communities despite social distancing requirements. Formal evaluation of real-world mobile app–based interventions is lacking. Objective: We aimed to evaluate the adoption, acceptability, and appropriateness of an academic medical center–sponsored app-based intervention (COVID-19 Guide App) designed to support access of first responders and essential workers to COVID-19 information and testing services. We also sought to better understand the COVID-19–related needs of these workers early in the pandemic. Methods: To understand overall community adoption, views and download data of the COVID-19 Guide App were described. To understand the adoption, appropriateness, and acceptability of the app and the unmet needs of workers, semistructured qualitative interviews were conducted by telephone, by video, and in person with first responders and essential workers in the San Francisco Bay Area who were recruited through purposive, convenience, and snowball sampling. Interview transcripts and field notes were qualitatively analyzed and presented using an implementation outcomes framework. Results: From its launch in April 2020 to September 2020, the app received 8262 views from unique devices and 6640 downloads (80.4% conversion rate, 0.61% adoption rate across the Bay Area). App acceptability was mixed among the 17 first responders interviewed and high among the 10 essential workers interviewed. Select themes included the need for personalized and accurate information, access to testing, and securing personal safety. First responders faced additional challenges related to interprofessional coordination and a “culture of heroism” that could both protect against and exacerbate health vulnerability. Conclusions: First responders and essential workers both reported challenges related to obtaining accurate information, testing services, and other resources. A mobile app intervention has the potential to combat these challenges through the provision of disease-specific information and access to testing services but may be most effective if delivered as part of a larger ecosystem of support. Differentiated interventions that acknowledge and address the divergent needs between first responders and non–first responder essential workers may optimize acceptance and adoption.

Background Integrating behavioral health in primary care is a widespread endeavor. Yet rampant variation exists in models and approaches. One significant question is whether frontline providers perceive that behavioral health includes substance use. The current study examined front line providers’: 1. definition of behavioral health, and 2. levels of comfort treating patients who use alcohol and other drugs. Frontline providers at two primary care clinics were surveyed using a 28-item instrument designed to assess their comfort and knowledge of behavioral health, including substance use. Two questions from the Integrated Behavioral Health Staff Perceptions Survey pertaining to confidence in clinics’ ability to care for patients’ behavioral health needs and comfort dealing with patients with behavioral health needs were used for the purposes of this report. Participants also self-reported their clinic role. Responses to these two items were assessed and then compared across roles. Chi square estimates and analysis of variance tests were used to examine relationships between clinic roles and comfort of substance use care delivery. Results Physicians, nurses/nurse practitioners, medical assistants, and other staff (N = 59) participated. Forty-nine participants included substance use in their definition of behavioral health. Participants reported the least comfort caring for patients who use substances (M = 3.5, SD = 1.0) compared to those with mental health concerns (M = 4.1, SD = 0.7), chronic medical conditions (M = 4.2, SD = 0.7), and general health concerns (M = 4.2, SD = 0.7) (p M = 3.0, SD = 0.7) reported significantly lower levels of comfort than medical assistants (M = 4.2, SD = 0.9) (p Conclusions In a small sample of key stakeholders from two primary care clinics who participated in this survey, most considered substance use part of the broad umbrella of behavioral health. Compared to other conditions, primary care providers reported being less comfortable addressing patients’ substance use. Level of comfort varied by role, where physicians were least comfortable, and medical assistants most comfortable.

In summer 2020, COVID-19 laid bare social determinants contributing to disproportional African-American death rates,1 and #BlackLivesMatter protests decried police brutality and systematic racism that continue to exert daily pressure on African American lives.2 These twin forces resulted in renewed commitment to health equity and criminal justice reform within the medical community.3 Microaggressions including “microinvalidation”—the denial of racialized experiences of people of color—may more profoundly impact racial anger, frustration, and self-confidence than overt forms of racism.4 Furthermore, denial of racism prevents team members from realizing and confronting their role in causing traumatic reactions or perpetuating disparities.5

The threat to the public health of the United States from the COVID-19 pandemic is causing rapid, unprecedented shifts in the health care landscape. Community health centers serve the patient populations most vulnerable to the disease yet often have inadequate resources to combat it. Academic medical centers do not always have the community connections needed for the most effective population health approaches. We describe how a bridge between a community health center partner (Roots Community Health Center) and a large academic medical center (Stanford Medicine) brought complementary strengths together to address the regional public health crisis. The 2 institutions began the crisis with an overlapping clinical and research faculty member (NKT). Building on that foundation, we worked in 3 areas. First, we partnered to reach underserved populations with the academic center's newly developed COVID test. Second, we developed and distributed evidence-based resources to these same communities via a large community health navigator team. Third, as telemedicine became the norm for medical consultation, the 2 institutions began to research how reducing the digital divide could help improve access to care. We continue to think about how best to create enduring partnerships forged through ongoing deeper relationships beyond the pandemic.

A new transformational model of primary care is needed to address patient care complexity and provider burnout. An 18-month design effort (2015-2016) included the following: (1) Needs Finding, (2) Integrated Facility Design, (3) Design Process Assessment, and (4) Development of Evaluation. Initial outcome metrics were assessed. The design team successfully applied Integrated Facility Design to primary care transformation design; qualitative survey results suggest that design consensus was facilitated by team-building activities. Initial implementation of Quadruple Aim–related outcome metrics showed positive trends. Redesign processes may benefit from emphasis on team building to facilitate consensus and increased patient involvement to incorporate patient voices successfully.

Improving our understanding of what physical activities are enjoyed and the factors that are associated with physical activity liking can promote participation in regular physical activity. We aimed to study physical activity (PA) liking in college women by modelling interactions between body size perception and dietary behaviors on PA liking, and by examining discrepancies between PA liking versus engagement on body size perception and dietary behaviors. Women (n = 251, 74% white) utilized an online survey to report their level of liking for PA types (scored into a PA liking index) and frequency of PA participation. They also reported their perceived body size, level of dietary restraint, and frequency of consuming foods (scored into a diet quality index). In multivariate analyses, a greater perceived body size was directly associated with lower PA liking and indirectly through greater dietary restraint but lower diet quality. Healthiest dietary behaviors were reported by women who both liked and engaged in PA. Women who reported high PA liking but low PA participation reported a higher dietary restraint and lower diet quality. These findings support the empowerment of women across all body sizes to identify physical activities that they enjoy. Health promotion efforts should encourage women to couple physical activity liking and engagement with a healthy level of dietary restraint and consumption of a healthy diet.

Background Current evaluation methods are mismatched with the speed of health care innovation and needs of health care delivery partners. We introduce a qualitative approach called the lightning report method and its specific product—the “Lightning Report.” We compare implementation evaluation results across four projects to explore report sensitivity and the potential depth and breadth of lightning report method findings. Methods The lightning report method was refined over 2.5 years across four projects: team‐based primary care, cancer center transformation, precision health in primary care, and a national life‐sustaining decisions initiative. The novelty of the lightning report method is the application of Plus/Delta/Insight debriefing to dynamic implementation evaluation. This analytic structure captures Plus (“what works”), Delta (“what needs to be changed”), and Insights (participant or evaluator insights, ideas, and recommendations). We used structured coding based on implementation science barriers and facilitators outlined in the Consolidated Framework for Implementation Research (CFIR) applied to 17 Lightning Reports from four projects. Results Health care partners reported that Lighting Reports were valuable, easy to understand, and they implied reports supported “corrective action” for implementations. Comparative analysis revealed cross‐project emphasis on the domains of Inner Setting and Intervention Characteristics, with themes of communication, resources/staffing, feedback/reflection, alignment with simultaneous interventions and traditional care, and team cohesion. In three of the four assessed projects, the largest proportion of coding was to the clinic‐level domain of Inner Setting—ranging from 39% for the cancer center project to a high of 56% for the life‐sustaining decisions project. Conclusions The lightning report method can fill a gap in rapid qualitative approaches and is generalizable with consistent but flexible core methods. Comparative analysis suggests it is a sensitive tool, capable of uncovering differences and insights in implementation across projects. The Lightning Report facilitates partnered evaluation and communication with stakeholders by providing real‐time, actionable insights in dynamic health care implementations.

To assess the effectiveness of a clinical decision support tool consisting of an electronic medical record best practice alert (BPA) on the frequency of lumbar imaging in patients with acute low back pain in the ambulatory care setting, and to explore why providers order imaging outside of clinical guidelines.On March 23, 2016, we implemented a BPA pop-up alert that informed the ordering physician of the Choosing Wisely recommendation to not order imaging within the first 6 weeks of low back pain in the absence of red flags. We calculated imaging rates 1 year before and after implementation of the BPA. To override the BPA, providers could ignore the alert or explain their rationale for ordering imaging using either preset options or a free-text submission. We tracked preset options and manually reviewed 125 free-text submissions.Significant decreases in both total imaging rate (9.6% decrease; P = 0.02) and magnetic resonance imaging rate (14.9% decrease; P0.01) were observed after implementation of the BPA. No change was found in the rates of X-ray or computed tomography scan orders. Almost two-thirds (64%) of the providers used preset options in overriding the BPA, and 36% of the providers entered a free-text submission. Among those providers using a free-text submission, 56% entered a non-guideline-supported rationale.The present study demonstrates the effectiveness of a simple, low-cost clinical decision support tool in reducing imaging rates for patients with acute low back pain. We also identify reasons why providers order imaging outside of clinical guidelines.

Artificial intelligence (AI) is poised as a transformational force in healthcare. This paper presents a current environmental scan, through the eyes of primary care physicians, of the top ten ways AI will impact primary care and its key stakeholders. We discuss ten distinct problem spaces and the most promising AI innovations in each, estimating potential market sizes and the Quadruple Aims that are most likely to be affected. Primary care is where the power, opportunity, and future of AI are most likely to be realized in the broadest and most ambitious scale. We propose how these AI-powered innovations must augment, not subvert, the patient-physician relationship for physicians and patients to accept them. AI implemented poorly risks pushing humanity to the margins; done wisely, AI can free up physicians' cognitive and emotional space for patients, and shift the focus away from transactional tasks to personalized care. The challenge will be for humans to have the wisdom and willingness to discern AI's optimal role in twenty-first century healthcare, and to determine when it strengthens and when it undermines human healing. Ongoing research will determine the impact of AI technologies in achieving better care, better health, lower costs, and improved well-being of the workforce.

BackgroundPrimary care (PC) is the foundation of the Kenyan health care system, providing comprehensive care, health promotion and managing all illnesses across the lifecycle. In the private sector in Nairobi, PC is principally offered by the general practitioners, also known as family doctors (FDs). The majority have no postgraduate training. Little is known about how patients perceive their capability.AimTo assess patients' perceptions of the scope of practice of FDs working in private sector PC clinics in Nairobi and their awareness of the new category of family physicians (FPs) and the discipline of family medicine.SettingPrivate sector PC clinics in Nairobi.MethodsA descriptive survey using a structured, self-administered questionnaire. Simple random sampling was used to recruit 162 patient participants.ResultsOf the participants, 30% knew the difference between FPs and FDs. There was a high to moderate confidence that FDs could treat common illnesses; provide lifestyle advice; family planning (66%) and childhood immunisations (64%). In adolescents and adults, low confidence was expressed in their ability to manage tuberculosis (58%), human immunodeficiency virus (55%) and cancer (33%). In the elderly, there was low confidence in their ability to manage depression (55%), anxiety (57%), urinary incontinence (57%) and diabetes (59%). There was low confidence in their ability to provide antenatal care (55%) and Pap smears (42%).ConclusionPatients did not perceive that FDs could offer fully comprehensive PC services. These perceptions may be addressed by defining the expected package of care, designing a system that encourages the utilisation of PC and employing FPs.

UNSTRUCTURED Primary care physicians report low confidence in their genetic testing knowledge. Practitioners in the early 20th century similarly reported hesitations towards now-routine chemistry-based blood tests, e.g. counts, glucose, and cholesterol measurement. Physicians in 2017 say the same things about genetic testing: it is hard to incorporate into daily practice, not consistently useful, less important than other priorities, and technically difficult. Technologies that are now commonplace in clinical practice were approached overcautiously at inception, similar to genetic testing today.

Background Data on breast healthcare knowledge, perceptions and practice among women in rural Kenya is limited. Furthermore, the role of the male head of household in influencing a woman’s breast health seeking behavior is also not known. The aim of this study was to assess the knowledge, perceptions and practice of breast cancer among women, male heads of households, opinion leaders and healthcare providers within a rural community in Kenya. Our secondary objective was to explore the role of male heads of households in influencing a woman’s breast health seeking behavior. Methods This was a mixed method cross-sectional study, conducted between Sept 1st 2015 Sept 30th 2016. We administered surveys to women and male heads of households. Outcomes of interest were analysed in Stata ver 13 and tabulated against gender. We conducted six focus group discussions (FGDs) and 22 key informant interviews (KIIs) with opinion leaders and health care providers, respectively. Elements of the Rapid Assessment Process (RAP) were used to guide analysis of the FGDs and the KIIs. Results A total of 442 women and 237 male heads of households participated in the survey. Although more than 80% of respondents had heard of breast cancer, fewer than 10% of women and male heads of households had knowledge of 2 or more of its risk factors. More than 85% of both men and women perceived breast cancer as a very serious illness. Over 90% of respondents would visit a health facility for a breast lump. Variable recognition of signs of breast cancer, limited decision- autonomy for women, a preference for traditional healers, lack of trust in the health care system, inadequate access to services, limited early-detection services were the six themes that emerged from the FGDs and the KIIs. There were discrepancies between the qualitative and quantitative data for the perceived role of the male head of household as a barrier to seeking breast health care. Conclusions Determining level of breast cancer knowledge, the characteristics of breast health seeking behavior and the perceived barriers to accessing breast health are the first steps in establishing locally relevant intervention programs. Electronic supplementary material The online version of this article (10.1186/s12889-019-6464-3) contains supplementary material, which is available to authorized users.

Academic medical centers need better ways to quantify the diverse academic contributions of primary care clinician-educators. We examined the feasibility and acceptability of an "academic achievement calculator" that quantifies academic activities using a point system.A cohort of 16 clinician-educators at a single academic medical center volunteered to assess the calculator using a questionnaire. Key measures included time needed to complete the calculator, how well it reflected participants' academic activities, whether it increased their awareness of academic opportunities, whether they intend to pursue more academic work, and their overall satisfaction with the calculator.Most participants (69%) completed the calculator in less than 20 minutes. Three-quarters (75%) reported that the calculator reflected the breadth of their academic work either "very well" or "extremely well". The majority (81%) stated that it increased their awareness of opportunities for academic engagement, and that they intend to pursue more academic activities. Overall, three-quarters (75%) were "very satisfied" or "extremely satisfied" with the calculator.To our knowledge, this is the first report of a tool designed to quantify the diverse academic activities of primary care clinician-educators. In this pilot study, we found that the use of an academic achievement calculator may be feasible and acceptable. This tool, if paired with an annual bonus plan, could help incentivize and reward academic contributions among primary care clinician-educators, and assist department leaders with the promotion process.

PurposeScribes are increasingly being used in clinical practice despite a lack of high-quality evidence regarding their effects. Our objective was to evaluate the effect of medical scribes on physician satisfaction, patient satisfaction, and charting efficiency.MethodsWe conducted a randomized controlled trial in which physicians in an academic family medicine clinic were randomized to 1 week with a scribe then 1 week without a scribe for the course of 1 year. Scribes drafted all relevant documentation, which was reviewed by the physician before attestation and signing. In encounters without a scribe, the physician performed all charting duties. Our outcomes were physician satisfaction, measured by a 5-item instrument that included physicians' perceptions of chart quality and chart accuracy; patient satisfaction, measured by a 6-item instrument; and charting efficiency, measured by time to chart close.ResultsScribes improved all aspects of physician satisfaction, including overall satisfaction with clinic (OR = 10.75), having enough face time with patients (OR = 3.71), time spent charting (OR = 86.09), chart quality (OR = 7.25), and chart accuracy (OR = 4.61) (all P values

Stanford Primary Care launched Humanwide, a demonstration project to provide patients with genetic screening, wearable sensors, health assessment, and wellness coaching. We synthesized patient-level biometric, genetic, social, environmental, and behavioral data into the electronic health record for

Hepatitis C (HCV) is the most common chronic blood-borne disease and the leading cause of liver transplantation in the US, affecting an estimated 3.2 million Americans 1, 2. Recent advancement in antiviral treatment options has significantly increased the response rates to anti-HCV therapy even among the difficult to treat populations 3, 4. Despite this, it is estimated that only 34–48% of chronic carriers are referred for liver specialist assessment 5–7, and less than 37% of patients receive treatment for hepatitis C 6–8. Therefore, instituting models of care that have the potential to overcome barriers and improve access to care represents a critical goal in addressing the HCV epidemic 9. The Institute of Medicine recently released a report identifying “missed opportunities” in the prevention and control of HCV, and specifically recommended the development, coordination, and evaluation of education programs targeting at-risk populations, as well as improved coordination of hepatitis care delivery services in its national strategy to improve hepatitis care services 10. In addition, the American Association for the Study of Liver Diseases (AASLD) and Centers for Disease Control and Prevention (CDC) joint conference proceedings on viral hepatitis emphasized the importance of a multidisciplinary approach to HCV care and HCV care coordination, including linkage of infected persons with care and treatment services to improve prevention of viral hepatitis and the effectiveness of treatment 8. Patients within the safety-net healthcare systems that predominantly serve the uninsured and underinsured populations are especially at risk for experiencing health disparities, have limited access to care, and represent a growing vulnerable patient population 11. HCV patient education is associated with positive outcomes in various models of HCV care, including increased disease-specific knowledge 12, 13, interest in treatment 14, willingness to accept treatment 5, 15, and increase liver specialty care clinic attendance 12, 13. In a prior study within the San Francisco safety-net healthcare system, formal HCV education by liver specialists not only resulted in a significant improvement in HCV knowledge among patients, but appeared to create efficiencies in this healthcare system to allow better access to specialty care for these individuals 13. Therefore, this patient-centered approach has the potential to impact HCV management, interest in receipt of HCV treatment, and treatment outcome. However, the impact of formal HCV education by specialists on facilitating HCV treatment initiation, adherence to treatment, and treatment outcome is not clearly understood. Furthermore, although primary care providers have a pivotal role in identifying patients with HCV, referring patients to specialty consultants for treatment, and collaborating with specialty care providers 16; whether formal patient education by a specialist has a positive impact on HCV co-management between primary and specialty care providers has not been previously studied. Considering the increasing emphasis on systemic improvements to our healthcare delivery system and enhanced coordination of health services, this study was conducted to evaluate the impact of the institution of a mandatory formal HCV education class by liver specialty providers on HCV treatment initiation and outcomes and to evaluate provider attitudes towards the impact of formal patient education on HCV management.

Background and methods Knowledge of utilization of health services and associated factors is important in planning and delivery of interventions to improve health services coverage. We determined the prevalence and factors associated with health services utilization in a rural area of Kenya. Our findings inform the local health management in development of appropriately targeted interventions. We used a cluster sample survey design and interviewed household key informants on history of illness for household members and health services utilization in the preceding month. We estimated prevalence and performed random effects logistic regression to determine the influence of individual and household level factors on decisions to utilize health services. Results and conclusions 1230/6,440 (19.1%, 95% CI: 18.3%-20.2%) household members reported an illness. Of these, 76.7% (95% CI: 74.2%-79.0%) sought healthcare in a health facility. The majority (94%) of the respondents visited dispensary-level facilities and only 60.1% attended facilities within the study sub-counties. Of those that did not seek health services, 43% self-medicated by buying non-prescription drugs, 20% thought health services were too costly, and 10% indicated that the sickness was not serious enough to necessitate visiting a health facility. In the multivariate analyses, relationship to head of household was associated with utilization of health services. Relatives other than the nuclear family of the head of household were five times less likely to seek medical help (Odds Ratio 0.21 (95% CI: 0.05–0.87)). Dispensary level health facilities are the most commonly used by members of this community, and relations at the level of the household influence utilization of health services during an illness. These data enrich the perspective of the local health management to better plan the allocation of healthcare resources according to need and demand. The findings will also contribute in the development of community-level health coverage interventions that target the disadvantaged household groups.

High rates of incarceration in urban, low income communities may exacerbate women's risk of HIV infection by decreasing the number of available male sexual partners and disrupting long-term partnerships. The Health Access Program for Prevention, Empowerment, and Networking for Women (HAPPEN) was established to address the HIV prevention needs of women partnered with incarcerated or recently released men in community settings. HAPPEN is an adaptation of the evidence-based HIV prevention intervention Health Options Mean Empowerment (HOME) project. HOME was designed specifically for women visiting their incarcerated male partners and was delivered at a prison visiting center. Recruitment and program implementation for HAPPEN occurred at community-based organizations serving women with histories of substance abuse, intimate partner violence and incarceration, and provided health education, HIV testing, and linkage to health care and social services. This paper describes the process of adapting HOME using input from target organization stakeholders and target population members.

Background and objectives: Family medicine postgraduate programmes in Kenya are examining the benefits of Community-Oriented Primary Care (COPC) curriculum, as a method to train residents in population-based approaches to health care delivery. Whilst COPC is an established part of family medicine training in the United States, little is known about its application in Kenya. We sought to conduct a qualitative study to explore the development and implementation of COPC curriculum in the first two family medicine postgraduate programmes in Kenya. Method: Semi-structured interviews of COPC educators, practitioners, and academic stakeholders and focus groups of postgraduate students were conducted with COPC educators, practitioners and academic stakeholders in two family medicine postgraduate programmes in Kenya. Discussions were transcribed, inductively coded and thematically analysed. Results: Two focus groups with eight family medicine postgraduate students and interviews with five faculty members at two universities were conducted. Two broad themes emerged from the analysis: expected learning outcomes and important community-based enablers. Three learning outcomes were (1) making a community diagnosis, (2) understanding social determinants of health and (3) training in participatory research. Three community-based enablers for sustainability of COPC were (1) partnerships with community health workers, (2) community empowerment and engagement and (3) institutional financial support. Conclusions: Our findings illustrate the expected learning outcomes and important communitybased enablers associated with the successful implementation of COPC projects in Kenya and will help to inform future curriculum development in Kenya.

As racial and ethnic diversity in the general population of the United States increases, research continues to show that diversity in the physician workforce improves health care quality and access to care for ethnic minorities.1–3 In 2004, three ethnic minority groups, African Americans, Latino Americans, and American Indians, represented more than 25% of the U.S. population but only 6% of the nation’s physicians.4 Several reports, including those of the Institute of Medicine and the Sullivan Commission, have called for measures to increase the diversity of the medical workforce.1,4,5 Recruitment and retention of racial and ethnic minority faculty at medical schools have been identified as key factors in increasing the pipeline of minority medical students. Minority faculty provide support for minority students in the form of role models, educators, and mentors.6,7 Unfortunately, minority faculty continue to be alarmingly underrepresented, comprising only 4.2% of medical school faculty nationwide in 2005.8 In that same year, approximately 20% of minority faculty were located at three historically black medical schools and three Puerto Rican medical schools accredited by the Liaison Committee on Medical Education.9 Minority academic medicine faculty are less likely to hold senior rank, are promoted at lower rates,10–12 and report more discrimination than white faculty.13 In addition, high rates of discrimination and harassment during medical education and training14,15 might explain differences in the level of physicians’ professional satisfaction according to race and ethnicity.16 A recent study of physicians of African descent found that race-related experiences can create “racial fatigue” and result in personal and professional costs for physicians.17 Diversity in the student body at medical schools has been shown to enhance the educational experience for all students.18 In addition to addressing health disparities in academic medicine and improving the education and training of all medical students, increasing the number of minority faculty may improve care by increasing the numbers of physicians working with underserved populations19 and by multiplying options for minority patients who prefer racially concordant physicians.20–22 The far-reaching effects of anti-affirmative-action policies, such as Proposition 209 in California, have negatively affected minority student enrollment and recruitment. Proposition 209, a constitutional measure passed in 1996, outlawed race- and gender-based admissions and hiring policies at California public institutions. As of 2008, the University of California–San Francisco (UCSF) School of Medicine faculty includes 2.1% African American and 2.6% Latino faculty. UCSF is working on a variety of strategies to increase diversity through initiatives such as the Underrepresented in Medicine Mentorship Program, the School of Medicine Task Force on Underrepresented Minorities, the Chancellor’s Advisory Committee on Diversity, and a new position for a director of academic diversity. In our study, we bring the voice of minority faculty to current diversity efforts by examining the effects of anti-affirmative-action policies on the diversity climate and by making specific recommendations for academic institutions seeking to increase diversity. Previous studies have focused on junior faculty or students,23,24 whereas our study explores both the junior and senior faculty experience. To explore the diversity climate at UCSF, we designed a qualitative study to examine the perceptions of minority faculty with regard to diversity and discrimination on campus. Our objectives were to (1) elicit and explore the perspectives of minority faculty regarding racial and ethnic diversity in academic medicine, and (2) generate collective recommendations on ways to increase diversity in academic medicine at our institution and nationwide.

This analysis compares patient and provider characteristics of African-American clinicians and non-African-American clinicians who called the National HIV Telephone Consultation Service (Warmline). In 2004, a total of 2,077 consultations were provided for 1,020 clinicians, 70 (6.9%) of whom were African American. Compared to the non-African-American group, a higher percentage of African-American clinicians were nurses (20.0% vs. 8.8%, p=0.002). A significantly lower percentage of African-American physicians were infectious disease specialists (3.5% vs. 25.6%, p=0.007). African-American clinicians were more likely to work in a community clinic (48.5% vs. 34.1%, p=0.015). Both African-American and non-African American clinicians reported caring for a similar number of HIV-infected patients. Patient-provider racial concordance was common among African-American clinicians (76.4%), whereas non-African-American clinicians called about patients of more diverse racial and ethnic backgrounds. African-American clinicians who called Warmline exhibited differences in patient and provider characteristics when compared to all other clinicians. These findings contribute to the growing body of research on HIV providers in the United States.

This study evaluates the consultation needs of clinicians who provide perinatal human immunodeficiency virus (HIV) care in the United States. The Perinatal Hotline (1-888-448-8765) is a telephone consultation service for providers who treat HIV-infected pregnant women and their infants. Hotline calls were analyzed for demographics about callers and their patients and information about consultation topics. There were 430 calls to the hotline from January 1, 2005, through June 30, 2006. Most calls (59.5%) were related to pregnant patients; 5.1% of the calls pertained to women currently in labor. The most common topic was HIV care in pregnancy (49.1%), particularly antiretroviral drug use (42.1%). HIV testing was discussed in 21.9%, and intrapartum treatment was discussed in 24.0%. Callers most often requested help choosing antiretroviral drug regimens; many of the discussions were about drug toxicities and viral resistance. Although the hotline received few calls about women in labor, the need for these consultations is expected to increase with the expanding use of rapid HIV testing. Access to 24-hour consultation can help ensure that state-of-the-art care is provided.

Structure/Method/Design: The development of the textbook began with the editor recruiting an editorial board of diverse experts, who then assisted in determining textbook content and identifying pertinent clinicians as chapter authors. Leadership from the Consortium of Universities for Global Health and the former GHEC provided critical input on selecting editorial board members, chapter contributors, and textbook content. Chapter content was developed through an intense and iterative process between chapter authors and the editorial board, including several stages of drafting, reviewing, editing, and revising. We also partnered closely with illustrators from Wiley-Blackwell to produce a text rich in illustrations and photographs. Outcomes & Evaluation: Essential Clinical Global Health includes contributions from nearly 100 global health experts, with content organized into 37 chapters and 6 sections: Introduction; Newborn and Child Health; Adolescent, Reproductive, and Maternal Health; Infectious Diseases; Non-Communicable Diseases; and Other Global Health Topics. Chapters cover the clinical diagnosis, management, and prevention of the leading causes of morbidity and mortality in lowand middle-income countries, along with special chapters on resource-limited health systems and other contextual topics, for example, “Working clinically in resourcelimited settings,” “Preparing for travel and staying safe abroad,” “Neglected tropical diseases,” “Laboratory skills,” “Nursing care,” “Pharmacy,” “Global health technologies,” “Illness in returning travelers,” and “Developing a career in global health.” Each chapter features key learning objectives, evidence-based clinical guidelines, practical clinical skills, realworld experiences from trainees and clinicians in the field, and core readings. The textbook’s accompanying electronic supplement contains additional resources, videos, and self-assessment questions and answers as well as an electronic version of the complete textbook e valuable for reference abroad on a laptop, tablet, or mobile device. Going Forward: As this collaborative textbook is published the beginning of 2015, our goal is to make it widely accessible to individual global health students, trainees, and clinicians, as well as to all institutions with global health programs. We welcome feedback from the global health community on how to improve future editions of Essential Clinical Global Health. We are also working with WileyBlackwell to develop online CME offerings based upon the textbook. Funding: None Abstract #: 01ETC068

HIV transmission among serodifferent couples has a significant impact on incidence of HIV worldwide. Antiretroviral interventions (i.e., preexposure prophylaxis, post-exposure prophylaxis, and treatment as prevention) are important aspects of comprehensive prevention and care for serodifferent couples. In this study, HIV-negative members of serodifferent couples were interviewed using open-ended questions to explore their health-care needs, perceptions of clinic-based prevention services, and experience of having an HIV-infected partner. Analysis of interviews with 10 HIV-negative partners revealed the following themes: (1) health needs during joint medical visits; (2) sexual risk reduction strategies; (3) relationship dynamics; and (4) strategies for coping. This study elucidated relationship, health and health care factors that might affect development and implementation of clinic-based prevention interventions for HIV serodifferent couples. The findings point to possible relationship-centered recommendations for health-care providers who serve HIV-affected couples in clinical settings.

In 2007, the US Food and Drug Administration (FDA) and Pfizer Inc recommended immediate discontinuation of nelfinavir (NFV) during pregnancy due to contamination with a potential teratogen. A few weeks after the announcement, we surveyed antenatal HIV care providers to determine how widely the warning was disseminated. Overall, 69 of 121 (57.0%) providers knew to discontinue NFV. Callers with more than 50 HIV-infected patients were 2.54 times as likely to be aware as callers with 1-3 HIV-infected patients (P < .01). Only 12 (33.3%) obstetricians were aware, compared to 21 (80.8%) infectious diseases specialists (P < .001). The FDA/Pfizer Inc recommendation to avoid nelfinavir mesylate (NFV) in pregnancy appears to have successfully reached HIV experts. However, not all pregnant women have access to experts and may receive most of their care from providers without extensive HIV experience. More effective dissemination of critical HIV-related information to all antenatal care providers, including general obstetricians, family physicians, and midwives, may be needed.

HIV disproportionately affects the Latino population in the United States. Little is known about clinicians who provide HIV care to the Latino community or the types of issues they face. This report presents descriptive analyses of calls made by clinicians who care for HIV-infected Latinos to two lines of the National HIV/AIDS Clinicians' Consultation Center, the National HIV Telephone Consultation Service (Warmline) and the National Perinatal HIV Consultation and Referral Service (Perinatal HIV Hotline). Separate analyses of data from Latino clinicians are also presented. The majority of Warmline calls about Latino patients (81.0%) concerned antiretroviral treatment strategies or HIV-related conditions. More than half (54.3%) of perinatal-specific calls concerned HIV management during pregnancy and the care of HIV-exposed infants. Latino clinicians most frequently called about minority patients. This descriptive study adds to the growing literature about the care of the Latino HIV-infected patient. The Warmline and Perinatal HIV Hotline are resources for HIV care providers in the nursing and medical care of Latinos.