Direct Patient Access Research Articles

Providing patients with direct access to musculoskeletal physiotherapy: the impact on general practice musculoskeletal workload and resource use. The STEMS-2 study

ObjectivesThis study examined the real-world impact of patient direct access to NHS physiotherapy (self-referral) on (a) general practice consultations for musculoskeletal (MSK) conditions and (b) specified clinical management for patients with MSK conditions. Design and settingNatural experiment in four general practices and the associated physiotherapy service. MethodsAnonymised routinely collected data were obtained. MSK coded GP consultations, recorded fit notes, MSK-related prescription medication, X-rays and MRI requests, and referrals to secondary care for patients consulting with MSK conditions were identified and trends described across a 6-year period (June 2011 to June 2017). Joinpoint regression analysis was used to identify any significant changes in GP MSK consultation trends before and after the introduction of self-referral to physiotherapy. Physiotherapy service data examined access methods used by patients (GP referred, GP recommended self-referral, true self-referral) and the number of physiotherapy sessions. ResultsDirect access resulted in inconsistent impact on general practices. In one arm of the experiment a significant increase in GP consultations was observed and in one arm was stable. Exploratory examination of clinical management showed only requests for X-rays (arm 1) and possibly requests for MRI (arm 2) changed over time. Physiotherapy service referrals showed a low uptake of true self-referral (10% and 6%) in each arm respectively. ConclusionThis is the first study to examine the real-world impact of patient direct access to physiotherapy at general practice level. We found no consistent impact of patient direct access on GP MSK workload. Impact on some clinical management was observed but not consistently in the direction suggested by previous studies.

First point of contact physiotherapy; a qualitative study

ObjectivesFirst point of contact physiotherapy (FPCP) provides patients direct access to a physiotherapist. Literature demonstrates efficacy of FPCP. Evidence has highlighted the need for cultural shifts from both patient and professional perspectives to optimise FPCP. This study explored stakeholder perceptions of patient awareness and understanding of FPCP to better inform FPCP implementation. Design, setting, participantsA qualitative methodology utilised semi-structured interviews and focus groups. Findings from a previous realist review were used to generate a priori topic guides. Participants included patients, physiotherapists, GPs, administration staff, and commissioners. A thematic analysis was undertaken. ResultsFour themes emerged that are described: level of patient awareness of the FPCP role situated against the GP as first contact practitioner, patients attain an awareness of FPCP from a variety of sources, patient understanding of physiotherapy arises from several sources and is poorly aligned with the FPCP model, characteristics and behaviours of patients influence access to FPCP services. Patient awareness and understanding was poor. Patients tended to view the GP as the default first contact practitioner. Traditional advertising approaches appeared on the whole invisible to patients and there was a reliance on signposting to facilitate patient access. ConclusionFindings from this study can inform implementation of FPCP. Several obstacles to the optimisation of FPCP were highlighted. Improved marketing of physiotherapy generally and FPCP specifically may increase patient awareness and understanding. However, it is likely further time will be required to bring about the cultural shift in public perception required to optimise the potential of FPCP.

The Power of Consumer Activism and the Value of Immunization Registries in a Pandemic

The Power of Consumer Activism and the Value of Immunization Registries in a Pandemic

Patient direct access to musculoskeletal physiotherapy in primary care: perceptions of patients, general practitioners, physiotherapists and clinical commissioners in England

Patient direct access to musculoskeletal physiotherapy in primary care: perceptions of patients, general practitioners, physiotherapists and clinical commissioners in England

The success of walk-in-computed tomography in practice

Background/objectiveLong access time to computed tomography (CT) facilities is seen as a substantial problem in many hospitals. Walk-in is an intervention that eliminates access times, since it gives patients direct access without an appointment. The Rijnstate hospital implemented walk-in CT in 2010, which offered the opportunity to study the positive and negative effects of walk-in CT in practice and how these effects are balanced. Material and methodsEmployee interviews (N = 10), patient surveys (N = 535) and a data analysis using data from the Electronic Patient Record (EPR) of 129.148 patients between October 2008 and March 2017 were conducted. ResultsAll stakeholders stated that the system improved with the introduction of walk-in. The interviews also resulted in main performance indicators: access time, waiting time, one-stop-shop, autonomy of choice, productivity and employee satisfaction. The patient survey divulged the maximum acceptable waiting time: 79% of patients stated this to be 15–30 minutes or more. When asked which performance indicator is most important, ‘one stop shop’ was mentioned by 134 patients over access time, waiting time and autonomy of choice (ranged from 79 to 88). The data analysis showed a doubling in production, while CT capacity hardly increased. The percentage of outpatients that had to wait 30 minutes or less has decreased from 85.2% in 2009 to 59.5% in 2016, but the absolute number of outpatients with these waiting times increased from 5.146 to 7.681. Overtime production regarding outpatients has decreased over the years. ConclusionsWalk-in CT performs better regarding the main performance indicators than a full appointment system. The reasons are that it almost nullifies CT access time and enhances one-stop-shop for patients. Walk-in also improves satisfaction of patients, referring physicians as well as the entire radiology staff, technicians and doctors alike. Furthermore, all results suggest that productivity can be higher with walk-in than with only appointments.

Identifying important health system factors that influence primary care practitioners’ referrals for cancer suspicion: a European cross-sectional survey

ObjectivesCancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence...

Challenges of Digital Medicine

Challenges of Digital Medicine Abstract. Digitization is increasingly covering more and more sectors, including medicine. To ensure medical operation 365 × 24 hours, progressively more human and financial resources are necessary. The transformation of patient histories from paper into electronic patient records focused initially on documentation. Today, hospital information systems are increasingly used as a platform for the communication of all professionals involved in the patient process - in Switzerland, however, so far without providing patients direct access to their data. Digititizing processes intend to increase efficiency, but also to enhance clinical and administrative decision support and quality assurance. The introduction of the electronic patient record in Switzerland in 2020 is expected to provide cross-company, more complete documentation of patient care. Multimorbid patients, often treated in different institutions and by different specialists, should benefit from this in particular. Advances in artificial intelligence offer new opportunities in medicine. Challenges include ensuring reliable data protection, and better interoperability of the systems involved. Semantically structured, machine-readable data exchange is a necessity for both networked services and internationally competitive research.

P161 SUSTAINABLE IMPROVEMENTS IN URGENT CARE ACCESS AND OUTCOMES FOR PATIENTS WITH INFLAMMATORY BOWEL DISEASE THROUGH IMPLEMENTATION OF AN URGENT ACCESS TOOLKIT

Patients with inflammatory bowel disease (IBD) without adequate access to urgent medical care for exacerbation of symptoms tend to obtain care from emergency departments (ED), which is associated with an increased use of opiates, steroids, and poor patient satisfaction. We previously described the development of an urgent access toolkit using a Breakthrough Series (BTS) Collaborative as part of IBD Qorus. The aim of this study was to demonstrate the sustainability and clinical impact of implementation of the urgent access toolkit after 1 year. The urgent access toolkit consisted of an urgent care hotline for direct patient access to a nurse, and patient educational processes. Data were collected from July 2015 through February 2017 from patients at the Baylor College of Medicine IBD clinic. The urgent access toolkit was implemented in December 2015. The baseline period was considered prior to December 2015 and the post-implementation period was after December 2015. Outcomes were assessed using run charts. A total of 1663 patient encounters were included in the study period, including 438 encounters in the baseline time period and 1225 encounters in the post-implementation period. In the baseline period, a median of 22% of patients reported ED visits, 24% with CT scans, 18% with IBD-related hospitalizations, 17% of patients on prednisone, and 11% on narcotics. Run charts after implementation of the toolkit demonstrated shifts in reduction in ED visits (Fig1), CT scans(Fig2), prednisone use, and an increase in patient satisfaction related to IBD urgent care. Implementation of the urgent access toolkit reduces IBD-associated ED visits, CT scans, and prednisone use, as well as increases patient satisfaction related to urgent care access. These improvements can be sustained for 1 year. Participation in a learning health system facilitates sustainable improvements in access to urgent IBD care and related outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Medical overuse and quaternary prevention in primary care \u2013 A qualitative study with general practitioners

BackgroundMedical overuse is a topic of growing interest in health care systems and especially in primary care. It comprises both over investigation and overtreatment. Quaternary prevention strategies aim at protecting patients from unnecessary or harmful medicine. The objective of this study was to gain a deeper understanding of relevant aspects of medical overuse in primary care from the perspective of German general practitioners (GPs). We focused on the scope, consequences and drivers of medical overuse and strategies to reduce it (=quaternary prevention).MethodsWe used the qualitative Grounded Theory approach. Theoretical sampling was carried out to recruit GPs in Bavaria, Germany. We accessed the field of research through GPs with academic affiliation, recommendations by interview partners and personal contacts. They differed in terms of primary care experience, gender, region, work experience abroad, academic affiliation, type of specialist training, practice organisation and position. Qualitative in-depth face-to-face interviews with a semi-structured interview guide were conducted (n = 13). The interviews were audiotaped and transcribed verbatim. Data analysis was carried out using open and axial coding.ResultsGPs defined medical overuse as unnecessary investigations and treatment that lack patient benefit or bear the potential to cause harm. They observed that medical overuse takes place in all three German reimbursement categories: statutory health insurance, private insurance and individual health services (direct payment). GPs criticised the poor acceptance of gate-keeping in German primary care. They referred to a low-threshold referral policy and direct patient access to outpatient secondary care, leading to specialist treatment without clear medical indication. The GPs described various direct drivers of medical overuse within their direct area of influence. They also emphasised indirect drivers related to system or societal processes. The proposed strategies for reducing medical overuse included a well-founded wait-and-see approach, medical education, a trustful doctor-patient relationship, the improvement of primary/health care structures and the involvement of patients and society.ConclusionsGPs are frequently located at the starting point of the diagnostic and treatment process. They have the potential to play a vital role in quaternary prevention. This requires a debate going beyond the medical profession and involving society as a whole.

Open notes: A qualitative study of oncology patients’ experiences reading their cancer care notes.

33 Background: Electronic medical record systems and patient portals increasingly allow patients direct access to their clinicians’ notes.While most believe that open notes benefit patients, some suggest negative consequences. Little is known about cancer patients’ experiences reading their own medical records outside of the primary care setting. We aimed to describe the experiences of patients with advanced cancer who read their own cancer care notes. Methods: We recruited 20 adult patients with metastatic or incurable cancer who were receiving active cancer treatment to participate in semi-structured qualitative interviews. The interview included four segments: assessing patients' overall experience reading notes, discussing how notes affected their cancer care experiences, having them read a real note with the interviewer, and making suggestions for improving notes. We used a constant comparison approach to analyze the qualitative data. Results: Four main themes emerged; patients reported that notes: (a) increased comprehension, (b) ameliorated uncertainty, relieved anxiety, and facilitated control, (c) increased trust, and (d) for a subset, increased anxiety. Patients described increased comprehension, as notes refreshed their memory and clarified their understanding of visits. Notes addressed uncertainty and relieved anxiety, in part because enhanced comprehension mitigated the unfamiliarity of cancer. They facilitated control, empowering patients to ask more questions to clinicians. The transparency of notes also increased the trust patients have in their clinicians. For a subset of patients, however, notes were emotionally difficult to read and raised concerns. Patients consistently identified medical jargon and repetition in notes as areas for improvement. Conclusions: Our findings suggest that most patients felt that reading notes improved their care experiences. A small subset experienced increased distress from “open notes.” As reading notes becomes a routine part of the patient experience, it is important for physicians to elicit and address concerns that arise from the notes, further engaging patients in their care.

Quality and readability of websites for patient information on tonsillectomy and sleep apnea

ObjectivesTonsillectomy is a common treatment for obstructive sleep apnea (OSA). The Internet allows patients direct access to medical information. Since information on the Internet is largely unregulated, quality and readability are variable. This study evaluates the quality and readability of the most likely visited websites presenting information on sleep apnea and tonsillectomy. MethodsThe three most popular search engines (Google, Bing, Yahoo) were queried with the phrase “sleep apnea AND tonsillectomy.” The DISCERN instrument was used to assess quality of information. Readability was evaluated using the Flesch-Kincaid Reading Grade Level (FKGL) and Flesch Reading Ease Score (FRES). ResultsOut of the maximum of 80, the average DISCERN quality score for the websites was 55.1 (SD- 12.3, Median- 60.5). The mean score for FRES was 42.3 (SD- 15.9, Median- 45.5), which falls in the range defined as difficult. No website was above the optimal score of 65. The mean score for the FKGL was US grade-level of 10.7 (SD- 1.6, Median- 11.6). Only 4(27%) websites were in the optimal range of 6–8. There was very weak correlation between FRES and DISCERN (r = 0.07) and FKGL and DISCERN (r = 0.21). ConclusionsTonsillectomy is one of the most common surgeries in the US. However, the internet information readily available to patients varies in quality. Additionally, much of the information is above the recommended grade level for comprehension by the public. By being aware of what information patients are reading online, physicians can better explain treatments and address misunderstandings. Physicians may consider using similar methods to test the readability for their own resources for patient education.

STEMS pilot trial: a pilot cluster randomised controlled trial to investigate the addition of patient direct access to physiotherapy to usual GP-led primary care for adults with musculoskeletal pain

IntroductionAround 17% of general practitioner (GP) consultations are for musculoskeletal conditions, which will rise as the population ages. Patient direct access to physiotherapy provides one solution, yet adoption in the...

VA mental health clinician experiences and attitudes toward OpenNotes.

To describe Department of Veterans Affairs (VA) mental health clinician attitudes toward and experiences with OpenNotes (also known as Blue Button), which provides patients direct access to clinical notes online. A 35-item online survey was administered to 263 mental health clinicians and nurses from one VA Medical Center. Seventy-nine percent of eligible subjects participated. Most respondents agreed or somewhat agreed that OpenNotes is a good idea in general, but only half agreed that making mental health notes available online is a good idea. Most believed that patients will better remember plans of care and be better prepared for visits. Most also felt that patients will worry more and request changes in notes. Many clinicians reported being less detailed and changing the tone of their notes. As a group, mental health clinicians are positive about OpenNotes in general but ambivalent about the use of OpenNotes in mental health care. The results call for research on outcomes of OpenNotes use in mental health and to develop education and support to help clinicians adapt to OpenNotes.

The history and accomplishments of the ICGG Gaucher registry.

The history and accomplishments of the ICGG Gaucher registry.

Going mainstream: Online sharing of health data and test results with patients

Going mainstream: Online sharing of health data and test results with patients

Direct-to-patient laboratory test reporting: balancing access with effective clinical communication.

In February 2014, the Department of Health and Human Services (HHS) issued a landmark ruling allowing patients direct access to completed medical laboratory reports.1 The ruling took effect April 7, 2014, and gives laboratories 180 days from that date to comply. Although this recent change to the Clinical Laboratory Improvement Amendments (CLIA) empowers patients by removing access barriers to personal health information, it raises a variety of clinical and ethical questions involving practitioners, patients, and society. To capture the benefits of the change and to minimize potential challenges, clinicians will need to proactively counsel patients to ensure that patients do not engage in detrimental self-interpretation of test results, especially because of the abundance of information and misinformation made available through the Internet and other sources.2

Diagnostic and procedural imaging curricula in physical therapist professional degree programs.

Descriptive survey. To describe the status of diagnostic and procedural imaging curricula within United States physical therapist professional degree programs. As patient direct access to physical therapy services increases, the ability to refer patients directly for diagnostic imaging could promote more efficient delivery of care. Appropriate patient referral is contingent on physical therapists having the requisite knowledge base and skills. While evidence describing imaging competence of physical therapists with advanced training in military institutions exists, evidence is lacking for other physical therapists, including new graduates of physical therapist professional degree programs. Faculty members teaching imaging at 206 United States physical therapist professional degree programs recognized by the Commission on Accreditation in Physical Therapy Education were recruited via e-mail correspondence. An e-mail attachment included the survey on which faculty reported imaging curricula and faculty qualifications, attitudes, and experiences. Faculty from 155 (75.2%) programs responded to the survey, with imaging being included in the curriculum of 152 programs. Content was integrated by required standalone courses or clinical science track courses, and/or through elective courses. The average reported estimate of imaging contact hours was 24.4 hours (range, 2-75 hours). Emphasis was on the musculoskeletal system, including 76.3% of the required standalone course content. Student competence was assessed in 147 (96.7%) programs, primarily by written (66.7%) and practical (19.7%) examinations. Faculty rated student competence on a scale of 1 (not competent) to 5 (competent), with ratings ranging from a high of 4.0 (identifying normal anatomy on plain-film radiography) to a low of 1.9 (identifying common tissue pathological processes/injuries on ultrasound). While a majority of programs reported including imaging curricula, variability was noted in all curricular aspects. These results may serve as a benchmark for faculty to assess existing curricula, allow for further development of imaging curricula, and provide a benchmark for the profession regarding current level of training for recent graduates of entry-level physical therapist professional degree programs.

The “Open Letter”: Radiologists' Reports in the Era of Patient Web Portals

Historically, radiologists' official written reports have functionally been proprietary communications between radiologists and referring providers. Although never secret, these reports have traditionally been archived in the medical record, with tightly controlled access. Patients rarely viewed reports directly. As patient-centered care, transparent communication, and electronic archiving have converged, however, radiologists' reports, like many other medical record components, are increasingly accessible to patients via web-based "portals." Many radiologists harbor justified anxiety about whether and how radiology reports should change in response to these portals. Direct patient access to radiology reports raises several questions, including: who are reports really for, what is their essential purpose, what content should they include or omit, what limits should be placed on their accessibility, and what ethical and legal ramifications arise from the reports' unfettered accessibility. In this paper, we outline the challenges and opportunities that arise from direct patient access to radiology reports via web-based portals, and propose an approach to optimizing radiologists' reports in an era of enhanced transparency. We conclude that, in effect, the health information web portal is a "train which has left the station"; patient portals are a nationwide reality, and transparency is now a public and professional expectation. Radiologists urgently need to consider quality implications for their report writing in order to address the challenges these developments pose, and to best harness the potential benefits for patients and providers.

Delivering an Evidence-Based Mental Health Treatment to Underserved Populations Using Telemedicine: The Case of a Trauma-Affected Adolescent in a Rural Setting

Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based psychological treatment that can effectively ameliorate symptoms of depression and anxiety that are common responses to trauma exposure. However, access to high-quality mental health services can be problematic, especially for traditionally underserved populations such as rural/remote residents, racial/ethnic minorities, and those from low socioeconomic strata. Individuals living in remote areas encounter additional obstacles to care, including long travel distances to reach services, increased time out of work or school, lack of access to transportation, and childcare difficulties. Many rural/remote communities struggle with scarcity of resources in general, and specialized mental health resources specifically, which may inadvertently exclude patients from obtaining the most appropriate health care. Telemedicine, or the use of Internet-based video conferencing, allows a patient live and direct virtual access to specialized mental health care providers. This article examines the application of TF-CBT via telemedicine to treat trauma exposure in a teenager living in a rural setting. Though this case example originates in the rural southeastern United States, the barriers and concepts addressed are generalizable to other remote areas in the United States and worldwide. Specific attention is given to evidence-based treatments for trauma, the merits of the telemedicine modality, and confidentiality considerations when using Internet-based teleconferencing for the application of psychological services.

Improving patients' electronic health record comprehension with NoteAid.

Allowing patients direct access to their electronic health record (EHR) notes has been shown to enhance medical understanding and may improve healthcare management and outcome. However, EHR notes contain medical terms, shortened forms, complex disease and medication names, and other domain specific jargon that make them difficult for patients to fathom. In this paper, we present a BioNLP system, NoteAid, that automatically recognizes medical concepts and links these concepts with consumer oriented, simplified definitions from external resources. We conducted a pilot evaluation for linking EHR notes through NoteAid to three external knowledge resources: MedlinePlus, the Unified Medical Language System (UMLS), and Wikipedia. Our results show that Wikipedia significantly improves EHR note readability. Preliminary analyses show that MedlinePlus and the UMLS need to improve both content readability and content coverage for consumer health information. A demonstration version of fully functional NoteAid is available at http://clinicalnotesaid.org.