Primary Care Provider Satisfaction Research Articles

Advancing Primary Care Access: Exploring the Impact of the Virtual Waiting Room on the Quadruple Aim.

Community health centers grapple with high no-show rates, posing challenges to patient access and primary care provider (PCP) utilization. To address these challenges, we implemented a virtual waiting room (VWR) program in April 2023 to enhance patient access and boost PCP utilization. Academic community health center in a small urban city in Massachusetts. Community health patients (n = 8706) and PCP (n = 14). The VWR program, initiated in April 2023, involved nurse triage of same-day visit requests for telehealth appropriateness, then placing patients in a standby pool to fill in as a telehealth visit for no-shows or last-minute cancellations in PCP schedules. Post-implementation, clinic utilization rates between July and September improved from 75.2% in 2022 to 81.2% in 2023 (p < 0.01). PCP feedback was universally positive. Patients experienced a mean wait time of 1.9h, offering a timely and convenient alternative to urgent care or the ER. The VWR is aligned with the quadruple aim of improving patient experience, population health, cost-effectiveness, and PCP satisfaction through improving same-day access and improving PCP schedule utilization. This innovative and reproducible approach in outpatient offices utilizing telehealth holds the potential for enhancing timely access across various medical disciplines.

Developing an innovative pediatric integrated mental health care program: interdisciplinary team successes and challenges.

Children and adolescents often do not receive mental healthcare when they need it. By 2021, the complex impact of the COVID-19 pandemic, structural racism, inequality in access to healthcare, and a growing shortage of mental health providers led to a national emergency in child and adolescent mental health in the United States. The need for effective, accessible treatment is more pressing than ever. Interdisciplinary, team-based pediatric integrated mental healthcare has been shown to be efficacious, accessible, and cost-effective. In response to the youth mental health crisis, Rady Children's Hospital-San Diego's Transforming Mental Health Initiative aimed to increase early identification of mental illness and improve access to effective treatment for children and adolescents. A stakeholder engagement process was established with affiliated pediatric clinics, community mental health organizations, and existing pediatric integrated care programs, leading to the development of the Primary Care Mental Health Integration program and drawing from established models of integrated care: Primary Care Behavioral Health and Collaborative Care. As of 2023, the Primary Care Mental Health Integration program established integrated care teams in 10 primary care clinics across San Diego and Riverside counties in California. Measurement-based care has been implemented and preliminary results indicate that patient response to therapy has resulted in a 44% reduction in anxiety symptoms and a 62% decrease in depression symptoms. The program works toward fiscal sustainability via fee-for-service reimbursement and more comprehensive payor contracts. The impact on patients, primary care provider satisfaction, measurement-based care, funding strategies, as well as challenges faced and changes made will be discussed using the lens of the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Preliminary results suggest that the Primary Care Mental Health Integration is a highly collaborative integrated care model that identifies the needs of children and adolescents and delivers brief, evidence informed treatment. The successful integration of this model into 10 primary care clinics over 3 years has laid the groundwork for future program expansion. This model of care can play a role addressing youth mental health and increasing access to care. Challenges, successes, and lessons learned will be reviewed.

Primary Care Management Pathways to Reduce Wait Times in Hematology: Monoclonal Gammopathy of Undetermined Significance

Background:Prolonged wait times are a worsening barrier to accessing specialist care in Canada and other countries across the globe. The flow of patients between primary care and specialists has been a recognized area for improvement (Liddy et al., 2020; Moir &amp; Barua, 2021). Kingston Health Sciences Centre (KHSC) has aimed to optimize referrals through the implementation of primary care management pathways (PCMPs). PCMPs are diagnostic and/or treatment algorithms, co-developed by local primary care physicians and specialists with input from patients. They are designed to support primary care providers in managing low risk medical conditions in the community while more quickly identifying patients with higher risk conditions to be seen by specialists. A PCMP was implemented in June 2021 for Monoclonal Gammopathy of Undetermined Significance (MGUS) (https://kingstonhsc.ca/refer/hematology). This asymptomatic condition with low levels of monoclonal protein in the blood or urine has an approximately 1% per year risk of transforming to a hematological malignancy such as multiple myeloma (Kyle et al., 2018). The MGUS PCMP outlines diagnostic criteria, management, and monitoring instructions for low-risk MGUS along with patient information. “Red flag” features, such as renal impairment, anemia or significantly increased monoclonal protein levels, are used to highlight those who need urgent referral. The aim of this study is to evaluate the impact of an MGUS PCMP on wait times in Hematology in Kingston, Ontario. Methods:All consecutive outpatient Hematology referrals received at KHSC from January 2021 to December 2022 were reviewed. Monthly outcome measures included the number of new referrals and median wait times for patients seen. Number of MGUS referrals deferred to the PCMP was included as a process measure. Monthly balancing measures included number of re-referrals of PCMP patients, number of deaths without being seen for MGUS, and number of new multiple myeloma diagnoses. To compare 6-month pre-PCMP implementation (January 2021 to June 2021) with 18-month post-PCMP implementation (July 2021 to December 2022), generalized linear regression analysis was conducted. p &amp;lt; 0.05 was considered statistically significant. A survey of primary care providers was distributed through the regional Primary Care Physicians' Council to assess primary care satisfaction with the PCMP. Results: Between January 2021 and December 2022, 4504 Hematology referrals were received, 278 (6%) of which were MGUS referrals. 76 (27%) of MGUS referrals were deferred to the PCMP. There was a significant increase in monthly Hematology referrals from a mean (± standard deviation (SD)) of 163.0 (± 13.9) pre-PCMP to 195.9 (± 27.3) post-PCMP (p&amp;lt;0.0001). There was no significant difference in mean monthly MGUS referrals pre-and post-PCMP (11.7 ± 4.7 versus 11.6 ± 3.5). Hematology's median wait time for those seen fell from a median (interquartile range (IQR)) of 51.3 days (13) pre-PCMP to 28.5 days (11) post-PCMP (p &amp;lt; 0.0001). The MGUS median wait time also fell from a median (IQR) of 40.5 days (59) to 37.0 days (32.5) (p &amp;lt; 0.0001). No significant difference was noted in the balancing measures. Pre-PCMP to post-PCMP, the mean number of deaths without being seen for MGUS (0.17 ± 0.41 versus 0.17 ± 0.38, p=0.36) and mean monthly new multiple myeloma diagnoses (5.17 ± 1.94 versus 5.17 ± 2.50, p = 0.54) remained stable. There were 7/76 (9.2%) re-referrals of patients deferred to the PCMP, with a median (IQR) time to re-referral of 64 days (348). A survey to assess primary care provider satisfaction with the PCMP included a total of 28 respondents; 19/28 (67.9%) reported using PCMPs. On a scale of 0 to 5, where 5 is the highest satisfaction, the median (IQR) overall experience was 4/5 (1.5) and impacts on supporting patient care and changing management were also 4/5 (1). The most common concern, raised by 7/28 respondents (25%), was the downloading of more work to primary care. Conclusion: The MGUS PCMP was associated with reduction in wait times for overall Hematology and MGUS despite an increase in referrals. Limitations of this study include concurrent changes in the program, including staffing and the COVID-19 pandemic. These results suggest that PCMPs may be an effective tool to address Hematology wait times, likely best complemented with other strategies to avoid overburdening primary care providers.

SAT184 Improving Access To Osteoporosis Specialists Using Electronic Consultations

Abstract Disclosure: C. Sethuram: None. W. Brown: None. G. Gill: None. C. Liddy: None. A. Afkham: None. E. Keely: None. Background: Timely access to osteoporosis specialists remains a challenge in Canada, where patients face long wait times for specialist care. Electronic consultations (eConsults) help address this issue by allowing primary care providers (PCPs) to pose clinical questions to specialists using a secure online platform. This study identifies the types of osteoporosis-related questions being asked by PCPs and describes the impact of the advice provided by osteoporosis specialists using eConsult. Methods: We performed a cross-sectional study of osteoporosis-related eConsults submitted to endocrinologists between January 2018 and December 2020 on the Champlain BASE™ eConsult Service in Ontario, Canada. Each eConsult was coded according to clinical question and answer type through consensus between two authors, based on pre-determined taxonomies established by the reviewers. We analyzed eConsult utilization data, including response times, PCP satisfaction, and referral outcomes, which were collected via PCP surveys following completion of the eConsult. Results: Of the 2534 eConsults sent to endocrinologists during the study period, 408 (16%) were specific to osteoporosis. The most common questions asked by PCPs were regarding whether or not to start treatment (18%), the initial therapy choice (13%), and how often to complete bone mineral density scans (8%). The most common responses from specialists included recommendations for bone mineral density scanning (13%), recommendation to start therapy (9%), and recommendation to treat using a bisphosphonate without the dose specified (9%). The median response interval was 3.1 days, and the median time spent by endocrinologists responding to the eConsult was 10.0 minutes. Eighty-four percent of cases were resolved without requiring an in-person referral. A course of action that PCPs already had in mind was confirmed in 42% of cases. Clear advice for a new course of action for PCPs to implement was provided in 54% of cases. Conclusion: Osteoporosis eConsults provide timely access to valuable specialist advice while avoiding unnecessary face-to-face clinic visits. Further, we identified commonly recurring osteoporosis questions asked by PCPs, which can be used to inform planning of future continuing professional development events. Presentation: Saturday, June 17, 2023

Improving Access to Osteoporosis Specialists Using Electronic Consultations

ObjectiveTo identify the types of osteoporosis-related questions being asked by primary care providers (PCPs) and describe the impact of the advice provided by osteoporosis specialists using eConsult. MethodsWe performed a cross-sectional study of osteoporosis-related eConsults submitted to endocrinologists between January 2018 and December 2020 on the Champlain eConsult BASE™ Service in Ontario, Canada. Each eConsult was coded according to clinical question and answer type through consensus between 2 authors, based on predetermined taxonomies. We analyzed eConsult utilization data, including response times, PCP satisfaction, and referral outcomes (collected via PCP surveys). ResultsOf the 2,528 eConsults sent to endocrinologists during the study period, 408 (16%) were specific to osteoporosis. The most common questions asked by PCPs were regarding whether or not to start treatment (35%), the initial therapy choice (25%), and how often to complete bone mineral density scans (15%). The most common responses from specialists included recommendations for bone mineral density scanning (34%), recommendation to start therapy (24%), and recommendation to treat using a bisphosphonate without the dose specified (23%). The median response interval was 3.1 days. Most cases (84%) were resolved without requiring an in-person referral. Clear advice for a new course of action for PCPs to implement was provided in 54% of cases. ConclusionOsteoporosis eConsults provide timely access to valuable specialist advice while avoiding unnecessary face-to-face clinic visits. We identified commonly recurring osteoporosis questions asked by PCPs, which can be used to inform planning of future continuing professional development events.

Improving Resident Hospital Discharge Communication by Changing Electronic Health Record Templates to Enhance Primary Care Provider Satisfaction.

Despite use of standardized electronic health record templates, the structure of discharge summaries may hinder communication from inpatient settings to primary care providers (PCPs). We developed an enhanced electronic discharge summary template to improve PCP satisfaction with written discharge summaries targeting diagnoses, medication reconciliation, laboratory test results, specialist follow-up, and recommendations. Resident template usage was measured using statistical process control charts. PCP reviewers' discharge summary satisfaction was surveyed using 5-point Likert scales analyzed using the Mann-Whitney U test. Residents were surveyed for satisfaction. Resident template usage increased from 61% initially to 72% of discharge summaries at 6 months. The PCP reviewers reported increased satisfaction for summaries using the template compared with those without (4.3 vs 3.9, P = .003). Surveyed residents desired template inclusion in the default electronic discharge summary (93%). This system-level resident-initiated quality improvement initiative created a novel discharge summary template that achieved widespread usage among residents and significantly increased outpatient PCP satisfaction.

Psychiatric consultation: Characteristics, satisfaction, and perceived opportunities among referrers to a 1-time service.

To further understand and optimize primary care provider (PCP) referrals to a 1-time psychiatric consultation service by developing profiles of PCP referrers, assessing PCP satisfaction with the service, and determining intervention opportunities. Secondary analysis of a referral database and subsequent cross-sectional survey of referrers. Winnipeg, Man. All family physicians who had made at least 1 referral in 2017 to the Centralized Psychiatric Consultation Service for Adults, a 1-time consultation service. Referral frequency, individual and practice characteristics, satisfaction with the Centralized Psychiatric Consultation Service for Adults, and subjective drivers of referral activity were assessed. Interest in a range of intervention opportunities to increase mental health knowledge and support were also examined. Of the 403 family physicians who referred patients to the consultation service in 2017, a total of 111 (27.5%) responded to the survey. Among all referrers, 287 (71.2%) were low referrers (1 to 4 referrals), 65 (16.1%) were moderate referrers (5 to 9 referrals), and 51 (12.7%) were high referrers (≥10 referrals). Solo practice (P=.04) and no access to collaborative mental health services (P<.001) were significantly associated with being a high referrer. Roughly 26.3% of low referrers, 29.2% of moderate referrers, and 15.4% of high referrers were satisfied with wait times for the service. Higher referrers did not identify a lack of comfort with providing psychiatric care as a driver of referrals; more indicated that they had a high volume of patients with mental health needs, that there was a lack of access to alternative services, and that patients sometimes requested referral. Overall, more than 40% of respondents expressed interest in a mental health care navigator, hard-copy resource information, and rapid access to consultation advice via telephone or an electronic platform. There was less interest in other proposed interventions. We found referrers to the Centralized Psychiatric Consultation Service for Adults to be clustered based on specific practice characteristics, as well as provider-patient factors. Overall, satisfaction with the service was fair and PCPs were not highly interested in a variety of proposed interventions. Future studies should explore how useful 1-time consultation services are for solo-practising PCPs and how best to support these and other PCPs in their management of patients with mental health needs.

The Practice of Psychiatric E-Consultation: Current State and Future Directions.

This article summarizes the existing literature on psychiatric electronic consultation (e-consultation or e-consult) to provide guidance on psychiatric e-consult practice and suggest next steps in research on psychiatric e-consults. A narrative review was conducted using relevant search terms in PubMed and Google Scholar. The psychiatric e-consult is a method of asynchronous consultation between primary care providers and psychiatric specialists that is associated with primary care provider satisfaction and promotes access to specialist guidance in mental health care. Major themes in the literature include contextual factors that affect implementation of psychiatric e-consult services, outcomes associated with psychiatric e-consults, and specific practical considerations that may affect psychiatric e-consult technique. Psychiatric e-consults may help address the widespread lack of access to specialty psychiatric care. Further studies are needed to examine clinical outcomes based on psychiatry e-consults.

Effect of an Integrated Clinical Pharmacist on the Drivers of Provider Burnout in the Primary Care Setting.

As the prevalence of provider burnout continues to increase, it is critical to identify interventions that may impact provider satisfaction, such as an integrated clinical pharmacist. This study aimed to assess the perceived effect of pharmacist integration on primary care provider satisfaction and drivers of provider burnout in the primary care setting. A cross-sectional survey with 11 questions across 4 domains was distributed to primary care providers in a large integrated health system. Of 295 providers invited to take the survey, 119 responded (40% response rate). Most providers had worked with a pharmacist for at least 2 years and utilized them weekly or daily. At least 87% of provider respondents strongly agreed or somewhat agreed that the integrated clinical pharmacist reduced their workload by working directly with patients and non-provider staff, improved overall medication use, helped patients meet health goals and quality measures, and overall helped them to effectively manage their panel of patients. Providers found greater meaning in work through the presence of the clinical pharmacist, which allowed them more time to focus on professionally fulfilling aspects of their work and helped them feel less emotional exhaustion. Overall, 91% of providers were extremely satisfied with the clinical pharmacy service. These findings may be used to justify the expansion of clinical pharmacy services in primary care to practice areas experiencing problems with 4 specific drivers of provider burnout: workload and job demands, efficiency and resources, meaning in work, and social support and community at work.

Primary care provider perceptions of an integrated community pharmacy hypertension management program

BackgroundTrained community pharmacists provided hypertension (HTN) management services in collaboration with a patient-centered medical home (PCMH). ObjectiveTo explore primary care provider (PCP) perceptions of a HTN management program in which patients at the PCMH with elevated blood pressure could choose to receive follow-up care with a trained community pharmacist at a chain community pharmacy. MethodsWe conducted informal interviews with 8 PCPs with a range of level of involvement with the collaborative HTN management program to inform the development of a 13-question online survey that was distributed to PCPs at 10 participating Michigan Medicine PCMH clinics. The primary outcome was the percent of PCPs who reported that the program improved their patient’s blood pressure. Secondary outcomes included awareness of the program, alternative follow-up strategies, PCP satisfaction, and barriers to using the program. ResultsA total of 39 PCPs (30.0%) responded to the survey. More than one-half (n = 21 of 39, 53.9%) of respondents reported that at least 1 of their patients had seen a trained community pharmacist for HTN management services. Almost all of these PCPs (n = 19 of 21, 90.5%) reported being satisfied with the program, and 80.9% (n = 17 of 21) agreed that it helped patients improve their blood pressure control. The most common barriers identified were patients preferring to follow up directly with their PCP (n = 18 of 39, 46.2%), PCPs being more comfortable with patients having a visit with an embedded ambulatory care pharmacist (n = 16 of 39, 41.0%), and a lack of written materials to share with patients about the program (n = 15 of 39, 38.5%). ConclusionPCPs who used the integrated community pharmacy HTN management program were satisfied with the program and thought that it resulted in improved blood pressure control. PCPs may benefit from written information to share with their patients as well as education to increase their awareness of the program and its beneficial effect on patient blood pressure.

Synchronous neurology-primary care collaboration in a medical home.

Synchronous collaboration as defined by a simultaneous encounter between primary care providers (PCPs), patients, and neurologists may improve access to neurologic expertise, care value, and satisfaction of PCPs and patients. We examined a series of synchronous collaborations and report outcomes, PCP satisfaction, downstream utilization, and illustrative case examples. Within an outpatient collaborative primary care-neurology care model, we implemented synchronous video consultations from a central hub to satellite clinics while increasing availability of synchronous telephone and face-to-face collaboration. PCP experience was assessed by a postcollaboration survey. Individual cases were summarized. Clinical and utilization outcomes were assessed by a neurologist immediately after and by follow-up chart review. A total of 58 total synchronous collaborations were performed: 30 by telephone (52%), 18 face to face (31%), and 10 by video (17%) over 27 clinic half-days. The most frequent outcomes as assessed by the neurologist were reassurance of the PCP (23/58; 40%) and patient (22/59; 38%), and the neurologist changed the treatment plan (23/58; 40%). A subsequent face-to-face consultation was completed in 15% (6/58) of patients initially assessed by telephone or video. Test utilization was avoided in 40% (23/58). Unintended utilization occurred 9% (5/58). Most PCPs were very satisfied with the ease of access, quality of care, and reported high likelihood of subsequent use. PCPs perceived similar or less time spent during synchronous vs asynchronous collaboration and neurologist usually altered the testing (87.8%) and treatment plan (95.2%). Synchronous collaboration between neurologists and PCPs may improve timely access to neurologic expertise, downstream utilization, and PCP satisfaction.

P48. Translation of the Interprofessional Spine Assessment and Education Clinic (ISAEC) to the New Brunswick population

BACKGROUND CONTEXT ISAEC is a shared-care model for LBP patients founded in Ontario. Patients are able to receive rapid assessment, education, and evidence based self-management plans. This successful model was adapted for the New Brunswick LBP population and implemented in two centers in Saint John and Moncton. PURPOSE To demonstrate the effective establishment, through knowledge translation of the ISAEC program in New Brunswick, assessed by examining patient outcome scores, patient compliance, and primary care provider satisfaction. STUDY DESIGN/SETTING Retrospective analysis of prospectively collected data. PATIENT SAMPLE Data from the NB-ISAEC database was included for all patients with both intake and 6 week follow-up data as of February 1, 2019 (N=111). OUTCOME MEASURES Outcome measures included the Oswestry Disability Index (ODI), NRS Scales for Back and Leg Pain (NRS-B/L), Pain Catastrophizing Score (PCS), patient compliance, and Primary Care Provider (PCP) satisfaction. METHODS Continuous variables were analyzed using a paired samples t-test, and one-way ANOVA and categorical variables were analyzed using chi-squared analysis. Significance was α RESULTS Six weeks following a NB-ISAEC appointment, participants reported statistically significant improvements in ODI scores (t(111)=8.384, p 30; χ2(1) =12.143, p≤0.001). At 6 weeks patients reported high compliance with their given exercise plan; 41.8% of patients reported daily exercise, and only 5.7% of patients reported not performing their exercise weekly. A repeated measures ANOVA was performed for a preliminary look at patients with 3 month outcomes, with changes in ODI (F(2,72)=5.983, p=0.004), PCS (F(2,64)=6.215, p=0.004). Preliminary PCP satisfaction results show a favorable attitude towards the program with 90.9% of PCPs indicating they believe this program improved patient support and management and 81.8% PCPs reporting improved access to care for their patients. CONCLUSIONS After participation in NB-ISAEC, the improvements in outcome scores, high patient activation and high PCP satisfaction suggest the successful translation and validation of the ISAEC program in the New Brunswick population. This presents a potential to improve the standard of care for low back pain across Canada. Future work should quantify longer term patient health and economic benefits, and Medicare cost avoidance and efficiency. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Toward a Unified Integration Approach: Uniting Diverse Primary Care Strategies Under the Primary Care Behavioral Health (PCBH) Model.

Primary care continues to be at the center of health care transformation. The Primary Care Behavioral Health (PCBH) model of service delivery includes patient-centered care delivery strategies that can improve clinical outcomes, cost, and patient and primary care provider satisfaction with services. This article reviews the link between the PCBH model of service delivery and health care services quality improvement, and provides guidance for initiating PCBH model clinical pathways for patients facing depression, chronic pain, alcohol misuse, obesity, insomnia, and social barriers to health.

Clinical pharmacists in primary care: Provider satisfaction and perceived impact on quality of care provided.

Purpose:The purpose of this study is to evaluate primary care provider satisfaction and perceived impact of clinical pharmacy services on the disease state management in primary care.Methods:A cross-sectional survey with 24 items and 4 domains was distributed anonymously to pharmacy residency program directors across the United States who were requested to forward the survey to their primary care provider colleagues. Primary care providers were asked to complete the survey.Results:A total of 144 primary care providers responded to the survey, with 130 reporting a clinical pharmacist within their primary care practice and 114 completing the entire survey. Primary care providers report pharmacists positively impact quality of care (mean = 5.5 on Likert scale of 1–6; standard deviation = 0.72), high satisfaction with pharmacy services provided (5.5; standard deviation = 0.79), and no increase in workload as a result of clinical pharmacists (5.5; standard deviation = 0.77). Primary care providers would recommend clinical pharmacists to other primary care practices (5.7; standard deviation = 0.59). Primary care providers perceived specific types of pharmacy services to have the greatest impact on patient care: medication therapy management (38.6%), disease-focused management (29.82%), and medication reconciliation (11.4%). Primary care providers indicated the most valuable disease-focused pharmacy services as diabetes (58.78%), hypertension (9.65%), and pain (11.4%).Conclusion:Primary care providers report high satisfaction with and perceived benefit of clinical pharmacy services in primary care and viewed medication therapy management and disease-focused management of diabetes, hypertension, and pain as the most valuable clinical pharmacy services. These results can be used to inform development or expansion of clinical pharmacy services in primary care.

Telemedicine consultation for patients with diabetes mellitus: a cluster randomised controlled trial

Introduction There is a widening discrepancy between the increasing number of patients with diabetes mellitus and the health care resources available to manage these patients. Telemedicine has been used in a number of instances to improve and deliver health care where traditional care delivery methods may encounter difficulty. We conducted a cluster randomised controlled trial of telemedicine consultation to manage patients with diabetes mellitus. Methods Eleven primary care centres attached to one Veteran Administration tertiary care centre were randomised to provide patients with diabetes consultation referral either by usual consultation in diabetes clinic or telemedicine consultations via videoconference. Results Altogether, 199 patients were managed by telemedicine consultation and 83 by usual consultation. Patients in both groups showed a small decrease in haemoglobin A1c, with no statistical difference between the groups (telemedicine consultation −1.01% vs usual consultation −0.68%, p = 0.19). Surveys of patients and semi-structured interviews with primary care providers showed better response and satisfaction with telemedicine consultations. Discussion This study shows similar clinical outcomes as measured by glycaemic control for patients with diabetes mellitus having a specialist consultation using real-time telemedicine consultation as compared to in-clinic consultation. Telemedicine consultation was also associated with better patient and primary care provider satisfaction.

Early introduction of palliative care and advanced care planning for children with complex chronic medical conditions: a pilot study.

Children with complex chronic medical conditions benefit from early introduction of palliative care services and advanced care planning for symptom management and to support quality of life and medical decision-making. This study evaluated whether introducing palliative care during primary care appointments (1) was feasible; (2) increased access and improved knowledge of palliative care; and (3) facilitated advanced care planning. Pilot study of a multi-modal intervention including targeted education for primary care providers (PCPs), an informational packet for families and presence of a palliative care team member in the outpatient clinic. PCPs completed pre- and post-surveys assessing experience, knowledge and comfort with palliative care. Enrolled families received an information packet; a subset also met a palliative care team member. All families were encouraged to make an appointment with the palliative care team, during which the team assessed palliative care needs and goals of care. Upon study completion, the investigators assessed family and PCP satisfaction and collected feedback on project feasibility. Twenty families were enrolled and received the information packet; 15 met a palliative care team member. Of the 17 participating families who were reached and completed a post-study survey, 11 families had never heard of palliative care and 13 were unaware that the palliative care team existed. Most families perceived palliative care information as 'very helpful' and 'very important'. All would recommend palliative care team services to others. Nine families followed up with the palliative care team, but none was prepared to complete an advanced care plan. PCPs reported lack of training in communicating bad news and conducting goals of care discussions. However, they felt increasingly comfortable introducing palliative care to families and supported program continuation. Initiating palliative care services in the outpatient primary care setting is logistically challenging but increases access to palliative care for children with complex chronic medical conditions and improves palliative care knowledge and comfort for PCPs.

Strategies for Primary Care Stakeholders to Improve Electronic Health Records (EHRs).

The use of electronic health records (EHRs) and the vendors that develop them have increased exponentially in recent years. While there continues to emerge literature on the challenges EHRs have created related to primary care provider satisfaction and workflow, there is sparse literature on the perspective of the EHR vendors themselves. We examined the role of EHR vendors in optimizing primary care practice through a qualitative study of vendor leadership and developers representing 8 companies. We found that EHR vendors apply a range of strategies to elicit feedback from their clinical users and to engage selected users in their development and design process, but priorities are heavily influenced by the macroenvironment and government regulations. To improve the "marriage" between primary care and the EHR vendor community, we propose 6 strategies that may be most impactful for primary care stakeholders seeking to influence EHR development processes.

Dermatology in an age of fully transparent electronic medical records.

More than 4 decades have passed since the call for “giving patients their medical records” was first proposed to increase patient engagement in health care delivery.1Today, this vision—once considered radical—is quickly becoming reality, with millions of Americans routinely accessing their medical records through web-based patient portals.1 The electronic health record content that patients can access online is expanding to include physicians’ documentation of patient visits. Recent studies evaluating OpenNotes, a patient-centered initiative enabling online access to providers’ clinical notes, have demonstrated high levels of patient utilization and improved self-reported understanding of care planning and medication adherence, resulting in patients “feeling more in control of their health care.”1 One year after implementation of OpenNotes in 3 diverse health care environments in 2010 (Beth Israel Deaconess Medical Center in Boston, Massachusetts; Geisinger Health System in northeastern and central Pennsylvania; and Harborview Medical Center in Seattle, Washington), more than 99% of patients wished to have ongoing online access to clinicians’ notes, paralleled by similar rates of primary care provider satisfaction.1 Open-access notes have since become standard of care at several large health care systems,2 including the Veterans Health Administration; as of January 2014, more than 1.4 million veterans have registered for full online access to their clinical notes.3 However, medical specialties may face distinct challenges consequent to adoption of open-access medical records. As more patients seek—and demand—comprehensive online availability of open-access notes, what will this mean for the field of dermatology? We believe the following issues merit particular attention among dermatologists in the era of medical record transparency.

Abstract P1-09-29: A new model of care for breast cancer survivorship

Abstract Background Breast cancer (BC) is the most common cancer diagnosed in women. With advances in diagnostics and therapy, early stage disease has an estimated 85% 10-year overall survival. Cancer survivors have unique needs including screening for recurrence, psychosocial concerns, as well as routine health maintenance. There is growing evidence to support the safe transition from oncologist to primary care. This is challenging in the era of complex adjuvant and extended adjuvant programs, which are standard of care for women with hormone receptor positive BC. In February 2013 the Wellness Beyond Cancer Program (WBCP), developed at the Ottawa Regional Cancer Program, started accepting BC patients. A risk stratification system enables the treating oncologist to determine the most appropriate care provider stream based on patient complexity and/or risk of relapse. There are three possible streams: primary care provider (PCP), nurse practitioner (NP), or oncologist. The program offers education on general and breast specific cancer survivorship issues. Unique to our program is a hormone re-assessment review (HRR), scheduled in advance, to discuss switching hormonal therapies and/or extended adjuvant strategies. A rapid re-entry system is in place for those with evidence of disease recurrence or a new primary. Specific aims The aims of our study are: 1. To describe unique aspects of WBCP developed for early stage BC patients 2. To assess efficacy of the WBCP 3. To evaluate safety of the HRR 4. To examine patient and primary care giver satisfaction with the program Methods All BC patients eligible for discharge through the WBCP will be included in the evaluation. We will evaluate patients by examining needs assessments completed at time of referral and one year later, as well as completed patient and PCP satisfaction surveys. The proportion of patients with changing scores, increasing or decreasing, will reflect improvements or worsening of needs. The proportion of both patients and PCP that are/are not satisfied with the program will be recorded and examined further. For the HRR we will code the proportion of patients where the consult was requested and was "scheduled vs. not scheduled". Finally, the number/proportion of patients and reasons for re-entry will be captured. Results February 2013–June 2014, 1339 BC patients were referred to the program, 584 patients to PCP, 740 to NP, and 15 remaining with their oncologist. Early results are reported here with results of the surveys expected by December 2014. 7 patients have required re-entry for disease recurrence and 30 HRR have been booked. No cancer specific negative outcomes have been reported. Survey results addressing patient needs, empowerment and concerns are being collated, with PCP satisfaction results to be reported. Conclusion Our institution has endorsed evidence-based recommendations for an organized survivorship program and has taken it a step further by developing a strategy to address the unique long term needs of hormone positive early stage breast cancer. Early feedback supports that this program has increased patient and caregiver knowledge of survivorship issues and anticipates improved patient empowerment, without compromising cancer specific outcomes. Citation Format: Moira Rushton, Robin Morash, Gail Larocque, Carrie Liska, Roanne Segal. A new model of care for breast cancer survivorship [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-09-29.

We need to talk: Primary care provider communication at discharge in the era of a shared electronic medical record.

Poor communication between hospitalists and outpatient physicians can contribute to adverse events after discharge. Electronic medical records (EMRs) shared by inpatient and outpatient clinicians offer primary care providers (PCPs) better access to information surrounding a patient's hospitalization. However, the PCP experience and subsequent expectations for discharge communication within a shared EMR are unknown. We surveyed PCPs 1 year after a shared EMR was implemented at our institution to assess PCP satisfaction with current discharge communication practices and identify areas for improvement. Seventy-five of 124 (60%) clinicians completed the survey. Although most PCPs reported receiving automated discharge notifications (71%), only 39% felt that notifications plus discharge summaries were adequate for safe transitions of care. PCPs expressed that complex hospitalizations necessitated additional communication via e-mail or telephone; only 31% reported receiving such communication. The content most important in additional communication included medication changes, follow-up actions, and active medical issues. Despite optimized access to information provided by a shared EMR, only 52% of PCPs were satisfied with current discharge communication. PCPs express a continued need for high-touch communication for safe transitions of care. Further standardization of discharge communication practices is necessary.