Developing an Audit and Feedback Dashboard for Family Physicians: A User-Centered Design Process

Audit and feedback (A&F), the summary and provision of clinical performance data, is a common quality improvement strategy. Successful design and implementation of A&F-or any quality improvement strategy-should incorporate evidence-informed best practices as well as context-specific end user input. We used A&F theory and user-centered design to inform the development of a web-based primary care A&F dashboard. We describe the design process and how it influenced the design of the dashboard. Our design process included 3 phases: prototype development based on A&F theory and input from clinical improvement leaders; workshop with family physician quality improvement leaders to develop personas (ie, fictional users that represent an archetype character representative of our key users) and application of those personas to design decisions; and user-centered interviews with family physicians to learn about the physician's reactions to the revised dashboard. The team applied A&F best practices to the dashboard prototype. Personas were used to identify target groups with challenges and behaviors as a tool for informed design decision-making. Our workshop produced 3 user personas, Dr Skeptic, Frazzled Physician, and Eager Implementer, representing common users based on the team's experience of A&F. Interviews were conducted to further validate findings from the persona workshop and found that (1) physicians were interested in how they compare with peers; however, if performance was above average, they were not motivated to improve even if gaps compared to other standards in their care remained; (2) burnout levels were high as physicians are trying to catch up on missed care during the pandemic and are therefore less motivated to act on the data; and (3) additional desired features included integration within the electronic medical record, and more up-to-date and accurate data. We found that carefully incorporating data from user interviews helped operationalize generic best practices for A&F to achieve an acceptable dashboard that could meet the needs and goals of physicians. We demonstrate such a design process in this paper. A&F dashboards should address physicians' data skepticism, present data in a way that spurs action, and support physicians to have the time and capacity to engage in quality improvement work; the steps we followed may help those responsible for quality improvement strategy implementation achieve these aims.

Cardiac rehabilitation and primary care: Bridging the two solitudes

IntroductionQuality improvement has failed to live up to its promise. In theory, the application of a method to solve complex quality issues holds face validity. In practice however, much of...

A Return to Training Days Gone By: A Case for a Uniform Report Card System for Gynaecologic Surgery.

Introduction Although most ultrasound facilities rely on the referring physicians' request for testing, inappropriate indications for ultrasound studies have been cited as a quality metric and source of poor resource use. In 2015, the Intersocietal Accreditation Commission mandated that ultrasound facilities undertake educational and other strategies to address this as a quality improvement initiative, including education of referring physicians. We proposed to study the indications noted in referrals to develop such quality strategies. Methods Dedicated vascular ultrasound facilities were asked to participate. An electronic search of guidelines, standards, and criteria for testing was done. The indication for testing in consecutive patients was collated with adherence to standards and criteria for testing, type of referring physician, patient demographics, and findings. Care gaps were identified to serve as a “needs assessment” for educational and other strategies to address quality improvement. Results Three facilities agreed to participate (one academic, two community). A total of 4,654 studies were analyzed. The vascular domains included were: carotid (610), aorta (217), renal (52), upper extremity arteries (56), lower extremity arteries (1,465), lower extremity venous for deep venous thrombosis (1,377), and lower extremity venous for chronic venous insufficiency (877). Overall, appropriate criteria were cited for 76–96% of studies; the academic facility had higher adherence. There was no difference between family physician and specialist referrals. Diagnostic positive yields were found in 48–68% in different test categories; aortic screening yield was 8.1%. Specific “teaching points” included “headaches” and “neck pain” for carotid studies, aortic screening outside of “targets,” “numb toes,” and “swelling” for arterial duplex; no clear issues were identified for venous studies. Conclusions This study does identify inappropriate indications for vascular ultrasound with no systematic findings. There are specific teaching points that can be used to direct educational strategies for referring physicians.

Beginning a Diabetes Quality Improvement Project.

Context: The first wave of COVID-19 in Calgary, Alberta health zone accelerated Primary Care (PC) integration. Specifically, it connected Family Physicians (FPs) with their counterparts in the broader health system to deliver wraparound patient care through a COVID-19 Integrated Pathway (CIP). A key element of the CIP included a data sharing platform that facilitated the provision of test results directly to the FP identified by patients. Public Health provided test results for all patients to the primary care system so they could be followed up by primary care to improve their outcomes. Objectives: To evaluate the CIP by describing its function and capacity to facilitate FP follow-up with COVID positive patients; and to inform refinement of the CIP for future use. Study Design: This abstract reports on the quantitative arm of a mixed methods study. Setting/Dataset: The Calgary Health Zone. Primary data were drawn from the Calgary COVID-19 Care Clinic (C4), a designated hub clinic for COVID-19 patients. Secondary data were drawn from provincially maintained records of hospitalization, emergency department visits, and FP claims. Participants: FPs and COVID-19 patients. Intervention: The data platform and PC attachment elements of the CIP. Outcome Measures: The characteristics of patients cared for via the CIP (age, sex, ethnicity, and risk-level); the proportion of patients without a FP who were attached to an FP; the number of patients followed by their FP in the community, and the number of specialist consultations made by FPs to support care, time from diagnosis to follow-up with PC/FP; ED and acute care utilization. Results: Between Apr. 16 and Sep. 27, 2020, 7706 patients were referred by the Public Health team to the C4 clinic. Of those, 51.4% were male, the median age was 36 y., and 86 deaths were reported. The majority of patients were referred to local PC networks where follow-up was conducted using the CIP: 3223 (43%) already had their own FP, 2448 (32%) were successfully attached to an FP, and 1899 (25%) of these patients were monitored by C4 physicians - these patients either did not have FP or their FP was not available to follow the patient. 8.6% of these patients visited ED and 3.1% were hospitalized. More than 80% of these patients had at least of 5 visits with their FP. Conclusion: Data suggest that the CIP facilitated primary care based management of patients with COVID-19.

<h3>Context:</h3> Continuity with the same family physician is associated with better patient outcomes and this can be encouraged through patient enrolment models. Access to health care was disrupted by the SARS-CoV-2 pandemic and much of primary care shifted to virtual care. Continuity with a family physician in Canada is generally high. It is not known if continuity was disrupted by the pandemic or if continuity varied according to patient enrolment status. <h3>Objective:</h3> To determine whether continuity of care with the same family physician changed since the pandemic among enrolled and non-enrolled patients. <h3>Study Design and Analysis:</h3> Retrospective analysis of family physician office-based and virtual visits (i.e. telephone or video) 16 months before and 16 months since the onset of pandemic restrictions in Ontario (March 11, 2020). <h3>Dataset:</h3> Population-based linked physician billing data. <h3>Population:</h3> All patients residing in Ontario, Canada (population 14.8 million) for whom a family physician/general practitioner could be assigned. Approximately 80% of patients are formally enrolled with a family physician and many non-enrolled patients can be attributed according to the majority of care provided. <h3>Outcome Measures:</h3> Continuity of care, defined as the mean of each patient’s proportion of visits to the assigned family physician among all family physician visits, was analyzed for all visits, office visits and virtual visits, for formally enrolled and non-enrolled patients. <h3>Results:</h3> Among enrolled patients, continuity with the assigned family physician pre-pandemic ranged from 65-68% and this did not decrease with the pandemic. Among non-enrolled patients, the mean proportion of all visits to the assigned family physician ranged from 60-67% before the pandemic and there were decreases by as much as 18% during the pandemic. For virtual visits, there was lower continuity among enrolled than non-enrolled patients before the pandemic, but higher continuity for enrolled than non-enrolled patients during the pandemic. Patients 65 years and older had higher continuity with their own family physician than younger patients in both periods. There were few differences by sex. <h3>Conclusions:</h3> Since the pandemic, continuity of care has been maintained among patients enrolled to a family physician but declined for patients who are not formally enrolled. Efforts may be needed to address potential disruptions to continuity for patients not formally enrolled to a family physician.

IntroductionUse of administrative health data and primary care electronic medical record data are both ubiquitous in Alberta, but linkage between them at patient level and implementation of the linked data into primary care practice are rare. This demonstration project sought to achieve this for a sample of patients with diabetes.&#x0D; Objectives and ApproachAcademic family physicians in the Department of Family Medicine at the University of Calgary who participate in the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) identified diabetes–related variables, either in their EMRs or in administrative data, that they wished to obtain in a linked dataset. Secure data linkage was obtained through Alberta Health Services (the provincial health authority) following transmission of patient mapping files direct from the clinics. The de-identified, linked, patient data was then transferred to CPCSSN-Alberta data managers for processing and displayed to users through an interactive Diabetes Dashboard.&#x0D; Results2598 patients with diabetes were identified using a validated CPCSSN case definition from 47 family physicians in three clinics. CPCSSN EMR data included primary care encounters, date of diagnosis, deprivation index, BMI, blood pressure, comorbidity, diabetes medications prescribed, risk factors, etc. Administrative data included laboratory results (HbA1c, fasting blood glucose, cholesterol, triglycerides, creatinine), medication dispensed, emergency room visits, inpatient admissions and costs. Integrated, interactive provider reports were created and sent to participating physicians. The reports presented the information about diabetes patients at individual provider level, bench-marked at clinic, primary care network and provincial levels. Follow-up with providers led to further dashboard development . We propose to scale up implementation of the integrated diabetes database and dashboard to include all 23,000 CPCSSN-identified diabetes patients in Alberta.&#x0D; Conclusion/ImplicationsIntegration of EMR and administrative data and its application to clinical care, panel management, and quality improvement in primary care, as well as to surveillance and research, was feasible and acceptable to the family physicians participating in this project.

Incorporating Quality Improvement Projects Into Stroke Care and Research.

INTRODUCTION: Given the significant turmoil during the COVID-19 pandemic, the authors evaluated burnout and other types of emotional distress experienced by family physicians in Kansas during the second year of the pandemic. The authors compared findings of this study to a similar study conducted three months into the pandemic. METHODS: A cross-sectional online survey of 272 actively practicing family physicians in Kansas was conducted from September 15 to October 18, 2021. A 34-item questionnaire was used to measure the physicians’ levels of burnout, personal depression, anxiety, and stress. A mixed method approach was used to collect, analyze, and interpret the data. Descriptive statistics, Mann-Whitney U test/independent samples t-test, Chi-square, adjusted odds ratio, and immersion-crystallization methods were used to analyze the data. RESULTS: The response rate was 48.9% (n=133). In aggregate, 69.2% of respondents reported at least one manifestation of professional burnout in 2021 compared with 50.4% in 2020; P<.01). The 2021 respondents were at higher odds of experiencing burnout compared with 2020 respondents (aOR=1.86; 95% CI, 1.00-3.57; P=.046). The respondents who reported at least one manifestation of professional burnout were more likely to screen positive for depression (aOR]=1.87; 95% CI, 1.31-2.66; P<.01), report higher levels of anxiety (aOR=1.53; 95% CI, 1.04-2.24; P=.013), and higher levels of stress (aOR=1.39; 95% CI, 1.17-1.66; P<.001). CONCLUSION: As the COVID-19 pandemic continues, there are significant and worsening rates of professional burnout and other forms of emotional distress among family physicians. These findings suggest particularly timely need for appropriate psychological supports.

Learning about quality improvement (QI) in resident physician training is often relegated to elective or noncore clinical activities. The authors integrated teaching, learning, and doing QI into the routine clinical work of inpatient internal medicine teams at a Veterans Affairs (VA) hospital. This study describes the design factors that facilitated and inhibited the integration of a QI curriculum-including real QI work-into the routine work of inpatient internal medicine teams. A realist evaluation framework used three data sources: field notes from QI faculty; semistructured interviews with resident physicians; and a group interview with QI faculty and staff. From April 2011 to July 2012, resident physician teams at the White River Junction VA Medical Center used the Model for Improvement for their QI work and analyzed data using statistical process control charts. Three domains affected the delivery of the QI curriculum and engagement of residents in QI work: setting, learner, and teacher. The constant presence of the QI material on a public space in the team workroom was a facilitating mechanism in the setting. Explicit sign-out of QI work to the next resident team formalized the handoff in the learner domain. QI teachers who were respected clinical leaders with QI expertise provided role modeling and local system knowledge. Integrating QI teaching into the routine clinical and educational systems of an inpatient service is challenging. Identifiable, concrete strategies in the setting, learner, and teacher domains helped integrate QI into the clinical and educational systems.

Objectives: To evaluate message exchange, between a family physician and her patients, during the first fourteen months of e-mail access. Study Design: Observational cross-sectional. Setting: A family practice in Senhora da Hora, Matosinhos, Portugal. Population: E-mail messages exchanged between physician and patients. Methods: A random sample of 20% of patient messages was evaluated for: person the message was written about, size, number and type of subjects mentioned, whether or not it elicited a reply from the family physician and, if so, the reply message size and time between initial message and reply, time of day messages were sent and message results. Socio-demographic and familiar data were collected for every patient using e-mail.The amount of time spent by family physician adressing e-mail during a whole week was measured. For descriptive statistical analysis the author used Excel 2003. Results: A total of 504 messages were received from 92 different patients, whose mean age was 37.1, being 73% of which female and 65% with higher education. The family physician herself sent 462 messages. Messages studied (n = 100) from patients were written about 112 persons (most often the one who wrote the message, children, dependent elderly or spouse). Mean message size was 57.1 words and mentioned a mean of 1.3 subjects (most often medical questions, test results, nursing or administrative procedures and medication). The family physician replied to 69% of the messages received, doing so in less than 48 hours for 94.2% of cases and using a mean of 58.2 words per message. Messages from patients were written out of hours in 22% of cases.The family physician sent 58% of replies during non-consultation time. Most often, the messages results were: reply with medical information or advice, prescription fills, tests or treatment forms, certificates, appointment scheduling and referral. During a week, the family physician took an average of 5 minutes and 31 seconds daily to address e-mail. Conclusions: As in other studies conducted in the United States, this study found that patients and carers, mainly professionally active and higher educated female, adhere to e-mail to communicate with their family physician, without causing physician overload. These results may favour higher adherence of family physicians to e-mail and of family practices to invest in this tool.

Background:The province of British Columbia is facing a family physician shortage despite consistent increases in the number of physicians per capita and ongoing reforms to address the shortage. We identify physicians’ priorities for structural reform, describe the alignment of those priorities with BC’s suite of reforms and compare responses between established physicians and those new to practice; we also assessed rates of burnout.Methods:All family physicians credentialed within Vancouver Coastal Health in 2018 were invited to participate in a cross-sectional survey. Respondents were asked about their practice model and characteristics, demographics, level of burnout and reform priorities. We used χ2 tests and multivariable logistic regression to investigate associations between personal and practice characteristics, burnout and reform priorities.Results:Of the 1017 family physicians invited to participate, 525 (51.6%) responded. Of these, 399 (76.0%) indicated a need for fundamental change to how primary care is delivered; 244 (46.4%) would prefer to be a clinic employee rather than a small business owner. Other reform priorities included options to practise in a team (stated as very important by 69.6% of respondents), direct funding for team roles (66.7%), direct clinic funding (59.8%), part-time work options (64.7%), and ability to take planned vacations and parental leave (81.1%). The importance of individual reform priorities varied based on the participants’ model of practice, location and years in practice. Of respondents, 108 (21.1%) had experienced a high level of burnout.Interpretation:Almost half of family physicians would prefer to be employees rather than small business owners and over 20% reported a high level of burnout. Practice models offering direct employment model have very limited availability and are not included in the current suite of reforms in BC, potentially pulling physicians away from community-based family medicine and into other models or specialties.

<h3>Context:</h3> One way to build vaccine confidence is through advice from a trusted health professional, like a family physician. We implemented and evaluated a practice facilitation intervention in partnership with Ontario Health, a provincial government agency, to support the family physicians in Ontario known to have the largest number of unvaccinated patients. <h3>Objective:</h3> To understand how and why this intervention offered to family physicians most in need was used and to identify opportunities to adapt this targeted approach for other aspects of primary care. <h3>Study Design and Analysis:</h3> This was a qualitative process evaluation embedded within a randomized trial. Data were analyzed using inductive and deductive techniques informed by the Theoretical Domains Framework. <h3>Setting or Dataset:</h3> Data was collected through interviews with participating and non-participating family physicians, as well as from practice facilitator field notes. <h3>Population Studied:</h3> Family physicians with the largest number of unvaccinated patients in the province. <h3>Intervention/Instrument:</h3> Practice facilitators offered physicians support to identify, reach out, and counsel their unvaccinated patients. <h3>Outcome Measures:</h3> N/A <h3>Results:</h3> Of the 300 physicians randomized to the intervention, 29% accepted support. Among those who received facilitation, 58% used technical support to identify unvaccinated patients, 29% were linked with medical student volunteers to contact patients on their behalf, and 31% used automated calling to reach patients. The main barriers encountered were: a) gatekeeping from the front-office staff, which prevented the practice facilitator from contacting the physician, b) inability to dedicate extra time, c) technical issues with identifying patients requiring vaccines, and d) belief that outreach to patients would not result in more vaccinations. Facilitators were: a) clinics that had support staff, especially a tech-savvy workforce, b) physician, or the team passionate about COVID-19 vaccine uptake, and therefore willing to prioritize time or resources to outreach, and c) the belief that COVID-19 vaccine uptake was part of their role as a family physician. <h3>Conclusion:</h3> Strategies to help family physicians regarding vaccine rollout or other primary care areas of public health import must acknowledge the scarcity of time and resources of these physicians, and seek to build trust and relationships over time, including the front-office staff.