Large multispecialty group practices and quality improvement: what is needed to transform care?

The objective of this study was to use successful quality improvement initiatives in large multispecialty medical groups to identify the organizational factors that were the most important to improvement. The study analyzed the most successful quality improvement initiatives from those submitted by the 24 members of the Council of Accountable Physician Practices. Twelve initiatives from 8 groups were selected that met the study criteria for large improvement for large numbers of patients. An independent group used these initiatives to identify potentially important factors and then asked key local leaders to rate the importance of these factors on a scale of 1 to 4, importance rating (1-4 scale) for each of 18 identified factors. Eighteen factors were identified and 5 stood out as ranked a 4 (Very Important) for at least 80% of the initiatives: Communication, Use of Evidence-Based Medicine, Leadership, Measurement, and Reporting. Another 7 of the 18 factors were ranked a 4 for more than 50% of the initiatives. All the factors are related to the 6 challenges in the Institute of Medicine report. It was concluded that any organization striving to greatly improve the quality of its healthcare delivery should consider these factors when planning improvement initiatives.     

Intradermal vaccine delivery: will new delivery systems transform vaccine administration?

There has been a recent resurgence of interest in intradermal vaccine delivery. The physiological advantages of intradermal vaccine delivery have been known for some time, but the difficulties associated with performing an intradermal injection have historically limited its use. New delivery systems currently in development facilitate convenient intradermal vaccination, unlocking the potential advantages of this delivery route, and potentially transforming vaccine delivery.     

Smoke and malaria: are interventions to reduce exposure to indoor air pollution likely to increase exposure to mosquitoes?

Indoor air pollution from the domestic use of biomass fuels by poor households in developing countries is known to be harmful to health, and efforts are being made to address this problem by changes in fuel type, stove technology, house design and fuel-use practices. However, anecdotal evidence suggests that smoke may play an important role by providing protection from biting insects and that efforts to reduce smoke may increase exposure, particularly to mosquitoes and malaria. This paper reviews the literature relating to the repellent effect of smoke on mosquitoes and finds that there is currently no evidence that smoke from domestic fuel use provides effective protection from mosquitoes and malaria. Given the limited number and quality of studies, this finding cannot be interpreted as conclusive. The literature relating to house ventilation and mosquito entry was also reviewed, and an association between eaves spaces and increased indoor mosquito density was noted. Additionally, literature on the effect of soot on the efficacy of insecticide-treated bed nets was considered, but no direct impact was shown. Efforts to reduce indoor air pollution remain desirable even in areas of malaria transmission.     

Can electronic medical record systems transform health care? Potential health benefits, savings, and costs

To broadly examine the potential health and financial benefits of health information technology (HIT), this paper compares health care with the use of IT in other industries. It estimates potential savings and costs of widespread adoption of electronic medical record (EMR) systems, models important health and safety benefits, and concludes that effective EMR implementation and networking could eventually save more than $81 billion annually--by improving health care efficiency and safety--and that HIT-enabled prevention and management of chronic disease could eventually double those savings while increasing health and other social benefits. However, this is unlikely to be realized without related changes to the health care system.     

Transitioning to telehealth? A guide to evaluating outcomes

ObjectivesTelehealth use has surged since the onset of the coronavirus disease 2019 (COVID-19) pandemic, but the evaluation of telehealth outcomes and performance has not necessarily matched the pace of its uptake. In this article we aim to guide the design of a telehealth evaluation system encompassing all four domains of the outcome measurement framework developed by the National Quality Forum (NQF) – access to care, cost, experience, and effectiveness. We aim to achieve this through proposing survey items that can be distributed to patients or clinicians as a questionnaire and providing suggestions on areas of focus for evaluation studies.MethodsUsing PubMed and Google Scholar search engines, we performed a literature review of articles related to the evaluation of telehealth outcomes that were published in English since 2000.ResultsWe found existing survey tools to assist the development of an evaluation questionnaire, and categorized items into the four NQF outcome domains. For each outcome domain, we also summarize existing work on evaluation and make recommendations on areas for future assessment. In particular, we found that telehealth accessibility and accommodations have been historically under-studied and provide tools to address this.ConclusionsEvaluating telehealth outcomes is critical to ensure efficient and high-quality care delivery, and we believe establishing an evaluation system will help practices assess and improve their telehealth systems as well as their ability to use telehealth to respond to the diverse needs of patients.Public Interest SummarySince the start of the coronavirus disease 2019 (COVID-19) pandemic, telehealth use has been on the rise. Evaluating outcomes related to telehealth is critically important, but given the urgency of telehealth uptake, many health systems and practices may not yet have evaluation systems in place. This article guides the design of a telehealth evaluation system by proposing several validated and novel survey questions that can be used as part of a patient or clinician questionnaire and suggesting important measures of outcome for evaluation studies to assess across the four domains of telehealth quality as outlined by the National Quality Forum (NQF) – access to care, cost, experience, and effectiveness. We present tools to reach priority populations who often lack access to remote care, including older adults, underrepresented minorities, and people with disabilities.     

Does my patient have capacity to consent to treatment?

A competent adult patient has an ethical and legal right to give or withhold consent to an examination, investigation or treatment. Depending on the nature and complexity of an intervention, a patient with a developmental disability may be capable of consenting to their own medical treatment. In circumstances in which an adult patient does not have the capacity to consent, there is specific guardianship legislation enacted in each state that provides for valid consent by a substitute decision maker.