Pearls of Precepting
Translating Concepts of the Patient-Centered Medical
Home (PCMH) Into Teaching Opportunities
Harald Lausen, DO, FACOFP
American College of Osteopathic Family Physicians
47th Annual Convention & Scientific Seminars
Las Vegas, Nevada
March 2010
Objectives
• List the general principles and concepts of the PCMH.
• Translate principles and concepts of the PCMH into
student learning experiences.
• Discuss and explore possible educational approaches
for preceptors to teach and demonstrate principles and
concepts of the PCMH.
• Capture several educational approaches that could be
implemented into their own practices as preceptors.
PowerPoint Rules
•
•
•
•
Forgive Me --- I Am Breaking the Rules!
Designed for Future Reference
Busy Slides
Be Merciful
The Patient Centered Medical Home
The Family Medicine Model
Great
Outcomes
Practice
Organization
Health IT
Quality
Measures
Heath
Health
IT
Information
Technology
Patient
Patient
Experience
Experience
Family Medicine Foundation
Patient-centered | Physician-directed
Foundation – Evidence & Facts
Slides by Jerry Kruse, MD, MSPH
2003
Rank
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Nation
France
Japan
Australia
Spain
Italy
Canada
Norway
Netherlands
Sweden
Greece
Austria
Germany
Finland
New Zealand
Denmark
United Kingdom
Ireland
Portugal
United States
1998
Rank
1
2
4
3
6
5
10
8
5
9
12
11
16
14
13
18
19
17
15
Change in
Rank
+1
-1
+1
+1
+3
-4
-1
+1
-1
+3
-2
+2
+2
-1
-4
% Improvement
1998-2003
+17%
+14
+23
+14
+20
+16
+24
+18
+ 8
+15
+28
+18
+25
+20
+12
+26
+30
+23
+ 5
Measuring the
Health of Nations:
Deaths from
Treatable
Conditions
E. Nolte, et al:
Measuring the Health of Nations:
Updating an Earlier Analysis,
Health Affairs, 2008, 27(1):58–71
Corroboration:
US ranks 37th in
2000 WHO Rankings
World Health Organization,
The World Health Report 2000,
Health Systems Improving Performance
Geneva, Switzerland
http://www.who.int/whr/2000/en/index.html
1
France
26 Saudi Arabia
2
Italy
27 United Arab Emirates
3
San Marino
28 Israel
4
Andorra
29 Morocco
5
Malta
30 Canada
6
Singapore
31 Finland
7
Spain
32 Australia
8
Oman
33 Chile
9
Austria
34 Denmark
10 Japan
35 Dominica
11 Norway
36 Costa Rica
12 Portugal
37 United States of America
13 Monaco
38 Slovenia
14 Greece
39 Cuba
15 Iceland
40 Brunei
16 Luxembourg
41 New Zealand
17 Netherlands
42 Bahrain
18 United Kingdom
43 Croatia
19 Ireland
44 Qatar
20 Switzerland
45 Kuwait
21 Belgium
46 Barbados
22 Colombia
47 Thailand
23 Sweden
48 Czech Republic
24 Cyprus
49 Malaysia
25 Germany
50 Poland
World Health
Organization 2000
Rankings:
Health Systems
Performance
Ranking includes:
1. Disability-adjusted life
expectancy (DALE)
2. Distribution of healthcare
3. System responsiveness
4. Cost of healthcare
World Health Organization,
The World Health Report 2000,
Health Systems Improving Performance;
Geneva, Switzerland
http://www.who.int/whr/2000/en/index.html
US Healthcare: Best in the World?
US ranking compared to 13 rich nations:
Low Birth Weight percentage
Neonatal and Infant mortality
Potential Years of Life Lost
Life Expectancy at 1 year
Life Expectancy at 15 years
Life Expectancy at 40 years
Life Expectancy at 65 years
Life Expectancy at 80 years
Age-adjusted mortality
Rank
13th
13th
13th
12th
11th
10th
7th
3rd
10th
Barbara Starfield, Journal of the American Medical Association, 2000;284:483-5
Comparison of US data to Australia, Belgium, Canada, Denmark, Finland, France, Germany, Japan,
Netherlands, Spain, Sweden, United Kingdom
Infant Mortality Rates 2000 and 2008
From: CIA – The World Factbook
8
Infant
Mort.
Rate
7
Deaths
per
1000
live
births
5
In 2002, the US infant
mortality rate rose for the
first time in 40 years.
7.5
6.8
2000
2008
6.3
5.9
6
4.8
4.5
4.0
4
3.3
3.9
3.5
2.8
3
3.7
2.7
2.3
2
1
USA
% Improvement
2000-2008
7%
Cuba
21%
Germany
France
Japan
Sweden
Singapore
20%
22%
28%
23%
31%
https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html
http://comdinet.com/comdi/templates/factbook/factbook/fields/infant_mortality_rate.html
Health Care
Spending
7000
United States
Germany
Canada
France
Australia
United Kingdom
6000
per capita
($US PPP)
Purchasing Power Parity
5000
4000
2006
OECD Data
United States
3000
$6714
Germany
$3371
Source: K. Davis, C. Schoen, S.
Guterman, T. Shih, S. C.
Schoenbaum, and I. Weinbaum,
2000
Slowing the Growth of U.S.
Health Care Expenditures: What
Are the Options?
1000
0
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
The Commonwealth Fund,
January 2007, updated with 2007
OECD data
Ratio of
Full-Time Equivalent Members of the Tax-paying Workforce
to the
Number of Medicare Beneficiaries
From 2010 to 2030
35% decline
Ratio of
Workers to
Medicare
Beneficiaries
Year
Source: David Walker, Comptroller General of the US, Government Accountability Office
2004 Annual Report of the Board of Trustees of the Federal Hospital Insurance and
Federal Supplemental Medicare Insurance Trust Funds
The Patient-Centered Medical Home:
The Evidence
Johns Hopkins
Bloomberg School of
Public Health
Examples:
Starfield, Shi, Macinko. Contributions of Primary Care to Health Systems and
Health: The Milbank Quarterly 83(3), 2005; 457-502
Starfield & Shi. The Medical Home Access to Care, and Insurance, A Review
of Evidence: Pediatrics, 2004;113:1493-99
Dartmouth Center for
Health Policy and
Clinical Practice
Formerly “The Center for Clinical
Evaluative Sciences at Dartmouth”
Comprehensive Review of the
Effectiveness of Primary Care
Contribution of Primary Care to Health
Systems and Health
Barbara Starfield, Leiyu Shi and James Macinko
Johns Hopkins University, New York University
The Milbank Quarterly, Volume 83, No. 3, 2005
Pages 457 - 502
Institute of Medicine
Definition of Primary Care
“… (1) the provision of integrated, accessible health
care services
(2) by clinicians who are accountable for
addressing a large majority of health care needs,
(3) developing sustained partnerships with
patients, and
(4) practicing within the context of the family and
community…”
General Pediatrics: The Medical Home (1967)
Family Medicine: The Personal Medical Home (2002)
General Internal Medicine: The Advanced Medical Home (2006)
Now: The Patient-Centered Medical Home (2007)
Donaldson, IOM Report, Primary Care: America’s Health in a New Era, 1996 IOM Report, 1978
Improving Health Outcomes for
Populations
Primary Care prevents illness and death through the
following four mechanisms:
1. Supply of primary care physicians:
Ratio of generalist physicians to the total population
2. Supply of primary care physicians:
Ratio of generalist physicians to all physicians
3. Relationship with a source of
primary care
Peds: Medical Home
FP: Personal Medical Home
GIM: Advanced Medical Home
PCMH
4. Important features of the Health Care System
Starfield, Shi, Macinko. The Milbank Quarterly 2005:83(3);457-502
Health System and Policy Characteristics
Associated With Improved Health Outcomes
•
Attempts to distribute health services equitably with
respect to regional health care needs
•
Universal or near-universal financial assistance
guaranteed by a publicly accountable body
•
Low or no co-pay for health services
•
Percentage of physicians who are generalists
•
Professional earnings of primary care physicians
relative to other specialties
Starfield, Shi, Macinko. The Milbank Quarterly 2005:83(3);457-502
Social Health Disparities and
Primary Care
• Social deprivation is accurately measured by
levels of income inequality (Gini Coefficient), and
is associated with very poor health outcomes
• A high supply of Primary Care Physicians
eliminates the adverse health effect of income
inequality
• A high supply of Primary Care Physicians
eliminates racial disparities in health outcomes in
rural and suburban populations
Data from multiple studies in the United States, United Kingdom, Mexico, Costa Rica, and 7 African
nations. Summarized in Starfield B, et al. Contribution of Primary Care to Health Systems and
Health, The Milbank Quarterly, 2005;83:457-502.
Most important data is in: Shi L et al: Journal of Family Practice, April 1999, p275-283
Population-Based
Health Outcomes, Equity and
Cost
• The nations and regions that emphasize these things consistently
have better health outcomes, more equitable systems, and
substantially lower costs.
a. Public health and preventive medicine
b. Usual sources of comprehensive care (Primary Care Physicians)
c. First-contact care with effective systems of care (PCMH)
• Health outcomes are optimized when 40-50% of the physician
workforce is made up of primary care physicians
• Socioeconomic and racial disparities in healthcare outcomes are
dramatically reduced when there is an appropriate primary care
workforce
Johns Hopkins Studies: Summary
Primary health outcome measures–
e.g., life expectancy, death rate,
infant mortality rate, death rates from
cancer and heart disease, etc.—
are optimized when 40 to 50 % of the physician
workforce is made up of generalist physicians
Starfield B: British Journal of General Practice, April 2001, p303
Shi L et al: Journal of Family Practice, April 1999, p275
Starfield B: Health Affairs, March 15, 2005, p97
Relationship of Quality and Cost of Health Care to Physician Workforce
QUALITY
OF CARE
COST OF
CARE
(Primary Clinical
Outcome Measures
and Indicators of
Quality Care)
US 2005-32%
US entering
residency classes –
2005, 2006 – 18%
2007 – 16%
2008, 2009 – 14%
20
30
40
50
60
Percentage of Generalist Physicians
(Family Physicians, General Internists, and General Pediatricians among all physicians)
Composite Model Using Data from:
The Bloomberg School of Public Health (John Hopkins University)
and the Dartmouth Center for Evaluative Clinical Science
The Cost and Quality
of Healthcare
Dartmouth Center for Evaluative
Clinical Sciences
Data Source: Medicare Data Base - 1995, 1999, 2003
State Medicare QIO Data - 2000, 2001
Unit of Care: State
Method:
Ranked the states using 24
recognized measures of health care
quality, and compared quality to
health care spending and the
composition of the health care
workforce
Baicker K et al: Health Affairs, Apr. 7,2004 p.184f
Fisher ES et al: Ann Int Med, Feb 18, 2003 p.273f
Jencks SF et al: JAMA, 2000;284:1670-76
These 24 measures of health quality have been
standardized by Steve Jencks and reported in 2000.
They include both measures of inpatient and outpatient
performance and measures of preventive medicine and
disease treatment. Examples include appropriate
screening for breast and cervical cancer, use of aspirin
after MI, and use of warfarin for atrial fib.
This is an example of how the data are reported in the Baicker article. Each state is ranked by health care quality, and this
is graphed against annual spending per Medicare beneficiary. There are 51 states because DC is included. The lower
numbers reflect higher quality. As health care spending rises, quality declines significantly. Subsequent slides are based
on the figures in the Baicker article, but leave out the points for each individual state.
QUALITY OF CARE and MEDICARE SPENDING
75th Percentile
Quality
$5200 per year
1
Overall
Quality of
Healthcare
Rank by State
11
(Smaller numbers
indicate higher quality)
31
25th Percentile
Quality
$6800 per year
21
41
51
3000
4000
5000
6000
7000
8000
Annual Spending Per Medicare Beneficiary
Source:
Baicker et al. Health Affairs. April 7, 2004. Dartmouth Center for Evaluative Clinical Science
Medicare Claims Data and Area Resource File, 2003.
GENERALIST PHYSICIANS and QUALITY OF CARE
Overall
Quality of
Healthcare
Rank by State
(Smaller numbers
indicate higher quality)
75th Percentile
Quality
3.9 per 10,000
1
25th Percentile
Quality
2.5 per 10,000
26
51
1
2
3
4
5
Generalist Physicians per 10,000 Population
Source:
Baicker et al. Health Affairs. April 7, 2004. Dartmouth Center for Evaluative Clinical Science
Medicare Claims Data and Area Resource File, 2003.
GENERALIST PHYSICIANS and
MEDICARE SPENDING
Annual
Spending per
Beneficiary
25th Percentile
Spending
3.8 per 10,000
8000
7000
(Dollars)
6000
5000
75th Percentile
Spending
2.4 per 10,000
4000
1
2
3
4
5
Generalist Physicians per 10,000 Population
Source:
Baicker et al. Health Affairs. April 7, 2004. Dartmouth Center for Evaluative Clinical Science
Medicare Claims Data and Area Resource File, 2003.
Practice Characteristics Associated With
Improved Health Outcomes and Lower Cost
The Patient-Centered Medical Home
•
•
•
•
First Contact Care
Patient-focused Care over time
Comprehensive Care
Coordinated and Integrated Care
• Family Orientation
• Community Orientation
• Cultural Competence
Starfield & Shi: Pediatrics, 2004;113:1493-99
Starfield et al: Milbank Quarterly 2005;83:457-502
The Patient-Centered Medical Home
Legislative Definition of AAFP, ACP, AAP & AOA
•
•
•
•
•
Personal Physician
Physician Directed Medical Practice
Whole Person Orientation
Coordinated and Integrated Care
Quality and Safety Measures Evident
•
•
•
•
•
Evidence Based Medicine and Clinical Decision Support
Voluntary Continuous Quality Improvement (CQI)
Patient’s Expectation Met
Health Information Technology used effectively
Voluntary Recognition Process
• Enhanced Access
• Appropriate Payment
A critical evaluation of the
scientific evidence for each of
these characteristics:
Rosenthal T: J Am Board Fam
Med 2008;21:427-440
PCMH Concept
Source: Adapted with permission by IBM from Daniel F. Duffy, M.D.
Today’s Care
Medical Home Care
My patients are those who make
appointments to see me
Registries
Care is determined by today’s problem and
time available today
Proactive Plans
Care varies by scheduled time and
memory or skill of the doctor
Evidence-based Point-of-Service
Care
(Enabling CME)
I know I deliver high quality care because
I’m well trained
Quality Measure (Reinforcing CME)
Patients are responsible for coordinating
their own care
Team: Coordinated, Integrated
It’s up to the patient to tell us what
happened to them
Tracking: Test and Referrals
Clinic operations center on meeting the
doctor’s needs
Optimal Function:
28
An interdisciplinary team works at the top
of our licenses to serve patients
Patient-Centered Medical Home
The Governmental Landscape
• Medicare Demonstration Projects
– Medicare Payment Advisory Commission (MedPAC)
• Medicaid Demonstration Projects
– The Medical Homes Act of 2007
– Community Care of North Carolina (CCNC)
• Industry and Hospital System Initiatives
• National Committee for Quality Assurance (NCQA)
Chapters
1. Direction for Delivery
Reform
2. Promoting the Use of
Primary Care
3. Hospital-Physician
Collaborative
Relationships
4. Bundled Payment
Around a Hospitalization
5. Producing Comparative
Effectiveness Information
6. Public Reporting of
Physician Financial
Relationships
http://www.medpac.gov/document_search.cfm
7. Revised Prospective
Payment System for
Skilled Nursing Facilities
Chapter 2
Promoting the Use of Primary Care
Congress should establish a budget-neutral
payment adjustment for primary care
services furnished by primary-carefocused practitioners.
Congress should initiate a Medical Home pilot
project in Medicare. Eligible Medical
Homes must include the following criteria:
Furnish Primary Care
Conduct Care Management
Use HIT for clinical decision support
Have formal QI program
24 hr. Communication/Enhanced Access
Records of Advanced Directives
Written Medical Home Designation
http://www.medpac.gov/documents/Jun08_EntireReport.pdf
Physician Payment Models
Pay For
Performance
Per Member-Per Month
Care Coordination
Payment
Fee
for
Service
Quality Measurement and Reporting
Based on Achievement in Quality Indicators
of Medical Practice and Service
Patient Centered Medical Home
PCMH
Based on a patient’s relationship
with an effective source of primary care
Relative Value Unit Scale
Based on physician work
( physician's time, mental effort, technical skill,
judgment, stress, education, and practice expense )
The Multiplicative
Financial Power
of the PCMH
Every
Results
In
And
$1
$4
$11
Collected by a
Primary Care
Physician
Collected by
Specialty
Physicians
Collected by
Hospital
Systems
Woodcock and Associates, Review of 13 scientific studies
Mean Annual Hospital
Revenue Generation by
Specialty
Invas. Cardiology $2,400,000
Orthopedics
2,300,000
Neurosurgery
2,100,000
Gen. Int. Med.
1,900,000
General Surgery
1,900,000
Heme/Onc
1,900,000
Family Medicine
1,600,000
Ob/Gyn
1,400,000
Gastroenterology
1,300,000
Pulmonology
1,300,000
Urology
1,200,000
Psychiatry
800,000
Nephrology
800,000
General Pediatrics 700,000
Ophthalmology
500,000
Neurology
500,000
Merritt, Hawkins and Associates: 2007 Physician
Inpatient/Outpatient Revenue Survey
http://www.merritthawkins.com/pdf/2007_Physician_Inpatient_Outpatient_Revenue_Survey.pdf
PCMH-PPC Proposed Content and Scoring
Standard 1: Access and Communication
A. Has written standards for patient access and patient
communication**
B.
Uses data to show it meets its standards for patient
access and communication**
Pts
Standard 2: Patient Tracking and Registry Functions
A. Uses data system for basic patient information
(mostly non-clinical data)
B.
Has clinical data system with clinical data in
searchable data fields
C. Uses the clinical data system
D. Uses paper or electronic-based charting tools to
organize clinical information**
E.
Uses data to identify important diagnoses and
conditions in practice**
F.
Generates lists of patients and reminds patients and
clinicians of services needed (population
management)
Pts
Standard 3: Care Management
A. Adopts and implements evidence-based guidelines
for three conditions **
B.
Generates reminders about preventive services for
clinicians
C. Uses non-physician staff to manage patient care
D. Conducts care management, including care plans,
assessing progress, addressing barriers
E.
Coordinates care//follow-up for patients who
receive care in inpatient and outpatient facilities
Pts
3
Standard 4: Patient Self-Management Support
A. Assesses language preference and other
communication barriers
B.
Actively supports patient self-management**
4
5
9
2
3
3
6
4
3
21
4
3
5
5
20
Pts
2
4
Standard 5: Electronic Prescribing
A. Uses electronic system to write prescriptions
B.
Has electronic prescription writer with safety
checks
C. Has electronic prescription writer with cost
checks
Pts
3
3
Standard 6: Test Tracking
A. Tracks tests and identifies abnormal results
systematically**
B.
Uses electronic systems to order and retrieve
tests and flag duplicate tests
Pts
7
Standard 7: Referral Tracking
A. Tracks referrals using paper-based or electronic
system**
PT
4
Standard 8: Performance Reporting and Improvement
A. Measures clinical and/or service performance
by physician or across the practice**
B.
Survey of patients’ care experience
C. Reports performance across the practice or by
physician **
D. Sets goals and takes action to improve
performance
E.
Produces reports using standardized measures
F.
Transmits reports with standardized measures
electronically to external entities
Pts
3
Standard 9: Advanced Electronic Communications
A. Availability of Interactive Website
B.
Electronic Patient Identification
C. Electronic Care Management Support
Pts
1
2
1
2
8
6
13
4
3
3
3
2
1
15
4
6
** Priority Elements
Physician Practice Connections and Patient Centered Medical Home
Framework – Application
Slides from AAFP
Family Physicians and the PCMH
• PCMH is a place, not a person.
• Patient-centered, Physician-directed.
• Family physicians
–
–
–
–
Provide comprehensive care
Care for all patients
Coordinate care
Provide care that is effective
and efficient*
• Future of Family Medicine
• *Starfield data
Great
Outcomes
Practice
Organization
Quality
Measures
Health
Information
Technology
Patient
Experience
Culture of
Improvement
• Starts with a culture of
improvement
• Ensure quality
improvement initiatives
are not punitive; should not
discourage physicians from
caring for patients
Quality
Measures
Performance
Measurement
• Quality measures should be
based in strong clinical
evidence
• You can’t improve what you
don’t measure
Reliable
Systems
• Develop reliable systems
to collect information
Convenient Access
Personalized Care
Care Coordination
• Patients want convenient
access to information,
communication, and care
• Patients want to access
to care when they are ill
• Patients are engaged in their
own care and want to share
in decision-making
• Patients want increased
ability to access information
• Patients want coordinated
care
• Patients want new
approaches to care: group
visits and on-line services
Quality
Measures
Patient
Experience
Financial Management
• All staff are aware of the
most effective ways to
deliver care
• National policies support the
investment of resources into
primary care practices that
are effective and efficient
Personnel Management
• Every team member
understands the important
role they play in delivering
efficient care and is
empowered to make
suggestions for
improvement
Practice
Organization
Quality
Measures
Patient
Experience
Clinical Systems
• Lab testing
• Prescriptions
• Registries
• Lab testing
• Prescriptions
• Patient Registries
Business & Clinical
Connectivity &
Evidence-Based
Clinical Data Analysis
Process Automation
Communication
Medicine Support
& Representation
• Patient reminders
• Patient notification for
new information
• Reminders for
recommended care or
health maintenance
• Makes patient registries
possible
• Enhances care
coordination by
improving information
flow with other
physicians, practices,
and providers
• Improves patient physician communication
Practice
Organization
Health
Information
Technology
Quality
Measures
Patient
Experience
Family Medicine Foundation
• Point-of-care learning
(e.g., Up-to-Date)
• Clinical decision support
(e.g., Epocrates)
• Can quickly pull clinical
data for quality analysis
• Can enhance business
processes
Great Outcomes
• Good for patients
– Patients enjoy better health.
– Patients share in health care decisions.
• Good for physicians
Great
Outcomes
Practice
Organization
Quality
Measures
Health
Information
Technology
Patient
Experience
Family Medicine Foundation
– Physicians focus on delivering excellent
medical care.
• Good for practices
– Team works effectively together.
– Resources support the delivery of
excellent patient care.
• Good for payors and employers
– Ensures quality and efficiency.
– Avoids unnecessary costs.
Goals – Education & Recruitment
Teaching Opportunities
•
•
•
•
•
Rotation – How Many Weeks?
Curriculum – Existing Assignments?
Experience – Patient Care?
Teaching – Frequency / Format?
Today’s Presentation
– Framing Concepts of the PCMH
Family Medicine
Digital Resource Library
•
•
•
•
http://www.fmdrl.org
Open to Everyone
Search Lausen
Resources, PowerPoints, Documents
The Patient-Centered Medical Home
Characteristics of Practices of Personal Physicians
Associated with Improved Health Outcomes and Equity,
and with Lower Costs
•
First Contact Care
-
•
The degree to which patients
seek advice and care first at the practice of the personal
physician, except for medical catastrophes
Patient-Focused Care Over Time - The degree to
which the practice emphasizes patient-focused care, rather
than disease-focused care; and longitudinal care, rather
than episodic care
•
Comprehensive Care
•
Coordinated (Integrated) Care
- The degree to which the
personal physician provides a broad range of health
services
-
The degree of
integration of care among health professionals and staff,
both within the Patient-Centered Medical Home and with
outside organizations and consultants, and the degree to
which talents of all members of the team are used
optimally.
•
Family Orientation - The degree to which medical
•
services are provided to family members by the same
personal physician
Community Orientation - The degree to which the
practice assesses the needs of the community, designs
interventions, and measures outcomes
•
Cultural Competence
- The degree to which the
biopsychosocial model is employed and health beliefs are
addressed
Starfield, et al: The Milbank Quarterly 83(3), 2005; 457-502
Starfield & Shi: Pediatrics, 2004;113:1493-99
AOA, AAFP, AAP and ACP
Legislative Definition of the PCMH
and Vision for the Office of the Future
(Joint Principles)
•Personal Physician
•Physician Directed Medical Practice
•Whole Person Orientation
•Coordinated and Integrated Care
•Quality and Safety Measures Evident
• EBM and Clinical Decision Support
• Voluntary CQI Processes
• Patient’s Expectation Met
• HIT used appropriately
• Voluntary Recognition Process
•Enhanced Access
•Appropriate Payment
http://www.medicalhomeinfo.org/Joint%20Statement.pdf
A critical evaluation of the scientific evidence for each of
these characteristics:
Rosenthal T: J Am Board Fam Med 2008;21:427-440
Educational Approaches
• 10 Concepts from PCMH Descriptions
• Reframe the Context
• Approaches
– Discussion
– Reflective Writing
– Worksheet / Exercise
– Assignment
– Real Clinic Examples
Be Interactive
•
•
•
•
Share Your Ideas
Discuss As We Go
Ask Questions
Comments & Concerns
Our 10 - Today
•
•
•
•
•
•
•
•
•
•
Personal Physician / Longitudinal Care
Longitudinal Patient-Focused Care
Cultural Competence
Coordinated / Integrated Care
Community Orientation
Comprehensive Whole-Person Care
Enhanced Access
Evidence-Based Medicine
Quality Improvement
Clinical Decision Support
Personal Physician / Longitudinal Care
• Longitudinal Patient-Focused Care (the degree to
which the practice emphasizes patient-focused care,
rather than disease-focused care; and longitudinal care,
rather than episodic care)
•
•
•
•
Biopsychosocial Model
Personal Knowledge of Patient
Medical / Personal Health History
Social Context of the Patient
– Socioeconomics
– Health Belief System
– Health Literacy
PC-MH Reflection
• Introduction: The purpose of this assignment is to promote the
recognition of a specific characteristic of the Patient-Centered
Medical Home that has been associated with improved health
outcomes and lower costs.
• Longitudinal Patient-Focused Care (the degree to which the
practice emphasizes patient-focused care, rather than diseasefocused care; and longitudinal care, rather than episodic care)
• Instructions: Reflect or Discuss your specific experience regarding
an established patient of the clinic. How did the relationship with
and prior knowledge of the patient affect the office visit, information
discussed, treatment plan, and future care / studies / labs?
Longitudinal Patient-Focused Care
• Longitudinal Patient-Focused Care (the degree to
which the practice emphasizes patient-focused care,
rather than disease-focused care; and longitudinal care,
rather than episodic care)
• Health Literacy
• Patient Education
Health Literacy
• Knowing Your Patients
– Education Level
– Reading Ability
– Comprehension
• Health Literacy Assessment Tool
– http://www.pfizerhealthliteracy.com/physicians
-providers/default.html#
Health Literacy Exercise
•
Mr. Stone is 57 and often is a “difficult” patient because he doesn’t seem to adhere to your
management recommendations. His BMI is 37 and his BP is 148/78. He is not diabetic, leads a
sedentary lifestyle, and prefers to eat meat and potatoes. You perform the Newest Vital Sign
health literacy assessment on him and find he scores a 3 which indicates the possibility of limited
literacy. You are talking to him about his hypertension. You begin to discuss diet and activity
with him as a ways of controlling his weight. As you are talking he asks you what this has to do
with hyperactive? He says for the past couple of years you have been telling him he is
hyperactive and giving him a pill to take and told him to watch his diet and to exercise more but he
can’t see what that has to do with being hyperactive. In fact he says he stopped taking his pill
because he wasn’t hyperactive.
•
What do you think just happened?
•
What are some ways to approach management discussion with Mr. Stone? (discuss 3 different
approaches)
– Use simple words, pictures, teach back
•
Use the Personal Health Prescription supplied and write out a management goal for either
nutrition or activity that you would provide to Mr. Stone.
- make sure the recommendations are written in measurable goals- i.e. not walk more but walk
15 minutes per day
Patient Education Points
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Educates Patient on Diet / Weight
Educates Patient on Medication Changes
Educates Patient on Importance of Regular Physician Visits
Educates Patient on Diabetes / Hypertension Management
Educates Patient on Drug / Tobacco / Alcohol Use
Assesses Barriers to Compliance / Understanding
Assesses Readiness for Change
Determines Patient Level of Understanding
Avoids Medical Jargon
Communicates with the Patient Clearly and Effectively
Clearly Identifies Issues / Problems
Utilizes Shared Decision-Making
Develops Appropriate Patient Education Strategies
Displays Understanding of Disease Pathophysiology
•
48 y/o male presents to the clinic for a diabetic check. He has been diabetic for
46 years. He first became diabetic at age 18 months after suffering from a mild
viral infection. He has been on insulin since. For most of his life he has taken
two shots per day of combination NPH and Regular. During college he was
admitted about once per year in DKA, requiring hospitalization for 2-3 days. He
was also admitted as a child with hyper and hypo glycemic spells and no comas.
He rarely has hypoglycemic episodes because he sticks his finger and checks if
he has that “feeling”. For him, it consists of a strange nausea and headache. If
his blood sugar is below 70 he drinks oj and eats jelly and some food. Recently
(the last 6-9 months) his daily AM blood sugar runs about 170 and the 1700 blood
sugar is about 210. It used to stay right at 120 because he ate so carefully and
took extra insulin before “parties” and if the blood sugars were above 140. He
wants to lose weight but has a stressful job as a counselor and eats for stress and
to battle fatigue. His weight has always been about 170, but has slightly
increased (~176) within the past two years. He has tried following the 1500
calorie diabetic diet more closely but has not lost the weight. He used to exercise
regularly (walk 3 times/week, swim 3 times/week) but just has no time left after
finishing the day with his busy practice. His physical and eye exams have been
remarkably normal with no real diabetic changes.
•
He has had no surgeries. His only medical illness is diabetes. He rarely drinks
alcohol but occasionally smokes marijuana. He does not smoke cigarettes. He is
allergic to penicillin and got an awful rash as a child with it.
•
45 y/o female presents to the clinic for a hypertension check. She wants to lose weight but
has a stressful job as an accountant and admits to eating “whatever she wants” and
sometimes snacking more than usual with lots of stress. Her weight has always fluctuated
up in the winter and down in the summer. She has tried following a diet on many occasions,
but readily admits to falling “off the wagon”, especially with desserts. She used to exercise
regularly (Nordic track 3 - 4 times/week) but just has no time left after finishing the day at
work, spending some time with family and evening paperwork, and keeping up with
household chores.
•
Vitals: BP – 140/90, P – 68, R – 16, Wt – 165, H – 5’6”, BMI 27
•
Her physical exams have been remarkably normal with only some central obesity and mildly
elevated blood pressure at rare intervals. She wears glasses to correct her vision.
•
Meds:
•
PMH: She has had no surgeries. Her medical illnesses are HTN, hypermyopia, and her
weight.
•
SH: She rarely drinks alcohol except for an occasional glass of wine or beer and 2-3 times
per year at parties. She does not smoke or use street drugs. She consumes a fair amount
of coffee on a regular basis. She is allergic to Walnuts which cause GI and respiratory
symptoms. She is married and has 2 kids.
1) Lopressor 100mg (Metoprolol) or common beta blocker
2) Vancenase AQ HS
Cultural Competence
• Cultural Competence (the degree to which the
biopsychosocial model is employed and health beliefs
are addressed)
• Health Belief System
• Shared Decision-Making
Health Belief System
Assessing for Acceptance
of Medical Management
1.
Ask the patient
– “Do you feel that you can check your blood sugar
every day?”
2. Assess for barriers to acceptance
– Recent diagnosis
– Denial of diagnosis
– Lack of knowledge
– Lack of trust in provider
– Lack of trust in medications
– Beliefs
Patient Ability & Adherence
Assess for:
1. Barriers to adherence
2. Motivation for adherence
3. Skills needed for adherence
Medication Adherence
What gets in the way of taking your medicine(s)?
•Makes me feel sick
•Cost
•Can’t remember
•Too many pills
•Nothing
•Other:
Provider: remember to document asking the patient and the patient response!
Shared Decision-Making
Rochester Participatory Decision-Making Scale









http://www.annfammed.org/cgi/reprint/3/5/436
Explain the clinical issue or nature of the decision
Discussion of the uncertainties associated with the situation
Clarification of agreement
Examine barriers to follow-through with treatment plan
Physician gives patient opportunity to ask questions and checks
patients understanding of the treatment plan
Physician’s medical language matches patient’s level of
understanding ****
Physician asks “Any questions?”
Physician asks open-ended questions
Physician checks his/her understanding of patient’s point of view
Coordinated / Integrated Care
• Coordinated/Integrated Care (the degree of integration
of care among health professionals and staff, both within
the PC-MH and with outside organizations and
consultants)
•
•
•
•
•
•
Transitions of Care
Specialty / Consultant Referrals
Procedural / Treatment Referral
Internal Referral
Counseling / Education
Community Services & Resources
PC-MH Reflection
• Introduction: The purpose of this assignment is to promote the
recognition of a specific characteristic of the Patient-Centered
Medical Home that has been associated with improved health
outcomes and lower costs.
• Coordinated/Integrated Care (the degree of integration of care
among health professionals and staff, both within the PC-MH and
with outside organizations and consultants)
• Instructions: Reflect or Discuss your specific experience regarding
an established patient of the clinic. How did the provider / practice
assist the patient with coordinating care to consultants, allied health
professionals, community resources, and/or care transitions? How
does the practice track these activities?
Community Orientation
• Community Orientation (the degree to which the
practice assesses the needs of the community, designs
interventions, and measures outcomes)
• Your Role In the Community
– Roles
– Services
– Procedures
• COPC Process
– Evaluate Need for Community
– http://www.mcg.edu/som/fmfacdev/fd_copc.htm
COPC Process
•
Community-Oriented Primary Care (COPC) is an approach to health care delivery
that undertakes responsibility for the health of a defined population. COPC is
practiced by combining epidemiologic study and social interventions with clinical care
of individual patients, so that the primary care practice itself becomes a community
medicine program. Both the individual patient and the community or population are
the foci of diagnosis, treatment and ongoing surveillance.
•
What does COPC offer me, as a physician?
The concept of COPC offers physicians the opportunity to impact significantly larger
populations and ultimately alter a community's health. A change in the overall health
in the community is reflected in better health for each individual patient the physician
treats on a daily basis.
•
How do I implement COPC in my practice?
There are basically four steps you will need to follow to transform your primary care
practice into a community medicine program:
Define the population.
Assess the defined population's health needs.
Organize an effective intervention strategy.
Evaluate the success of the intervention.
COPC Exercise
•
What is meant by “caring for the patient not in the room?”
– Room to room care doesn’t work- you need to care for those who aren’t in the room, those who encounter
barriers, etc.
•
•
Compare individual clinical care to COPC population care
Examination of patient: Interview and examination of individuals using history, PE, lab, xray, etc. versus
Community survey: State of health of community and families, using local opinion, secondary data sources,
questionnaires, physical ,psychological and lab testing
Diagnosis: individual- usually related to complaint using DDX or appraisal of health status of a well person (ie.
Pregnant, well children, periodic health exams) versus
Community diagnosis: usually problem-oriented, higher frequency of a particular condition in the community
and its causes or health status of community as a whole or defined segments of it ie. Health of expectant mothers,
growth and development or children, birth and death rates
Treatment: clinical: according to dx and depending on resources of patient and institution versus Population:
according to the community dx and depending on resources of health services system and community and
population interventions to prevent/treat specific diseases or reduce risk
Therapy: monitoring- evaluate patient’s progress and response to tx, ongoing tx of chronic illnesses versus
Evaluation: evaluation of intervention, programs, COPC process. Surveillance of health indicators in community
and incorporation of community treatment into community health care system
•
•
•
•
•
What are the 5 steps of the COPC process?
– Step 1: Define the Community
– Step 2: Characterize the Community’s Health Needs Intervention
– Step 3: Identify Community Health Problems
– Step 4: Develop
– Step 5: Monitor Impact of Intervention
Comprehensive Whole-Person Care
• Comprehensive Care (the degree to which the
personal physician provides a broad range of health
services)
• Family Orientation (the degree to which medical
services are provided to family members by the same
personal physician)
• “Cradle to Grave” – Describe Your Practice
• Tempered Independence – Your Special Skills
• Basket of Services – What You Provide
– Prevention
– Acute and Chronic Care
– Procedures
CASE 1: 25y/o Female - Prenatal Visit
Vitals:
Ht: 5’8”
WT: 135#
P: 65
R: 16
BP: 114/70
Susan Phillips is a 25 y/o G2 P1001 patient who presents for her first
prenatal visit. She also complains of a chronic non-productive cough for the
last 4 weeks. She has a prior medical hx of asthma and tobacco abuse (8
pack years). She denies any other symptoms. Her family history is positive
for hypertension, hyperlipidemia, and diabetes. Currently, she lives at home
with her 1 year old son (Tyler) and her boyfriend of 2 years. There is a copy
of a recent ED visit for physical abuse in her chart.
Readings for Susan Phillips
Asthma Guidelines
Evidence Based Prenatal Care (Parts 1&2)
STD Screening
Gestational Diabetes Screening
Family Violence Screening
Tobacco Counseling
(AFP 2009)
(AFP 2005)
(AFP 2007)
(AIM 2008)
(USPSTF 2004)
(USPSTF 2009)
CASE 2: 1 y/o Male - Well Child Visit
Vitals:
Ht: 50%
Wt: 95%
HC: 60%
Tyler Phillips is a 1 y/o male who presents for a well child visit with his
mother. There are no complaints. Tyler is an obese child acting normally
and being playful. Up to now his development has been normal and his
immunizations are up to date. He has no previous medical history. His
family history is positive for hypertension, diabetes, and asthma. He is
currently eating table foods and drinks about 5 sippy cups of juice daily. His
mother also notes that he loves candy. He lives with his mother (Susan)
and her boyfriend. There is tobacco exposure at home.
Readings for Tyler Phillips
Childhood Obesity and CV Risk
Childhood Obesity
Obesity Screening
Dental Caries Screening
Lead Screening
Immunization Schedule
(AFP 2008)
(AFP 2008)
(USPSTF 2005)
(USPSTF 2004)
(USPSTF 2006)
(CDC 2010)
CASE 3: 60 y/o Grandmother - Acute Visit
Vitals:
Ht: 5’5”
Wt: 198
P: 76
R: 21
BP: 142/84
Betty Phillips is a 60 year old grandmother who presents with exertional
dyspnea for the last four weeks. She notes difficulty with doing her normal
level of activity. She denies chest pain. She has a prior medical hx of
hypertension, hyperlipidemia, and obesity. Her family history is positive for
hypertension, diabetes, asthma, stroke, breast cancer, and coronary artery
disease. Her husband presents with her today and quietly tells you he is
concerned about her memory. Her chart reveals it has been over 1 year
since her last visit.
Readings for Betty Phillips
Acute Dyspnea
Cardiovascular Disease in Women
Breast Cancer Screening
Cervical Cancer Screening
Dementia Screening
Depression Screening
Osteoporosis Screening
(AFP 2003)
(AFP 2006)
(USPSTF 2005)
(USPSTF 2003)
(USPSTF 2003)
(USPSTF 2002)
(USPSTF 2002)
CASE 4: 68 y/o Grandfather – Home Visit
Vitals:
Ht: 5’6”
WT: 157#
P: 82
R: 16
BP: 140/82
Joe Mason is a 68 year old grandfather who is homebound due to
agoraphobia and post-traumatic stress disorder. He called the office with a
complaint of intermittent episodes of dizziness. He has never had similar
symptoms. He has a prior medical hx of hypertension, hyperlipidemia,
osteoarthritis, and chronic back pain. His family history is positive for
hypertension, diabetes, asthma, stroke, breast cancer, and coronary artery
disease. He lives alone. His sister (Betty Phillips) and niece (Susan
Phillips) help him with groceries, supplies, etc. You typically do home visits
for this patient.
Readings for Joe Mason
Chronic Low Back Pain
Osteoarthritis
Geriatric Patient
Home Visit
Colon cancer Screening
Prostate Cancer Screening
Geriatric Cancer Screening
(AFP 2009)
(AFP 2002)
(AFP 2000)
(AFP 1999)
(AFP 2008)
(AFP 2008)
(AFP 2008)
Article References
• American Academy of Family Physicians
– http://www.aafp.org/online/en/home/publicatio
ns/journals/afp.html
• USPSTF
– http://www.ahrq.gov/clinic/USpstfix.htm
• Annals of Internal Medicine
– http://www.annals.org/content/by/year
Enhanced Access
• What are Your Clinic Strategies?
– Open Access Scheduling
– Variable Office Hours
– Electronic Patient Portal
– Phone Visits / Tele-Health
– Visit Options / Groups / Health Team
• Patient Email Exercise
– Specific Examples and Challenges
– Scoring Rubric
Patient Email
• Goal:
• The purpose of this assignment is to practice the
application of patient email communication guidelines
• Instructions:
• You will receive an email from the patient or patient’s
family member.
• Reply to the email in an appropriate manner.
• The reply should be returned to the original sender.
• You should assume that you are using an approved
system for email use and that your patient has agreed to
the rules you provided and discussed.
Email Guideline Resources
• Kane, Beverly, MD, and Sands, Daniel MD, MPH.
Guidelines for the Clinical Use of Electronic Mail with
Patients. For the AMIA internet working group, task
force on guidelines for the use of clinic-patient electronic
mail. JAMIA: 1998;5:104-111.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC61279/pdf/0050104.pdf
• Stephanie L. Prady, BSC, Deidre Norris, RN, John E.
Lester, BS,Daniel B. Hoch, MD, PHD; Expanding the
Guidelines for Electronic Communication with
Patients: JAMIA: 2001;8:344–348.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC130078/pdf/0080344.pdf
• AMA Guidelines for Physician-Patient Electronic
Communication Last updated: Feb 27, 2008. Content
provided by: Janice Robertson. Copyright 1995 2008
American Medical Association.
Email Cases
Challenge
•
Case 1
“As you know my boyfriend and I had some trouble in the past. I was
wondering what my cultures from my prenatal visit showed.”
•
•
•
Content
HIPAA
Lay Language
•
Case 2
“Tyler has an appointment next week for his 1 year check-up. I was
wondering if he is due for shots at that time?”
•
•
Content
Lay Language
•
HIPAA
•
Urgent Issue
•
•
Case 3
"My wife has an appointment with you next week and I am concerned with
some memory loss she is having. She just doesn't seem to be herself. Did
you notice any problems with her memory last year when you saw
her? Can you provide her with some medication to help with this? Please
don’t tell my wife that I contacted you. She seems very sensitive about her
recent memory issues.”
Case 4
"I am so sorry to bother you but I wanted to let you know this before my
home visit scheduled next Tuesday. This morning after I got up I started a
little blurrred vision and almost passsed out. The room seemed to spin. I
am better now but I know how you like you to know everything for our visits.
Should I be worried? See you later week.”
Components
CLINICAL:
Communication
Question addressed
Concise
Proofread
Clear, lay language
Sharp, clear font
Avoidance of jargon
Formatting/salutations/closing appropriate/confidentiality statement
KNOWLEDGE:
Background
Content correct
HIPPA
Discipline
Emergent/non-emergent identified
Problem-Solving
Plan provided
NONCOGNITIVE:
Self-directed
Timely response
Motivation
Overall quality
Yes
No
Quality Improvement
• What Are Your Processes?
– Clinical Assessment Program (AOA)
– Maintenance of Certification (AAFP)
– Physician Quality Reporting Initiative (CMS)
– Private / Public Payors
– Internal Quality Improvement Efforts
Quality Improvement Worksheet
(Diabetes)
• Goal:
• The purpose of this assignment is to become familiar
with the general approach of chart review as a
fundamental step toward quality improvement.
• Instructions:
• Identify a patient with diabetes and perform a chart
review.
• Complete the Diabetes Quality Improvement Worksheet
while you are doing the chart review.
Quality Improvement Worksheet – Diabetes (Type 2)
Patient Gender:
M
F
Age_________
EHR:
Y
N
Please circle the appropriate answer if the information is recorded in the chart.
Vital Signs and Weight Recorded (each visit)
BMI / Weight Loss Discussed (last year)
Diet Education Reviewed (last year)
Exercise Discussed (last year)
Tobacco Cessation Discussed (last year if applicable)
Dilated Eye Exam Referral (last year)
Influenza Vaccination Offered (last year)
Urine Microalbumin Ordered (last year)
Foot / Neuro Exam Completed (last year)
Fasting Lipid Panel Ordered (last year)
Hemoglobin A1C Ordered (last 6 months)
BP at Goal (<130/80)
HgA1C at Goal (<7)
LDL at Goal (<100)
HDL at Goal (>40men, >50 women)
Patient on ACE/ARB (or contraindication noted)
Patient on Aspirin (or contraindication noted)
Student Signature_____________________________________________________
Preceptor Signature____________________________________________________
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Chronic Care Model / QI
•
•
•
•
•
•
Your patient, Jane Smith, is a 38 year old female who comes in to clinic today for her diabetic follow up
visit. Her prior medical history includes hypertension, hyperlipidemia, obesity, depression and prior
tobacco use. Vital signs today are T 98.6 P 80 R 16 BP 136/84 BMI 38.
Current medication list includes: Metformin 500 mg twice per day, Simvastatin 20mg at bedtime one
time/day, Hydrochlorothiazide 25mg every day, Fluoxetine 20 mg every morning
Labs from 6 months prior revealed: HgA1c 9.5%, LDL 140. Jane had to cancel her last scheduled visit.
What are the reoccurring preventive measures that should be completed within each year for diabetic chronic
disease management for Jane?
– BP check at every visit
– Weight at every visit (to calculate BMI)
– HgA1c at least every 6 months
– Lipid panel at least every 6 months (may also include liver function)
– Urine microalbumin at least every 12 months (may also include creatinine)
– Foot exam/monofilament exam at least every 12 months
– Ophthalmologic exam at least every 12 months
– Depression screening at least every 12 months
– Assess barriers to disease management and adherence
What are the current management goals (may not be evidence based) for at least four of the numerical categories
you listed in question 1.
Would you make any medication changes or additions due to the lab values listed above? What would those
changes be and why?
– Ace inhibitor (decrease BP and kidney protection)
– DM med (increase metformin or add another med to lower average BS)
– Statin (increase simvastatin to lower LDL below 100)
Evidence-Based Medicine
• Primary Articles
– Literature Search (PubMed)
– Critical Appraisal
• http://www.fmdrl.org/
• Search – Lausen
• The PCMH: Lessons Learned From A New Family Medicine
Clerkship Curriculum
• Select EBM Critical Appraisal of Lit.pdf
• Clinical Decision Support
– Point of Care Resources
– “Quick & Dirty”
EVIDENCE-BASED MEDICINE
CRITICAL APPRAISAL ASSIGNMENT
1. Develop a clinical question from a patient that you
encounter during your Family Medicine clerkship.
2. Conduct a systematic literature search using PubMed.
3. Choose three to five references that answer your search
question.
4. Identify a primary clinical article that answers your
clinical question (do not use a review article or a meta
analysis).
5. Critically appraise the article using the appropriate
questions (see EBM Critical Appraisal of Literature pdf
for appropriate questions).
6. Present a critical appraisal of the article that answers
your clinical question.
Clinical Decision Support
• Evidence-Based
• Point of Care
• Efficient
• Electronic Database (examples)
– National Guideline Clearinghouse
– Essential Evidence Plus
– DynaMed
National Guideline Clearinghouse
Guideline Synthesis - Instructions
• http://www.guideline.gov/compare/synthesis.aspx
• Goal:
• To gain experience with using evidence-based clinical
decision support through an electronic format during a
patient care visit.
• Instructions:
• The Guideline Synthesis worksheet is to be completed
during a patient visit (at the point of care).
• The worksheet will be reviewed and completed with your
preceptor.
Evidence-Based Medicine at the Point of Care
NGC Guideline Synthesis Worksheet
Student Name________________________________
Preceptor Name_______________________________
Date_________
Class of_______
Rotation #_____
Site________________________________________
Clinical Question___________________________________________________________________________
Search Terms:_______________________________________
Strength of Evidence:_____________________
Briefly describe the clinical scenario leading to the question:
Guideline used:____________________________________________________________________________
Decision/Intervention:________________________________________________________________________
Time required to find information and formulate decision:________ minutes
Total number of Guidelines reviewed prior to finding the Guideline used:________
Did you learn new clinical information by completing this exercise?
Did applying the information affect patient care?
Explain:
PRECEPTOR
Was an appropriate Guideline found for the clinical question?
Did the student’s findings affect patient care?
YES
YES
NO
NO
YES
YES
NO
NO
Comments:
Preceptor Signature_______________________________________
Date________________________
Essential Evidence Plus - Instructions
• Goal:
• To gain experience with using evidence-based clinical
decision support through an electronic format during a
patient care visit.
• Instructions:
• The Essential Evidence Plus worksheet is to be
completed during a patient visit (at the point of care).
• The worksheet will be reviewed and completed with your
preceptor.
Evidence-Based Medicine at the Point of Care
Essential Evidence Plus Worksheet
Student Name________________________________
Preceptor Name_______________________________
Date_________
Class of_______
Rotation #_____
Site________________________________________
Clinical Question___________________________________________________________________________
Search Terms:_______________________________________
Level of Evidence:_____________________
Briefly describe the clinical scenario leading to the question:
InfoPoem used:____________________________________________________________________________
Decision/Intervention:________________________________________________________________________
Time required to find information and formulate decision:________ minutes
Total number of InfoPoems reviewed prior to finding the InfoPoem used:________
Did you learn new clinical information by using this InfoPoem?
Did applying the InfoPoem affect patient care?
Explain:
PRECEPTOR
Was an appropriate InfoPoem found for the clinical question?
Did the student’s findings affect patient care?
YES
YES
NO
NO
YES
YES
NO
NO
Comments:
Preceptor Signature_______________________________________
Date________________________
Comments / Questions
Thank You!
Harald Lausen, DO
[email protected]
Descargar

Medical Home Pictorial and Messaging