Dr. Megan Mahoney is Chief of Staff of Stanford Health Care and Clinical Professor in the Department of Medicine at Stanford University. She relies on a close collaboration between health care administration, researchers, and medical education which is essential for ensuring a learning health system at Stanford. She served as Section Chief of General Primary Care from 2015-2020 and the Medical Director and Clinic Chief of Stanford Family Medicine, Stanford's academic family medicine practice at Hoover Pavilion 2014-2016. She has a passion for teams and technology in health care and leads team-based care redesign efforts and the precision health initiative called Humanwide (humanwide.stanford.edu). Her career has focused on developing innovative and transformational approaches to integrated, team-based care that empowers patients, health care providers, and communities in the U.S. and globally. Before joining Stanford, she was a faculty member at UCSF for 10 years where she served in several leadership capacities in clinic operations, medical education and research.
Dr. Mahoney endeavors to provide patient-centered and compassionate services that enable patients to reach their health and wellness goals. Her academic focus is to develop innovative and transformative approaches to proactive and personalized team-based primary care that empowers patients, health care providers, and communities in the U.S. and internationally.
- Family Medicine
- Primary Care
Clinical Professor, Medicine - Primary Care and Population Health
Chief of Staff, Stanford Health Care (2020 - Present)
Associate Physician Improvement Leader, Department of Medicine (2019 - Present)
Vice Chief of Staff, Stanford Health Care (2017 - 2020)
Chief, General Primary Care Section (2015 - 2020)
Honors & Awards
The Dr. Augustus A. White III and Family Faculty Professionalism Award, Stanford University School of Medicine Office of Faculty Development and Diversity (2019)
Fellow, California Healthcare Foundation Leadership Fellowship (2015-2017)
The Hellman Fellows Fund Recipient http://www.hellmanfellows.org/, University of California (2010)
Presidential Award of Distinction for Presentation, AASLD Annual Meeting, American Association for the Study of Liver Disease (2009)
"Outstanding Family Service Network HIV Provider" for the Family HIV Clinic, Family Service Network, Ryan White Care Act Part D (2007)
Boards, Advisory Committees, Professional Organizations
Board Member, Stanford Health Care Board of Directors (2020 - Present)
Board Member, University Healthcare Alliance Board of Directors (2018 - Present)
Member, HHS Office on Women's Health Trauma Working Group in Washington D.C. (2011 - 2015)
Member, Kenyan Ministry of Medical Services Family Medicine Coordinating Committee (2011 - 2014)
Member, California Department of Public Health STI and Viral Hepatitis Division Viral Hepatitis Task Force (2010 - 2012)
Reviewer, Human Resources and Services Administration HIV Clinical Review Textbook (2010 - 2011)
Member, California Department of Public Health Office of AIDS Rural Think Tank (2009 - 2010)
Member, California Department of Corrections Clinical Guidelines Committee (2007 - 2011)
Member, California Department of Corrections HIV and Hepatitis Advisory Committee (2007 - 2011)
Member, California Department of Corrections Hepatitis C Program Implementation Task Force (2007 - 2011)
Medical Education: UCSF Graduate Medical Education Office (2001) CA
Residency: UCSF School of Medicine SF General Hospital (2004) CA
Board Certification: American Board of Family Medicine, Family Medicine (2004)
Community and International Work
Family Medicine Global Exchange, Nairobi, San Francisco, Martinez, Palo Alto
Exchange of family medicine residents training opporutnities
Stanford, Aga Khan University, UCSF, Contra Costa County Hospital
Family Medicine Residents
Opportunities for Student Involvement
Integrated Primary Health Care Program, Kaloleni, Kenya
Global Health, Primary Health Care Systems Strengthening
Aga Khan University
Medical Students, Residents, Masters Students
Opportunities for Student Involvement
Current Research and Scholarly Interests
As Chief of General Primary Care, I led a team who is innovating primary care strategies that serve as a model for the US and abroad. Stanford Primary Care delivers innovative, high-quality, personalized and holistic care for patients and families throughout their lives. Our team is pioneering the shift from a health care system focused on medical care for individual patients toward an integrated health system focused on health and wellness of a population. Stanford Primary Care partners with multiple stakeholders across Stanford Health Care and Stanford University to achieve the quadruple aim. To optimize the health of our patient population, we build upon the biomedical and biopsychosocial models, augmented by recent advancements in big data and genomics, to better understand and address determinants of health throughout the life course. This emphasis on population health management promotes health and prevents disease in addition to managing and treating disease.
Stanford Primary Care, staffed entirely by internal medicine and family medicine faculty members in the division, include those with extensive research and medical education backgrounds. With 11 clinics across the Peninsula, high-performing primary care at Stanford relies on effective and efficient interprofessional care teams to meet abroad spectrum of needs presented by a diverse population of people --to the healthiest who need only preventive maintenance and wellness experts to those with multiple, complex chronic disorders that require painstaking attention to details that make it possible to maintain a normal life. Stanford Health Care’s primary care providers take time during office visits and between visits to fully understand our patients’ illness and partner with the patient on successful implementation of their self-management plan.
Stanford Primary Care is part of the larger primary care network at Stanford Health Care including the University Healthcare Alliance. With sweeping access to Stanford’s world-renowned specialists, Stanford Primary Care offers world-class, innovative patient and family care.
Related to this work, I am a Visiting Associate Professor at the Aga Khan University East Africa and a lead consultant for the Integrated Primary Health Care Program which is a public-private partnership between AKU, government and community. At IPHC, we develop and assess strategies that lead to a better integrated primary health care system in a rural region of Kenya. This setting provides educational and research experiences for medical students, residents and masters students from U.S. and AKU. Current research projects include an assessment of the health information system, enumeration of community, population based survey of district maternal child health indicators, population based research on common mental illnesses, and population based research on hypertension.
As the inaugural family medicine residency director at Aga Khan University in Nairobi, my main focus was generating well-trained family physicians who can provide high-quality and cost-effective ambulatory care in urban and rural resource-constrained settings. An important aspect of previous position was relationship building among different health sciences disciplines and different stakeholders, including Ministry of Health and community health committees. Recent curricular developments include community-based primary care and interprofessional, community-based education, in partnership with AKU School of Nursing and Kenya Ministry of Health Community Health Workers.
In addition, I assist in providing placements for family medicine and emergency medicine residents who are doing their elective at the Aga Khan University Hospital in Nairobi, and have mentored Global Health students during their field experience in Kenya.
Evaluation of Implementation of Precision Health Care in Primary Care “Humanwide”, Stanford University
Evaluation of the Implementation of Primary Care 2.0, Primary Care Practice Redesign at Stanford Health Care, Stanford Health Care
Hypertension Initiative, Stanford Health Care and University Health Care Alliance
Ambulatory Care Sensitive Conditions in Primary Care, Stanford Health Care
Pragmatic Design for Enhanced Team-based Primary Care, Intermountain-Stanford Collaboration Grant
Utah and California
Implementation outcomes of Humanwide: integrated precision health in team-based family practice primary care.
BMC family practice
2021; 22 (1): 28
BACKGROUND: Humanwide was precision health embedded in primary care aiming to leverage high-tech and high-touch medicine to promote wellness, predict and prevent illness, and tailor treatment to individual medical and psychosocial needs.METHODS: We conducted a study assessing implementation outcomes to inform spread and scale, using mixed methods of semi-structured interviews with diverse stakeholders and chart reviews. Humanwide included: 1) health coaching; 2) four digital health tools for blood-pressure, weight, glucose, and activity; 3) pharmacogenomic testing; and 4) genetic screening/testing. We examined implementation science constructs: reach/penetration, acceptability, feasibility, and sustainability. Chart reviews captured preliminary clinical outcomes.RESULTS: Fifty of 69 patients (72%) invited by primary care providers participated in the Humanwide pilot. We performed chart reviews for the 50 participating patients. Participants were diverse overall (50% non-white, 66% female). Over half of the participants were obese and 58% had one or more major cardiovascular risk factor: dyslipidemia, hypertension, diabetes. Reach/penetration of Humanwide components varied: pharmacogenomics testing 94%, health coaching 80%, genetic testing 72%, and digital health 64%. Interview participants (n=27) included patients (n=16), providers (n=9), and the 2 staff who were allocated dedicated time for Humanwide patient intake and orientation. Patients and providers reported Humanwide was acceptable; it engaged patients holistically, supported faster medication titration, and strengthened patient-provider relationships. All patients benefited clinically from at least one Humanwide component. Feasibility challenges included: low provider self-efficacy for interpreting genetics and pharmacogenomics; difficulties with data integration; patient technology challenges; and additional staffing needs. Patient financial burden concerns surfaced with respect to sustainability.CONCLUSION: This is the first report of implementation of a multi-component precision health model embedded in team-based primary care. We found acceptance from both patients and providers; however, feasibility barriers must be overcome to enable broad spread and sustainability. We found that barriers to implementation of precision health in a team-based primary care clinic are mundane and straightforward, though not necessarily easy to overcome. Future implementation endeavors should invest in basics: education, workflow, and reflection/evaluation. Strengthening fundamentals will enable healthcare systems to more nimbly accept the responsibility of meeting patients at the crossroads of innovative science and routinized clinical systems.
View details for DOI 10.1186/s12875-021-01373-4
View details for PubMedID 33530939
Building Bridges Between Community Health Centers and Academic Medical Centers in a COVID-19 Pandemic.
Journal of the American Board of Family Medicine : JABFM
2021; 34 (Supplement): S229–S232
The threat to the public health of the United States from the COVID-19 pandemic is causing rapid, unprecedented shifts in the health care landscape. Community health centers serve the patient populations most vulnerable to the disease yet often have inadequate resources to combat it. Academic medical centers do not always have the community connections needed for the most effective population health approaches. We describe how a bridge between a community health center partner (Roots Community Health Center) and a large academic medical center (Stanford Medicine) brought complementary strengths together to address the regional public health crisis. The 2 institutions began the crisis with an overlapping clinical and research faculty member (NKT). Building on that foundation, we worked in 3 areas. First, we partnered to reach underserved populations with the academic center's newly developed COVID test. Second, we developed and distributed evidence-based resources to these same communities via a large community health navigator team. Third, as telemedicine became the norm for medical consultation, the 2 institutions began to research how reducing the digital divide could help improve access to care. We continue to think about how best to create enduring partnerships forged through ongoing deeper relationships beyond the pandemic.
View details for DOI 10.3122/jabfm.2021.S1.200182
View details for PubMedID 33622844
Supporting First Responders and Essential Workers During a Pandemic: Needs Assessment and Mixed-Methods Implementation Evaluation of a COVID-19 App-Based Intervention.
Journal of medical Internet research
The COVID-19 pandemic has created unprecedented challenges for first responders (e.g., police, fire, and emergency medical services) and non-medical essential workers (e.g., food, transportation and other industries). Health systems may be uniquely suited to support these workers given their medical expertise, and mobile applications ("apps") can reach local communities despite social distancing requirements. Formal evaluation of real-world mobile app-based interventions are lacking.We aimed to evaluate the adoption, acceptability and appropriateness of an academic medical center's app-based intervention (COVID-19 Guide App) designed to support first responders and essential workers' access to COVID-19 information and testing services. We also sought to better understand the COVID-19 related needs of these workers early in the pandemic.To understand overall community adoption, COVID-19 Guide App views and download data were described. To understand adoption, appropriateness and acceptability of the app and workers' unmet needs, semi-structured qualitative interviews were conducted by phone, video and in-person with first responder and essential workers in the San Francisco Bay Area, recruited through purposive, convenience, and snowball sampling. Interview transcripts and field notes were qualitatively analyzed and presented using an implementation outcomes framework.From April 2020 launch to September 2020, the app received 8,262 views from unique devices and 6,640 downloads (80.4% conversion rate, 0.61% adoption rate across the Bay Area). App acceptability was mixed amongst 17 first responders interviewed and high amongst 10 essential workers interviewed. Select themes included the need for personalized and accurate information, access to testing, and securing personal safety. First responders faced additional challenges related to inter-professional coordination and a culture of heroism that could both protect against and exacerbate health vulnerability.First responders and essential workers both report challenges related to obtaining accurate information, testing services, and other resources. A mobile app intervention has the potential to combat these challenges through the provision of disease-specific information and access to testing services but may be most effective if delivered as part of a larger ecosystem of support. Differentiated interventions that acknowledge and address the divergent needs between first responders and non-first responder essential workers may optimize acceptance and adoption.
View details for DOI 10.2196/26573
View details for PubMedID 33878023
What constitutes "behavioral health"? Perceptions of substance-related problems and their treatment in primary care.
Addiction science & clinical practice
2020; 15 (1): 29
BACKGROUND: Integrating behavioral health in primary care is a widespread endeavor. Yet rampant variation exists in models and approaches. One significant question is whether frontline providers perceive that behavioral health includes substance use. The current study examined front line providers': 1. definition of behavioral health, and 2. levels of comfort treating patients who use alcohol and other drugs. Frontline providers at two primary care clinics were surveyed using a 28-item instrument designed to assess their comfort and knowledge of behavioral health, including substance use. Two questions from the Integrated Behavioral Health Staff Perceptions Survey pertaining to confidence in clinics' ability to care for patients' behavioral health needs and comfort dealing with patients with behavioral health needs were used for the purposes of this report. Participants also self-reported their clinic role. Responses to these two items were assessed and then compared across roles. Chi square estimates and analysis of variance tests were used to examine relationships between clinic roles and comfort of substance use care delivery.RESULTS: Physicians, nurses/nurse practitioners, medical assistants, and other staff (N=59) participated. Forty-nine participants included substance use in their definition of behavioral health. Participants reported the least comfort caring for patients who use substances (M=3.5, SD=1.0) compared to those with mental health concerns (M=4.1, SD=0.7), chronic medical conditions (M=4.2, SD=0.7), and general health concerns (M=4.2, SD=0.7) (p<0.001). Physicians (M=3.0, SD=0.7) reported significantly lower levels of comfort than medical assistants (M=4.2, SD=0.9) (p<0.001) caring for patients who use substances.CONCLUSIONS: In a small sample of key stakeholders from two primary care clinics who participated in this survey, most considered substance use part of the broad umbrella of behavioral health. Compared to other conditions, primary care providers reported being less comfortable addressing patients' substance use. Level of comfort varied by role, where physicians were least comfortable, and medical assistants most comfortable.
View details for DOI 10.1186/s13722-020-00202-w
View details for PubMedID 32727589
"MAKING A LIST AND CHECKING IT TWICE": A HIGH BLOOD PRESSURE ADVISORY IN PRIMARY CARE
SPRINGER. 2020: S702
View details for Web of Science ID 000567143602227
- COVID-19 Preoperative Assessment and Testing: From Surge to Recovery. Annals of surgery 2020
Implementation outcomes of humanwide: A pilot project of integrated precision health in team-based primary care
View details for Web of Science ID 000533323500064
INTEGRATED BEHAVIORAL HEALTH: PATIENT AND PROVIDER PERSPECTIVES FROM TWO PRIMARY CARE CLINICS
OXFORD UNIV PRESS INC. 2020: S599
View details for Web of Science ID 000546262401421
CFIR simplified: Pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system.
Learning health systems
2020; 4 (1): e10201
The Consolidated Framework for Implementation Research (CFIR) is a commonly used implementation science framework to facilitate design, evaluation, and implementation of evidence-based interventions. Its comprehensiveness is an asset for considering facilitators and barriers to implementation and also makes the framework cumbersome to use. We describe adaptations we made to CFIR to simplify its pragmatic application, for use in a learning health system context, in the evaluation of a complex patient-centered care transformation.We conducted a qualitative study and structured our evaluation questions, data collection methods, analysis, and reporting around CFIR. We collected qualitative data via semi-structured interviews and observations with key stakeholders throughout. We identified and documented adaptations to CFIR throughout the evaluation process.We analyzed semi-structured interviews with key stakeholders (n = 23) from clinical observations (n = 5). We made three key adaptations to CFIR: (a) promoted "patient needs and resources," a subconstruct of the outer setting, to its own domain within CFIR during data analysis; (b) divided the "inner setting" domain into three layers that account for the hierarchy of health care systems (i. pilot clinic, ii. peer clinics, and iii. overarching health care system); and (c) tailored several construct definitions to fit a patient-centered, primary care setting. Analysis yielded qualitative findings concentrated in the CFIR domains "intervention characteristics" and "outer setting," with a robust number of findings in the new domain "patient needs and resources."To make CFIR more accessible and relevant for wider use in the context of patient-centered care transformations within a learning health system, a few adaptations are key. Specifically, we found success by teasing apart interactions across the inner layers of a health system, tailoring construct definitions, and placing additional focus on patient needs.
View details for DOI 10.1002/lrh2.10201
View details for PubMedID 31989028
View details for PubMedCentralID PMC6971122
Qualitative Assessment of Rapid System Transformation to Primary Care Video Visits at an Academic Medical Center.
Annals of internal medicine
The coronavirus disease 2019 pandemic spurred health systems across the world to quickly shift from in-person visits to safer video visits.To seek stakeholder perspectives on video visits' acceptability and effect 3 weeks after near-total transition to video visits.Semistructured qualitative interviews.6 Stanford general primary care and express care clinics at 6 northern California sites, with 81 providers, 123 staff, and 97 614 patient visits in 2019.Fifty-three program participants (overlapping roles as medical providers [n = 20], medical assistants [n = 16], nurses [n = 4], technologists [n = 4], and administrators [n = 13]) were interviewed about video visit transition and challenges.In 3 weeks, express care and primary care video visits increased from less than 10% to greater than 80% and from less than 10% to greater than 75%, respectively. New video visit providers received video visit training and care quality feedback. New system workflows were created to accommodate the new visit method.Nine faculty, trained in qualitative research methods, conducted 53 stakeholder interviews in 4 days using purposeful (administrators and technologists) and convenience (medical assistant, nurses, and providers) sampling. A rapid qualitative analytic approach for thematic analysis was used.The analysis revealed 12 themes, including Pandemic as Catalyst; Joy in Medicine; Safety in Medicine; Slipping Through the Cracks; My Role, Redefined; and The New Normal. Themes were analyzed using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to identify critical issues for continued program utilization.Evaluation was done immediately after deployment. Although viewpoints may have evolved later, immediate evaluation allowed for prompt program changes and identified broader issues to address for program sustainability.After pandemic-related systems transformation at Stanford, critical issues to sustain video visit long-term viability were identified. Specifically, technology ease of use must improve and support multiparty videoconferencing. Providers should be able to care for their patients, regardless of geography. Providers need decision-making support with virtual examination training and home-based patient diagnostics. Finally, ongoing video visit reimbursement should be commensurate with value to the patients' health and well-being.Stanford Department of Medicine and Stanford Health Care.
View details for DOI 10.7326/M20-1814
View details for PubMedID 32628536
The Stanford Lightning Report Method: A comparison of rapid qualitative synthesis results across four implementation evaluations.
Learning health systems
2020; 4 (2): e10210
Current evaluation methods are mismatched with the speed of health care innovation and needs of health care delivery partners. We introduce a qualitative approach called the lightning report method and its specific product-the "Lightning Report." We compare implementation evaluation results across four projects to explore report sensitivity and the potential depth and breadth of lightning report method findings.The lightning report method was refined over 2.5 years across four projects: team-based primary care, cancer center transformation, precision health in primary care, and a national life-sustaining decisions initiative. The novelty of the lightning report method is the application of Plus/Delta/Insight debriefing to dynamic implementation evaluation. This analytic structure captures Plus ("what works"), Delta ("what needs to be changed"), and Insights (participant or evaluator insights, ideas, and recommendations). We used structured coding based on implementation science barriers and facilitators outlined in the Consolidated Framework for Implementation Research (CFIR) applied to 17 Lightning Reports from four projects.Health care partners reported that Lighting Reports were valuable, easy to understand, and they implied reports supported "corrective action" for implementations. Comparative analysis revealed cross-project emphasis on the domains of Inner Setting and Intervention Characteristics, with themes of communication, resources/staffing, feedback/reflection, alignment with simultaneous interventions and traditional care, and team cohesion. In three of the four assessed projects, the largest proportion of coding was to the clinic-level domain of Inner Setting-ranging from 39% for the cancer center project to a high of 56% for the life-sustaining decisions project.The lightning report method can fill a gap in rapid qualitative approaches and is generalizable with consistent but flexible core methods. Comparative analysis suggests it is a sensitive tool, capable of uncovering differences and insights in implementation across projects. The Lightning Report facilitates partnered evaluation and communication with stakeholders by providing real-time, actionable insights in dynamic health care implementations.
View details for DOI 10.1002/lrh2.10210
View details for PubMedID 32313836
View details for PubMedCentralID PMC7156867
- "Racial Bias…I'm Not Sure if It Has Affected My Practice": a Qualitative Exploration of Racial Bias in Team-Based Primary Care. Journal of general internal medicine 2020
- Ten Ways Artificial Intelligence Will Transform Primary Care JOURNAL OF GENERAL INTERNAL MEDICINE 2019; 34 (8): 1626–30
Role definition is key-Rapid qualitative ethnography findings from a team-based primary care transformation.
Learning health systems
2019; 3 (3): e10188
Purpose: Implementing team-based care into existing primary care is challenging; understanding facilitators and barriers to implementation is critical. We assessed adoption and acceptability of new roles in the first 6months of launching a team-based care model focused on preventive care, population health, and psychosocial support.Methods: We conducted qualitative rapid ethnography at a community-based test clinic, including 74hours of observations and 28 semi-structured interviews. We identified implementation themes related to team-based care and specifically the integration of three roles purposively designed to enhance coordination for better patient outcomes, including preventive screening and mental health: (1) medical assistants as care coordinators; (2) extended care team specialists, including clinical pharmacist and behavioral health professional; and (3) advanced practice providers (APPs)-ie, nurse practitioners and physician assistants.Results: All stakeholders (ie, patients, providers, and staff) reported positive perceptions of care coordinators and extended care specialists; these roles were well defined and quickly implemented. Care coordinators effectively managed care between visits and established strong patient relationships. Specialist colocation facilitated patient access and well-supported diabetes services and mental health care. We also observed unanticipated value: Care coordinators relayed encounter-relevant chart information to providers while scribing; extended care specialists supported informal continuing medical education. In contrast, we observed uncertain definition and expectations of the APP role across stakeholders; accordingly, adoption and acceptability of the role varied.Conclusions: Practice redesign can redistribute responsibility and patient connection throughout a team but should emphasize well-defined roles. Ethnography, conducted early in implementation with multistakeholder perspectives, can provide rapid and actionable insights about where roles may need refinement or redefinition to support ultimate physical and mental health outcomes for patients.
View details for DOI 10.1002/lrh2.10188
View details for PubMedID 31317071
- Primary Care 2.0: Design of a Transformational Team-Based Practice Model to Meet the Quadruple Aim AMERICAN JOURNAL OF MEDICAL QUALITY 2019; 34 (4): 339–47
Humanwide: A Comprehensive Data Base for Precision Health in Primary Care.
Annals of family medicine
2019; 17 (3): 273
View details for PubMedID 31085532
Breast Cancer knowledge, perceptions and practices in a rural Community in Coastal Kenya.
BMC public health
2019; 19 (1): 180
BACKGROUND: Data on breast healthcare knowledge, perceptions and practice among women in rural Kenya is limited. Furthermore, the role of the male head of household in influencing a woman's breast health seeking behavior is also not known. The aim of this study was to assess the knowledge, perceptions and practice of breast cancer among women, male heads of households, opinion leaders and healthcare providers within a rural community in Kenya. Our secondary objective was to explore the role of male heads of households in influencing a woman's breast health seeking behavior.METHODS: This was a mixed method cross-sectional study, conducted between Sept 1st 2015 Sept 30th 2016. We administered surveys to women and male heads of households. Outcomes of interest were analysed in Stata ver 13 and tabulated against gender. We conducted six focus group discussions (FGDs) and 22 key informant interviews (KIIs) with opinion leaders and health care providers, respectively. Elements of the Rapid Assessment Process (RAP) were used to guide analysis of the FGDs and the KIIs.RESULTS: A total of 442 women and 237 male heads of households participated in the survey. Although more than 80% of respondents had heard of breast cancer, fewer than 10% of women and male heads of households had knowledge of 2 or more of its risk factors. More than 85% of both men and women perceived breast cancer as a very serious illness. Over 90% of respondents would visit a health facility for a breast lump. Variable recognition of signs of breast cancer, limited decision- autonomy for women, a preference for traditional healers, lack of trust in the health care system, inadequate access to services, limited early-detection services were the six themes that emerged from the FGDs and the KIIs. There were discrepancies between the qualitative and quantitative data for the perceived role of the male head of household as a barrier to seeking breast health care.CONCLUSIONS: Determining level of breast cancer knowledge, the characteristics of breast health seeking behavior and the perceived barriers to accessing breast health are the first steps in establishing locally relevant intervention programs.
View details for DOI 10.1186/s12889-019-6464-3
View details for PubMedID 30755192
Ten Ways Artificial Intelligence Will Transform Primary Care.
Journal of general internal medicine
Artificial intelligence (AI) is poised as a transformational force in healthcare. This paper presents a current environmental scan, through the eyes of primary care physicians, of the top ten ways AI will impact primary care and its key stakeholders. We discuss ten distinct problem spaces and the most promising AI innovations in each, estimating potential market sizes and the Quadruple Aims that are most likely to be affected. Primary care is where the power, opportunity, and future of AI are most likely to be realized in the broadest and most ambitious scale. We propose how these AI-powered innovations must augment, not subvert, the patient-physician relationship for physicians and patients to accept them. AI implemented poorly risks pushing humanity to the margins; done wisely, AI can free up physicians' cognitive and emotional space for patients, and shift the focus away from transactional tasks to personalized care. The challenge will be for humans to have the wisdom and willingness to discern AI's optimal role in twenty-first century healthcare, and to determine when it strengthens and when it undermines human healing. Ongoing research will determine the impact of AI technologies in achieving better care, better health, lower costs, and improved well-being of the workforce.
View details for PubMedID 31090027
Effect of Electronic Clinical Decision Support on Imaging for the Evaluation of Acute Low Back Pain in the Ambulatory Care Setting.
To assess the effectiveness of a clinical decision support tool consisting of an electronic medical record Best Practice Alert (BPA) on the frequency of lumbar imaging in patients with acute low back pain (LBP) in the ambulatory care setting. To understand why providers order imaging outside of clinical guidelines.We implemented a BPA pop-up alert on 3/23/16 that informed the ordering physician of the Choosing Wisely recommendation to not order imaging within the first 6 weeks of low back pain in the absence of red flags. We measured imaging rates 1 year before and after implementation of the BPA. To override the BPA, providers could ignore the alert or explain their rationale for ordering imaging using either pre-set options or free-text submission. We tracked pre-set options and manually reviewed 125 free-text submissions.Significant decreases in both total imaging rate (9.6% decrease, p = 0.02) and MRI rate (14.9% decrease, p < 0.01) were observed after implementation of the BPA. No change was found in the rates of x-ray or CT ordering. 64% of providers used pre-set options in overriding the BPA, while 36% of providers entered a free-text submission. Among those providers using a free-text submission, 56% entered a non-guideline supported rationale.The present study demonstrates the effectiveness of a simple, low-cost clinical decision support tool in reducing imaging rates for patients with acute low back pain. We additionally identify reasons providers order imaging outside of clinical guidelines.
View details for DOI 10.1016/j.wneu.2019.11.031
View details for PubMedID 31733384
Perceptions regarding the scope of practice o family doctors amongst patients in primary care settings in Nairobi
AFRICAN JOURNAL OF PRIMARY HEALTH CARE & FAMILY MEDICINE
2018; 10 (1): e1–e7
Primary care (PC) is the foundation of the Kenyan health care system, providing comprehensive care, health promotion and managing all illnesses across the lifecycle. In the private sector in Nairobi, PC is principally offered by the general practitioners, also known as family doctors (FDs). The majority have no postgraduate training. Little is known about how patients perceive their capability. To assess patients' perceptions of the scope of practice of FDs working in private sector PC clinics in Nairobi and their awareness of the new category of family physicians (FPs) and the discipline of family medicine. Private sector PC clinics in Nairobi. A descriptive survey using a structured, self-administered questionnaire. Simple random sampling was used to recruit 162 patient participants. Of the participants, 30% knew the difference between FPs and FDs. There was a high to moderate confidence that FDs could treat common illnesses; provide lifestyle advice; family planning (66%) and childhood immunisations (64%). In adolescents and adults, low confidence was expressed in their ability to manage tuberculosis (58%), human immunodeficiency virus (55%) and cancer (33%). In the elderly, there was low confidence in their ability to manage depression (55%), anxiety (57%), urinary incontinence (57%) and diabetes (59%). There was low confidence in their ability to provide antenatal care (55%) and Pap smears (42%). Patients did not perceive that FDs could offer fully comprehensive PC services. These perceptions may be addressed by defining the expected package of care, designing a system that encourages the utilisation of PC and employing FPs.
View details for DOI 10.4102/phcfm.v10i1.1818
View details for Web of Science ID 000448326700001
View details for PubMedID 30326721
View details for PubMedCentralID PMC6191765
- A comparative study of artificial intelligence and human doctors for the purpose of triage and diagnosis arXiv 2018
- Transforming Medical Assistant to Care Coordinator to Achieve the Quadruple Aim. Society of General Internal Medicine Forum 2018 ; V4 (4)
- Community-Oriented Primary Care Curricula in Kenyan Family Medicine Residencies. African Journal of Primary Health Care and Family Medicine 2017
An Academic Achievement Calculator for Clinician-Educators in Primary Care.
2017; 49 (8): 640–43
Academic medical centers need better ways to quantify the diverse academic contributions of primary care clinician-educators. We examined the feasibility and acceptability of an "academic achievement calculator" that quantifies academic activities using a point system.A cohort of 16 clinician-educators at a single academic medical center volunteered to assess the calculator using a questionnaire. Key measures included time needed to complete the calculator, how well it reflected participants' academic activities, whether it increased their awareness of academic opportunities, whether they intend to pursue more academic work, and their overall satisfaction with the calculator.Most participants (69%) completed the calculator in less than 20 minutes. Three-quarters (75%) reported that the calculator reflected the breadth of their academic work either "very well" or "extremely well". The majority (81%) stated that it increased their awareness of opportunities for academic engagement, and that they intend to pursue more academic activities. Overall, three-quarters (75%) were "very satisfied" or "extremely satisfied" with the calculator.To our knowledge, this is the first report of a tool designed to quantify the diverse academic activities of primary care clinician-educators. In this pilot study, we found that the use of an academic achievement calculator may be feasible and acceptable. This tool, if paired with an annual bonus plan, could help incentivize and reward academic contributions among primary care clinician-educators, and assist department leaders with the promotion process.
View details for PubMedID 28953298
Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial.
Annals of family medicine
2017; 15 (5): 427–33
Scribes are increasingly being used in clinical practice despite a lack of high-quality evidence regarding their effects. Our objective was to evaluate the effect of medical scribes on physician satisfaction, patient satisfaction, and charting efficiency.We conducted a randomized controlled trial in which physicians in an academic family medicine clinic were randomized to 1 week with a scribe then 1 week without a scribe for the course of 1 year. Scribes drafted all relevant documentation, which was reviewed by the physician before attestation and signing. In encounters without a scribe, the physician performed all charting duties. Our outcomes were physician satisfaction, measured by a 5-item instrument that included physicians' perceptions of chart quality and chart accuracy; patient satisfaction, measured by a 6-item instrument; and charting efficiency, measured by time to chart close.Scribes improved all aspects of physician satisfaction, including overall satisfaction with clinic (OR = 10.75), having enough face time with patients (OR = 3.71), time spent charting (OR = 86.09), chart quality (OR = 7.25), and chart accuracy (OR = 4.61) (all P values <.001). Scribes had no effect on patient satisfaction. Scribes increased the proportion of charts that were closed within 48 hours (OR =1.18, P =.028).To our knowledge, we have conducted the first randomized controlled trial of scribes. We found that scribes produced significant improvements in overall physician satisfaction, satisfaction with chart quality and accuracy, and charting efficiency without detracting from patient satisfaction. Scribes appear to be a promising strategy to improve health care efficiency and reduce physician burnout.
View details for PubMedID 28893812
Utilization of health services in a resource-limited rural area in Kenya: Prevalence and associated household-level factors.
2017; 12 (2)
Knowledge of utilization of health services and associated factors is important in planning and delivery of interventions to improve health services coverage. We determined the prevalence and factors associated with health services utilization in a rural area of Kenya. Our findings inform the local health management in development of appropriately targeted interventions. We used a cluster sample survey design and interviewed household key informants on history of illness for household members and health services utilization in the preceding month. We estimated prevalence and performed random effects logistic regression to determine the influence of individual and household level factors on decisions to utilize health services.1230/6,440 (19.1%, 95% CI: 18.3%-20.2%) household members reported an illness. Of these, 76.7% (95% CI: 74.2%-79.0%) sought healthcare in a health facility. The majority (94%) of the respondents visited dispensary-level facilities and only 60.1% attended facilities within the study sub-counties. Of those that did not seek health services, 43% self-medicated by buying non-prescription drugs, 20% thought health services were too costly, and 10% indicated that the sickness was not serious enough to necessitate visiting a health facility. In the multivariate analyses, relationship to head of household was associated with utilization of health services. Relatives other than the nuclear family of the head of household were five times less likely to seek medical help (Odds Ratio 0.21 (95% CI: 0.05-0.87)). Dispensary level health facilities are the most commonly used by members of this community, and relations at the level of the household influence utilization of health services during an illness. These data enrich the perspective of the local health management to better plan the allocation of healthcare resources according to need and demand. The findings will also contribute in the development of community-level health coverage interventions that target the disadvantaged household groups.
View details for DOI 10.1371/journal.pone.0172728
View details for PubMedID 28241032
View details for PubMedCentralID PMC5328402
- Preparing Family Physicians to Care for Underserved Populations: A Historical Perspective Family Medicine 2017
- An academic achievement calculator for clinician-educators in primary care Family Medicine 2017
An assessment of implementation of CommunityOriented Primary Care in Kenyan family medicine postgraduate medical education programmes.
African journal of primary health care & family medicine
2016; 8 (1): e1-e4
Family medicine postgraduate programmes in Kenya are examining the benefits of Community-Oriented Primary Care (COPC) curriculum, as a method to train residents in population-based approaches to health care delivery. Whilst COPC is an established part of family medicine training in the United States, little is known about its application in Kenya. We sought to conduct a qualitative study to explore the development and implementation of COPC curriculum in the first two family medicine postgraduate programmes in Kenya.Semi-structured interviews of COPC educators, practitioners, and academic stakeholders and focus groups of postgraduate students were conducted with COPC educators, practitioners and academic stakeholders in two family medicine postgraduate programmes in Kenya. Discussions were transcribed, inductively coded and thematically analysed.Two focus groups with eight family medicine postgraduate students and interviews with five faculty members at two universities were conducted. Two broad themes emerged from the analysis: expected learning outcomes and important community-based enablers. Three learning outcomes were (1) making a community diagnosis, (2) understanding social determinants of health and (3) training in participatory research. Three community-based enablers for sustainability of COPC were (1) partnerships with community health workers, (2) community empowerment and engagement and (3) institutional financial support.Our findings illustrate the expected learning outcomes and important communitybased enablers associated with the successful implementation of COPC projects in Kenya and will help to inform future curriculum development in Kenya.
View details for DOI 10.4102/phcfm.v8i1.1064
View details for PubMedID 28155322
View details for PubMedCentralID PMC5153406
"I have it just like you do": voices of HIV-negative partners in serodifferent relationships receiving primary care at a public clinic in San Francisco.
2015; 27 (3): 401-408
HIV transmission among serodifferent couples has a significant impact on incidence of HIV worldwide. Antiretroviral interventions (i.e., preexposure prophylaxis, post-exposure prophylaxis, and treatment as prevention) are important aspects of comprehensive prevention and care for serodifferent couples. In this study, HIV-negative members of serodifferent couples were interviewed using open-ended questions to explore their health-care needs, perceptions of clinic-based prevention services, and experience of having an HIV-infected partner. Analysis of interviews with 10 HIV-negative partners revealed the following themes: (1) health needs during joint medical visits; (2) sexual risk reduction strategies; (3) relationship dynamics; and (4) strategies for coping. This study elucidated relationship, health and health care factors that might affect development and implementation of clinic-based prevention interventions for HIV serodifferent couples. The findings point to possible relationship-centered recommendations for health-care providers who serve HIV-affected couples in clinical settings.
View details for DOI 10.1080/09540121.2014.964659
View details for PubMedID 25311152
- Global-Local Framework on Medical Vulnerabilities Medical Management of Underserved and Vulnerable Populations 2015
- AIDS Family Medicine McGraw-Hill. 2014; 6
- Reversely Innovative Journal for the San Francisco Medical Association 2014
Formal hepatitis C education enhances HCV care coordination, expedites HCV treatment and improves antiviral response
2013; 33 (7): 999-1007
Formal Hepatitis C virus (HCV) education improves HCV knowledge but the impact on treatment uptake and outcome is not well described. We aimed to evaluate the impact of formal HCV patient education on primary provider-specialist HCV comanagement and treatment.Primary care providers within the San Francisco safety-net health care system were surveyed and the records of HCV-infected patients before and after institution of a formal HCV education class by liver specialty (2006-2011) were reviewed retrospectively.Characteristics of 118 patients who received anti-HCV therapy were: mean age 51, 73% males and ~50% White and uninsured. The time to initiation of HCV treatment was shorter among those who received formal education (median 136 vs 284 days, P < 0.0001). When controlling for age, gender, race and HCV viral load, non-1 genotype (OR 6.17, 95% CI 2.3-12.7, P = 0.0003) and receipt of HCV education (OR 3.0, 95% CI 1.1-7.9, P = 0.03) were associated with sustained virologic treatment response. Among 94 provider respondents (response rate = 38%), mean age was 42, 62% were White, and 63% female. Most providers agreed that the HCV education class increased patients' HCV knowledge (70%), interest in HCV treatment (52%), and provider-patient communication (56%). A positive provider attitude (Coef 1.5, 95% CI 0.1-2.9 percent, P = 0.039) was independently associated with referral rate to education class.Formal HCV education expedites HCV therapy and improves virologic response rates. As primary care provider attitude plays a significant role in referral to HCV education class, improving provider knowledge will likely enhance access to HCV specialty services in the vulnerable population.
View details for DOI 10.1111/liv.12150
View details for Web of Science ID 000321344000005
View details for PubMedID 23509897
ADAPTATION OF AN EVIDENCE-BASED HIV PREVENTION INTERVENTION FOR WOMEN WITH INCARCERATED PARTNERS: EXPANDING TO COMMUNITY SETTINGS
AIDS EDUCATION AND PREVENTION
2013; 25 (1): 1-13
High rates of incarceration in urban, low income communities may exacerbate women's risk of HIV infection by decreasing the number of available male sexual partners and disrupting long-term partnerships. The Health Access Program for Prevention, Empowerment, and Networking for Women (HAPPEN) was established to address the HIV prevention needs of women partnered with incarcerated or recently released men in community settings. HAPPEN is an adaptation of the evidence-based HIV prevention intervention Health Options Mean Empowerment (HOME) project. HOME was designed specifically for women visiting their incarcerated male partners and was delivered at a prison visiting center. Recruitment and program implementation for HAPPEN occurred at community-based organizations serving women with histories of substance abuse, intimate partner violence and incarceration, and provided health education, HIV testing, and linkage to health care and social services. This paper describes the process of adapting HOME using input from target organization stakeholders and target population members.
View details for Web of Science ID 000315129800001
View details for PubMedID 23387947
Applying HIV Testing Guidelines in Clinical Practice
AMERICAN FAMILY PHYSICIAN
2009; 80 (12): 1441-1444
An estimated one fourth of persons with human immunodeficiency virus (HIV) are not aware they are infected. Early diagnosis of HIV has the potential to ensure optimal outcomes for infected persons and to limit the spread of the virus. Important barriers to testing among physicians include insufficient time, reimbursement issues, and lack of patient acceptance. Current HIV testing guidelines address many of these barriers by making the testing process more streamlined and less stigmatizing. The opt-out consent process has been shown to improve test acceptance. Formal pretest counseling and written consent are no longer recommended by the Centers for Disease Control and Prevention. Nevertheless, pretest discussions provide an opportunity to give information about HIV, address fears of discrimination, and identify ongoing high-risk activities. With increased HIV screening in the primary care setting, more persons with HIV could be identified earlier, receive timely and appropriate care, and get treatment to prevent clinical progression and transmission.
View details for Web of Science ID 000273015000012
View details for PubMedID 20000306
Clinicians' knowledge of 2007 Food and Drug Administration recommendation to discontinue nelfinavir use during pregnancy.
Journal of the International Association of Physicians in AIDS Care (Chicago, Ill. : 2002)
2009; 8 (4): 249-252
In 2007, the US Food and Drug Administration (FDA) and Pfizer Inc recommended immediate discontinuation of nelfinavir (NFV) during pregnancy due to contamination with a potential teratogen. A few weeks after the announcement, we surveyed antenatal HIV care providers to determine how widely the warning was disseminated. Overall, 69 of 121 (57.0%) providers knew to discontinue NFV. Callers with more than 50 HIV-infected patients were 2.54 times as likely to be aware as callers with 1-3 HIV-infected patients (P < .01). Only 12 (33.3%) obstetricians were aware, compared to 21 (80.8%) infectious diseases specialists (P < .001). The FDA/Pfizer Inc recommendation to avoid nelfinavir mesylate (NFV) in pregnancy appears to have successfully reached HIV experts. However, not all pregnant women have access to experts and may receive most of their care from providers without extensive HIV experience. More effective dissemination of critical HIV-related information to all antenatal care providers, including general obstetricians, family physicians, and midwives, may be needed.
View details for DOI 10.1177/1545109709337034
View details for PubMedID 19506052
- . In Reply to HIV Testing: Removing Barriers Can Lead to Earlier Detection and Reduced Transmission American Family Physician 2009
Minority Faculty Voices on Diversity in Academic Medicine: Perspectives From One School
2008; 83 (8): 781-786
To examine the perceptions and experiences of ethnic minority faculty at University of California-San Francisco regarding racial and ethnic diversity in academic medicine, in light of a constitutional measure outlawing race- and gender-based affirmative action programs by public universities in California.In 2005, underrepresented minority faculty in the School of Medicine at University of California-San Francisco were individually interviewed to explore three topics: participants' experiences as minorities, perspectives on diversity and discrimination in academic medicine, and recommendations for improvement. Interviews were tape-recorded, transcribed verbatim, and subsequently coded using principles of qualitative, text-based analysis in a four-stage review process.Thirty-six minority faculty (15 assistant professors, 11 associate professors, and 10 full professors) participated, representing diversity across specialties, faculty rank, gender, and race/ethnicity. Seventeen were African American, 16 were Latino, and 3 were Asian. Twenty participants were women. Investigators identified four major themes: (1) choosing to participate in diversity-related activities, driven by personal commitment and institutional pressure, (2) the gap between intention and implementation of institutional efforts to increase diversity, (3) detecting and reacting to discrimination, and (4) a need for a multifaceted approach to mentorship, given few available minority mentors.Minority faculty are an excellent resource for identifying strategies to improve diversity in academic medicine. Participants emphasized the strong association between effective mentorship and career satisfaction, and many delineated unique mentoring needs of minority faculty that persist throughout academic ranks. Findings have direct application to future institutional policies in recruitment and retention of underrepresented minority faculty.
View details for Web of Science ID 000267654300013
View details for PubMedID 18667896
Care of HIV-infected Latinos in the United States: A description of calls to the National HIV/AIDS Clinicians' Consultation Center
20th Annual Conference of the Association-of-Nurses-in-AIDS-Care
ELSEVIER SCIENCE INC. 2008: 302–10
HIV disproportionately affects the Latino population in the United States. Little is known about clinicians who provide HIV care to the Latino community or the types of issues they face. This report presents descriptive analyses of calls made by clinicians who care for HIV-infected Latinos to two lines of the National HIV/AIDS Clinicians' Consultation Center, the National HIV Telephone Consultation Service (Warmline) and the National Perinatal HIV Consultation and Referral Service (Perinatal HIV Hotline). Separate analyses of data from Latino clinicians are also presented. The majority of Warmline calls about Latino patients (81.0%) concerned antiretroviral treatment strategies or HIV-related conditions. More than half (54.3%) of perinatal-specific calls concerned HIV management during pregnancy and the care of HIV-exposed infants. Latino clinicians most frequently called about minority patients. This descriptive study adds to the growing literature about the care of the Latino HIV-infected patient. The Warmline and Perinatal HIV Hotline are resources for HIV care providers in the nursing and medical care of Latinos.
View details for DOI 10.1016/j.jana.2008.05.002
View details for Web of Science ID 000257758100007
View details for PubMedID 18598905
African-American clinicians providing HIV care: The experience of the national HIV/AIDS clinicians' consultation center
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
2008; 100 (7): 779-782
This analysis compares patient and provider characteristics of African-American clinicians and non-African-American clinicians who called the National HIV Telephone Consultation Service (Warmline). In 2004, a total of 2,077 consultations were provided for 1,020 clinicians, 70 (6.9%) of whom were African American. Compared to the non-African-American group, a higher percentage of African-American clinicians were nurses (20.0% vs. 8.8%, p=0.002). A significantly lower percentage of African-American physicians were infectious disease specialists (3.5% vs. 25.6%, p=0.007). African-American clinicians were more likely to work in a community clinic (48.5% vs. 34.1%, p=0.015). Both African-American and non-African American clinicians reported caring for a similar number of HIV-infected patients. Patient-provider racial concordance was common among African-American clinicians (76.4%), whereas non-African-American clinicians called about patients of more diverse racial and ethnic backgrounds. African-American clinicians who called Warmline exhibited differences in patient and provider characteristics when compared to all other clinicians. These findings contribute to the growing body of research on HIV providers in the United States.
View details for Web of Science ID 000257844700001
View details for PubMedID 18672554
- Chronic Care Program: Hepatitis C California Department of Corrections and Rehabilitation. Inmate Medical Services Policies and Procedures edited by Mahoney, M. 2008
Consultation needs in perinatal HIV care: experience of the National Perinatal HIV consultation service
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2007; 197 (3): S137-S141
This study evaluates the consultation needs of clinicians who provide perinatal human immunodeficiency virus (HIV) care in the United States. The Perinatal Hotline (1-888-448-8765) is a telephone consultation service for providers who treat HIV-infected pregnant women and their infants. Hotline calls were analyzed for demographics about callers and their patients and information about consultation topics. There were 430 calls to the hotline from January 1, 2005, through June 30, 2006. Most calls (59.5%) were related to pregnant patients; 5.1% of the calls pertained to women currently in labor. The most common topic was HIV care in pregnancy (49.1%), particularly antiretroviral drug use (42.1%). HIV testing was discussed in 21.9%, and intrapartum treatment was discussed in 24.0%. Callers most often requested help choosing antiretroviral drug regimens; many of the discussions were about drug toxicities and viral resistance. Although the hotline received few calls about women in labor, the need for these consultations is expected to increase with the expanding use of rapid HIV testing. Access to 24-hour consultation can help ensure that state-of-the-art care is provided.
View details for DOI 10.1016/j.ajog.2007.02.033
View details for Web of Science ID 000249582700019
View details for PubMedID 17825645
- AIDS Family Medicine 5th Edition 2007
- Syphilis Taylor's 10-minute diagnosis manual: symptoms and signs in the time-limited encounter 2007
- The changing role of family physicians in HIV care AMERICAN FAMILY PHYSICIAN 2006; 74 (10): 1683-1684
- HIV Infection: Clues to Timely Diagnosis. Consultant 2006; 46 (8): 853-860
- Beyond Antiretrovirals Synapse 2000