Stacie Vilendrer

All Publications

• Patient and caregiver perspectives of fluid discharge protocols following pituitary surgery. Journal of clinical & translational endocrinology Chang, J. J., Amano, A., Brown-Johnson, C., Chu, O., Gates-Bazarbay, V., Wipff, E., Kling, S. M., Alhadha, M., Carlos Fernandez-Miranda, J., Vilendrer, S. 2024; 35: 100336

  Abstract

  Post-operative fluid restriction after transsphenoidal surgery (TSS) for pituitary tumors may effectively prevent delayed hyponatremia, the most common cause of readmission. However, implementation of individualized fluid restriction interventions after discharge is often complex and poses challenges for provider and patient. The purpose of this study was to understand the factors necessary for successful implementation of fluid restriction and discharge care protocols following TSS.Semi-structured interviews with fifteen patients and four caregivers on fluid discharge protocols were conducted following TSS. Patients and caregivers who had surgery before and after the implementation of updated discharge protocols were interviewed. Data were analyzed inductively using a procedure informed by rapid and thematic analysis.Most patients and caregivers perceived fluid restriction protocols as acceptable and feasible when indicated. Facilitators to the protocols included clear communication about the purpose of and strategies for fluid restriction, access to the care team, and involvement of patients' caregivers in care discussions. Barriers included patient confusion about differences in the care plan between teams, physical discomfort of fluid restriction, increased burden of tracking fluids during recovery, and lack of clarity surrounding desmopressin prescriptions.Outpatient fluid restriction protocols are a feasible intervention following pituitary surgery but requires frequent patient communication and education. This evaluation highlights the importance of patient engagement and feedback to effectively develop and implement complex clinical interventions.

  View details for DOI 10.1016/j.jcte.2024.100336

  View details for PubMedID 38545460

  View details for PubMedCentralID PMC10965805

• Screening for Social Determinants of Health During Primary Care and Emergency Department Encounters. JAMA network open Vilendrer, S., Thomas, S. C., Belnap, T., Burnisholz, K., Song, N., Srivastava, R., Singer, S. 2023; 6 (12): e2348646

  View details for DOI 10.1001/jamanetworkopen.2023.48646

  View details for PubMedID 38113046

  View details for PubMedCentralID PMC10731480

• An initiative to promote value-based stress test selection in primary care and cardiology clinics: A mixed methods evaluation. Journal of evaluation in clinical practice Kling, S. M., Kalwani, N. M., Winget, M., Gupta, K., Saliba-Gustafsson, E. A., Baratta, J., Garvert, D. W., Veruttipong, D., Brown-Johnson, C. G., Vilendrer, S., Gaspar, C., Levin, E., Tsai, S. 2023

  Abstract

  Exercise stress echocardiograms (stress echos) are overused, whereas exercise stress electrocardiograms (stress ECGs) can be an appropriate, lower-cost substitute. In this post hoc, mixed methods evaluation, we assessed an initiative promoting value-based, guideline-concordant ordering practices in primary care (PC) and cardiology clinics.Change in percent of stress ECGs ordered of all exercise stress tests (stress ECGs and echos) was calculated between three periods: baseline (January 2019-February 2020); Period 1 with reduced stress ECG report turnaround time + PC-targeted education (began June 2020); and Period 2 with the addition of electronic health record-based alternative alert (AA) providing point-of-care clinical decision support. The AA was deployed in two of five PC clinics in July 2020, two additional PC clinics in January 2021, and one of four cardiology clinics in February 2021. Nineteen primary care providers (PCPs) and five cardiologists were interviewed in Period 2.Clinicians reported reducing ECG report turnaround time was crucial for adoption. PCPs specifically reported that value-based education helped change their practice. In PC, the percent of stress ECGs ordered increased by 38% ± 6% (SE) (p < 0.0001) from baseline to Period 1. Most PCPs identified the AA as the most impactful initiative, yet stress ECG ordering did not change (6% ± 6%; p = 0.34) between Periods 1 and 2. In contrast, cardiologists reportedly relied on their expertise rather than AAs, yet their stress ECGs orders increased from Period 1 to 2 to a larger degree in the cardiology clinic with the AA (12% ± 5%; p = 0.01) than clinics without the AA (6% ± 2%; p = 0.01). The percent of stress ECGs ordered was higher in Period 2 than baseline for both specialties (both p < 0.0001).This initiative influenced ordering behaviour in PC and cardiology clinics. However, clinicians' perceptions of the initiative varied between specialties and did not always align with the observed behaviour change.

  View details for DOI 10.1111/jep.13896

  View details for PubMedID 37459156

• From Acceptable to Superlative: Scaling a Technologist Coaching Intervention to Improve Image Quality. Journal of the American College of Radiology : JACR Hwang, G. L., Vilendrer, S., Amano, A., Brown-Johnson, C., Kling, S. M., Faust, A., Willis, M. H., Larson, D. B. 2023; 20 (6): 570-584

  Abstract

  To explore factors influencing the expansion of the peer-based technologist Coaching Model Program (CMP) from its origins in mammography and ultrasound to all imaging modalities at a single tertiary academic medical center.After success in mammography and ultrasound, efforts to expand the CMP across all Stanford Radiology modalities commenced in September 2020. From February to April 2021 as lead coaches piloted the program in these novel modalities, an implementation science team designed and conducted semistructured stakeholder interviews and took observational notes at learning collaborative meetings. Data were analyzed using inductive-deductive approaches informed by two implementation science frameworks.Twenty-seven interviews were collected across modalities with radiologists (n = 5), managers (n = 6), coaches (n = 11), and technologists (n = 5) and analyzed with observational notes from six learning meetings with 25 to 40 recurrent participants. The number of technologists, the complexity of examinations, or the existence of standardized auditing criteria for each modality influenced CMP adaptations. Facilitators underlying program expansion included cross-modality learning collaborative, thoughtful pairing of coach and technologist, flexibility in feedback frequency and format, radiologist engagement, and staged rollout. Barriers included lack of protected coaching time, lack of pre-existing audit criteria for some modalities, and the need for privacy of auditing and feedback data.Adaptations to each radiology modality and communication of these learnings were key to disseminating the existing CMP to new modalities across the entire department. An intermodality learning collaborative can facilitate the dissemination of evidence-based practices across modalities.

  View details for DOI 10.1016/j.jacr.2022.10.007

  View details for PubMedID 37302811

• Evaluating the Implementation of Patient-Reported Outcomes in Heart Failure Clinic: A Qualitative Assessment. Circulation. Cardiovascular quality and outcomes Brown-Johnson, C., Calma, J., Amano, A., Winget, M., Harris, S. R., Vilendrer, S., Asch, S. M., Heidenreich, P., Sandhu, A. T., Kalwani, N. M. 2023: e009677

  Abstract

  Patient-reported outcomes (PROs) may improve care for patients with heart failure. The Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) is a patient survey that captures symptom frequency, symptom burden, physical limitations, social limitations, and quality of life. Despite the utility of PROs and the KCCQ-12, the implementation and routine use of these measures can be difficult. We conducted an evaluation of clinician perceptions of the KCCQ-12 to identify barriers and facilitators to implementation into clinical practice.We conducted interviews with cardiologists from 4 institutions across the United States and Canada (n=16) and observed clinic visits at 1 institution in Northern California (n=5). Qualitative analysis was conducted in 2 rounds: (1) rapid analysis constructed around major themes related to the aims of the study and (2) content analysis with codes derived from the rapid analysis and implementation science.Most heart failure physicians and advanced practice clinicians reported that the KCCQ-12 was acceptable, appropriate, and useful in clinical care. Clinician engagement efforts, trialability, and the straightforward design of the KCCQ-12 facilitated its use in clinical care. Further opportunities identified to facilitate implementation include more streamlined integration into the electronic health record and comprehensive staff education on PROs. Participants highlighted that the KCCQ-12 was useful in clinic visits to improve the consistency of patient history taking, focus patient-clinician conversations, collect a more accurate account of patient quality of life, track trends in patient well-being over time, and refine clinical decision-making.In this qualitative study, clinicians reported that the KCCQ-12 enhanced several aspects of heart failure patient care. Use of the KCCQ-12 was facilitated by a robust clinician engagement campaign and the design of the KCCQ-12 itself. Future implementation of PROs in heart failure clinic should focus on streamlining electronic health record integration and providing additional staff education on the value of PROs.URL: https://clinicaltrials.gov; Unique identifier: NCT04164004.

  View details for DOI 10.1161/CIRCOUTCOMES.122.009677

  View details for PubMedID 37114990

• Physician Perceptions of Performance Feedback and Impact on Personal Well-Being: A Qualitative Exploration of Patient Satisfaction Feedback in Neurology. Joint Commission journal on quality and patient safety Vilendrer, S., Levoy, E., Miller-Kuhlmann, R., Amano, A., Brown-Johnson, C., De Borba, L., Luu, J. H., Sakamuri, S., Gold, C. A. 2022

  Abstract

  BACKGROUND: To understand neurologists' experiences and perspectives on patient satisfaction feedback and its impact on personal well-being and behavior.METHODS: From May to June 2021, the researchers conducted 19 semistructured interviews with neurologists from a large academic medical center. Clinical Performance Feedback Intervention Theory informed a combined inductive and deductive thematic analysis of the qualitative data, which focused on perceptions of current feedback practices, its impact on physician behavior, and recommendations for improvement.RESULTS: Participants tended to be female (n = 12/19, 63.2%), aged 30-39 (n = 8/19, 42.1%), white (n = 9/19, 47.4%), and were 10+ years into clinical practice (n = 18/19, 94.7%). Physicians were receptive to feedback overall, but perceptions varied by feedback type. Physicians preferred informal feedback (delivered unprompted directly by patients), given its tendency toward actionability. They disliked formal feedback (derived from anonymous surveys) due to low actionability, bias and validity issues, lack of contextual considerations, delivery through public reports, and links to financial incentives. Nearly all physicians reported formal feedback programs had the potential to negatively affect well-being and were not beneficial to their practice; a few reported adjusting their clinical practice to improve patient satisfaction performance. Five recommendations to improve patient satisfaction feedback programs emerged: Align on feedback intent, acknowledge survey limitations during program administration, increase actionability of feedback through specificity and control, support direct patient-physician feedback and problem resolution, and support empathetic integration of feedback.CONCLUSION: Understanding physician perceptions of current approaches to patient satisfaction feedback offers the opportunity to shape subsequent collection and distribution methods to improve physician performance and optimize professional fulfillment.

  View details for DOI 10.1016/j.jcjq.2022.12.003

  View details for PubMedID 36732115

• The Patient-Reported Outcome Measurement in Heart Failure Clinic Trial: Rationale and Methods of The PRO-HF Trial. American heart journal Kalwani, N. M., Calma, J., Varghese, G. M., Gupta, A., Zheng, J., Brown-Johnson, C., Amano, A., Vilendrer, S., Winget, M., Asch, S. M., Heidenreich, P., Sandhu, A. 2022

  Abstract

  BACKGROUND: Among patients with heart failure (HF), patient-reported health status provides information beyond standard clinician assessment. Although HF management guidelines recommend collecting patient-reported health status as part of routine care, there is minimal data on the impact of this intervention.STUDY DESIGN: The Patient-Reported Outcomes in Heart Failure Clinic (PRO-HF) trial is a pragmatic, randomized, implementation-effectiveness trial testing the hypothesis that routine health status assessment via the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) leads to an improvement in patient-reported health status among patients treated in a tertiary health system HF clinic. PRO-HF has completed randomization of 1,248 participants to routine KCCQ-12 assessment or usual care. Patients randomized to the KCCQ-12 arm complete KCCQ-12 assessments before each HF clinic visit with the results shared with their treating clinician. Clinicians received education regarding the interpretation and potential utility of the KCCQ-12. The primary endpoint is the change in KCCQ-12 over 1 year. Secondary outcomes are HF therapy patterns and healthcare utilization, including clinic visits, testing, hospitalizations, and emergency department (ED) visits. As a sub-study, PRO-HF also evaluated the impact of routine KCCQ-12 assessment on patient experience and the accuracy of clinician-assessed health status. In addition, clinicians completed semi-structured interviews to capture their perceptions on the trial's implementation of routine KCCQ-12 assessment in clinical practice.CONCLUSIONS: PRO-HF is a pragmatic, randomized trial based in a real-world HF clinic to determine the feasibility of routinely assessing patient-reported health status and the impact of this intervention on health status, care delivery, patient experience, and the accuracy of clinician health status assessment.

  View details for DOI 10.1016/j.ahj.2022.10.081

  View details for PubMedID 36309127

• Evaluating clinician-led quality improvement initiatives: A system-wide embedded research partnership at Stanford Medicine. Learning health systems Vilendrer, S., Saliba-Gustafsson, E. A., Asch, S. M., Brown-Johnson, C. G., Kling, S. M., Shaw, J. G., Winget, M., Larson, D. B. 2022; 6 (4): e10335

  Abstract

  Many healthcare delivery systems have developed clinician-led quality improvement (QI) initiatives but fewer have also developed in-house evaluation units. Engagement between the two entities creates unique opportunities. Stanford Medicine funded a collaboration between their Improvement Capability Development Program (ICDP), which coordinates and incentivizes clinician-led QI efforts, and the Evaluation Sciences Unit (ESU), a multidisciplinary group of embedded researchers with expertise in implementation and evaluation sciences.To describe the ICDP-ESU partnership and report key learnings from the first 2 y of operation September 2019 to August 2021.Department-level physician and operational QI leaders were offered an ESU consultation to workshop design, methods, and overall scope of their annual QI projects. A steering committee of high-level stakeholders from operational, clinical, and research perspectives subsequently selected three projects for in-depth partnered evaluation with the ESU based on evaluability, importance to the health system, and broader relevance. Selected project teams met regularly with the ESU to develop mixed methods evaluations informed by relevant implementation science frameworks, while aligning the evaluation approach with the clinical teams' QI goals.Sixty and 62 ICDP projects were initiated during the 2 cycles, respectively, across 18 departments, of which ESU consulted with 15 (83%). Within each annual cycle, evaluators made actionable, summative findings rapidly available to partners to inform ongoing improvement. Other reported benefits of the partnership included rapid adaptation to COVID-19 needs, expanded clinician evaluation skills, external knowledge dissemination through scholarship, and health system-wide knowledge exchange. Ongoing considerations for improving the collaboration included the need for multi-year support to enable nimble response to dynamic health system needs and timely data access.Presence of embedded evaluation partners in the enterprise-wide QI program supported identification of analogous endeavors (eg, telemedicine adoption) and cross-cutting lessons across QI efforts, clinician capacity building, and knowledge dissemination through scholarship.

  View details for DOI 10.1002/lrh2.10335

  View details for PubMedID 36263267

  View details for PubMedCentralID PMC9576232

• Evaluating clinician-led quality improvement initiatives: A system-wide embedded research partnership at Stanford Medicine LEARNING HEALTH SYSTEMS Vilendrer, S., Saliba-Gustafsson, E. A., Asch, S. M., Brown-Johnson, C. G., Kling, S. R., Shaw, J. G., Winget, M., Larson, D. B. 2022

  View details for DOI 10.1002/lrh2.10335

  View details for Web of Science ID 000843397900001

• A 360 degree mixed-methods evaluation of a specialized COVID-19 outpatient clinic and remote patient monitoring program. BMC primary care Vilendrer, S., Lestoquoy, A., Artandi, M., Barman, L., Cannon, K., Garvert, D. W., Halket, D., Holdsworth, L. M., Singer, S., Vaughan, L., Winget, M. 2022; 23 (1): 151

  Abstract

  BACKGROUND: Our goals are to quantify the impact on acute care utilization of a specialized COVID-19 clinic with an integrated remote patient monitoring program in an academic medical center and further examine these data with stakeholder perceptions of clinic effectiveness and acceptability.METHODS: A retrospective cohort was drawn from enrolled and unenrolled ambulatory patients who tested positive in May through September 2020 matched on age, presence of comorbidities and other factors. Qualitative semi-structured interviews with patients, frontline clinician, and administrators were analyzed in an inductive-deductive approach to identify key themes.RESULTS: Enrolled patients were more likely to be hospitalized than unenrolled patients (N=11/137 in enrolled vs 2/126 unenrolled, p=.02), reflecting a higher admittance rate following emergency department (ED) events among the enrolled vs unenrolled, though this was not a significant difference (46% vs 25%, respectively, p=.32). Thirty-eight qualitative interviews conducted June to October 2020 revealed broad stakeholder belief in the clinic's support of appropriate care escalation. Contrary to beliefs the clinic reduced inappropriate care utilization, no difference was seen between enrolled and unenrolled patients who presented to the ED and were not admitted (N=10/137 in enrolled vs 8/126 unenrolled, p=.76). Administrators and providers described the clinic's integral role in allowing health services to resume in other areas of the health system following an initial lockdown.CONCLUSIONS: Acute care utilization and multi-stakeholder interviews suggest heightened outpatient observation through a specialized COVID-19 clinic and remote patient monitoring program may have contributed to an increase in appropriate acute care utilization. The clinic's role securing safe reopening of health services systemwide was endorsed as a primary, if unmeasured, benefit.

  View details for DOI 10.1186/s12875-022-01734-7

  View details for PubMedID 35698064

• A qualitative assessment of medical assistant professional aspirations and their alignment with career ladders across three institutions. BMC primary care Vilendrer, S., Amano, A., Johnson, C. B., Morrison, T., Asch, S. 2022; 23 (1): 117

  Abstract

  BACKGROUND: Growing demand for medical assistants (MAs) in team-based primary care has led health systems to explore career ladders based on expanded MA responsibilities as a solution to improve MA recruitment and retention. However, the practical implementation of career ladders remains a challenge for many health systems. In this study, we aim to understand MA career aspirations and their alignment with available advancement opportunities.METHODS: Semi-structured focus groups were conducted August to December 2019 in primary care clinics based in three health systems in California and Utah. MA perspectives of career aspirations and their alignment with existing career ladders were discussed, recorded, and qualitatively analyzed.RESULTS: Ten focus groups conducted with 59 participants revealed three major themes: mixed perceptions of expanded MA roles with concern over increased responsibility without commensurate increase in pay; divergent career aspirations among MAs not addressed by existing career ladders; and career ladder implementation challenges including opaque advancement requirements and lack of consistency across practice settings.CONCLUSION: MAs held positive perceptions of career ladders in theory, yet recommended a number of improvements to their practical implementation across three institutions including improving clarity and consistency around requirements for advancement and matching compensation to job responsibilities. The emergence of two distinct clusters of MA professional needs and desires suggests an opportunity to further optimize career ladders to provide tailored support to MAs in order to strengthen the healthcare workforce and talent pipeline.

  View details for DOI 10.1186/s12875-022-01712-z

  View details for PubMedID 35578176

• Nursing Workflow Change in a COVID-19 Inpatient Unit Following the Deployment of Inpatient Telehealth: An Observational Study Using a Real-Time Locating System. Journal of medical Internet research Vilendrer, S., Lough, M. E., Garvert, D. W., Lambert, M. H., Lu, J. H., Patel, B., Shah, N. H., Williams, M. Y., Kling, S. M. 2022

  Abstract

  BACKGROUND: The COVID-19 pandemic prompted widespread implementation of telehealth, including in the inpatient setting with the goals to reduce potential pathogen exposure events and personal protective equipment (PPE) utilization. Nursing workflow adaptations in these novel environments is of particular interest given the association between nursing time at the bedside and patient safety. Understanding the frequency and duration of nurse-patient encounters following the introduction of a novel telehealth platform in the context of COVID-19 may therefore provide insight into downstream impacts on patient safety, pathogen exposure, and PPE utilization.OBJECTIVE: To evaluate changes in nursing workflow relative to pre-pandemic levels using real-time locating system (RTLS) following the deployment of inpatient telehealth on a COVID-19 unit.METHODS: In March 2020, telehealth was installed in patient rooms in a COVID-19 unit and on movable carts in 3 comparison units. Existing RTLS captured nurse movement during 1 pre- and 5 post-pandemic stages (January-December 2020). Change in direct nurse-patient encounters, time spent in patient rooms per encounter, and total time spent with patients per shift relative to baseline were calculated. Generalized linear models assessed difference-in-differences in outcomes between COVID-19 and comparison units. Telehealth adoption was captured and reported at the unit level.RESULTS: Change in frequency of encounters and time spent per encounter from baseline differed between the COVID-19 and comparison units at all stages of the pandemic (all P's<0.0001). Frequency of encounters decreased (difference-in-differences range: -6.6 to -14.1 encounters) and duration of encounters increased (difference-in-differences range: 1.8 to 6.2 minutes) from baseline to a greater extent in the COVID-19 units compared to the comparison units. At most stages of the pandemic, the change in total time nurses spent in patient rooms per patient per shift from baseline did not differ between the COVID-19 and comparison units (p's>0.17). The primary COVID-19 unit quickly adopted telehealth technology during the observation period, initiating 15,088 encounters that averaged 6.6 minutes (standard deviation = 13.6) each.CONCLUSIONS: RTLS movement data suggests total nursing time at the bedside remained unchanged following the deployment of inpatient telehealth in a COVID-19 unit. Compared to other units with shared mobile telehealth units, frequency of nurse-patient in-person encounters decreased and duration lengthened on a COVID-19 unit with in-room telehealth availability, indicating "batched" redistribution of work to maintain total time at bedside relative to pre-pandemic periods. The simultaneous adoption of telehealth suggests virtual care was a complement to, rather than a replacement for, in-person care. Study limitations, however, preclude our ability to draw a causal link between nursing workflow change and telehealth adoption, and further evaluation is needed to determine potential downstream implications on disease transmission, PPE utilization, and patient safety.CLINICALTRIAL:

  View details for DOI 10.2196/36882

  View details for PubMedID 35635840

• Gearing Up for a Vaccine Requirement: A Mixed Methods Study of COVID-19 Vaccine Confidence Among Workers at an Academic Medical Center. Journal of healthcare management / American College of Healthcare Executives Mahoney, M., Winget, M., Brown-Johnson, C., de Borba, L., Veruttipong, D., Luu, J., Jones, D., Bohman, B., Vilendrer, S. 2022; 67 (3): 206-220

  Abstract

  Assessing barriers to vaccination among healthcare workers may be particularly important given their roles in their respective communities. We conducted a mixed methods study to explore healthcare worker perspectives on receiving COVID-19 vaccines at a large multisite academic medical center.A total of 5,917 employees completed the COVID-19 vaccine confidence survey (20% response rate). Most participants were vaccinated (93%). Compared to vaccinated participants, unvaccinated participants were younger (60% < 44 years), more likely to be from a non-Asian minority group (48%), and more likely to be nonclinical employees (57% vs. 46%). Among the unvaccinated respondents, 53% indicated they would be influenced by their healthcare provider, while 19% reported that nothing would influence them to get vaccinated. Key perceived barriers to vaccination from the qualitative analysis included the need for more long-term safety and efficacy data, a belief in the right to make an individual choice, mistrust, a desire for greater public health information, personal health concerns, circumstances such as prior COVID-19 infection, and access issues.Strategies endorsed by some participants to address their concerns about safety and access included a communication campaign, personalized medicine approaches (e.g., individual appointments to discuss how the vaccine might interact with personal health conditions), and days off to recover. Mistrust and a belief in the right to make an individual choice may be harder barriers to overcome; further dialogue is needed.These findings reflect potential strategies for vaccine requirements that healthcare organizations can implement to enhance vaccine confidence. In addition, organizations can ask respected health professionals to serve as spokespeople, which may help shift the perspectives of unvaccinated healthcare workers.

  View details for DOI 10.1097/JHM-D-21-00226

  View details for PubMedID 35576446

• Patient Perspectives of Inpatient Telemedicine During COVID-19: A Qualitative Assessment. JMIR formative research Vilendrer, S., Sackeyfio, S., Akinbami, E., Ghosh, R., Luu, J. H., Pathak, D., Shimada, M., Williamson, E. E., Shieh, L. 2022

  Abstract

  Telemedicine has been adopted in the inpatient setting to facilitate clinical interactions between on-site clinicians and isolated hospitalized patients. Such remote interactions have the potential to reduce pathogen exposure and use of personal protective equipment but may also pose new safety concerns given prior evidence that isolated patients can receive suboptimal care. Formal evaluations into the use and practical acceptance of inpatient telemedicine amongst hospitalized patients are lacking.We aimed to evaluate the experience of patients hospitalized for COVID-19 with inpatient telemedicine introduced as an infection control measure during the pandemic.We conducted a qualitative evaluation in a COVID-19 designated non-intensive care hospital unit at a large academic health center (Stanford Health Care) October 2020 through January 2021. Semi-structured qualitative interviews focused on patient experience, impact on quality of care, communication, and mental health. Purposive sampling were used to recruit participants represent-ing diversity across varying demographics until thematic saturation was reached. Interview transcripts were qualitatively analyzed using an inductive-deductive approach.Interviews with 20 hospitalized patients suggested non-emergency clinical care and bridging to in-person care comprised the majority of inpatient telemedicine use. Nurses were reported to enter the room and call on the tablet far more frequently than physicians, who typically entered the room at least daily. Patients reported broad acceptance of the technology, citing improved convenience and reduced anxiety but preferred in-person care where possible. Quality of care was believed to be similar to in-person care with the exception of a few patients who wanted more frequent in-person examinations. Ongoing challenges included low volume, shifting tablet location, and inconsistent verbal introductions from the clinical team.Patient experiences with in-patient telemedicine were largely favorable. Although most patients ex-pressed a preference for in-person care, telemedicine was acceptable given the circumstances asso-ciated with COVID-19. Technical and care team use improvements may enhance acceptability. Fur-ther evaluation is needed to understand the impact of inpatient telemedicine and the optimal balance between in-person and virtual care in the hospital setting.

  View details for DOI 10.2196/32933

  View details for PubMedID 35147510

• Engaging Frontline Physicians in Value Improvement: A Qualitative Evaluation of Physician-Directed Reinvestment. Journal of healthcare leadership Vilendrer, S., Amano, A., Asch, S. M., Brown-Johnson, C., Lu, A. C., Maggio, P. 2022; 14: 31-45

  Abstract

  Purpose: Physicians can limit upward trending healthcare costs, yet legal and ethical barriers prevent the use of direct financial incentives to engage physicians in cost-reduction initiatives. Physician-directed reinvestment is an alternative value-sharing arrangement in which a health system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into professional areas of the physicians' choosing. Formal evaluations of such programs are lacking.Methods: To understand the impact of Stanford Health Care's physician-directed reinvestment in its first year (2017-2018) on physician engagement, adherence to program requirements around safety and fund use, and factors facilitating program dissemination, semi-structured qualitative interviews with physician participants, non-participants, and administrative stakeholders were conducted July-November 2019. Interview transcripts were qualitatively analyzed through an implementation science lens. To support contextual analysis of the qualitative data, a directional estimation of the program's impact on cost from the perspective of the health system was calculated by subtracting annual maintenance cost (derived from interview self-reported time estimates and public salary data) from internal cost accounting of the total savings from first year cohort to obtain annual net benefit, which was then divided by the annual maintenance cost.Results: Physician participation was low compared with the overall physician population (n=14 of approximately 2300 faculty physicians), though 32 qualitative interviews suggested deep engagement across physician participants and adherence to target program requirements. Reinvestment funds activated intrinsic motivators such as autonomy, purpose and inter-professional relations, and extrinsic motivators, such as the direction of resources and external recognition. Ongoing challenges included limited physician awareness of healthcare costs and the need for increased clarity around which projects rise above one's existing job responsibilities. Administrative data excluding physician time, which was not directly compensated, showed a direct cost savings of $8.9M. This implied an 11-fold return on investment excluding uncompensated physician time.Conclusion: A physician-directed reinvestment program appeared to facilitate latent frontline physician innovation towards value, though additional evaluation is needed to understand its long-term impact.

  View details for DOI 10.2147/JHL.S335763

  View details for PubMedID 35422669

• Developing best practices for PPE Portraits across 25 sites: a systematic assessment ofimplementation and spread of adaptations using FRAME. BMC health services research Baratta, J., Amano, A., Parsons, P. K., Vilendrer, S., Winter, S. G., Verano, M., Perez, C., Kalanithi, L., Asch, S. M., Heffernan, M. B., Brown-Johnson, C. 2021; 21 (1): 1182

  Abstract

  BACKGROUND: Adaptation, a form of modification that aims to improve an intervention's acceptability and sustainability in each context, is essential to successful implementation in some settings. Due to the COVID-19 pandemic, clinicians have rapidly adapted how they deliver patient care. PPE Portraits are a form of adaptation, whereby health workers affix a postcard size portrait of themselves to the front of their personal protective equipment (PPE) to foster human connection during COVID-19.METHODS: We used the expanded framework for reporting adaptations and modifications to evidence-based interventions (FRAME) method to better understand the reasoning behind and results of each adaptation. We hypothesized that using the FRAME in conjunction with design-thinking would lead to emerging best practices and that we would find adaptation similarities across sites. Throughout multiple implementations across 25 institutions, we piloted, tracked, and analyzed adaptations using FRAME and design thinking. For each adaptation, we assessed the stage of implementation, whether the change was planned, decision makers involved, level of delivery impacted, fidelity to original intervention, and the goal and reasoning for adaptation. We added three crucial components to the FRAME: original purpose of the adaptation, unintended consequences, and alternative adaptations.RESULTS: When implementing PPE Portraits across settings, from a local assisted living center's memory unit to a pediatric emergency department, several requests for adaptations arose during early development stages before implementation. Adaptations primarily related to (1) provider convenience and comfort, (2) patient populations, and (3) scale. Providers preferred smaller portraits and rounded (rather than square) laminated edges that could potentially injure a patient. Affixing the portrait with a magnet was rejected given the potential choking hazard the magnetic strip presented for children. Other adaptations, related to ease of dissemination, included slowing the process down during early development and providing buttons, which could be produced easily at scale.CONCLUSIONS: The FRAME was used to curate the reasoning for each adaptation and to inform future dissemination. We look forward to utilizing FRAME including our additions and design thinking, to build out a range of PPE Portrait best practices with accompanying costs and benefits.

  View details for DOI 10.1186/s12913-021-06922-2

  View details for PubMedID 34717597

• Financial Incentives for Medical Assistants: A Mixed-Methods Exploration of Bonus Structures, Motivation, and Population Health Quality Measures. Annals of family medicine Vilendrer, S., Brown-Johnson, C., Kling, S. M., Veruttipong, D., Amano, A., Bohman, B., Daines, W. P., Overton, D., Srivastava, R., Asch, S. M. 2021; 19 (5): 427-436

  Abstract

  PURPOSE: Medical assistants (MAs) have seen their roles expand as a result of team-based primary care models. Unlike their physician counterparts, MAs rarely receive financial incentives as a part of their compensation. This exploratory study aims to understand MA acceptability of financial incentives and perceived MA control over common population health measures.METHODS: We conducted semistructured focus groups between August and December of 2019 across 10 clinics affiliated with 3 institutions in California and Utah. MAs' perceptions of experienced and hypothetical financial incentives, their potential influence on workflow processes, and perceived levels of control over population health measures were discussed, recorded, and qualitatively analyzed for emerging themes. Perceived levels of control were further quantified using a Likert survey; measures were grouped into factors representing vaccinations, and workflow completed in the same day or multiple days (multiday). Mean scores for each factor were compared using repeated 1-way ANOVA with Tukey-Kramer adjustment.RESULTS: MAs reported little direct experience with financial incentives. They indicated that a hypothetical bonus representing 2% to 3% of their average annual base pay would be acceptable and influential in improving consistent performance during patient rooming workflow. MAs reported having greater perceived control over vaccinations (P <.001) and same-day measures (P <.001) as compared with multiday measures.CONCLUSIONS: MAs perceived that relatively small financial incentives would increase their motivation and quality of care. Our findings suggests target measures should focus on MA work processes that are completed in the same day as the patient encounter, particularly vaccinations. Future investigation is needed to understand the effectiveness of MA financial incentives in practice.

  View details for DOI 10.1370/afm.2719

  View details for PubMedID 34546949

• How Feedback Is Given Matters: A Cross-Sectional Survey of Patient Satisfaction Feedback Delivery and Physician Well-being. Mayo Clinic proceedings Vilendrer, S. M., Kling, S. M., Wang, H., Brown-Johnson, C., Jayaraman, T., Trockel, M., Asch, S. M., Shanafelt, T. D. 2021

  Abstract

  OBJECTIVE: To evaluate how variation in the way patient satisfaction feedback is delivered relates to physician well-being and perceptions of its impact on patient care, job satisfaction, and clinical decision making.PARTICIPANTS AND METHODS: A cross-sectional electronic survey was sent to faculty physicians from a large academic medical center in March 29, 2019. Physicians reported their exposure to feedback (timing, performance relative to peers, or channel) and related perceptions. The Professional Fulfillment Index captured burnout and professional fulfillment. Associations between feedback characteristics and well-being or perceived impact were tested using analysis of variance or logistic regression adjusted for covariates.RESULTS: Of 1016 survey respondents, 569 (56.0%) reported receiving patient satisfaction feedback. Among those receiving feedback, 303 (53.2%) did not believe that this feedback improved patient care. Compared with physicians who never received feedback, those who received any type of feedback had higher professional fulfillment scores (mean, 6.6±2.1 vs 6.3±2.0; P=.03) but also reported an unfavorable impact on clinical decision making (odds ratio [OR], 2.9; 95% CI, 1.8 to 4.7; P<.001). Physicians who received feedback that included one-on-one discussions (as opposed to feedback without this channel) held more positive perceptions of the feedback's impact on patient care (OR, 2.0; 95% CI, 1.3 to 3.0; P=.003), whereas perceptions were less positive in physicians whose feedback included comparisons to named colleagues (OR, 0.5; 95% CI, 0.3 to 0.8; P=.003).CONCLUSION: Providing patient satisfaction feedback to physicians was associated with mixed results, and physician perceptions of the impact of feedback depended on the characteristics of feedback delivery. Our findings suggest that feedback is viewed most constructively by physicians when delivered through one-on-one discussions and without comparison to peers.

  View details for DOI 10.1016/j.mayocp.2021.03.039

  View details for PubMedID 34479736

• A Specialized Acute COVID-19 Outpatient Clinic at an Academic Medical Center. American journal of medical quality : the official journal of the American College of Medical Quality Artandi, M., Barman, L., Srinivasan, M., Thomas, S., Singh, J., Asch, S. M., Vilendrer, S. 2021

  Abstract

  Health systems are challenged to provide equitable access to coronavirus disease 2019 (COVID-19) outpatient care during the pandemic. Infected patients may have difficulties accessing regular care and rely on emergency rooms. With the goal to improve system efficiencies and access to care, Stanford launched a designated outpatient COVID-19 "Care and Respiratory Observation of Patients With Novel Coronavirus" clinic in April 2020 in which all adult Stanford patients with newly diagnosed severe acute respiratory syndrome coronavirus 2 were offered follow-up for 2-3 weeks through video, telephone, and in-person encounters. Patients were triaged into risk categories and received home pulse oximeters based on a standardized protocol. Between April 15, 2020, and March 26, 2021, the Care and Respiratory Observation of Patients With Novel Coronavirus clinic enrolled 1317 patients. The clinic provided evaluation of Patients under Investigation, management of acute COVID-19 symptoms, care for COVID-19 patients after hospital discharge, clinical advice, and opportunities for research. The authors share crucial implementation lessons related to team agility, care personalization, and resource optimization.

  View details for DOI 10.1097/JMQ.0000000000000006

  View details for PubMedID 34310381

• Predicting and Responding to Clinical Deterioration in Hospitalized Patients by Using Artificial Intelligence: Protocol for a Mixed Methods, Stepped Wedge Study. JMIR research protocols Holdsworth, L. M., Kling, S. M., Smith, M., Safaeinili, N., Shieh, L., Vilendrer, S., Garvert, D. W., Winget, M., Asch, S. M., Li, R. C. 2021; 10 (7): e27532

  Abstract

  BACKGROUND: The early identification of clinical deterioration in patients in hospital units can decrease mortality rates and improve other patient outcomes; yet, this remains a challenge in busy hospital settings. Artificial intelligence (AI), in the form of predictive models, is increasingly being explored for its potential to assist clinicians in predicting clinical deterioration.OBJECTIVE: Using the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model, this study aims to assess whether an AI-enabled work system improves clinical outcomes, describe how the clinical deterioration index (CDI) predictive model and associated work processes are implemented, and define the emergent properties of the AI-enabled work system that mediate the observed clinical outcomes.METHODS: This study will use a mixed methods approach that is informed by the SEIPS 2.0 model to assess both processes and outcomes and focus on how physician-nurse clinical teams are affected by the presence of AI. The intervention will be implemented in hospital medicine units based on a modified stepped wedge design featuring three stages over 11 months-stage 0 represents a baseline period 10 months before the implementation of the intervention; stage 1 introduces the CDI predictions to physicians only and triggers a physician-driven workflow; and stage 2 introduces the CDI predictions to the multidisciplinary team, which includes physicians and nurses, and triggers a nurse-driven workflow. Quantitative data will be collected from the electronic health record for the clinical processes and outcomes. Interviews will be conducted with members of the multidisciplinary team to understand how the intervention changes the existing work system and processes. The SEIPS 2.0 model will provide an analytic framework for a mixed methods analysis.RESULTS: A pilot period for the study began in December 2020, and the results are expected in mid-2022.CONCLUSIONS: This protocol paper proposes an approach to evaluation that recognizes the importance of assessing both processes and outcomes to understand how a multifaceted AI-enabled intervention affects the complex team-based work of identifying and managing clinical deterioration.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/27532.

  View details for DOI 10.2196/27532

  View details for PubMedID 34255728

• Inpatient telemedicine implementation as an infection control response to COVID-19: A qualitative process evaluation. JMIR formative research Safaeinili, N., Vilendrer, S., Williamson, E., Zhao, Z., Brown-Johnson, C., Asch, S. M., Shieh, L. 2021

  Abstract

  BACKGROUND: The COVID-19 pandemic created new challenges to delivering safe and effective healthcare while minimizing staff and non-COVID-19 patient exposure to the virus. Health systems worldwide have moved quickly to implement telemedicine in diverse settings to reduce infection, but little is understood about how best to connect acutely ill patients with nearby clinical team members, even in the next room.OBJECTIVE: To inform these efforts, this paper provides an early example of inpatient telemedicine implementation and its perceived acceptability and effectiveness.METHODS: Using purposive sampling, this study conducted 15 semi-structured interviews with nurses (n=5) and attending (n=5) and resident (n=15) physicians on a single COVID-19 unit within Stanford Health Care to evaluate implementation outcomes and perceived effectiveness of inpatient telemedicine. Semi-structured interview protocols and qualitative analysis were framed around the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework and identified key themes using a rapid analytic process and consensus approach.RESULTS: All clinical team members reported wide reach of inpatient telemedicine, with some use for almost all COVID-19 patients. Inpatient telemedicine was perceived to be effective in reducing COVID-19 exposure and personal protective equipment (PPE) use without significantly compromising quality of care. Physician workflows remained relatively stable as most standard clinical activities were conducted via telemedicine following the initial intake examination, though resident physicians reported reduced educational opportunities given limited opportunities to conduct physical exams. Nurse workflows required significant adaptations to cover non-nursing duties such as food delivery and facilitating technology connections for patients and physicians alike. Perceived patient impact included consistent care quality, with some considerations around privacy. Reported challenges included: patient-clinical team communication and personal connection with the patient, perceptions of patient isolation, ongoing technical challenges, and certain aspects of the physical exam.CONCLUSIONS: Clinical team members reported inpatient telemedicine encounters as acceptable and effective in reducing COVID-19 exposure and PPE use. Nurses adapted their workflows more than physicians to implement the new technology and bore a higher burden of in-person care and technical support. Recommendations for improved inpatient telemedicine use include information technology (IT) support and training, increased technical functionality, and remote access for the clinical team.CLINICALTRIAL:

  View details for DOI 10.2196/26452

  View details for PubMedID 34033576

• Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool. Surgery Brown-Johnson, C. G., Spargo, T., Kling, S. M., Saliba-Gustafsson, E. A., Lestoquoy, A. S., Garvert, D. W., Vilendrer, S., Winget, M., Asch, S. M., Maggio, P., Nazerali, R. S. 2021

  Abstract

  BACKGROUND: Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.METHODS: This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n= 20) and surgeons (n= 10) to explore stakeholder perspectives on video visits.RESULTS: During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.CONCLUSION: Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

  View details for DOI 10.1016/j.surg.2021.03.029

  View details for PubMedID 33941389

• 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 Vilendrer, S. n., Amano, A. n., Brown Johnson, C. G., Favet, M. n., Safaeinili, N. n., Villasenor, J. n., Shaw, J. G., Hertelendy, A. J., Asch, S. M., Mahoney, M. n. 2021

  Abstract

  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

• Using a Real-Time Locating System to Evaluate the Impact of Telemedicine in an Emergency Department During COVID-19: Observational Study. Journal of medical Internet research Patel, B., Vilendrer, S., Kling, S. M., Brown, I., Ribeira, R., Eisenberg, M., Sharp, C. 2021

  Abstract

  Telemedicine has been deployed by healthcare systems in response to the COVID-19 pandemic to enable healthcare workers to provide remote care for both outpatients and inpatients. Although it is reasonable to suspect telemedicine visits limit unnecessary personal contact and thus decrease the risk of infection transmission, the impact of the use of such technology on clinician workflows in the emergency department is unknown.To use real-time locating systems (RTLS) to evaluate the impact of a new telemedicine platform, which permitted clinicians located outside patient rooms to interact with patients who were under isolation precautions in the emergency department, on in-person interaction between healthcare workers and patients.A pre-post analysis was conducted using a badge-based RTLS platform to collect movement data including entrances and duration of stay within patient rooms of the emergency department for nursing and physician staff. Movement data was captured between March 2nd, 2020, the date of the first patient screened for COVID-19 in the emergency department, and April 20th, 2020. A new telemedicine platform was deployed on March 29th, 2020. Number of entrances and duration of in-person interactions per patient encounter, adjusted for patient length of stay, were obtained for pre- and post-implementation phases and compared with t-tests to determine statistical significance.There were 15,741 RTLS events linked to 2,662 encounters for patients screened for COVID-19. There was no significant change in number of in-person interactions between the pre- and post-implementation phases for both nurses (5.7 vs 7.0 entrances per patient, p=0.07) and physicians (1.3 vs 1.5 entrances per patient, p=0.12). Total duration of in-person interaction did not change (56.4 vs 55.2 minutes per patient, p=0.74) despite significant increases in telemedicine videoconference frequency (0.6 vs 1.3 videoconferences per patient, p<0.01 for change in daily average) and duration (4.3 vs 12.3 minutes per patient, p<0.01 for change in daily average).Telemedicine was rapidly adopted with the intent of minimizing pathogen exposure to healthcare workers during the COVID-19 pandemic, yet RTLS movement data did not reveal significant changes for in-person interactions between staff and patients under investigation for COVID-19 infection. Additional research is needed to better understand how telemedicine technology may be better incorporated into emergency departments to improve workflows for frontline healthcare clinicians.

  View details for DOI 10.2196/29240

  View details for PubMedID 34236993

• Employers' Role in Employee Health: Why They Do What They Do. Journal of occupational and environmental medicine Singer, S. J., Vilendrer, S., Joseph, G., Kim, J., Pfeffer, J. 2020

  Abstract

  OBJECTIVE: Employers affect the health of employees and their families through work environments and employee benefits. We sought to understand employer decisions around those topics.METHODS: Interviews with 21 executives from diverse, purposely-sampled, progressive companies with transcripts analyzed using inductive and deductive methods.RESULTS: Companies often viewed keeping employees healthy primarily as a means to profitability rather than an end in itself and rationalized stressful workplaces as necessary and non-changeable. Many possible actions including job redesign and changing benefits administrators were seen as infeasible. Even large, resource-rich organizations were strikingly nonagentic.CONCLUSIONS: Companies seem less committed to the goal of increasing employee health than they claim or than they should be, given the significant relationship between employee health and economic performance, and see external and internal barriers to improving health that are often self-created.

  View details for DOI 10.1097/JOM.0000000000001967

  View details for PubMedID 32769791

• An Incentive to Innovate: Improving Health Care Value and Restoring Physician Autonomy Through Physician-Directed Reinvestment. Academic medicine : journal of the Association of American Medical Colleges Vilendrer, S. M., Asch, S. M., Anzai, Y., Maggio, P. 2020

  Abstract

  PROBLEM: Many health care systems in the United States are shifting from a fee-for-service reimbursement model to a value-based payment model. To remain competitive, health care administrators must engage frontline clinicians in their efforts to reduce costs and improve patient outcomes. Engaging physicians and other clinicians is challenging, however, as many feel overwhelmed with clinical responsibilities and do not view cost reduction as in their purview. Even if they are willing, providing a direct financial incentive to clinicians to control costs poses ethical and legal challenges. An effective incentive in the current system must motivate clinicians to engage in creative problem solving and mitigate ethical and legal risk.APPROACH: Evidence suggests the most successful behavior change interventions in physicians are multi-faceted and combine intrinsic motivators, such as increased autonomy, with extrinsic motivators, such as access to funding or social recognition. Two academic health centers-the University of Utah Health and Stanford Health Care-have begun experimenting with an alternative value-sharing arrangement. Physician-directed reinvestment is an explicit agreement in which a health care system reinvests a portion of savings attributed to physician-led cost reduction initiatives back into areas of the physician's choosing, such as capital investment, research, or education.OUTCOMES: Both organizations reported similar positive outcomes, including increased engagement from clinicians and administrators, sustained or improved quality of care, reduced costs of care, and benefits from reinvested funds. Many savings opportunities were previously unknown to administrators.NEXT STEPS: Physician-directed reinvestment appears to effectively engage physicians in ongoing efforts to improve value in health care, although formal evaluation is still needed. This incentive structure may hold promise in other configurations, such as inviting non-physicians to apply as project leaders (clinician-directed reinvestment) and expanding the program to non-academic and ambulatory settings.

  View details for DOI 10.1097/ACM.0000000000003650

  View details for PubMedID 32739931

• PPE Portraits-a Way to Humanize Personal Protective Equipment. Journal of general internal medicine Brown-Johnson, C., Vilendrer, S., Heffernan, M. B., Winter, S., Khong, T., Reidy, J., Asch, S. M. 2020

  Abstract

  The use of personal protective equipment (PPE) has skyrocketed, as providers don masks, glasses, and gowns to protect their eyes, noses, and mouths from COVID-19. Yet these same facial features express human individuality, and are crucial to nonverbal communication. Isolated ICU patients may develop "post intensive-care syndrome," which mimics PTSD with sometimes debilitating consequences. While far from a complete solution, PPE Portraits (disposable portrait picture stickers- 4" * 5") have the potential to humanize care. Preparing for a larger effectiveness evaluation on patient and provider experience, we collected initial qualitative implementation insights during Spring 2020's chaotic surge preparation. Front-line providers reported more comfort with patient interactions while wearing PPE Portraits: "It makes it feel less like a disaster zone [for the patient]." A brief pilot showed signs of significant adoption: a participating physician requested PPE Portraits at their clinic, shift nurses had taken PPE Portraits with them to inpatient services, and masked medical assistant team-members requested PPE Portraits to wear over scrubs. We believe PPE Portraits may support patient care and health, and even potentially healthcare team function and provider wellness. While we await data on these effects, we hope hospitals can use our findings to speed their own implementation testing.

  View details for DOI 10.1007/s11606-020-05875-2

  View details for PubMedID 32410125

• Qualitative Assessment of Rapid System Transformation to Primary Care Video Visits at an Academic Medical Center. Annals of internal medicine Srinivasan, M. n., Asch, S. n., Vilendrer, S. n., Thomas, S. C., Bajra, R. n., Barman, L. n., Edwards, L. M., Filipowicz, H. n., Giang, L. n., Jee, O. n., Mahoney, M. n., Nelligan, I. n., Phadke, A. J., Torres, E. n., Artandi, M. n. 2020

  Abstract

  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

• Rapid Deployment of Inpatient Telemedicine In Response to COVID-19 Across Three Health Systems. Journal of the American Medical Informatics Association : JAMIA Vilendrer, S. n., Patel, B. n., Chadwick, W. n., Hwa, M. n., Asch, S. n., Pageler, N. n., Ramdeo, R. n., Saliba-Gustafsson, E. A., Strong, P. n., Sharp, C. n. 2020

  Abstract

  To reduce pathogen exposure, conserve personal protective equipment, and facilitate health care personnel work participation in the setting of the COVID-19 pandemic, three affiliated institutions rapidly and independently deployed inpatient telemedicine programs during March 2020. We describe key features and early learnings of these programs in the hospital setting.Relevant clinical and operational leadership from an academic medical center, pediatric teaching hospital, and safety net county health system met to share learnings shortly after deploying inpatient telemedicine. A summative analysis of their learnings was re-circulated for approval.All three institutions faced pressure to urgently standup new telemedicine systems while still maintaining secure information exchange. Differences across patient demographics and technological capabilities led to variation in solution design, though key technical considerations were similar. Rapid deployment in each system relied on readily available consumer-grade technology, given the existing familiarity to patients and clinicians and minimal infrastructure investment. Preliminary data from the academic medical center over one month suggested positive adoption with 631 inpatient video calls lasting an average (standard deviation) of 16.5 minutes (19.6) based on inclusion criteria.The threat of an imminent surge of COVID-19 patients drove three institutions to rapidly develop inpatient telemedicine solutions. Concurrently, federal and state regulators temporarily relaxed restrictions that would have previously limited these efforts. Strategic direction from executive leadership, leveraging off-the-shelf hardware, vendor engagement, and clinical workflow integration facilitated rapid deployment.The rapid deployment of inpatient telemedicine is feasible across diverse settings as a response to the COVID-19 pandemic.

  View details for DOI 10.1093/jamia/ocaa077

  View details for PubMedID 32495830

• Two treatments, one disease: childhood malaria management in Tanga, Tanzania MALARIA JOURNAL Foster, D., Vilendrer, S. 2009; 8

  Abstract

  In the Tanga District of coastal Tanzania, malaria is one of the primary causes of mortality for children under the age of five. While some children are treated with malaria medications in biomedical facilities, as the World Health Organization recommends, others receive home-care or treatment from traditional healers. Recognition of malaria is difficult because symptoms can range from fever with uncomplicated malaria to convulsions with severe malaria. This study explores why caregivers in the Tanga District of Tanzania pursue particular courses of action to deal with malaria in their children.Qualitative data were collected through interviews with three samples: female caregivers of children under five (N = 61), medical practitioners (N = 28), and traditional healers (N = 18) in urban, peri-urban, and rural areas. The female caregiver sample is intentionally stratified to reflect the greater population of the Tanga District in level of education, marital status, gender of household head, religion, and tribal group affiliation. Qualitative data were counted, coded and analysed using NVivo7 software.Results indicate that a variety of factors influence treatment choice, including socio-cultural beliefs about malaria symptoms, associations with spiritual affliction requiring traditional healing, knowledge of malaria, and fear of certain anti-malaria treatment procedures. Most notably, some caregivers identified convulsions as a spiritual condition, unrelated to malaria. While nearly all caregivers reported attending biomedical facilities to treat children with fever (N = 60/61), many caregivers stated that convulsions are best treated by traditional healers (N = 26/61). Qualitative interviews with medical practitioners and traditional healers confirmed this belief.Results offer insight into current trends in malaria management and have implications in healthcare policy, educational campaigns, and the importance of integrating traditional and biomedical approaches.

  View details for DOI 10.1186/1475-2875-8-240

  View details for Web of Science ID 000272254600001

  View details for PubMedID 19860900

  View details for PubMedCentralID PMC2779815

• How Can Health Systems Develop Physician Leaders to Implement Better? Lessons From the Stanford-Intermountain Fellowship in Population Health, Delivery Science, and Primary Care. Quality management in health care Olsen, G. n., Knighton, A. n., Vilendrer, S. n., Taylor, N. K., Ho, V. T., Thomas, S. n., Carmichael, H. n., Brunisholz, K. n., Wolfe, D. n., Allen, L. n., Belnap, T. n., Asch, S. n., Srivastava, R. n. ; 30 (2): 140–43

  View details for DOI 10.1097/QMH.0000000000000317

  View details for PubMedID 33783427