Electronic health record (EHR) systems have transformed the medical industry. Despite their known benefits, their implementation has resulted in new digital administrative tasks and responsibilities for physicians. This increase in administrative burden has been shown to contribute to physician burnout. Most sources of EHR-related burnout can be categorized into three groups: poor usability, excessive time spent in the EHR, and inefficient workflows. Evidence-based interventions for EHR-related burnout focus on training and education, which improve efficiency in EHR use and may reduce burnout. Optimization of the EHR interface, including personalization and use of targeted workflows, can help address physician frustrations and improve productivity. In the United States, the federal government regulates EHR system development and sets usability requirements. These requirements are critical because visualization and operational design of the user interface have been shown to directly affect patient care and safety. Negative effects of EHR implementation generally are related to increased administrative burden. Positive effects include greater clinician productivity and administrative cost savings. EHR adoption has consistently been associated with positive financial and clinical outcomes. Federal laws continue to be implemented to improve EHR usability, interoperability, and standards for data access and security.

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The association between electronic health record (EHR) documentation and physician burnout is well-known. A combination of insufficient time to complete tasks, clinical documentation burden, and electronic inbox overload comprises the definition of documentation-related burnout. Burnout mitigation strategies related to clinical documentation include use of targeted EHR training for documentation, use of medical scribes, and institutional documentation redesign. Mitigation strategies related to electronic inbox overload include assigning designated administrative time for inbox management, tailoring of message content to decrease length, and a team-based approach to clinical workflows. Best practices for improving the efficiency of clinical documentation in the EHR include use of automation tools (eg, macros, templates), physician note optimization, and use of team-based documentation. Clinical documentation aids such as medical scribes, speech recognition software, and artificial intelligence (AI)-based software are popular and often considered a necessary resource in health care. For most practices, decisions regarding which aid to use will likely be determined by cost. Speech recognition software is the lowest cost option. AI-based software and medical scribes are more costly.

Telemedicine is defined as the provision of clinical services via telephone or video and is a type of telehealth. Telehealth is defined as the use of electronic information and telecommunications technologies for the delivery of health care, health education, and health information. During the COVID-19 pandemic, telemedicine availability and use of telehealth care significantly increased. The integral role of telemedicine during this time prompted the unprecedented integration of telehealth as a quasi-standard of care. Recent studies have shown telemedicine can achieve comparable or superior quality performance compared with in-office visits for a range of clinical areas in large primary care populations. Implementation of telemedicine at the practice level depends on use of strong clinical workflows across the medical team. Effective telemedicine visits rely on adaptation to a digital environment and patient cooperation for virtual physical examinations. There are subtle differences in coding for billing telemedicine visits (mainly for audio-only visits), and many add-on codes for preventive care are eligible for telehealth. Concerns exist about the ethical implications of virtual care, especially regarding privacy and access. The future success of telehealth will depend on a balance of patient autonomy and health outcomes in the context of health equity.

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INTRODUCTION:Unplanned readmissions can be avoided by standardizing and improving the coordination of care after discharge. Telemedicine has been increasingly utilized; however, the quality of this care has not been well studied. Standardized measures can provide an objective comparison of care quality. The purpose of our study was to compare quality performance transitions of care management in the office vs telemedicine.METHODS:The Epic SlicerDicer tool was used to compare the percentage of encounters that were completed via telemedicine (video visits); or via in-person for comparison, Chi-squared tests were used.RESULTS:A total of 13,891 patients met the inclusion criteria during the study time frame. There were 12,846 patients in the office and 1,048 in the telemedicine cohort. The office readmission rate was 11.9% with 1,533 patients out of 12,846 compared with telemedicine with the rate of readmission at 12.1% with 126 patients out of 1,045 patients. The P-value for the Chi-squared test between the prepandemic and study time frame was 0.15 and 0.95, respectively. Demographic comparability was seen.DISCUSSION:Our study found a comparable readmission rate between patients seen via in-office and telemedicine for Transitions of Care Management (TCM) encounters. The findings of this study support the growing body of evidence that telemedicine augments quality performance while reducing cost and improving access without negatively impacting HEDIS performance in health care systems.CONCLUSION:Telemedicine poses little threat of negatively impacting HEDIS performance and might be as effective as posthospitalization traditional office care transitions of care management.

Remote patient monitoring (RPM) provides real-time clinical patient data to the medical team. The foundational element of RPM is communication, including data processing and integration in the electronic health record and communication of data between patients and clinicians. Patient portals are integral to this communication and their use can result in improved health outcomes and patient safety. Patient portals promote engagement of patients in their care, increase access to the medical team, and integrate RPM system data. RPM systems can monitor a spectrum of parameters related to chronic conditions, from vital signs (eg, heart and respiration rates, blood pressure, blood oxygen and glucose levels) to advanced cardiovascular measures. Some RPM systems are capable of automated monitoring. Health care insurance coverage of RPM systems varies widely, which has health equity implications, particularly for high-risk patients with endocrine and cardiovascular conditions. Additional challenges to widespread adoption of RPM include its contribution to administrative burden for physicians, patient data privacy issues, and variable effectiveness of RPM systems in the management of different chronic conditions.

INTRODUCTION:Tobacco cessation remains a critical challenge in healthcare, with evidence-based interventions often underutilized due to misaligned economic incentives and inadequate training. This study aims to quantify the economic impact of missed billing opportunities for tobacco cessation in a healthcare system, thereby assessing potential revenue loss and evaluating the effectiveness of systems-based approaches to enhancing tobacco cessation efforts. METHODS:A retrospective cohort study utilized aggregated deidentified patient health data from an 8-hospital regional health system across Pennsylvania and Maryland, from 1/1/21 to 12/31/23. The analysis focused on primary care encounters eligible for tobacco cessation counseling (CPT codes 99406 or 99407), with potential revenue calculated based on the Medicare reimbursement rate. RESULTS:Over 3 years, and 507,656 office visits, only 1,557 (0.3%) of encounters with persons using tobacco were billed for cessation services. The estimated total potential revenue gained if each person who was identified as using tobacco was billed consistently for tobacco cessation counseling was $5,947,018.13, and $1,982,339.38 annually. CONCLUSIONS:The study reveals a significant gap between the potential and actual billing for tobacco cessation services, highlighting not only the financial implications of missed opportunities but also a validation of a health system's public health impact. Underbilling contributes to considerable annual revenue loss and undermines primary prevention efforts against tobacco-related diseases. The findings illuminate the need for enhanced billing practices and systemic changes, including policy improvements that influence proper billing to promote public health benefits through improved tobacco cessation interventions.

Introduction The term comprehensiveness was introduced into the literature as early as the 1960s and is regarded as a core attribute of primary care. Although comprehensive care is a primary care research priority encompassing patient and provider experience, cost, and health outcomes, there has been a lack of focus on consolidating existing definitions. Aim To unify definitions of comprehensiveness in primary care. Methods The PRISMA extension for scoping reviews was followed, hierarchically filtering 'comprehensiveness' MeSH terms and literature-defined affiliated terms. Snowballing methods were used to include additional literature from known experts. Articles were systematically reviewed with a three-clinician team. Results The initial search populated 679 607 articles, of which 25 were included. Identified key terms include: whole-person care (WPC), range of services, and referral to specialty care. WPC is the extent which primary care physicians (PCPs) consider the physical, emotional, and social aspects of a patient's health. It has been shown to positively impact clinical costs and outcomes, satisfaction, and trust. Range of services encompasses most health problems to reduce unnecessary spending on specialty care and promote continuity. Referral to specialty care is utilized when PCPs cannot provide the necessary services - balancing depth and breadth of care with the limitations of primary care scope. Discussion This scoping review unified the interrelatedness of comprehensiveness's main aspects - whole-person care, range of services, and referral to specialty care - framing a working, evidence-based definition: managing most medical care needs and temporarily complementing care with special integrated services in the context of patient's values, preferences, and beliefs.

We have studied the effect of modafinil and amphetamine, two waking drugs, on the electrical activity of central dopaminergic and noradrenergic neurons in the rat. Modafinil (128 mg/kg, i.p.) was unable to modify the firing pattern of these neurons, while amphetamine (2 or 5 mg/kg, i.p.) consistently inhibited their activity. A pretreatment with modafinil did not change thereafter the effect of amphetamine. Contrary to amphetamine, the waking effect of modafinil does not seem to be mediated by the catecholaminergic neuron activity per se.

Background:Despite widespread adoption during COVID-19, there is limited evidence supporting the quality of telemedicine care in managing patients with abnormal BMI. Objective:To evaluate the comparability of telemedicine and in-person (office) quality performance for abnormal body mass index (BMI kg/m2) screening and management in primary care. Methods:This retrospective cohort study measured Healthcare Effectiveness Data and Information Set (HEDIS) quality performance for abnormal BMI screening (patients with BMIs <18.5 or >25 kg/m2 and a qualifying documented follow up plan) across an 8-hospital integrated health system seen via primary care from 4/1/20 - 9/30/21. Encounters were divided into three exposure groups: office (excluding telemedicine), telemedicine (excluding office), and blended telemedicine (office + telemedicine). Demographic stratification compared group composition. Chi squared tests determined statistical differences in quality performance (p = <0.05). Results:Demographics of sub-groups for the 287,387 patients (office: 222,333; telemedicine: 1,556; blended-telemedicine: 63,489) revealed a modest female predominance, majority ages 26-70, mostly White non-Hispanics of low health risk, and the majority BMI representation was overweight, followed closely by class 1 obesity. In both HEDIS specified and HEDIS modified performance, blended-telemedicine performed better than office (12.56%, 95% CI 12.29%-13.01%; 11.16%, 95% CI: 10.85%-11.48%; p < 0.0001); office performed better than telemedicine (4.29%, 95% CI 2.84%-5.54%; 4.79%, 95% CI 3.99%-5.35%; p < 0.0001). Conclusion:Quality performance was highest for blended-telemedicine, followed by office-only, then telemedicine-only. Given the known cost savings, adding telemedicine as a care venue might promote value within health systems without negatively impacting HEDIS performance.

IMPORTANCE Despite its rapid adoption during the COVID-19 pandemic, it is unknown how telemedicine augmentation of in-person office visits has affected quality of patient care. OBJECTIVE To examine whether quality of care among patients exposed to telemedicine differs from patients with only in-person office-based care. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, standardized quality measures were compared between patients with office-only (in-person) visits vs telemedicine visits from March 1, 2020, to November 30, 2021, across more than 200 outpatient care sites in Pennsylvania and Maryland. EXPOSURES Patients completing telemedicine (video) visits. MAIN OUTCOMES AND MEASURES chi(2) tests determined statistically significant differences in Health Care Effectiveness Data and Information Set (HEDIS) quality performance measures between office-only and telemedicine-exposed groups. Multivariable logistic regression controlled for sociodemographic factors and comorbidities. RESULTS The study included 526 874 patients (409 732 office-only; 117 142 telemedicine exposed) with a comparable distribution of sex (196 285 [49.7%] and 74 878 [63.9%] women), predominance of non-Hispanic (348 127 [85.0%] and 105 408 [90.0%]) and White individuals (334 215 [81.6%] and 100 586 [85.9%]), aged 18 to 65 years (239 938 [58.6%] and 91 100 [77.8%]), with low overall health risk scores (373 176 [91.1%] and 100 076 [85.4%]) and commercial (227 259 [55.5%] and 81 552 [69.6%]) or Medicare or Medicaid (176 671 [43.1%] and 52 513 [44.8%]) insurance. For medication-based measures, patients with office-only visits had better performance, but only 3 of 5 measures had significant differences: patients with cardiovascular disease (CVD) receiving antiplatelets (absolute percentage difference [APD], 6.71%; 95% CI, 5.45%-7.98%; P <.001), patients with CVD receiving statins (APD, 1.79%; 95% CI, 0.88%-2.71%; P =.001), and avoiding antibiotics for patients with upper respiratory infections (APD, 2.05%; 95% CI, 1.17%-2.96%; P <.001); there were insignificant differences for patients with heart failure receiving beta-blockers and those with diabetes receiving statins. For all 4 testing-based measures, patients with telemedicine exposure had significantly better performance differences: patients with CVD with lipid panels (APD, 7.04%; 95% CI, 5.95%-8.10%; P <.001), patients with diabetes with hemoglobin A1c testing (APD, 5.14%; 95% CI, 4.25%-6.01%; P <.001), patients with diabetes with nephropathy testing (APD, 9.28%; 95% CI, 8.22%-10.32%; P <.001), and blood pressure control (APD, 3.55%; 95% CI, 3.25%3.85%; P <.001); this was also true for all 7 counseling-based measures: cervical cancer screening (APD, 12.33%; 95% CI, 11.80%-12.85%; P <.001), breast cancer screening (APD, 16.90%; 95% CI, 16.07%-17.71%; P <.001), colon cancer screening (APD, 8.20%; 95% CI, 7.65%-8.75%; P <.001), tobacco counseling and intervention (APD, 12.67%; 95% CI, 11.84%-13.50%; P <.001), influenza vaccination (APD, 9.76%; 95% CI, 9.47%-10.05%; P <.001), pneumococcal vaccination (APD, 5.41%; 95% CI, 4.85%-6.00%; P <.001), and depression screening (APD, 4.85%; 95% CI, 4.66%-5.04%; P <.001). CONCLUSIONS AND RELEVANCE In this cohort study of patients with telemedicine exposure, there was a largely favorable association with quality of primary care. This supports telemedicine's value potential for augmenting care capacity, especially in chronic disease management and preventive care. This study also identifies a need for understanding relationships between the optimal blend of telemedicine and in-office care.

Background Emergency department overutilization is a known contributor to the high per-capita healthcare cost in the United States. There is a knowledge gap regarding the substitution effect of walk-in clinic availability in primary care provider (PCP) offices and emergency department utilization (EDU). This study evaluates associations between PCP availability and EDU and analyzes the potential cost savings for health systems. Methods A retrospective cohort analysis compared low acuity EDU rates in established patients at a family medicine residency's PCP office before and after walk-in clinic implementation. The practice had 12 providers, 12 residents, and a patient panel of approximately 7,000-8,000. Inclusion criteria were met if patients were: (1) established with the PCP office, (2) had a low acuity emergency department (ED) visit (emergency index score level 4 or 5) OR had a walk-in clinic visit at the family practice. ED visits were tracked from January 2018 to January 2020 and encounters were compared numbers to pre and post-implementation of a walk-in clinic. Cost savings for comparable management was estimated with average price differences for low acuity encounters in the ED versus clinic. Results Over the two-year timeframe, there were 10,962 total visits to the ED by family practice patients, 4,250 of these visits were low acuity. Despite gross monthly increases of EDU from 2018-2020, after implementation of a walk-in clinic in 2019, rates of total EDU decreased by 1.5% and low acuity utilization rates also decreased. The average annual patient census nearly doubled from 5,763 to 8,042. T-tests confirmed statistical significance with p-values <0.05. Average low acuity ED visits ($437) cost 4.9 times more than comparable PCP office visits ($91). Managing 2,387 patients in the walk-in clinic resulted in an estimated annual cost savings of $ 825,902. Conclusion Extended walk-in availability in primary care offices provides non-ED capacity for low acuity management and might mitigate low acuity ED utilization while providing more cost-effective care. This study supports similarly described pre-hospital diversions in reducing ED over-utilization by increasing access to care. Higher levels of evidence are needed to establish causality.

This cohort study assesses patient adherence to diabetes screening using hemoglobin A1c level at in-person vs telemedicine encounters during the COVID-19 pandemic in the US.

This is a case of a 53-year-old male patient with a history of hypertension who developed sudden onset of right lower quadrant pain. On arrival, chest X-ray showed prominent aortic arch without cardiomegaly. CT of the abdomen/pelvis showed aortic dissection in descending aorta without rupture. CT of the chest displayed sparing of ascending and aortic arch. Ultrasound Doppler of the kidney displayed mild renal artery stenosis. Differential diagnosis was acute appendicitis, acute ureteric and severe gastroenteritis. The patient was started on oral blood pressure (BP) medicine to titrate off intravenous nicardipine and esmolol drip. After 10 days, he was switched to oral BP medicine. His leg pain was resolved with normal palpable pulse. One week later, his kidney function worsened. Thus, Lasix and minoxidil were stopped. The patient had no chest/abdominal pain and was tolerating the medicine well during his 2-week follow-up. Acute aortic dissection can be a fatal clinical emergency. Timing is critical during diagnosis and management of patients.