PIs:  Auerbach, Najafi (UCSF)

Co-Investigators (see below): Raman Khanna UCSF, Arora (Univ Chicago), Gupta (UCLA), Moriates (UT Austin).

Although there is intense scrutiny on costs of care and improving healthcare value, there are few data to describe how trainees and attending physicians’ day-to-day workload, local culture, and training interact to produce variations in the value of care delivered.  As a result, there is a substantial gap in our ability to train physicians towards a value-focused future practice style.

Aim: The overall goal of this study is to develop a prospective and scalable approach to gaining periodic, valid snapshots of trainees’ and attending physicians’ practices in delivering healthcare. 

Hypotheses: That 'ecological momentary assessments' timed to clinical care work will provide important contextual information needed to understand issues such as burnout, specific practice patterns (such as choice of high or low-value tests or medications).  

Methods: We will utilize electronic health record systems (Epic, primarily) linked to call schedules maintained at each site, to carry out prospective momentary ecological assessments – periodic surveys delivered at or near the time specific clinical experiences take place - of how trainees and attending physicians perceptions of the key factors (culture, training, workload) which are highly associated with choices at the point of care. As a key first metric, we will focus on newly validated ‘culture of value’ indicators derived by Drs. Gupta, Arora, and Moriates.

Gaining understanding of front line providers’ perceptions will provide a critical layer of contextual data needed to develop training models, frame approaches to workforce issues (e.g. novel work hours models), as well as enhanced decision support needed to overcome barriers to best practices (or take advantages of opportunities to improve care more rapidly).

Our project will be led by investigators at UCSF (Drs. Auerbach, Najafi, Khanna), University of Chicago (Vineet Arora MD, MAPP), the University of California, Los Angeles (Reshma Gupta MD), as well as the Dell Medical School at The University of Texas at Austin (Christopher Moriates MD);.

We plan to use FHIR AP access to Epic systems at each site to identify general medical patients, certain target care practices (such as obtaining a CT scan for dyspnea, or repeated CBC’s in patients with pneumonia) and the identifier of the team caring for them.  

By linking Epic data to call schedule data (Amion.com or similar) maintained at each site, we can then deliver personalized surveys to provider physicians within a period of time likely to reduce recall bias and increase validity of the results. Examples of surveys to be tested and disseminated include the high-value care culture survey developed by members of our team, surveys examining the perceived utility of specific testing, as well as surveys asking about burnout and job satisfaction. These surveys will be delivered via web-based survey and subsequently linked to clinical and/or administrative data (e.g. total costs of care for pneumonia) from each site.

Our technical approach is built on one successfully piloted by Nader Najafi MD in the Division of Hospital Medicine at UCSF, and will be extended through expertise we are gaining (FHIR APIs) as part of Dr. Auerbach and Dr. Khanna’s work developing the UCSF Digital Diagnostics and Therapeutics Program,  an oversight body charged with the implementation of FHIR integration at UCSF. Finally, and most importantly, our program builds on the leadership and extensive expertise of Drs. Arora, Gupta, and Moriates in defining optimal work hour models, approaches to assessing and improving healthcare value, and GME training,

Study design: We propose a technical feasiblity pilot at sites with Epic health system EHRs, and which utilize AMION for hospitalist and resident call schedules.

Characteristics of sites who might participate: Should have local expertise in API-driven integrations with Epic, use of a standard call schedule program such as Amion. 

Potential funders: We anticipate applying for CTSA supplementary funding in November 2017.