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This Issue: Ensuring High-Quality Care | Table of Contents: Fall 2017 | Download this issue

Editorials from VA Research Scientists

Dr. Richard L. Street Dr. Richard L. Street

A research agenda for communication between health care professionals and patients living with serious illness. James A. Tulsky, M.D.; Mary Catherine Beach, M.D., MPH; Phyllis N. Butow, Ph.D.; Susan E. Hickman, Ph.D.; Jennifer W. Mack, M.D., MPH; R. Sean Morrison, M.D.; Richard L. Street, Ph.D.; Rebecca L. Sudore, M.D.; Douglas B. White, M.D., MAS; Kathryn I. Pollak, Ph.D. JAMA Internal Medicine.

Dr. Richard L. Street, chief of the Health Decision-Making and Communication Program at the Michael E. DeBakey VA Medical Center in Houston, and his colleagues met to outline the role that poor communication can play in worsening the experience of patients with serious illness.

In an article published in JAMA, the researchers noted that poor communication can leave providers unsure of patient values, which can result in care that is not in sync with patient goals and is correlated with higher use of invasive care at the end of life. Patients may also not completely understand the extent of their illness and the treatment options open to them, say the study authors, if providers do not take the time to communicate in a meaningful way.

The research team identified evidence gaps and suggested five areas where further research could benefit patient care: measuring the quality of provider-patient communication, identifying provider behaviors that inspire patient trust, promoting advance care planning that focuses on better communication, teaching provider communication skills, and finding approaches to motivate clinicians to change their communication behavior.

Dr. Hardeep Singh Dr. Hardeep Singh

Towards more proactive approaches to safety in the electronic health record era. Dean F. Sittig, Ph.D., and Hardeep Singh, M.D., M.P.H. The Joint Commission Journal of Quality and Patient Safety.

Dr. Hardeep Singh is chief of the Health Policy, Quality and Informatics Program at the Michael E. DeBakey VA Medical Center. Together with his colleague Dr. Dean Sittig, he recently updated the electronic health record (EHR) patient safety guidelines known as the SAFER Guides—Safety Assurance Factors for EHR Resilience. They were developed to share best practices in health information technology to ensure patient safety. The guides' purpose are to assist both health care organizations and EHR developers in conducting recurring IT risk assessments. 

The authors suggest in their article that by taking a proactive approach to EHR risk assessment, health care professionals will be better able to mitigate technology-related patient care errors and learn from system vulnerabilities identified during SAFER assessments. They recommend that patient safety professionals, rather than IT staff, spearhead this process, so that risk assessments do not fall by the wayside.

To learn more about Dr. Singh's work on ways to improve patient safety via the technology, read "The Power and Perils of Electronic Health Records."

Dr. Hal S. Wortzel Dr. Hal S. Wortzel

Why suicide risk assessment still matters. Hal S. Wortzel, M.D.; Sarra Nazem, Ph.D.; Nazanin H. Bahraini, Ph.D.; Bridget B. Matarazzo, PsyD. Journal of Psychiatric Practice.

VA has made suicide prevention one of its key areas of focus and improvement in recent years. Unfortunately, the rate of death by suicide has remained relatively stable over the past 10 years, despite efforts aimed at risk assessment, says Dr. Hal S. Wortzel, director of neuropsychiatric services for the VA Rocky Mountain MIRECC in Denver. He and his co-authors argue that despite the seemingly limited effectiveness of suicide risk assessments, they still can be of value to clinicians and their patients, in an editorial published in the Journal of Psychiatric Practice.

The team cautions that when suicide risk assessment is done in a vacuum it can be of limited value, because it does not take into account the varied and unique attributes that each patient possesses. They recommend that risk assessment take place in concert with a comprehensive mental health assessment and treatment plan. Doing so may enhance the therapeutic relationship between provider and patient, help identify treatment targets, improve care, and perhaps, save a life.

Dr. David Shulkin Dr. David Shulkin

Curing hepatitis C virus infection: Best practices from the U.S. Department of Veterans Affairs. Pamela S. Belperio, PharmD.; Maggie Chartier, PsyD, MPH; David B. Ross, M.D., Ph.D., MBI; Poonam Alaigh, M.D.; David Shulkin, M.D.. Annals of Internal Medicine.

VA is the nation's largest provider of care for hepatitis C, having treated more than 92,000 Veterans since direct-acting antiviral (DAA) therapy became available in January 2014. VA Secretary Dr. David Shulkin and his coauthors suggest that VA's program of care for hepatitis C (HCV) could be a model for national efforts to combat the disease, in an article published in the Annals of Internal Medicine.

Recommendations put forth by the National Academies of Sciences, Engineering, and Medicine that emphasize prevention, screening, and universal treatment closely mesh with VA guidelines that embrace aggressive treatment of HCV. The VA health system uses an integrated approach to care delivered through multidisciplinary HCV Innovation Teams. It also tracks care for Veterans using population health tools like data registries that can identify patterns of access to care, a task closely aligned with improved patient outreach.

VA treatment approaches like the use of nonphysician providers, telehealth technologies, and integrated care practices that address mental health and substance use issues could be effectively adopted in the private sector, say the authors.

Dr. Jeffrey Kullgren Dr. Jeffrey Kullgren

Choosing Wisely: How to fulfill the promise in the next 5 years. Eve Kerr, M.D.; Jeffrey Kullgren, M.D.; Sameer Saini, M.D. Health Affairs.

In 2012, the American Board of Internal Medicine Foundation and Consumer Reports developed the Choosing Wisely campaign. Their goal was to reduce the incidence of "low value" care by encouraging physicians and their patients to talk about potentially unnecessary medical testing and procedures, and by issuing 45 clinical recommendations that have now grown to 500 at the end of 2016. Unfortunately, the targeted decreases in low-value care have not yet fully materialized.  

In a commentary published in the journal Health Affairs, three authors with the Center for Clinical Management Research at the VA Ann Arbor Healthcare System in Michigan—Drs. Eve Kerr, Jeffrey Kullgren and Sameer Saini—discuss the progress that the Choosing Wisely campaign has made, and suggest future areas of improvement.

The researchers say new efforts should start by identifying top-priority clinical targets, developing theory-based interventions, and applying clinically meaningful metrics to evaluating present interventions. They propose that one way forward could include collaboration between medical societies to develop standardized clinical recommendations for common tests and procedures among different patient populations. 

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