Tracy A. Lieu

Importance: Asynchronous structured electronic visits (e-visits) in which online systems ask defined questions about prespecified conditions are an emerging modality for providing highly convenient outpatient care. Scant information exists on their use and outcomes. Objectives: To (1) compare the percentage of initial visits made via e-visits with telephone, video, or office appointments for 4 common outpatient conditions; (2) compare rates of related follow-up visits within 7 days among visit modalities; and (3) identify patient characteristics associated with e-visit and follow-up visit use. Design, Setting, and Participants: Cross-sectional analysis of e-visits and telephone, video, and office visits made in Kaiser Permanente Northern California, where The Permanente Medical Group provides care for 4.6 million patients. The study population was defined based on initial outpatient visits (e-visits, telephone or video appointment visits, or physician’s office visits) by persons aged 18 years and older between January 1 and December 31, 2024, for 4 prespecified conditions. Data from 2023 and 2025 were used to analyze selected baseline variables. Main Outcomes and Measures: The numbers of e-visits and other types of visits for 4 diagnoses (urinary tract infection [UTI], seasonal allergies, acne, and international travel advice) in adults from January through December 2024 identified in electronic health record data and, secondarily, telephone advice calls identified for UTI alone. Initial visits were those without previous visits or medications for the condition in the prior 365 days. Analyses of the rates of follow-up visits used modified Poisson regression and adjusted for patient characteristics. To simplify interpretation, adjusted percentages of different types of visits and adjusted rates of follow-up visits were calculated via marginal standardization. Results: In 73 560 initial visits (86% by females; 41% by participants aged 18-39 years), e-visits were used in 58% (27 268 of 47 264) of UTI, 24% (3718 of 15 646) of seasonal allergy, 24% (1532 of 6426) of acne, and 56% (2377 of 4224) of international travel visits. E-visit use was highest among patients aged 18 to 29 years or 30 to 39 years for most conditions. After e-visits, follow-up visits for the same diagnosis within 7 days were uncommon: for UTI, the adjusted rate was 2.48%; for seasonal allergy, 6.45%; for acne, 2.11%; and for international travel, 0.12%. Follow-up visit rates after e-visits were lower than after other visit modalities for UTI, higher for seasonal allergy, and similar for acne and travel. For UTI e-visits, the risk of follow-up visits was higher among patients aged older than 65 years (adjusted relative risk, 2.50; 95% CI, 1.60-3.92), Hispanic patients, Asian patients, or those who were Medicaid insured. For seasonal allergy and acne, the risk of follow-up visits did not vary with patient characteristics. Conclusions and Relevance: In this cross-sectional study, high percentages of patients selected asynchronous physician-managed e-visits for common outpatient conditions in a setting where other visit types were available. Both e-visits and other visit types attained high rates of resolution without follow-up within 7 days.

During the pandemic, the US government loosened restrictions on telemedicine prescribing for controlled substance refills. Parent requests for attention-deficit/hyperactivity disorder (ADHD) medication refills have increased electronic inbox workload for physicians. Pharmacists can now fulfill these requests via collaborative practice agreements, but scant information exists on the effectiveness of this approach. To compare pharmacist with pediatrician management of ADHD medication refill requests regarding quality, timeliness, and parent ratings. This cluster randomized clinical trial assigned electronic ADHD medication refill requests from 63 medical facilities in a regional health care system to either Pharmacist Care by a regional team (32 facilities) or local Pediatrician Care (31 facilities) from May 14, 2024, to June 21, 2024. The primary outcome was prespecified in the study protocol as a quality measure to be evaluated among patients without weight and height recorded within 180 days before the refill request. This measure was based on national clinical guideline recommendations to monitor weight and height in children taking ADHD medications, which can be associated with reduced weight gain. It was met if the prescribing clinician collected a weight and height by parent report or initiated an in-person appointment. Among 2,442 eligible refill requests among study patients (mean age = 11.6 [SD = 3.1] years, 28.6% female), 512 received Pharmacist Care and 1,930 received Pediatrician Care; the latter group included 706 patients with unintended crossover from the group assigned to Pharmacist Care. Of the 793 refill requests eligible for evaluation of the primary outcome, 88.6% (132/149) with Pharmacist Care and 66.1% (426/644) with Pediatrician Care met the quality measure (adjusted rate ratio = 1.26; 95% CI = 1.13-1.40). Compared with pediatricians, pharmacists had slightly longer times to prescription ordering (median = 2.15 vs 1.78 hours, difference = 22 minutes) but similar times to medication filling and similar parent ratings of quality. Pharmacist management yielded more consistent quality of care and similar timeliness and parent ratings as pediatrician management of electronic ADHD medication refill requests.Study registration number: ClinicalTrials.gov NCT06388694.

Electronic visits (e-visits), defined as structured asynchronous electronic messages between patients and clinicians requiring clinical decision-making, are being increasingly used to enhance access to outpatient health care services, but the primary care physicians who typically manage them face work overflow. Pharmacists have been proposed to manage e-visits that lead to prescription requests, but scant evidence exists about the effectiveness of this approach. To compare pharmacist management of structured asynchronous e-visit requests for COVID-19 medication with physician management regarding quality of care, timeliness, and patient care experience. This cluster-randomized clinical trial included adults from 17 medical facilities of Kaiser Permanente Northern California who made e-visits requesting COVID-19 medication (nirmatrelvir-ritonavir) from October 9 to December 11, 2023. In the Pharmacist Care group, a regional team of pharmacists managed e-visits for COVID-19 medication; in the Physician Care group, pools of adult and family medicine physicians managed these visits. The primary outcome was whether a patient with 1 or more potential serious drug-drug interactions received counseling via an electronic secure message. Secondary outcomes included prescribing rates, time to the prescription, and patient perceptions of care quality. Among the 1,753 eligible patients (mean age = 52.2 [SD = 15.9] years; 57.7% female), 642 received Pharmacist Care and 1,111 received Physician Care. The percentage of patients with a potential drug-drug interaction who were sent counseling messages by the clinician did not differ between the Pharmacist Care (76 of 79 [96.2%]) and Physician Care groups (193 of 201 [96.0%]) (risk difference [RD] = 0.18%; 95% CI = -4.8% to 5.2%). The pharmacist and physician groups had similar rates of prescribing (87.4% vs 84.4%; RD = 2.9; 95% CI = -0.4 to 6.3). Pharmacist Care compared with Physician Care had faster mean time from the initial e-visit submission to the resulting prescription (1.0 vs 2.5 hours; RD = -1.5; 95% CI = -1.9 to -1.2). Pharmacist Care took more clinician time per visit than Physician Care (10.7 vs 4.2 minutes), resulting in higher estimated cost ($11.40 vs $6.70). After the study period, the pharmacist team made protocol changes to improve workflow efficiency, and a follow-up analysis 12 months later found significant reductions in per-visit time (to 5.7 minutes) and estimated cost (to $6.03) under Pharmacist Care. Patient perceptions of care did not differ significantly between groups. Pharmacist care and physician care for patient e-visits for COVID-19 medication both yielded high quality of care, with no significant group differences. Evaluation of pharmacist care may be warranted for other e-visits designed to facilitate medication prescribing. ClinicalTrials.gov NCT06096863.

Introduction Video visits have created new opportunities to enhance access to care, but limited information exists on strategies medical groups can employ to facilitate video visit use by higher-risk patients. Our objective was to identify ...

Vaccination is a crucial tool for controlling COVID-19, which has caused disproportionately high morbidity and mortality among Black and Latino persons in the US.^1,2 Vaccination rates among adults in these racial and ethnic groups initially trailed those of Asian and White adults, and uptake in Black adults continues to lag.³ Possible causes of this gap include worse access, skepticism about vaccine effectiveness or safety, and mistrust.^4,5

This quality improvement study assesses the success of medical assistant-supported virtual rooming for physician video visits among patients in Kaiser Permanente Northern California.

This Viewpoint summarizes a report from the National Academies of Sciences, Engineering, and Medicine that provides a taxonomy of evidence gaps in preventive se

Background: Increased work through electronic health record (EHR) messaging is frequently cited as a factor of physician burnout. However, studies to date have relied on anecdotal or self-reported measures, which limit the ability to match EHR use patterns with continuous stress patterns throughout the day. Objective: The aim of this study is to collect EHR use and physiologic stress data through unobtrusive means that provide objective and continuous measures, cluster distinct patterns of EHR inbox work, identify physicians’ daily physiologic stress patterns, and evaluate the association between EHR inbox work patterns and physician physiologic stress. Methods: Physicians were recruited from 5 medical centers. Participants (N=47) were given wrist-worn devices (Garmin Vivosmart 3) with heart rate sensors to wear for 7 days. The devices measured physiological stress throughout the day based on heart rate variability (HRV). Perceived stress was also measured with self-reports through experience sampling and a one-time survey. From the EHR system logs, the time attributed to different activities was quantified. By using a clustering algorithm, distinct inbox work patterns were identified and their associated stress measures were compared. The effects of EHR use on physician stress were examined using a generalized linear mixed effects model. Results: Physicians spent an average of 1.08 hours doing EHR inbox work out of an average total EHR time of 3.5 hours. Patient messages accounted for most of the inbox work time (mean 37%, SD 11%). A total of 3 patterns of inbox work emerged: inbox work mostly outside work hours, inbox work mostly during work hours, and inbox work extending after hours that were mostly contiguous to work hours. Across these 3 groups, physiologic stress patterns showed 3 periods in which stress increased: in the first hour of work, early in the afternoon, and in the evening. Physicians in group 1 had the longest average stress duration during work hours (80 out of 243 min of valid HRV data; P=.02), as measured by physiological sensors. Inbox work duration, the rate of EHR window switching (moving from one screen to another), the proportion of inbox work done outside of work hours, inbox work batching, and the day of the week were each independently associated with daily stress duration (marginal R2=15%). Individual-level random effects were significant and explained most of the variation in stress (conditional R2=98%). Conclusions: This study is among the first to demonstrate associations between electronic inbox work and physiological stress. We identified 3 potentially modifiable factors associated with stress: EHR window switching, inbox work duration, and inbox work outside work hours. Organizations seeking to reduce physician stress may consider system-based changes to reduce EHR window switching or inbox work duration or the incorporation of inbox management time into work hours.