Background Change champions are important for moving new innovations through the phases of initiation, development, and implementation. While research attributes positive healthcare changes to the help of champions, little work provides details on the champion role. Methods Using a combination of immersion/crystallization and matrix techniques, we analyzed qualitative data from a sample of 8 practices which included field notes of team meetings, interviews, and transcripts of facilitator meetings. Results Our analysis yielded insights into the value of having two discrete types of change champions: 1) those associated with a specific project (project champions) and 2) those leading change for entire organizations (organizational change champions). Relative to other practices under study, those that had both types of champions who complemented each other were best able to implement and sustain diabetes improvements. We provide insights into the emergence and development of these champion types, as well as key qualities necessary for effective championing. Discussion Practice transformation requires a sustained improvement effort that is guided by a larger vision and commitment and assures that individual changes fit together into a meaningful whole. Change champions – both project and organizational change champions – are critical players in supporting both innovation-specific and transformative change efforts.

This workaround typology provides a framework for EHR users to identify and address workarounds in their own practices, and for researchers to examine the effect of different types of EHR workarounds on patient safety, care quality, and efficiency.

Emergency department (ED) use for non-urgent needs is widely viewed as a contributor to various health care system flaws and inefficiencies. There are few qualitative studies designed to explore the complexity of patients' decision-making process to use the ED vs. primary care alternatives. In this study, semi-structured interviews were conducted with 30 patients who were discharged from the low acuity area of a university hospital ED. A grounded theory approach including cycles of immersion/crystallization was used to identify themes and reportable interpretations. Patients reported multiple decision-making considerations that hinged on whether or not they knew about primary care options. A model is developed depicting the complexity and variation in patients' decision-making to use the ED. Optimizing health system navigation and use requires improving objective factors such as access and costs as well as subjective perceptions of patients' health care, which are also a prominent part of their decision-making process.

BACKGROUND:The use of electronic health records (EHR) is widely recommended as a means to improve the quality, safety and efficiency of US healthcare. Relatively little is known, however, about how implementation and use of this technology affects the work of clinicians and support staff who provide primary health care in small, independent practices. OBJECTIVE: To study the impact of EHR use on clinician and staff work burden in small, communitybased primary care practices. DESIGN: We conducted in-depth field research in seven community-based primary care practices. A team of field researchers spent 9-14 days over a 4-8 week period observing work in each practice, following patients through the practices, conducting interviews with key informants, and collecting documents and photographs. Field research data were coded and analyzed by a multidisciplinary research team, using a grounded theory approach. PARTICIPANTS: All practice members and selected patients in seven community-based primary care practices in the Northeastern US. KEY RESULTS: The impact of EHR use on work burden differed for clinicians compared to support staff. EHR use reduced both clerical and clinical staff work burden by improving how they check in and room patients, how they chart their work, and how they communicate with both patients and providers. In contrast, EHR use reduced some clinician work (i.e., prescribing, some lab-related tasks, and communication within the office), while increasing other work (i.e., charting, chronic disease and preventive care tasks, and some lab-related tasks). Thoughtful implementation and strategic workflow redesign can mitigate the disproportionate EHRrelated work burden for clinicians, as well as facilitate population-based care. CONCLUSIONS: The complex needs of the primary care clinician should be understood and considered as the next iteration of EHR systems are developed and implemented.KEY WORDS: electronic health records; primary care; work burden; qualitative research.

Background: Care coordinators are increasingly featured in patient-centered medical home (PCMH) projects, yet little research examines how coordinators themselves define and experience their role. This is the first study describing experiences of care coordinators across the US from their own perspectives.Methods: This qualitative study used a 5-month private, online discussion forum to gather data from 25 care coordinators from PCMH practices representing diversity in practice size, setting, and type. Participants answered questions and interacted with one another, creating an online social learning collaborative while allowing for data collection for research.Results: Coordinators identified barriers and facilitators in their work at the organization/system level, the interpersonal level, and the individual level. Some factors emerged as both barriers and facilitators, including the functionality of clinical information technology; the availability of community resources; interactions with clinicians and other health care facilities; interactions with patients; and self-care practices for mental health and wellness. Colocation and full integration into practices were other key facilitators, whereas excessive case loads and data management responsibilities were felt to be important barriers.Conclusions: While all the barriers and facilitators were important to performing coordinators' roles, relationship building materialized as key to effective care coordination, whether with clinicians, patients, or outside organizations. We discuss implications for practice and provide suggestions for further research.

This paper has two complementary agendas. One is to develop a formal analysis of temporal ambiguity in self-identification. This refers specifically to having two conflicting orientations toward the future with regard to one's identity (e.g., a temporary expecting orientation and a permanent accepting orientation). I use the recovery identity (e.g., alcoholic, anorexic, agoraphobic) as a temporally ambiguous case because this identity is established as a means to an end but is susceptible to becoming an end in itself through identification with the disorder label. My analysis is based on the recovery narratives of individuals who have disidentified with their disorder labels; this allows for a consideration of the entire recovery career, from entry to exit. My second agenda is to explore the underresearched phenomenology of exiting from recovery identities specifically. Both of these agendas contribute new insight into identity research, labeling theory, and the sociology of mental health.

PURPOSE Despite a burgeoning population of cancer survivors and pending shortages of oncology services, clear definitions and systematic approaches for engaging primary care in cancer survivorship are lacking. We sought to understand how primary care clinicians perceive their role in delivering care to cancer survivors. METHODSWe conducted digitally recorded interviews with 38 clinicians in 14 primary care practices that had national reputations as workforce innovators. Interviews took place during intense case study data collection and explored clinicians' perspectives regarding their role in cancer survivorship care. We analyzed verbatim transcripts using an inductive and iterative immersion-crystallization process. RESULTS Divergent views exist regarding primary care's role in cancer survivor care with a lack of coherence about the concept of survivorship. A few clinicians believed any follow-up care after acute cancer treatment was oncology's responsibility; however, most felt cancer survivor care was within their purview. Some primary care clinicians considered cancer survivors as a distinct population; others felt cancer survivors were like any other patient with a chronic disease. In further interpretative analysis, we discovered a deeply ingrained philosophy of whole-person care that creates a professional identity dilemma for primary care clinicians when faced with rapidly changing specialized knowledge.CONCLUSIONS This study exposes an emerging identity crisis for primary care that goes beyond cancer survivorship care. Facilitated national conversations might help specialists and primary care develop knowledge translation platforms to support the prioritizing, integrating, and personalizing functions of primary care for patients with highly complicated issues requiring specialized knowledge.

IMPORTANCE Despite a decade of effort by national stakeholders to bring cancer survivorship to the forefront of primary care, there is little evidence to suggest that primary care has begun to integrate comprehensive services to manage the care of long-term cancer survivors.OBJECTIVE To explain why primary care has not begun to integrate comprehensive cancer survivorship services. DESIGN, SETTING, AND PARTICIPANTS Comparative case study of 12 advanced primary care practices in the United States recruited from March 2015 to February 2017. Practices were selected from a national registry of 151 workforce innovators compiled for the Robert Wood Johnson Foundation. Practices were recruited to include diversity in policy context and organizational structure. Researchers conducted 10 to 12 days of ethnographic data collection in each practice, including interviews with practice personnel and patient pathways with cancer survivors. Fieldnotes, transcripts, and practice documents were analyzed within and across cases to identify salient themes.MAIN OUTCOMES AND MEASURES Description of cancer survivorship care delivery in advanced patient-centered medical homes, including identification of barriers and promotional factors related to that care. RESULTSThe 12 practices came from multiple states and policy contexts and had a mix of clinicians trained in family or internal medicine. All but 3 were recognized as National Committee on Quality Assurance level 3 patient-centered medical homes. None of the practices provided any type of comprehensive cancer survivorship services. Three interdependent explanatory factors emerged: the absence of a recognized, distinct clinical category of survivorship in primary care; a lack of actionable information to treat this patient population; and current information systems unable to support survivorship care. CONCLUSIONS AND RELEVANCETo increase the potential for primary care transformation efforts to integrate survivorship services into routine care, survivorship must become a recognized clinical category with actionable care plans supported by a functional information system infrastructure.