A 21-item questionnaire can reliably measure four important organizational attributes relevant to family practices. These attributes can be used both as outcome measures as well as important features for targeting system interventions.

BACKGROUND-Obesity is associated with increased colorectal cancer incidence and mortality. Previous studies using telephone survey data showed that obese women were less likely to receive colorectal cancer screening. It is unknown if this is true among patients in primary care practices.

PURPOSEThe Using Learning Teams for Refl ective Adaptation (ULTRA) study used facilitated refl ective adaptive process (RAP) teams to enhance communication and decision making in hopes of improving adherence to multiple clinical guidelines; however, the study failed to show signifi cant clinical improvements. The purpose of this study was to examine qualitative data from 25 intervention practices to understand how they engaged in a team-based collaborative change management strategy and the types of issues they addressed. METHODSWe analyzed fi eld notes and interviews from a multimethod practice assessment, as well as fi eld notes and audio-taped recordings from RAP meetings, using an iterative group process and an immersion-crystallization approach.RESULTS Despite a history of not meeting regularly, 18 of 25 practices successfully convened improvement teams. There was evidence of improved practicewide communication in 12 of these practices. At follow-up, 8 practices continued RAP meetings and found the process valuable in problem solving and decision making. Seven practices failed to engage in RAP primarily because of key leaders dominating the meeting agenda or staff members hesitating to speak up in meetings. Although the number of improvement targets varied considerably, most RAP teams targeted patient care-related issues or practice-level organizational improvement issues. Not a single practice focused on adherence to clinical care guidelines.CONCLUSION Primary care practices can successfully engage in facilitated team meetings; however, leaders must be engaged in the process. Additional strategies are needed to engage practice leaders, particularly physicians, and to target issues related to guideline adherence. Ann Fam Med 2010;8:425-432. doi:10.1370/afm.1159. INTRODUCTIONThe quality of care in the United States is substandard, 1 and the early promise of improving care by translating research into practice has been disappointing. 2,3 Initial efforts to improve quality often target improving knowledge, attitudes, and behaviors of individual health professionals by using such strategies as audit and feedback, reminder systems, continuing medical education, and educational outreach. 4 These strategies have been found to produce modest change. 2,3,[5][6][7][8] Even when improvement changes are adopted, they are often not sustained over time 7 and may deteriorate after practice members' attention shifts elsewhere.8 Sustaining change appears to be an active process that requires continual attention as innovations are adapted to fi t continually evolving environments.9,10 Additionally, small, independent primary care practices often lack the resources 426T E A M -BA SED CHANGE M A NAGEMENT or motivation needed to develop quality improvement strategies that can address multiple clinical issues. 11The substantial, broad improvements required for optimal primary care cannot be achieved by focusing improvement efforts on specifi c diseases or on individual professional behavior. In fact, primary care pract...

Accurate measurement of cancer-preventive behaviors is important for quality improvement, research studies, and public health surveillance. Findings differ, however, depending on whether patient self-report or medical records are used as the data source. We evaluated concordance between patient self-report and medical records on risk factors, cancer screening, and behavioral counseling among primary care patients. Data from patient surveys and medical records were compared from 742 patients in 25 New Jersey primary care practices participating at baseline in SCOPE (supporting colorectal cancer outcomes through participatory enhancements), an intervention trial to improve colorectal cancer screening in primary care offices. Sensitivity, specificity, and rates of agreement describe concordance between self-report and medical records for risk factors (personal or family history of cancer, smoking), cancer screening (breast, cervical, colorectal, prostate), and counseling (cancer screening recommendations, diet or weight loss, exercise, smoking cessation). Rates of agreement ranged from 41% (smoking cessation counseling) to 96% (personal history of cancer). Cancer screening agreement ranged from 61% (Pap and prostatespecific antigen) to 83% (colorectal endoscopy) with self-report rates greater than medical record rates. Counseling was also reported more frequently by self-report (83% by patient self-report versus 34% by medical record for smoking cessation counseling). Deciding which data source to use will depend on the outcome of interest, whether the data is used for clinical decision making, performance tracking, or population surveillance; the availability of resources; and whether a false positive or a false negative is of more concern. (Cancer Epidemiol Biomarkers Prev 2008;17(11):2987 -94)

PURPOSE Care of patients with diabetes requires management of complex clinical information, which may be improved by the use of an electronic medical record (EMR); however, the actual relationship between EMR usage and diabetes care quality in primary care settings is not well understood. We assessed the relationship between EMR usage and diabetes care quality in a sample of family medicine practices. METHODSWe conducted cross-sectional analyses of baseline data from 50 practices participating in a practice improvement study. Between April 2003 and December 2004 chart auditors reviewed a random sample of medical records from patients with diabetes in each practice for adherence to guidelines for diabetes processes of care, treatment, and achievement of intermediate outcomes. Practice leaders provided medical record system information. We conducted multivariate analyses of the relationship between EMR usage and diabetes care adjusting for potential practice-and patient-level confounders and practice-level clustering.RESULTS Diabetes care quality in all practices showed room for improvement; however, after adjustment, patient care in the 37 practices not using an EMR was more likely to meet guidelines for process (odds ratio [OR], 2.25; 95% confi dence interval [CI], 1.42-3.57) treatment (OR, 1.67; 95% CI, 1.07-2.60), and intermediate outcomes (OR, 2.68; 95% CI,) than in the 13 practices using an EMR . CONCLUSIONSThe use of an EMR in primary care practices is insuffi cient for insuring high-quality diabetes care. Efforts to expand EMR use should focus not only on improving technology but also on developing methods for implementing and integrating this technology into practice reality. INTRODUCTIONU se of an electronic medical record (EMR) in ambulatory care settings has been widely recommended as a method for reducing errors, improving the quality of health care, and reducing costs. [1][2][3][4][5][6][7][8][9][10] One area where EMRs are expected to improve quality is in the management of care for patients with chronic illnesses, such as diabetes. For example, by facilitating the management of complex clinical information, EMRs have been shown to improve the coordination of tasks among members of the health care team, 8 to lead to lower rates of missing clinical information, 11and to support evidence-based clinical decision making. 12-15 Several recent systematic reviews of EMRs and clinical decision support systems have shown that systems developed in-house over many years lead health care institutions to improve adherence to clinical guidelines. [16][17][18] There is little evidence, however, on whether commercially developed multifunctional health information technology systems, such as EMRs, improve patient care in the primary care settings, where most chronic illness care is delivered. EMR A ND DIA BE T ES C A R E QU A L I T YMuch of the current evidence addressing EMR effectiveness in primary care settings is derived from a few intervention studies and from case study reports. Some studies have doc...