An electronic health record-based clinical alert intervention was associated with increases in captured opportunities for vaccination at both sick and well visits and significant improvements in immunization rates at 2 years of age. As electronic health records become more common in medical practice, such systems may transform immunization delivery to children.

Netflix was founded in 1997 to allow consumers access to video content from home. By 2000, focused on second-tier films, Netflix developed a subscription service featuring unlimited, fixed-price rentals. That same year, Netflix approached Blockbuster, the dominant movie rental company at that time, first offering to become Blockbuster's online retail arm and then to sell itself for $50 million. Both offers were declined. In 2008, Blockbuster declared that Netflix is "not even on the radar screen in terms of competition." 1 Failing to recognize Netflix's ability to satisfy the customer, Blockbuster filed for bankruptcy in 2010. In contrast, Netflix, now with more than 100 million subscribers, achieved dominance by betting on emerging technology for streaming video. What might this example teach us about the future of a very different service, pediatric primary care? By many measures, pediatric primary care is thriving. Primary care pediatricians serve a growing proportion of children compared with other specialists, are more accessible to the underserved, and address increasingly complex health and social problems. In parallel, the concept of the medical home championed by the American Academy of Pediatrics has fostered health care that is comprehensive, patient centered, and technology enabled, and that engages community resources.However, the Blockbuster case suggests that impressive achievements and scale should not lull any business, even one addressing a compelling social good, into complacency. Financial and lifestyle demands have already triggered dramatic changes in US pediatric primary care, with almost two-thirds of pediatricians working in group or health maintenance organization practices, compared with fewer than half of all pediatricians in the late 1980s. Now, a new wave of pressures from disruptive, consumer-focused competitors are challenging practice models. In this Viewpoint, we argue that these pressures threaten to undermine the medical home and underscore the urgent need for pediatricians to rethink the delivery of primary care.These pressures embody 2 prominent business concepts that provide a framework for understanding and responding to market challenges: creative destruction and the "innovator's dilemma." 2,3 Creative destruction emphasizes that all businesses and industries proceed through stages of formation, growth, maturity, and decline. As industries approach the decline stage, they can either disappear, as Blockbuster did, or reinvent themselves. Creative destruction is driven by changes in technology and consumer priorities, 2 forces directly affecting primary care. The innovator's dilemma addresses a common way in which existing businesses succumb to innovators. These businesses, including

Objectives/Hypothesis Pediatricians are the first physicians to see a dysphonic child (DC), yet there are limited data on their proficiency in caring for them. The objective of this study was to understand how pediatricians’ experience and their comfort in recognizing/diagnosing voice disorders affects their referral patterns and use of basic treatment options. Study Design Survey study. Methods A 13‐question survey was sent to pediatricians in the Children's Hospital of Philadelphia's primary care network; 45/216 were returned. Statistical analyses were performed using the Student t test, linear/logistic regression model, Fisher exact test, Kruskal‐Wallis test, and Spearman's correlation test. Results Pediatricians practicing longer are more comfortable recognizing dysphonia (P = .0022). They are significantly more likely to refer a DC, even without subjective complaints of hoarseness by the family/patient or compounding medical issues. For each year in practice, the probability of referring increases by 1.55% (P = .0017). Pediatricians with a higher percentage of dysphonic children in their practice are more likely to trust their own perceptual recognition when deciding to refer (P = .0496). Nearly all pediatricians (40/45) would refer to a pediatric otolaryngologist. None would refer to a laryngologist or a voice therapist. No factors significantly affected treatment options. Conclusions Veteran pediatricians feel more comfortable diagnosing a voice disorder and are more likely to refer a DC, regardless of patient/parent complaints or compounding factors. Pediatricians are most likely to refer to a pediatric otolaryngologist versus a voice specialist. These findings suggest that education of younger, less‐experienced pediatricians about recognizing voice disorders and options for referral is needed. This may improve the overall care of the DC. Level of Evidence 4 Laryngoscope, 129:1756–1762, 2019

Guidelines recommend that primary care clinicians address a broad range of wellness topics, but time constraints limit clinicians' ability to address them in the context of well child visits. A greater understanding of the salience of different wellness topics to families and clinicians may aid in prioritizing topics for practice-based interventions to promote wellness. We aimed to identify and compare parent and primary care clinicians' priorities for early childhood wellness. We conducted a cross-sectional discrete choice experiment with 100 parents/guardians of 2-4-year old children and 27 clinicians from three pediatric primary care practices (two urban, one suburban). Participants rated the relative importance of 24 wellness attributes from six domains: child physical, mental, social, and educational health, family wellness, and community wellness. We compared the rankings of attributes across the parent and clinician samples to understand the differential priorities of the groups and examined the domains of attributes that were highly ranked. In both parent and clinician samples, the highest ranked attributes related to the child or family while community-level attributes were ranked lower. Parents and clinicians both highly prioritized the parent/child relationship and avoiding family substance use. Parents more strongly prioritized child learning while clinicians more strongly prioritized food security and parent mood. Neighborhood social cohesion and parent health problems were of low priority to both groups. Priorities were similar across subgroups of parent race, education, income, and neighborhood poverty. Findings may aid primary care practices and clinicians in prioritizing topics for interventions to promote wellness in pediatric primary care.