PURPOSE We wanted to undertake a critical review of the medical literature regarding the relationships between interpersonal continuity of care and the outcomes and cost of health care.METHODS A search of the MEDLINE database from 1966 through April 2002 was conducted by the primary author to fi nd original English language articles focusing on interpersonal continuity of patient care. The articles were then screened to select those articles focusing on the relationship between interpersonal continuity and the outcome or cost of care. These articles were systematically reviewed and analyzed by both authors for study method, measurement technique, and quality of evidence.RESULTS Forty-one research articles reporting the results of 40 studies were identifi ed that addressed the relationship between interpersonal continuity and care outcome. A total of 81 separate care outcomes were reported in these articles. Fifty-one outcomes were signifi cantly improved and only 2 were signifi cantly worse in association with interpersonal continuity. Twenty-two articles reported the results of 20 studies of the relationship between interpersonal continuity and cost. These studies reported signifi cantly lower cost or utilization for 35 of 41 cost variables in association with interpersonal continuity.CONCLUSIONS Although the available literature refl ects persistent methodologic problems, it is likely that a signifi cant association exists between interpersonal continuity and improved preventive care and reduced hospitalization. Future research in this area should address more specifi c and measurable outcomes and more direct costs and should seek to defi ne and measure interpersonal continuity more explicitly. Ann Fam Med INTRODUCTIONC ontinuity of care traditionally is considered one of the core principles of family medicine, 1,2 and it is a core element of the Institute of Medicine defi nition of primary care. 3 Recently there has been a resurgence of interest in this subject, and the Annals of Family Medicine has devoted a theme issue to the topic. 4 This resurgence has occurred in part because of the growing sophistication of research in family medicine and because of changes in American health care that many believe have undermined continuity in the relationship between physicians and their patients.5-11 A central question facing the future of family medicine is the degree to which we will provide personal health care based on the individual doctor-patient relationship, or whether we will seek to provide a medical home for patients based on an interdisciplinary team with less emphasis on personal care. 12Continuity has proved to be a diffi cult variable to defi ne and measure. Several previous reviews of this subject have noted major limitations to its research foundation because of inconsistent defi nitions and complex methodologic challenges. [13][14][15][16][17][18] In early 2002, we undertook a comprehensive review of the medical literature to examine one aspect of continuity 160INTERPERSONAL CONTINUITY AND...

Background Rates of burnout among physicians have been high in recent years. The electronic health record (EHR) is implicated as a major cause of burnout. Objective This article aimed to determine the association between physician burnout and timing of EHR use in an academic internal medicine primary care practice. Methods We conducted an observational cohort study using cross-sectional and retrospective data. Participants included primary care physicians in an academic outpatient general internal medicine practice. Burnout was measured with a single-item question via self-reported survey. EHR time was measured using retrospective automated data routinely captured within the institution's EHR. EHR time was separated into four categories: weekday work-hours in-clinic time, weekday work-hours out-of-clinic time, weekday afterhours time, and weekend/holiday after-hours time. Ordinal regression was used to determine the relationship between burnout and EHR time categories. Results EHR use during in-clinic sessions was related to burnout in both bivariate (odds ratio [OR] = 1.04, 95% confidence interval [CI]: 1.01, 1.06; p = 0.007) and adjusted (OR = 1.07, 95% CI: 1.03, 1.1; p = 0.001) analyses. No significant relationships were found between burnout and after-hours EHR use. Conclusion In this small single-institution study, physician burnout was associated with higher levels of in-clinic EHR use but not after-hours EHR use. Improved understanding of the variability of in-clinic EHR use, and the EHR tasks that are particularly burdensome to physicians, could help lead to interventions that better integrate EHR demands with clinical care and potentially reduce burnout. Further studies including more participants from diverse clinical settings are needed to further understand the relationship between burnout and after-hours EHR use.

Background:Health system redesign necessitates understanding patient population characteristics, yet many primary care physicians are unable to identify patients on their panel. Moreover, accounting for differential workload due to patient variation is challenging. We describe development and application of a utilization-based weighting system accounting for patient complexity using sociodemographic factors within primary care at a large multidisciplinary group practice.Methods:A retrospective observational study was conducted of 27 clinics across primary care serving more than 150 000 patients. Before and after implementation, we measured empanelment by comparing weighted to unweighted panel size and the number of physicians who could accept patients. Perceived access was measured by the number of patients strongly agreed that an appointment was available when needed.Results:After instituting weighting, the percentage of physicians with open panels decreased for family physicians and pediatricians, but increased for general internists; the number of active patients increased by 2%. One year after implementation, perceived access improved significantly in family and general internal medicine clinics (P < .05). There were no significant changes for general pediatric and adolescent medicine patients.Conclusions:The creation of a weighing system accounting for complexity resulted in changes in practice closure, increased total patients, and improved access.

Community and population health principles have become part of the fabric of the entire residency curriculum in the DFMCH. Faculty development was a key part of this work and will be integral to sustaining improvements.

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