After-visit Summaries Research Articles

Quality Improvement to Identify and Address Food Insecurity During Pediatric Hospitalizations.

Hospitalized children represent a vulnerable population with high rates of unidentified food insecurity (FI). We aimed to improve FI screening for eligible families from 0% to 60%. Secondarily, we sought to provide location-based food resources to families that screened positive. In February 2021, we developed a multidisciplinary team and used the Model for Improvement to improve routine FI screening for eligible children on 1 inpatient unit at a single institution. Our primary measure was the overall percentage of eligible families screened for FI. Our secondary measure was the percentage of families with FI who received food resource information. Statistical process control charts were used to analyze the impact of our interventions. A total of 8850 families were eligible for screening during the project period. The percentage of eligible families screened for FI increased from 0 to a mean of 77%, exceeding our goal, with special cause variation noted by 5 centerline shifts. The most impactful interventions were expansion of screening to patients admitted to all services and making FI screening questions required nursing admission documentation. Eleven percent of families screened positive for FI. Provision of resources increased from 56% with manual resource insertion into the after-visit summary to 100% with special cause variation associated with automated resource provision for positive screens. Integrating FI screening into the nursing admission workflow with automated resource provision for positive screens is a feasible approach to integrating FI screening into routine clinical practice during pediatric hospitalizations.

Improving Access to Community-Based Services for Sexual Assault Survivors

ABSTRACT Background Emergency department (ED) encounters are often the only healthcare provider encounter for patients seeking care after a reported sexual assault (SA), making the encounter a crucial opportunity to connect patients to support services in the community. An opportunity existed at an urban Level II trauma center to standardize SA discharge planning. Aims This quality improvement project aimed to improve access to SA support services. Methods The Model for Improvement guided two plan–do–study–act (PDSA) cycles. Implementation included (a) creation of a QR-code-accessible SA resource website, (b) ED standardized patient print and electronic medical record after-visit summaries with follow-up guidelines and the QR code, (c) ED staff education, and (d) a community stakeholder survey to assess facilitators and barriers to support services. Results During the first PDSA cycle, 19 reported SA survivors were seen in the ED (18 adult, one pediatric) and 14 SA resource website visits. During the second PDSA cycle, 13 reported SA survivors (10 adult, three pediatric) were seen in the ED and 29 website visits. Stakeholder survey data revealed barriers to support services were transportation, overloaded support services, and survivor knowledge of existing services. Conclusion The QR code intervention model is a discrete method of improving access to resources and is applicable to other vulnerable populations. The multiagency SA response team will utilize partner survey data to improve access to community resources such as housing and transportation.

Decoding oxygen prescriptions: electronic health record documentation versus patient-reported use

BackgroundLong term oxygen therapy (LTOT) is prescribed for hypoxemia in pulmonary disease. Like other medical therapies, LTOT requires a prescription documenting the dosage (flow rate) and directions (at rest, with activity) which goes to a supplier. Communication with patients regarding oxygen prescription (flow rate, frequency, directions), monitoring (pulse oximetry) and dosage adjustment (oxygen titration) differs in comparison with medication prescriptions. We examined the communication of oxygen management plans in the electronic health record (EHR), and their consistency with patient-reported LTOT use.Study design and methodsA cross-sectional study was conducted in 71 adults with chronic lung disease on LTOT. Physician communication regarding oxygen management was obtained from the EHR. Participants were interviewed on their LTOT management plan. The information from each source was compared.ResultsThe study population was, on average, 64 years, two-thirds women, and most used oxygen for over 3 years. Only 45% of both at-rest and with-activity oxygen prescriptions were documented in the Electronic Health Record (EHR). Less than 20% of prescriptions were relayed to the patient in the after-visit summary. Of those with EHR-documented oxygen prescriptions, 44% of patients adhered to prescribed oxygen flow rates. Nearly all patients used a pulse oximeter (96%).InterpretationWe identified significant gaps in communication of oxygen management plans from provider to patient. Even when the oxygen prescription was clearly documented, there were differences in patient-reported oxygen management. Critical gaps in oxygen therapy result from the lack of consistent documentation of oxygen prescriptions in the EHR and patient-facing documents. Addressing these issues systematically may improve home oxygen management.

Patient-Representing Population's Perceptions of GPT-Generated Versus Standard Emergency Department Discharge Instructions: Randomized Blind Survey Assessment.

Discharge instructions are a key form of documentation and patient communication in the time of transition from the emergency department (ED) to home. Discharge instructions are time-consuming and often underprioritized, especially in the ED, leading to discharge delays and possibly impersonal patient instructions. Generative artificial intelligence and large language models (LLMs) offer promising methods of creating high-quality and personalized discharge instructions; however, there exists a gap in understanding patient perspectives of LLM-generated discharge instructions. We aimed to assess the use of LLMs such as ChatGPT in synthesizing accurate and patient-accessible discharge instructions in the ED. We synthesized 5 unique, fictional ED encounters to emulate real ED encounters that included a diverse set of clinician history, physical notes, and nursing notes. These were passed to GPT-4 in Azure OpenAI Service (Microsoft) to generate LLM-generated discharge instructions. Standard discharge instructions were also generated for each of the 5 unique ED encounters. All GPT-generated and standard discharge instructions were then formatted into standardized after-visit summary documents. These after-visit summaries containing either GPT-generated or standard discharge instructions were randomly and blindly administered to Amazon MTurk respondents representing patient populations through Amazon MTurk Survey Distribution. Discharge instructions were assessed based on metrics of interpretability of significance, understandability, and satisfaction. Our findings revealed that survey respondents' perspectives regarding GPT-generated and standard discharge instructions were significantly (P=.01) more favorable toward GPT-generated return precautions, and all other sections were considered noninferior to standard discharge instructions. Of the 156 survey respondents, GPT-generated discharge instructions were assigned favorable ratings, "agree" and "strongly agree," more frequently along the metric of interpretability of significance in discharge instruction subsections regarding diagnosis, procedures, treatment, post-ED medications or any changes to medications, and return precautions. Survey respondents found GPT-generated instructions to be more understandable when rating procedures, treatment, post-ED medications or medication changes, post-ED follow-up, and return precautions. Satisfaction with GPT-generated discharge instruction subsections was the most favorable in procedures, treatment, post-ED medications or medication changes, and return precautions. Wilcoxon rank-sum test of Likert responses revealed significant differences (P=.01) in the interpretability of significant return precautions in GPT-generated discharge instructions compared to standard discharge instructions but not for other evaluation metrics and discharge instruction subsections. This study demonstrates the potential for LLMs such as ChatGPT to act as a method of augmenting current documentation workflows in the ED to reduce the documentation burden of physicians. The ability of LLMs to provide tailored instructions for patients by improving readability and making instructions more applicable to patients could improve upon the methods of communication that currently exist.

A Quality Improvement Project to Improve After-visit Summary Patient Instructions in a Pediatric Multidisciplinary Neuromuscular Program.

Multidisciplinary clinics aim to coordinate care between multiple specialties for children with medical complexity yet may result in information overload for caregivers. The after-visit summary (AVS) patient instruction section offers a solution by summarizing visit details and recommendations. No known studies address patient instruction optimization and integration within a multidisciplinary clinic setting. This project aimed to improve the quality of patient instructions to support better postvisit communication between caregivers and providers in a multidisciplinary pediatric neuromuscular program. A multidisciplinary stakeholder team created a key driver diagram to improve postvisit communication between caregivers and providers in the clinic. The first specific aim was to achieve an 80% completion rate of AVS patient instructions within 6 months. To do so, a standardized electronic medical record "text shortcut" was created for consistent information in each patient's instructions. Feedback on AVS from caregivers was obtained using the Family Experiences with Coordination of Care survey and open-ended interviews. This feedback informed the next specific aim: to reduce medical jargon within patient instructions by 25% over 3 months. Completion rates and jargon use were reviewed using control charts. AVS patient instruction completion rates increased from a mean of 39.4%-85.0%. Provider education reduced mean jargon usage in patient instructions, from 8.2 to 3.9 jargon terms. Provider education and caregiver feedback helped improve patient communication by enhancing AVS compliance and diminishing medical jargon. Interventions to improve AVS patient instructions may enhance patient communication strategies for complex medical visits.

Improving Naloxone Co-prescribing Through Clinical Decision Support.

Despite national guidelines recommending naloxone co-prescription with high-risk medications, rates remain low nationally.This was reflected atour institution with remarkably low naloxone prescribing rates.We sought to determine if a clinical decision support (CDS) tool could increase rates of naloxone co-prescribing with high-risk prescriptions. An alert in the electronic health record was triggered upon signing an order for a high-risk opioid medication without a naloxone co-prescription.We examined all opioid prescriptions written by family and general internal medicine practitioners at the University of Iowa Hospitals and Clinics in outpatient encounters between November 30, 2020, and February 28, 2022.Once triggered by a high-risk prescription, the CDS tool had the option to choose an order set with an automatically selected co-prescription for naloxone along with patient instructions automatically added to the patient's after-visit summary (AVS).We examined the monthly percentage of patients receiving Schedule II opioid prescriptions ≥90 morphine milliequivalents (MME)/day who received concurrent naloxone prescriptions in the 12 months before the CDS went live and the three months following go-live. Concurrent naloxone prescriptions increased from 1.1% in the 12 months prior to implementation in November 2021 to 9.4% (p<0.001) during the post-intervention period across eight family medicine and internal medicine clinics. This single-center quality improvement project with retrospective analysis demonstrates the potential efficacy of a single CDS tool in increasing the rate of naloxone prescription.The impact of such prescribing on overall mortality requires further research. The CDS tool was easy to implement and improved rates of appropriate naloxone co-prescribing.

The Feasibility and Acceptability of Sharing Video Recordings of Amyotrophic Lateral Sclerosis Clinical Encounters With Patients and Their Caregivers: Pilot Randomized Clinical Trial.

Multidisciplinary clinics (MDCs) provide benefits to patients with amyotrophic lateral sclerosis (ALS) and their caregivers, but MDC visits are information-heavy and can last 4 hours, with patients and caregivers meeting with multiple specialists within each MDC visit. There are questions about the effectiveness of current methods of sharing information from MDCs with patients. Video recordings are a promising new method of sharing information that may allow patients and caregivers to revisit the MDC and remind them of clinical recommendations and conversations. The objective of this trial is to determine the feasibility and acceptability of sharing information through video recordings of ALS MDC visits with patients and caregivers. This study was a randomized, controlled pilot trial with 3 months of follow-up from April 2021 to March 2022 in a rural multidisciplinary neurology clinic. We recruited patients with ALS, their caregivers, and their clinicians. Patients and their caregivers were randomized to either receive their normal after-visit summary (treatment as usual) or to receive their normal after-visit summary and a video recording of their MDC visit (video). Each specialist visit had its own recording and was accessible by patients and caregivers using a secure web-based platform called HealthPAL over a 3-month follow-up period. Primary study outcomes were feasibility and acceptability of the video intervention measured by recruitment rate (target: 70%), percentage of participants watching videos (target: 75%), and the Feasibility of Intervention Measure and Acceptability of Intervention Measure (targets: 3/5). We hypothesized that video recording would be feasible and acceptable to patients and their caregivers. Of the 30 patients approached, 24 were recruited, while all caregivers (n=21) and clinicians (n=34) approached were recruited. A total of 144 specialist visits were recorded, approximately 12 specialist visits at a median of one MDC visit per patient. Of the recorded patients, 75% (9/12) viewed videos. High median intervention feasibility (4, SD 0.99) and acceptability (4, SD 1.22) of intervention measures were reported by patients and caregivers in the intervention arm. High median intervention feasibility (5, SD 0.21) and acceptability (4.88, SD 0.4) were reported by clinicians. Of the 24 patients, 50% (n=12) did not complete a 3-month follow-up, primarily due to death (n=10). Video recording is highly feasible and acceptable for patients, caregivers, and clinicians at a rural ALS clinic. Our level of attrition is a useful benchmark for future studies in MDC populations. Despite high rates of patient death, 1-week assessments highlight the value of recordings for both patients and caregivers. ClinicalTrials.gov NCT04719403; https://clinicaltrials.gov/study/NCT04719403.

Communicating visit information to family caregivers: How does method matter? A national survey.

The clinic visit is a critical point of contact for family caregivers. However, only 37% of family caregivers are able to accompany patients to visits. When they cannot attend, caregivers receive visit information to assist with their caregiving. However, little is known about how method of receiving information from clinic visits is associated with important caregiver outcomes. This study sought to determine whether mode of receiving clinic visit information (speaking with the patient, attending the visit, or using an after-visit summary [AVS]) was associated with changes in caregiver burden, caregiver preparedness, and the positive aspects of caregiving. Cross-sectional web-based survey of a national sample of adult family caregivers. Multiple linear regression models determined associations between communication modes and caregivers' burden, preparedness, and positive aspects of caregiving, adjusting for sociodemographic covariates. Respondents (N = 340) were mostly male (58%), White (59%), ranged from 18 to 85 years old, and supported patients with conditions including diabetes, dementia, and cancer. Speaking with patients was associated with increases in positive aspects of caregiving (95% CI = 2.01, 5.42) and an AVS was associated with increases in positive aspects of caregiving (95% CI = 0.4, 3.56) and preparedness for caregiving (95% CI = 0.61, 3.15). Using any method of receiving information from visits was associated with the greatest increase in preparedness, compared to not receiving visit information. We did not observe an association between method of communication and caregiver burden. Method of communicating visit information is associated with improvements in caregiver preparedness and the positive aspects of caregiving, though caregiver burden may be unaffected by information exchange. Given the limitations of current communication methods, future work should explore directionality of the associations we found and identify visit communication strategies with caregivers that optimize caregiver and patient outcomes.

Abstract P155: Identifying Inpatient and Outpatient Factors That Reduce Heart Failure Exacerbation Readmissions

Acute heart failure 30-day readmissions are associated with increased patient morbidity and mortality. Our aim is to identify systemic factors that can reduce heart failure readmissions, including the implementation of a heart failure care coordination team. We assessed the hypothesis that individualized post-discharge education and summary from the heart failure care coordination team will reduce 30-day heart failure readmissions.This retrospective study included 213 patients, 18 years and older admitted with NYHA Class II-IV and ACC/AHA Stage B-D heart failure exacerbations from July 2021- March 2022, at a community hospital. Collected variables included demographics, medical comorbidities, labs, echocardiographic findings, inpatient orders, LACE index score, discharge follow-up, receipt of an after-visit summary, length of stay, and 30-day readmission. Descriptive data was summarized as counts and percentages for categorical data, and mean or median for continuous data. Between-group parametric data means were compared by calculating the t-test for independent variables, or medians using the Mann-Whitney U test for data that were nonparametric. Categorical variables were compared by calculating the chi-square test for association or Fisher’s exact test, as appropriate. The primary study objective was tested using Logistic regression modeling. Throughout this study, a p-value ≤0.05 (two-tail) was considered statistically significant. The medical records of all available reduced treatment plan patients were compared to preserved treatment plan patients in approximately equal numbers. Pair-wise t-tests required the greatest number of subjects. Using the conventional power level of 80%, a two-tailed alpha of 0.05, and assuming a medium effect size, it was estimated that this comparison will require at least 114 subjects. In this study, 189 of 213 patients were reached by the heart failure care coordination team. 49/189 were readmitted in 30 days and 140/189 were not. For the readmission group, the percentage of patients who were CKD Stage 3 or 4 (39.4%, 28 of 71) was higher than those who were not (21.1%, 30 of 142) with a p-value of 0.005. The percentage of patients who had discharge BNP checked (39.1%, 18 of 46) was higher than those who were not (24.1%, 40 of 166) with a p-value of 0.043. A higher LACE index score was associated with readmission as compared to a lower score, with a p-value of &lt; 0.001. In conclusion, presence of CKD stage 3 or 4, discharge BNP, and a higher LACE-index score were associated with 30-day heart failure readmission. Counterintuitively, the heart failure care coordination team did not have an impact on this endpoint, contrary to our hypothesis. Future studies with a larger sample size and focus on the outpatient care team efforts may be helpful in elucidating the team's potential in preventing heart failure readmission.

Patients and dermatologists are largely satisfied with ChatGPT-generated after-visit summaries: A pilot study

Patients and dermatologists are largely satisfied with ChatGPT-generated after-visit summaries: A pilot study

Abstract A004: Quitxt mobile text messaging cessation program for primary care and cancer patients development and implementation process

Abstract Background: Physicians have unparalleled access to smokers. It is estimated that over 70% of smokers visit a physician every year, which provides a powerful opportunity to promote tobacco cessation by asking about smoking behaviors and providing cessation advice and counseling to tobacco users at every visit. In general, smokers consider a physician’s advice to quit an important motivator to make a quit attempt. Every patient is screened for tobacco use; if the patient is a tobacco user, healthcare providers (HCPs) advise them to quit, offer nicotine replacement therapy if needed, and recommend enrollment in the Quitxt program to receive daily messages from the program as well as patient navigator support. Purpose: To conduct a system change to facilitate the integration of Quitxt into the healthcare setting of the Primary Care Center (PCC) and the Mays Cancer Center (MCC) at UT Health San Antonio, to increase accessibility and utilization of a bilingual, evidence-based tobacco cessation service among patients. Methods: We adapted our Quitxt program to the patient population attending the PCC and MCC, integrated it into EPIC, and added it to the Best Practice Advisories Banner. All patients are screened for tobacco use, and if a tobacco-using patient is identified, the Best Practice Advisories banner appears on HCPs’ screen, prompting them to counsel patients to quit and encourage them to enroll in Quitxt. Enrollment cards are available in exam rooms and help providers talk about the program and provide information on how to enroll. The EPIC system also places instructions on how to enroll in Quitxt in the patients’ after-visit summary. Selecting referral to Quitxt activates our Patient Navigators (PNs) follow-up. PNs contact patients monthly and provide support, positive reinforcement, and encouragement. They continue with monthly follow-ups throughout the duration of the program (6 months). Results: To date, 194 patients have been referred to the BestPractice basket. PNs made 829 follow-up phone calls. Of those patients, 104 have enrolled in the program. So far, 96% are English speakers, with a mean age of 47 yrs (SD 11.4); 64% female, 38% Hispanic, the mean number of cigarettes smoked per day was 12, and 60% were ready to make a quit attempt the next day. Preliminary results show cessation rates of 22.1% at day 1; 26.2% at 7 days; 20.4% at 1 month; 31.4% at 4 months and 27.6% at 6 months. Conclusion: Integrating Quitxt into the healthcare setting increases the accessibility and utilization of the Quitxt cessation service among primary care and cancer patients. Quitxt can be easily replicated and represents an affordable approach to reach tobacco-using patients, produce a public health impact, and reduce health service costs and tobacco-related diseases and mortality. Citation Format: Patricia Chalela, Vivian Cortez, Sandra G. Sivak, Armida Flores, Edgar Muñoz, Cliff Despres, Ramon Cancino, Mio Kitano, Rahul Mundlamuri, Ganesh R. Gunnam, David Akopian, Amelie G. Ramirez. Quitxt mobile text messaging cessation program for primary care and cancer patients development and implementation process [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A004.

Improving Treatment Adherence in Patients with Sickle Cell Disease

BACKGROUND: Crizanlizumab is approved for treatment of sickle cell disease (SCD) patients with frequent pain crises and hospital admissions. Here, we address systemic factors that have led to sub-optimal adherence to monthly crizanlizumab infusions at our institution. Due to 340B status limitation, the drug was originally offered at a site affiliated to our hospital with little SCD team presence. In 2020, UW hospital (primary site of SCD care) acquired 340B status, but transferring crizanlizumab infusions to UW hospital was not prioritized. In 2022, our institution's crizanlizumab adherence was 22% 1. Patients receiving crizanlizumab were interviewed to identify adherence barriers. Top barriers included location (44%), scheduling (44%), and low knowledge about the medication (67%). A detailed analysis with SCD team input revealed barriers such as restriction on opioids for day treatment, scheduling delays after hospital admissions, onerous paper orders process, different EMRs, and poor communication/coordination between sites (Fig 1). METHODS: The hospital leadership was appraised of these barriers in a series of meetings by the SCD team and approval to administer crizanlizumab at UW hospital infusion center was granted. UW health pharmacy and infusion staff planned a transition phase with 5 patients transitioned each month between March-April 2023. Crizanlizumab orders were updated in the EMR, and infusion nursing staff received training about the drug. Smart phrases were created for patient education in after visit summaries (AVS). Day treatment with IV fluids and pain management was offered with infusions. SCD care coordinator and social worker helped with scheduling, transport, and childcare. Providers aimed to discuss treatment goals and pros/cons during visits. Goal was set to assess adherence at months 3 and 12 after implementation. Average rate of adherence was defined as percent of prescribed treatments taken by the patient over a specified time period. In case of hospitalization, adherence was defined as rescheduling and receiving the treatment. We aimed to improve adherence to 50% at 3 months and 75% at 12 months if crizanlizumab FDA approval is maintained. RESULTS: By mid-July 2023, 11 patients were transitioned to UW Hospital for crizanlizumab infusions. 10/11 patients received the drug during this period (1 patient taken off due to pregnancy). The average adherence rate increased from 22% to 71% at 3 months, exceeding the original goal. 5/10 patients had an adherence rate of 75% or more. Additionally, 70% received at least one visit from the SCD social worker (SW) during treatment and 70% saw their provider concurrently with at least one visit. All patients received day treatment with supportive IVFs and/or pain medications during the infusion visit (Fig. 2). Only 2/10 patients had 25% or less adherence which occurred due to scheduling errors that will be addressed moving forward. DISCUSSION: Our study aims to address both intentional and unintentional barriers to crizanlizumab adherence that included infusion location, scheduling, and patient education. Our team advocated for the transition of infusions to the main hospital where they receive all other SCD care. This provided patients with direct access to their SCD team during infusions. Care coordinator and social work involvement helped consolidate treatment-related orders to one EMR, standardize nursing and patient education, organize scheduling, and address social barriers. The adherence rate increased from 22% to 71% at 3 months after implementation. Although the current approval of crizanlizumab is under review, we believe the barriers addressed in this project can be extended to current SCD treatments and upcoming novel therapies. Splitting care sites due to insurance and logistical reasons can create barriers for this vulnerable population due to complex care coordination and psychosocial needs. The rapid improvement in crizanlizumab adherence displayed here is a testament to the impact of having a dedicated SCD team at one leading site to advocate for and address the unique barriers to healthcare experienced by people with SCD. Sources 1. Nixon G, Fallon M, Fulcer K, Curran W, Nazeef M, Pradhan R. How can infusion therapy adherence by improved in Sickle Cell Disease. American Society of Health-System Pharmacists; Dec. 2022. Las Vegas, NV.

Increasing influenza and COVID-19 vaccination assessment rate in medical oncology clinics at a safety-net hospital.

437 Background: Vaccination against influenza and COVID-19 have been shown to reduce the risk of severe infection and adverse outcomes in immunocompromised individuals such as cancer patients. Consistent and accurate immunization assessment is the first step to identify patients who could benefit from these vaccines. The CDC Standards for Adult Immunization Practices recommend a vaccine assessment at every clinical encounter to ensure patients benefit from the latest recommendations. This process improvement project aims to increase COVID-19 and influenza vaccination assessment rate in new medical oncology patients within 2 weeks of their initial visit from a baseline of 6.1% - measured between 08/15/22 and 12/02/22. Methods: Parkland Health (PH) is the safety-net system for Dallas County, TX with an average of 2300 new cancer cases, of whom almost half are uninsured, and the majority belong to the racial/ethnic minorities. After mapping the assessment process and a root cause analysis, the multidisciplinary project team recommended a set of interventions with the goal to improve the assessment rate to 50%. The first PDSA cycle developed assessment policies and procedures, as well as group/individual training for clinic nurses. In the second PDSA, the weekly aggregate assessment rate was reviewed in safety huddles and a SmartPhrase was developed to document the immunization assessment in the after-visit summary (AVS). In the 3rd PDSA cycle, the immunization assessment tab was moved to nursing visit navigator in the electronic medical records (EMR) to streamline nursing assessment functions. This project is supported by the ASCO Quality Training Program and funded by the CDC/CMSS. Results: The first PDSA cycle resulted in a significant increase in vaccination rate, reaching 73.9% by week 4 (6-week average 51.9%). The second PDSA cycle resulted in the 5-week average rate increasing to 67.7%. A chart audit (included 25% of cases) showed that in 86.2%, patient’s vaccination was not up to date; however, the SmartPhrase was used in only 3.4% cases to document this in the AVS. Partial data (4-weeks) for the 3rd PDSA cycle shows an increase in average immunization assessment rate to 76.2%. In a post-intervention survey (response rate= 40.5%; 15), RNs estimated that the new immunization assessment added 1-5 minutes to their patient care time. In addition, 78.6% agreed/strongly agreed that the immunization assessment was an important part of their job, and 71.4% agreed/strongly agreed that the current process meets their expectations. Conclusions: Our interventions resulted in a consistent increase in immunization assessment for our new patients with minimal impact on clinic nurses’ time. In our next steps, we plan to further streamline the process across all patients (new and established). The ultimate goal of this project is to facilitate a high immunization rate among our cancer patients.

User-Centered Design and Evaluation of Clinical Decision Support to Improve Early Peanut Introduction: Formative Study.

Peanut allergy has recently become more prevalent. Peanut introduction recommendations have evolved from suggesting peanut avoidance until the age of 3 years to more recent guidelines encouraging early peanut introduction after the Learning Early about Peanut Allergy (LEAP) study in 2015. Guideline adherence is poor, leading to missed care opportunities. In this study, we aimed to develop a user-centered clinical decision support (CDS) tool to improve implementation of the most recent early peanut introduction guidelines in the primary care clinic setting. We edited the note template of the well-child check (WCC) visits at ages 4 and 6 months with CDS prompts and point-of-care education. Formative and summative usability testing were completed with pediatric residents in a simulated electronic health record (EHR). We estimated task completion rates and perceived usefulness of the CDS in summative testing, comparing a test EHR with and without the CDS. Formative usability testing with the residents provided qualitative data that led to improvements in the build for both the 4-month and 6-month WCC note templates. During summative usability testing, the CDS tool significantly improved discussion of early peanut introduction at the 4-month WCC visit compared to scenarios without the CDS tool (9/15, 60% with CDS and 0/15, 0% without CDS). All providers except one at the 4-month WCC scenario gave at least an adequate score for the ease of use of the CDS tool for the history of present illness and assessment and plan sections. During the summative usability testing with the 6-month WCC new build note template, providers more commonly provided comprehensive care once obtaining a patient history concerning for an immunoglobulin E-mediated peanut reaction by placing a referral to allergy/immunology (P=.48), prescribing an epinephrine auto-injector (P=.07), instructing on how to avoid peanut products (P<.001), and providing an emergency treatment plan (P=.003) with CDS guidance. All providers gave at least an adequate score for ease of use of the CDS tool in the after-visit summary. User-centered CDS improved application of early peanut introduction recommendations and comprehensive care for patients who have symptoms concerning for peanut allergy in a simulation.

Inequalities in Communicating about Nutrition Information during Prenatal Care: The After-Visit Summary

ABSTRACT Background Though prenatal nutrition information is critical, it is not known whether information is shared equitably by patient race, financial security, or English proficiency. Purpose To evaluate whether delivery or receipt of ChooseYourFish.org nutrition information in the first prenatal visit differed by patient demographics. Methods Analysis of clinician-document electronic health record (EHR) or patient-reported surveys compared delivery and receipt of fish-related nutrition information in the first prenatal visit. Inferential statistics were used to compare delivery or receipt and race, ethnicity, payor, or interpreter use. Results EHR analysis (n = 2,329) revealed Medicaid patients who used an interpreter were half as likely to have the fish nutrition message in their after-visit summary compared to those with Medicaid who did not use an interpreter (OR = 0.54, 95% CL: 0.35–0.84). The same was not true for non-Medicaid patients. Survey analysis (n = 52) showed respondents identifying as Black or African American were 25% less likely to report receiving the after-visit summary compared to respondents who identified as white (p < .01). Discussion The results presented here illustrate how nutrition communication in the prenatal period can differ by patient race, financial security, and language. Translation to Health Education Practice: Culturally humble efforts to understand drivers of healthcare communication are needed to eliminate inequalities. A AJHE Self-Study quiz is online for this article via the SHAPE America Online Institute (SAOI) http://portal.shapeamerica.org/trn-Webinars

Improving Accessibility in the Emergency Department for Patients with Disabilities: A Qualitative Study.

The emergency department (ED) is a critical service area for patients living with disabilities in the United States. Despite this, there is limited research on best practices from the patient experience regarding accommodation and accessibility for those with disabilities. In this study we investigate the ED experience from the perspective of patients living with physical and cognitive disability, as well as visual impairment and blindness, to better understand the barriers to accessibility in the ED for these populations. Twelve individuals with either physical or cognitive disabilities, visual impairments or blindness were interviewed regarding their ED experiences, particularly related to accessibility. Interviews were transcribed and coded for qualitative analysis with generation of significant themes relating to accessibility in the ED. Major themes from coded analysis were as follows: 1) inadequate communication between staff and patients with visual impairments and physical disabilities; 2) the need for electronic delivery for after-visit summaries for individuals with cognitive and visual disabilities; 3) the importance of mindful listening and patience by healthcare staff; 4) the role of increased hospital support including greeters and volunteers; and 5) comprehensive training with both prehospital and hospital staff around assistive devices and services. This study serves as an important first step toward improving the ED environment to ensure accessibility and inclusivity for patients presenting with various types of disabilities. Implementing specific training, policies, and infrastructure changes may improve the experiences and healthcare of this population.

Patient Satisfaction With Speech Recognition in the Exam Room: Exploratory Survey.

Medical speech recognition technology uses a microphone and computer software to transcribe the spoken word into text and is not typically used in outpatient clinical exam rooms. Patient perceptions regarding speech recognition in the exam room (SRIER) are therefore unknown. This study aims to characterize patient perceptions of SRIER by administering a survey to consecutive patients scheduled for acute, chronic, and wellness care in three outpatient clinic sites. We used a microphone and medical speech recognition software to complete the "assessment and plan" portion of the after-visit summary in the patient's presence, immediately printed the after-visit summary, and then administered a 4-question exploratory survey to 65 consecutive patients in internal medicine and pulmonary medicine clinics at an academic medical center and a community family practice clinic in 2021 to characterize patient perceptions of SRIER. All questions were completed by all participants. When compared to patients' recollection of usual care (visits with no microphone and an after-visit summary without an "assessment and plan"), 86% (n=56) of respondents agreed or strongly agreed that their provider addressed their concerns better, and 73% (n=48) agreed or strongly agreed that they understood their provider's advice better. A total of 99% (n=64) of respondents agreed or strongly agreed that a printed after-visit summary including the "assessment and plan" was helpful. By comparing the "agree" and "strongly agree" responses to the neutral responses, we found that patients felt that clinicians using SRIER addressed their concerns better (P<.001), they understood their clinician's advice better (P<.001), and receiving a paper summary was helpful (P<.001). Patients were likely to recommend a provider using a microphone based on the Net Promoter Score of 58. This survey suggests patients have a very positive perception of speech recognition use in the exam room.

Evaluating the Usability of an Emergency Department After Visit Summary: Staged Heuristic Evaluation.

Heuristic evaluations, while commonly used, may inadequately capture the severity of identified usability issues. In the domain of health care, usability issues can pose different levels of risk to patients. Incorporating diverse expertise (eg, clinical and patient) in the heuristic evaluation process can help assess and address potential negative impacts on patient safety that may otherwise go unnoticed. One document that should be highly usable for patients-with the potential to prevent adverse outcomes-is the after visit summary (AVS). The AVS is the document given to a patient upon discharge from the emergency department (ED), which contains instructions on how to manage symptoms, medications, and follow-up care. This study aims to assess a multistage method for integrating diverse expertise (ie, clinical, an older adult care partner, and health IT) with human factors engineering (HFE) expertise in the usability evaluation of the patient-facing ED AVS. We conducted a three-staged heuristic evaluation of an ED AVS using heuristics developed for use in evaluating patient-facing documentation. In stage 1, HFE experts reviewed the AVS to identify usability issues. In stage 2, 6 experts of varying expertise (ie, emergency medicine physicians, ED nurses, geriatricians, transitional care nurses, and an older adult care partner) rated each previously identified usability issue on its potential impact on patient comprehension and patient safety. Finally, in stage 3, an IT expert reviewed each usability issue to identify the likelihood of successfully addressing the issue. In stage 1, we identified 60 usability issues that violated a total of 108 heuristics. In stage 2, 18 additional usability issues that violated 27 heuristics were identified by the study experts. Impact ratings ranged from all experts rating the issue as "no impact" to 5 out of 6 experts rating the issue as having a "large negative impact." On average, the older adult care partner representative rated usability issues as being more significant more of the time. In stage 3, 31 usability issues were rated by an IT professional as "impossible to address," 21 as "maybe," and 24 as "can be addressed." Integrating diverse expertise when evaluating usability is important when patient safety is at stake. The non-HFE experts, included in stage 2 of our evaluation, identified 23% (18/78) of all the usability issues and, depending on their expertise, rated those issues as having differing impacts on patient comprehension and safety. Our findings suggest that, to conduct a comprehensive heuristic evaluation, expertise from all the contexts in which the AVS is used must be considered. Combining those findings with ratings from an IT expert, usability issues can be strategically addressed through redesign. Thus, a 3-staged heuristic evaluation method offers a framework for integrating context-specific expertise efficiently, while providing practical insights to guide human-centered design.

Disparities in eye clinic patient encounters among patients requiring language interpreter services

BackgroundCommunication barriers are a major cause of health disparities for patients with limited English proficiency (LEP). Medical interpreters play an important role in bridging this gap, however the impact of interpreters on outpatient eye center visits has not been studied. We aimed to evaluate the differences in length of eyecare visits between LEP patients self-identifying as requiring a medical interpreter and English speakers at a tertiary, safety-net hospital in the United States.MethodsA retrospective review of patient encounter metrics collected by our electronic medical record was conducted for all visits between January 1, 2016 and March 13, 2020. Patient demographics, primary language spoken, self-identified need for interpreter and encounter characteristics including new patient status, patient time waiting for providers and time in room were collected. We compared visit times by patient’s self-identification of need for an interpreter, with our main outcomes being time spent with ophthalmic technician, time spent with eyecare provider, and time waiting for eyecare provider. Interpreter services at our hospital are typically remote (via phone or video).ResultsA total of 87,157 patient encounters were analyzed, of which 26,443 (30.3%) involved LEP patients identifying as requiring an interpreter. After adjusting for patient age at visit, new patient status, physician status (attending or resident), and repeated patient visits, there was no difference in the length of time spent with technician or physician, or time spent waiting for physician, between English speakers and patients identifying as needing an interpreter. Patients who self-identified as requiring an interpreter were more likely to have an after-visit summary printed for them, and were also more likely to keep their appointment once it was made when compared to English speakers.ConclusionsEncounters with LEP patients who identify as requiring an interpreter were expected to be longer than those who did not indicate need for an interpreter, however we found that there was no difference in the length of time spent with technician or physician. This suggests providers may adjust their communication strategy during encounters with LEP patients identifying as needing an interpreter. Eyecare providers must be aware of this to prevent negative impacts on patient care. Equally important, healthcare systems should consider ways to prevent unreimbursed extra time from being a financial disincentive for seeing patients who request interpreter services.

Abstract P6-05-20: Quitxt Mobile Cessation Service for Cancer Patients: Development and Implementation Process

Abstract Background: Physicians have unparalleled access to smokers. It is estimated that over 70% of smokers visit a physician every year, which provides a powerful opportunity to promote tobacco cessation by asking about smoking behaviors and providing cessation advice and counseling to tobacco users at every visit. In general, smokers consider a physician’s advice to quit an important motivator to make a quit attempt. We adapted our Quitxt program to the patient population attending the Mays Cancer Center at UT Health San Antonio. Every patient is screened for tobacco use; if the patient is a tobacco user, healthcare providers (HCPs) advise them to quit, offer nicotine replacement therapy if needed, and recommend enrollment in the Quitxt program. Purpose: We present the development process and implementation of Quitxt, our evidence-based, bilingual mobile cessation service tailored to the patient population of the Mays Cancer Center (MCC). Methods: Tobacco screening was integrated into EPIC, and the Quitxt program was added to the BestPractice Advisories Banner. All patients are screened for tobacco use. If a tobacco-using patient is identified, the BestPractice Advisories Banner will appear, prompting HCPs to counsel patients to quit and encourage them to enroll in Quitxt. Selecting referral to Quitxt will activate our Patient Navigator (PNs) follow-up. PNs contact patients and provide support, positive reinforcement, and encouragement. They continue with monthly follow-ups for the duration of the program. The EPIC system also places instructions on how to enroll in Quitxt in the patients’ after-visit summary. The Quitxt library of messages was adapted to the patient population of the MCC. We also developed a news-style video for HCPs with peer modeling on how to approach patients and enroll them in Quitxt. Results: The program will be launched at the MCC on August 1st, 2022. We will present the development and implementation process and preliminary results related to patient enrollment characteristics, stages of change, smoking abstinence, and patient navigation support. Conclusion: This project will greatly increase the accessibility and utilization of a bilingual evidence-based smoking cessation service among primary care and cancer patients. Quitxt will also serve as a model that can be easily adapted and replicated by any organization or network interested in serving their patients with an evidence-based cessation program. Quitxt represents an affordable approach to reach tobacco-using patients, produce a public health impact, reduce health service costs, and reduce tobacco-related diseases and mortality. Citation Format: Patricia Chalela, Vivian Cortez, Armida Flores, Sandra Sivak, Ysabel Lew, Edgar Munoz, Cliff Despres, Sarah Ruiz, Ramon Cancino, Mio Kitano, Rahul Mundlamuri, Ganesh Gunnam, David Akopian, Ruben Mesa, Amelie Ramirez. Quitxt Mobile Cessation Service for Cancer Patients: Development and Implementation Process [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-20.