Clinical Documentation Research Articles

Athletic Trainers’ Perceptions of the Structure and Barriers to Online Continuing Education Clinical Documentation Modules

Context Athletic trainers (ATs) appreciate the accessibility of web-based continuing education (CE) opportunities. ATs describe needing more CE opportunities related to clinical documentation, but the effectiveness of CE in this content area has not been studied. Objective Obtain ATs’ perceptions of their experiences accessing web-based CE specific to clinical documentation. Design Qualitative study. Setting Web-based audio interviews. Patients or Other Participants Twenty-nine ATs, averaging 36.2 ± 9.0 years of age, including 16 women and 13 men who represented 8 different clinical practice settings. Data Collection and Analysis Participants previously completed 1 of 2 web-based CE modules specific to clinical documentation, a personalized learning pathway (PLP) or passive reading list (PAS). After completing the modules, 1 investigator interviewed each participant regarding their experiences accessing and completing the modules. Following the Consensual Qualitative Research approach, 4 investigators (3 primary coders and 1 internal auditor) inductively analyzed the interview transcripts. We completed 5 rounds of consensus coding and finalized themes and supporting categories. Results We identified 2 themes: (1) structure and (2) barriers to completing the modules. Although both groups were satisfied with the content of the modules, PLP participants were more satisfied with the structure and experience of accessing the resources than the PAS participants. PLP participants enjoyed the engagement of the variety of resources included, whereas PAS participants inconsistently accessed reading materials based on personal preference. Both groups described time as a barrier to completing the modules, and some participants experienced technology barriers. Conclusions ATs value web-based CE opportunities that compile information related to a topic. Learners find a variety of learning formats, including videos, case studies, knowledge checks, and reflection prompts, to be more engaging than only reading materials. Although time continues to be a barrier to completing CE, offering accessible and engaging learning opportunities improves satisfaction with completing CE.

Current Applications of Artificial Intelligence in Billing Practices and Clinical Plastic Surgery

Summary: Integration of artificial intelligence (AI), specifically with natural language processing and machine learning, holds tremendous potential to enhance both clinical practices and administrative workflows within plastic surgery. AI has been applied to various aspects of patient care in plastic surgery, including postoperative free flap monitoring, evaluating preoperative risk assessments, and analyzing clinical documentation. Previous studies have demonstrated the ability to interpret current procedural terminology codes from clinical documentation using natural language processing. Various automated medical billing companies have used AI to improve the revenue management cycle at hospitals nationwide. Additionally, AI has been piloted by insurance companies to streamline the prior authorization process. AI implementation holds potential to enhance billing practices and maximize healthcare revenue for practicing physicians.

929 An Audit of the Perioperative Clinical Assessment and Documentation of Delirium in Older Patients Following Vascular Surgery

929 An Audit of the Perioperative Clinical Assessment and Documentation of Delirium in Older Patients Following Vascular Surgery

Poster 314: Early Full Knee Extension Predicts Successful Return to Sport Following Anterior Cruciate Ligament Reconstruction

Objectives: To identify predictive factors for successful return to sport (RTS) following anterior cruciate ligament reconstruction (ACL-R) with quadriceps tendon (QT) autograft. Methods: Data was retrospectively collected on consecutive patients who underwent ACL-R with QT autograft at a single institution between 2010-2020. Patient demographics, knee range of motion (ROM), injury characteristics, and intraoperative data were collected from the electronic medical record. Full RTS was defined as the patient returning to their prior level of sport and the presence of a clinical documentation of no further complications. Univariate and multivariate cox regression were utilized to conduct time-to-event analyses to identify predictors of early RTS clearance by surgeon. Additionally, both logistic regression analysis and generalized estimating equations were used to identify significant predictors of successful full RTS. STATA 16SE software was utilized for all analyses with statistical significance set to p < 0.05. Results: A total of 307 patients were included, consisting of 176 males (57.3%) and 131 females (42.7%), with an average of 20.7 ± 7.1 years of age and 14.5 ± 8.9 months follow-up. Ten patients (3.3%) were professional/semi-professional athletes, 38 (12.4%) were collegiate athletes, 144 (46.9%) were high school athletes (46.9%), and 115 (37.5%) were recreational athletes. Complete knee extension was achieved by 64.1% of patients at 6 weeks postoperatively, by 77.7% at 3 months, by 84.4% at 6 months, and by 84.7% at 1 year. Full knee extension at 3 (HR: 1.55, 95% CI: 1.13–2.12, p = 0.007) and 6 months (HR: 1.49, 95% CI: 1.05–2.12, p = 0.025) postoperatively were predictors of a higher rate of RTS clearance. Moreover, patients who achieved full knee extension at 3 months follow-up had a greater rate of RTS (1.02/person-years) compared to patients who did not achieve full knee extension at 3 months (0.83 per person-years). When considering RTS, only full knee extension at 4-6 weeks (OR:2.02, 95% CI:1.02–4.03, p = 0.045) and at 3 months (OR:2.36, 95% CI: 1.12–4.99, p = 0.024) postoperatively were predictive of successful RTS. No other significant predictors were identified. Conclusions: Restoration of full knee extension was strongly associated with higher rates of both surgeon clearance and successful RTS. The role of full knee extension in the ability to regain strength at 6 months, as measured by limb symmetry indices, after ACL-R has been previously described. While both ROM and strength play crucial roles in the rehabilitation process, achieving full ROM typically precedes restoration of full strength. Lack of full extension 3 months postoperatively may require further investigation and serves as a possible opportunity for a goal metric to maximize RTS rates and minimize complications after ACL-R.

Rotation X: An Innovative Quality Improvement Focused Curriculum Built Into an Internal Medicine Residency

Background: The Accreditation Council for Graduate Medical Education (ACGME) states that resident physicians must participate in quality improvement (QI) and patient safety (PS) initiatives during their training. Furthermore, once residents enter the workforce as attending physicians, their performance is often based on metrics related to the quality of care provided and the patient’s experience while in the hospital. However, many internal medicine residency programs have a variation of curriculum that is focused on QI and PS. Methods: At our institution, we sought to incorporate education in QI and PS in a longitudinal and structures fashion throughout a resident’s three years of training. Hence, Rotation X was created as both a collaborative and innovative one-week long curriculum with targeted teaching across the continuum of residency training. Rotation X was implemented as a mandatory rotation for all post graduate year (PGY) 1 and 3 trainees in our internal medicine program. During this rotation, learners meet with the clinical documentation improvement (CDI) team, learn about the process of completing a root cause analysis, and review a case with the quality improvement team. Learners also participate in multidisciplinary meetings including a nursing-physician series, focused on improving communication in the hospital, and met with patients nearing discharge to learn about their unique perspective during inpatient hospital stay. Results: All residents participating in Rotation X were surveyed over the course of a year to ascertain their perspective on the rotation. We collated responses from the PGY-1s (interns) and PGY-3s (senior residents). Of the PGY-3 class, at least 80% found the heart failure/pharmacy session, RN-MD session, root cause analysis (RCA) session, CDI session, and catheter associated urinary tract infection (CAUTI) rounds either very or extremely useful. Of the intern class, more than 75% found all session at least somewhat useful with at least half finding the sessions very or extremely useful to their training. Conclusions: With the growing landscape of QI and PS in medicine, we sought out to seamlessly integrate a focused curriculum into our internal medicine residency program. Rotation X, a one-week long rotation embedded with collaborative sessions, was curated to engage our learners in these domains. We found that the curriculum was well received by both our interns and senior residents. Our curriculum is easily adaptable and can be integrated into existing programs, with the capacity to tailor Rotation X sessions to a program’s goals and focus points in the domain of quality improvement.

Design, Implementation, and Evaluation of a Logbook for Clinical Education of Undergraduate Physiotherapy Students

Introduction: Clinical performance without documentation, assessment, and feedback may lead to an inefficient internship in the field. Logbooks are recommended to assess physiotherapy (PT) students’ clinical practice in the curriculum, therefore, this study aims to design, implement, and evaluate a logbook for undergraduate PT students. Materials and Methods: The present study includes three phases. In the first phase, a logbook was designed based on the existing evidence, undergraduate PT program curriculum, and opinions of clinical instructors of the relevant internships. After that, it was adjusted based on the topics of clinical rotations. In the implementation phase, students completed these logbooks during neurology, musculoskeletal inpatient, outpatient, and cardiovascular inpatient rotations. In the third phase, a 29-item questionnaire was used to assess the students’ and instructors’ perspectives on the logbook. Results: The designed logbook for undergraduate PT students consisted of two major sections, assessment of students’ clinical competencies and documentation of clinical experience. Sixtynine students and 12 clinical instructors completed the questionnaires. Approximately 49% of the students and 87% of the instructors felt that the logbook’s quality was satisfactory. Nearly 53% of the students and over 90% of the instructors consider the use of the logbook and its content essential. Conclusion: A logbook was developed as a workplace-based assessment (WBA) method. It was designed to cover different internships, including PT in musculoskeletal, cardiovascular, and neurological conditions in outpatient or inpatient settings. Both students and instructors agreed on using the designed logbook to assess the student’s clinical performance.

New-Graduate Physiotherapists’ Reflections on Training Experiences for Clinical Documentation

Background: Clinical documentation is a core component of physiotherapy practice and a required competency for professional accreditation in Australia, however there is a gap in understanding how physiotherapists’ documentation skills are developed. Objective: To explore new-graduate physiotherapists’ experiences and perspectives of learning clinical documentation in Australian entry-level physiotherapy programs. Methods: A qualitative study, featuring inductive reflexive thematic analysis of semi-structured interviews with new-graduate physiotherapists who graduated less than two years prior from Australian higher education institutions. Results: Sixteen new-graduate physiotherapists from six different entry-level physiotherapy programs participated. Four themes were generated to describe the data: 1) mixed experiences of learning documentation, 2) clinical placements are highly influential for skill development, 3) documentation education affects engagement in clinical settings, and 4) exposure, practice, feedback – repeat. Conclusion: Strong views were expressed amongst all participants regarding the importance of documentation training, with high value placed on early and repeated opportunities for exposure, practice and feedback when learning documentation skills. Authentic or ‘realistic’ settings for skill development were most influential, such as practical classes, simulation activities and clinical placements. Concerns were raised regarding inconsistencies in training experiences. Implications for enhancing entry-level physiotherapy training in clinical documentation are discussed.

Identifying stigmatizing language in clinical documentation: A scoping review of emerging literature

Background Racism and implicit bias underlie disparities in health care access, treatment, and outcomes. An emerging area of study in examining health disparities is the use of stigmatizing language in the electronic health record (EHR). Objectives We sought to summarize the existing literature related to stigmatizing language documented in the EHR. To this end, we conducted a scoping review to identify, describe, and evaluate the current body of literature related to stigmatizing language and clinician notes. Methods We searched PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Embase databases in May 2022, and also conducted a hand search of IEEE to identify studies investigating stigmatizing language in clinical documentation. We included all studies published through April 2022. The results for each search were uploaded into EndNote X9 software, de-duplicated using the Bramer method, and then exported to Covidence software for title and abstract screening. Results Studies (N = 9) used cross-sectional (n = 3), qualitative (n = 3), mixed methods (n = 2), and retrospective cohort (n = 1) designs. Stigmatizing language was defined via content analysis of clinical documentation (n = 4), literature review (n = 2), interviews with clinicians (n = 3) and patients (n = 1), expert panel consultation, and task force guidelines (n = 1). Natural language processing was used in four studies to identify and extract stigmatizing words from clinical notes. All of the studies reviewed concluded that negative clinician attitudes and the use of stigmatizing language in documentation could negatively impact patient perception of care or health outcomes. Discussion The current literature indicates that NLP is an emerging approach to identifying stigmatizing language documented in the EHR. NLP-based solutions can be developed and integrated into routine documentation systems to screen for stigmatizing language and alert clinicians or their supervisors. Potential interventions resulting from this research could generate awareness about how implicit biases affect communication patterns and work to achieve equitable health care for diverse populations.

Can the Administrative Loads of Physicians be Alleviated by AI-Facilitated Clinical Documentation?

Can the Administrative Loads of Physicians be Alleviated by AI-Facilitated Clinical Documentation?

Aesthetic Surgery Tourism: An Opportunity or a Danger?

Medical and surgical tourism is a rapidly growing phenomenon in post-pandemic Europe. The exodus of patients abroad to perform surgery, especially cosmetic treatments, is spreading recently in industrialized countries. In the social media era, the ease of access to advertising about surgical procedures and their costs favors traveling. However, the information given is not always punctual, and there is often a lack of patient awareness about the risks related to the procedures. The objective of the manuscript is to investigate, through clinical examples, the path that a patient operated on in a non-European country must face once he returns home. From the availability and translation of clinical documentation to the problems encountered in revision surgeries. Thirteen cases of surgical tourism, patients who presented to our department with surgical complications, are investigated. Adverse events occurring during medical treatment abroad raised medico-legal and appropriateness issues, as well as concerns regarding the follow-up of patients. The current literature confirmed the high complication rate: It affects individual patients and the native country's healthcare systems. Therefore, patients must learn more about the dangers of traveling abroad for surgery. Education initiatives in the patient's home country might help achieve this. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Potential application of artificial intelligence in cancer therapy.

This review underscores the critical role and challenges associated with the widespread adoption of artificial intelligence in cancer care to enhance disease management, streamline clinical processes, optimize data retrieval of health information, and generate and synthesize evidence. Advancements in artificial intelligence models and the development of digital biomarkers and diagnostics are applicable across the cancer continuum from early detection to survivorship care. Additionally, generative artificial intelligence has promised to streamline clinical documentation and patient communications, generate structured data for clinical trial matching, automate cancer registries, and facilitate advanced clinical decision support. Widespread adoption of artificial intelligence has been slow because of concerns about data diversity and data shift, model reliability and algorithm bias, legal oversight, and high information technology and infrastructure costs. Artificial intelligence models have significant potential to transform cancer care. Efforts are underway to deploy artificial intelligence models in the cancer practice, evaluate their clinical impact, and enhance their fairness and explainability. Standardized guidelines for the ethical integration of artificial intelligence models in cancer care pathways and clinical operations are needed. Clear governance and oversight will be necessary to gain trust in artificial intelligence-assisted cancer care by clinicians, scientists, and patients.

Unlocking the Potential of Underutilized Technology: A New Paradigm for Resident Doctor Efficiency.

Background The precision of clinical documentation in trauma and orthopaedic surgery is pivotal, given its profound implications on patient care and medicolegal risks. This study assessed the impact of an autotext template intervention on the adherence of clinical documentation to the neurovascular assessment standards set by the National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association Standards for Trauma (BOAST). Methods Conducted at a single hospital, this observational study comprised two phases: a retrospective analysis of clinical documentation for 56 fracture patients (n=56) followed by the implementation of an autotext template and subsequent analysis of a new cohort of 57 patients (n=57). The intervention aimed to enhance documentation quality in line with NICE and BOAST guidelines. Results Initial findings revealed a prevalent use of the nonspecific term "NVI" (neurovascularly intact), with only 8.5% (n=5) of pre-intervention documents adhering to detailed motor function assessments and a mere 6.8% (n=4) recording limb colour. Post-intervention analysis showed a significant improvement, with 91.23% (n=52) of documents listing nerves (P < 0.001) and 96.49% (n=55) adhering to motor function documentation using the Medical Research Council (MRC) grading scale (P < 0.001). Despite these advancements, the study acknowledges potential limitations such as the Hawthorne effect and the ongoing challenge of staff rotations. Conclusion The autotext template intervention markedly enhanced the adherence to neurovascular assessment documentation standards, as evidenced by the substantial increases in detailed parameter reporting and supported by statistically significant P-values. This advancement highlights the necessity of equipping clinicians with practical tools to uphold high documentation standards amidst challenging clinical conditions. Future investigations should focus on the long-term sustainability of these improvements across varying medical staff cohorts.

(121) DISCREPANCY IN SEXUAL DYSFUNCTION, SEXUAL DESIRE, AND RELATIONSHIP SATISFACTION BETWEEN MALE AND FEMALE PARTNERS DURING THE POSTPARTUM PERIOD AND THE IMPACT OF POSTPARTUM DEPRESSION

Abstract Introduction Studies suggest that changes in sexual health and relationship satisfaction are common in women during pregnancy and postpartum, however these are often overlooked during postpartum care. Furthermore, one in seven women experience additional challenges of postpartum depression within the first postnatal yea. Studies have recognized depression as a major predictor for reduced sexual desire and satisfaction. There is little empirical data on the impact of postpartum depression on the sexual health of both male and female partners and relationship satisfaction. Objective This study assesses the relationship between postpartum depression, relationship satisfaction, and sexual satisfaction at three postpartum time points: immediate, six weeks, and twelve weeks postpartum, in postpartum patients and their partners. Methods This longitudinal study was conducted on heterosexual couples recruited from the postpartum unit, excluding patients with pregnancy complications. Each partner was consented immediately postpartum and individually surveyed to evaluate their sexual desire, relationship satisfaction, and sexual dysfunction immediately, 6 weeks, and 12 weeks postpartum. The Sexual Desire Inventory-2, Sexual Dysfunction Questionnaire, and Couples Satisfaction Index were utilized. Mothers were additionally screened for postpartum depression using the Edinburgh Postnatal Depression Scale at the three time points. We then conducted a retrospective chart review from 6 and 12 week postpartum visits to investigate delivery details and sexual dysfunction screening as reported in clinic documentation. Results This sample consisted of 89 female (54.60%), and 74 male (45.40%). 5 had postpartum depression at least 1 timepoint (8.20%). Sexual desire differed significantly between female and male partners over the entire postpartum period (p &amp;lt; 0.01), and relationship satisfaction differed significantly over time throughout the postpartum period across both female and male partners (p &amp;lt; 0.01). Across the entire postpartum period, female partner sexual desire scores were, on average, 7.02 units lower than male partner sexual desire scores (Mean Difference; 95% CI: -7.02; -11.02, -3.02), meaning that female partner sexual desire was significantly lower than male partner sexual desire throughout the postpartum period. For both female and male partners, relationship satisfaction scores were significantly lower at 12 weeks postpartum (p &amp;lt; 0.01) and at 6 weeks postpartum (p &amp;lt; 0.01) as compared to immediately postpartum, meaning that both female and male partners were significantly less satisfied with their relationships at 6 weeks postpartum and at 12 weeks postpartum as compared to immediately postpartum. 82% females were not screened for sexual dysfunction at 6 weeks postpartum and 2% were screened. Conclusions Discrepancy in relationship satisfaction and sexual desire between male and female partners was found throughout the postpartum period. Yet, a majority of patients are not screened for sexual dysfunction at their 6 week postpartum visit. These findings elucidate the need to normalize and address sexual health during the postpartum period as standard of care, including screening and treatment, in both male and female partners. Disclosure No.

(043) INACCURATE AND INADEQUATE ICD-10 CODING RELATED TO FEMALE SEXUAL HEALTH THREATENS PATIENT CARE, RESEARCH AND BILLING

Abstract Introduction The International Classification of Diseases (ICD) is an international health information system for the collection, processing, classification, and presentation of mortality statistics. The ICD 10th Edition (ICD-10) is a tool for physicians and billing professionals to accurately bill for the care provided. However, physicians who treat female sexual health (FSH) disorders report difficulty in finding appropriate codes for diagnoses and clinical syndromes (Parish et al. 2021). These issues impede the process for appropriate treatment and allotting the correct reimbursement to providers. Additionally, quantitative and qualitative research on FSH is limited due to the lack of accurate ICD codes for FSH disorders in this cohort. Objective This study aims to evaluate the ICD-10 coding system to assess the accuracy and quality of codes related to common FSH disorders. Methods A list of 50 most commonly encountered clinical FSH diagnoses was created based on clinical practice findings and ISSWSH guidelines. The list was compared against existing ICD-10 codes to characterize current FSH disorders that are recognized in ICD-10 and determine which FSH disorders are billable (ICD10data.com categorizes codes as “billable” or “non-billable”) or missing entirely. FSH diagnoses explicitly listed as an independent diagnosis or generally listed were considered ICD-10 coded. Diagnoses were considered to not have an existing code if they were not explicitly listed independently or under a more general term. Results 44% (n=22) of the diagnoses did not have existing ICD-10 codes, and 6% (n=3) of the diagnoses had appropriate ICD-10 codes but were not billable (Figure 1, Table 1). FSH diagnoses such as “clitoral adhesions”, “clitorodynia” and “persistent genital arousal disorder” were not coded in ICD-10. Many diagnoses were grouped under general terms - pelvic floor pain disorders were grouped under “R10.2: Pelvic and peroneal pain” which included both male and female diagnoses. Other codes had significant diagnostic overlap - “vulvodynia” was separately cataloged as “N94.810: vulvar vestibulitis”, “N94.818: Other vulvodynia” and “N94.819: vulvodynia, unspecified”. There were numerous common FSH diagnoses with incomplete, inaccurate, or outdated ICD codes. Conclusions These findings highlight the pressing need for an expanded, comprehensive, and precise set of ICD codes dedicated to FSH disorders. Without appropriate coding for 50% of FSH diagnoses, clinical care, research, and healthcare billing are severely impeded. It is much more difficult for physicians to accurately classify and bill for their procedures, which may create problems with clinical documentation leading to delayed treatment and poor clinical outcomes. For example, existing codes for “vulvodynia,” a common disorder affecting 16% of women, are vague and unclear, which lacks practicality for charting and billing purposes. Additionally, the limitations of ICD coding make it nearly impossible to research specific disorders, as they can not be searched in databases like TriNetX. These limitations may explain the large gaps in the literature regarding FSH disorders. Additionally, electronic medical records often have outdated ICD codes, further creating obstacles for clinicians. The current gap in classification, including ICD-10 coding and medical records, must be addressed to advance the understanding and management of FSH disorders. Disclosure No.

Impact of Preoperative Malnutrition on Patients with Pancreatic Neoplasms Post-Duodenopancreatectomy: A Retrospective Cohort Study.

Preoperative malnutrition is a significant factor in patients with pancreatic tumors undergoing pancreaticoduodenectomy. The aim of this study was to assess the association between preoperative malnutrition and delayed discharge within a ten-day timeframe and potential correlations between preoperative malnutrition and postoperative surgical complications. A retrospective cohort study was conducted, recruiting a final sample of 79 patients with benign or malignant cephalic pancreatic tumors from 2015 to 2022. The risk of malnutrition was assessed using the Malnutrition Universal Screening Tool, while length of hospital stay and relevant clinical data were extracted from clinical documentation. The preoperative malnutrition risk was high in 21.52% of the sample, moderate in 36.71%, and low in 41.77%. Body mass index (BMI) (p = 0.007) and postoperative surgical complications (p < 0.001) were significantly correlated with delayed discharge. No statistically significant differences were found between levels of malnutrition risk and delayed discharge (p = 0.122), or postoperative surgical complications (p = 0.874). Postoperative complications and BMI emerge as significant risk factors. The limited sample size may have compromised the collection of homogeneous and significant data. Future studies should evaluate the implementation of personalized nutritional screening tools, nutritional assessment plans, and the involvement of specialized health professionals.

MRI-Based Prediction of Clinical Improvement after Ventricular Shunt Placement for Normal Pressure Hydrocephalus: Development and Evaluation of an Integrated Multisequence Machine Learning Algorithm.

Symptoms of normal pressure hydrocephalus (NPH) are sometimes refractory to shunt placement, with limited ability to predict improvement for individual patients. We evaluated an MRI-based artificial intelligence method to predict postshunt NPH symptom improvement. Patients with NPH who underwent MRI before shunt placement at a single center (2014-2021) were identified. Twelve-month postshunt improvement in mRS, incontinence, gait, and cognition were retrospectively abstracted from clinical documentation. 3D deep residual neural networks were built on skull-stripped T2-weighted and FLAIR images. Predictions based on both sequences were fused by additional network layers. Patients from 2014-2019 were used for parameter optimization, while those from 2020-2021 were used for testing. Models were validated on an external validation data set from a second institution (n = 33). Of 249 patients, n = 201 and n = 185 were included in the T2-based and FLAIR-based models according to imaging availability. The combination of T2-weighted and FLAIR sequences offered the best performance in mRS and gait improvement predictions relative to models trained on imaging acquired by using only 1 sequence, with area under the receiver operating characteristic (AUROC) values of 0.7395 [0.5765-0.9024] for mRS and 0.8816 [0.8030-0.9602] for gait. For urinary incontinence and cognition, combined model performances on predicting outcomes were similar to FLAIR-only performance, with AUROC values of 0.7874 [0.6845-0.8903] and 0.7230 [0.5600-0.8859]. Application of a combined algorithm by using both T2-weighted and FLAIR sequences offered the best image-based prediction of postshunt symptom improvement, particularly for gait and overall function in terms of mRS.

Identification of an ANCA-Associated Vasculitis Cohort Using Deep Learning and Electronic Health Records.

ANCA-associated vasculitis (AAV) is a rare but serious disease. Traditional case-identification methods using claims data can be time-intensive and may miss important subgroups. We hypothesized that a deep learning model analyzing electronic health records (EHR) can more accurately identify AAV cases. We examined the Mass General Brigham (MGB) repository of clinical documentation from 12/1/1979 to 5/11/2021, using expert-curated keywords and ICD codes to identify a large cohort of potential AAV cases. Three labeled datasets (I, II, III) were created, each containing note sections. We trained and evaluated a range of machine learning and deep learning algorithms for note-level classification, using metrics like positive predictive value (PPV), sensitivity, F-score, area under the receiver operating characteristic curve (AUROC), and area under the precision and recall curve (AUPRC). The deep learning model was further evaluated for its ability to classify AAV cases at the patient-level, compared with rule-based algorithms in 2,000 randomly chosen samples. Datasets I, II, and III comprised 6,000, 3,008, and 7,500 note sections, respectively. Deep learning achieved the highest AUROC in all three datasets, with scores of 0.983, 0.991, and 0.991. The deep learning approach also had among the highest PPVs across the three datasets (0.941, 0.954, and 0.800, respectively). In a test cohort of 2,000 cases, the deep learning model achieved a PPV of 0.262 and an estimated sensitivity of 0.975. Compared to the best rule-based algorithm, the deep learning model identified six additional AAV cases, representing 13% of the total. The deep learning model effectively classifies clinical note sections for AAV diagnosis. Its application to EHR notes can potentially uncover additional cases missed by traditional rule-based methods.

Application of palatally positioned mini-screws together with the Herbst appliance for rehabilitating adult patients with skeletal types of distal dental arch relationships: a clinical case

Relevance. Utilizing the Herbst appliance for managing distal occlusal relationships in patients with completed facial growth serves as an alternative to surgico-orthodontic methods. This approach, however, extends the treatment duration and necessitates stabilization of the upper molars following removal of the appliance when moving the anterior segment of the upper dentition distally.Objective. To clinically substantiate the feasibility of combining the Herbst appliance with palatally positioned mini-screws for treating distal dental occlusal relationships in adult patients.Description of сlinical сases. Clinical photographic documentation and diagnostic modeling of facial and dentition were conducted for two patients. This was complemented by the computation and analysis of jaw CT scans and profile cephalometric radiographs. The AMORF method was employed for a quantitative evaluation of dentomaxillofacial anomalies. Hypotheses were drawn based on the employment of a 6.0 mm micro-implant at the median suture in projection with teeth 1.6-2.6, alongside the Herbst appliance, suggesting potential stability of the upper molars during the distal repositioning of the anterior segment of the upper dentition.Conclusion. The outcomes from the documented clinical cases suggest that integrating palatally positioned mini-screws with the Herbst appliance facilitates stable positioning of the upper jaw’s first molars during the distal movement of the anterior segment, attributed to the solid support provided by the mini-screw implant.

Spreading Standardized Documentation of Pediatric Occupational and Physical Therapy Dose: A Quality Improvement Initiative.

Clinicians and researchers can leverage clinical documentation of therapy services for quality improvement and research purposes. However, documentation is often institution specific and may not adequately capture the dose of therapy delivered, thus limiting collaboration. To implement documentation of pediatric occupational and physical therapy dose from one institution to another institution. Dose documentation includes the frequency, intensity, time, and type of interventions delivered (FITT Epic® Flowsheet) at each session. Prospective time-series quality improvement study. Two large urban pediatric hospitals. Occupational and physical therapy staff members. Staff training and feedback loops utilizing existing groups. The process measure (number of available staff trained and using the FITT Epic Flowsheet over time) and the outcome measure (percentage of FITT Epic Flowsheets used for treatment visits each month) were analyzed using a statistical process control chart. The balancing measure (percentage of notes closed before 7 p.m. on the same day as the encounter) was analyzed using mean per month across three time periods. Fifty-seven staff members (68%) attended formal training. On average, clinicians documented 90% of sessions using the FITT Epic Flowsheet after implementation. There was no change observed in the balancing measure. Documentation of dose was spread from one institution to another. Shared documentation will facilitate future collaboration for quality improvement and research purposes. Occupational therapy practitioners and leaders should consider implementing documentation with common dose elements. Plain-Language Summary: Occupational therapy documentation is often institution specific and may not adequately capture the dose of therapy (frequency, intensity, time) or types of interventions that were delivered, thus limiting opportunities for collaboration between institutions. This article adds to the literature on administrative supports for clinical and quality improvement research by illustrating a specific example of how documentation of dose can be shared from one institution to another. The data show that clinicians at one institution started using a new style of documentation using the FITT Epic® Flowsheet and shared discrete dose elements with another institution, creating new opportunities for collaboration. Shared documentation can facilitate future collaboration for quality improvement and research purposes.

Artificial Intelligence in the Provision of Health Care: An American College of Physicians Policy Position Paper.

Internal medicine physicians are increasingly interacting with systems that implement artificial intelligence (AI) and machine learning (ML) technologies. Some physicians and health care systems are even developing their own AI models, both within and outside of electronic health record (EHR) systems. These technologies have various applications throughout the provision of health care, such as clinical documentation, diagnostic image processing, and clinical decision support. With the growing availability of vast amounts of patient data and unprecedented levels of clinician burnout, the proliferation of these technologies is cautiously welcomed by some physicians. Others think it presents challenges to the patient-physician relationship and the professional integrity of physicians. These dispositions are understandable, given the "black box" nature of some AI models, for which specifications and development methods can be closely guarded or proprietary, along with the relative lagging or absence of appropriate regulatory scrutiny and validation. This American College of Physicians (ACP) position paper describes the College's foundational positions and recommendations regarding the use of AI- and ML-enabled tools and systems in the provision of health care. Many of the College's positions and recommendations, such as those related to patient-centeredness, privacy, and transparency, are founded on principles in the ACP Ethics Manual. They are also derived from considerations for the clinical safety and effectiveness of the tools as well as their potential consequences regarding health disparities. The College calls for more research on the clinical and ethical implications of these technologies and their effects on patient health and well-being.