Clinical Subject Matter Experts Research Articles

Implementing a natural language processing pipeline to expedite clinical chart review to assess germline genetic testing in veterans with breast cancer.

e13640 Background: The Making Advances in Mammography and Medical Options for Veterans Act of 2022 mandated that the Department of Veterans Affairs (VA) perform a study of germline genetic testing in Veterans with breast cancer (BC). Assessing whether a Veteran with BC was offered germline genetic testing based on electronic health records requires time-consuming review of unstructured clinical notes by clinical experts who are also extremely busy providing care. To expedite this review process, we implemented a productionized natural language processing (NLP) pipeline to identify relevant concepts and highlight them within a custom-made chart review interface. Methods: Clinical subject-matter experts (SMEs) were convened to identify keywords suggestive of genetic testing. These were categorized into 3 sets: gene-related concepts, VA-specific services, and exams and tests. We then used entity recognition and entity linking to link these concepts to a knowledge base. These were enriched with entities similarly extracted from an open-source reference clinical text on germline genetic testing in BC. The resulting concepts were visualized as a word cloud and reviewed by the SMEs. We implemented a Power BI and Power Apps interface to display clinical notes from 200 randomly selected Veterans, with relevant concepts highlighted. Each Veteran’s notes were reviewed independently by 2 of the 5 SMEs, who assessed whether the Veteran was offered testing, referred to a genetic counseling service, or otherwise had evidence of testing. Disagreements were adjudicated by the whole team. Results: 11622 notes (mean 58/Veteran, 3028 characters/note) were reviewed. Table shows the most prevalent entities among genes, mutations, and exam names. Of the 5 reviewers, 3 annotated 80 patients each in a single session, lasting less than 50 minutes on average. Reviewers had an inter-annotator agreement of 85.5%. Mention of target concepts was associated with germline genetic testing with an accuracy of 80.4%, precision of 76.4%, recall of 99.1%, and F1 of 86.3%. Germline genetic testing rates are detailed in a separate submission. Conclusions: Modern informatics tools such as productionized NLP, the Microsoft Power Platform, and high-performance computing environments allow for rapid implementation of health information technology tools that can enable clinicians to gain critical insights quickly and efficiently from electronic health record data. [Table: see text]

Analyzing Patterns of Service Utilization Using Graph Topology to Understand the Dynamic of the Engagement of Patients with Complex Problems with Health Services

Background: Providing care to persons with complex problems is inherently difficult due to several factors, including the impacts of proximal determinants of health, treatment response, the natural emergence of comorbidities, and service system capacity to provide timely required services. Providing visibility into the dynamics of patients’ engagement can help to optimize care for patients with complex problems. Method: In a previous work, graph machine learning and NLP methods were used to model the products of service system dynamics as atemporal entities, using a data model that collapsed patient encounter events across time. In this paper, the order of events is put back into the data model to provide topological depictions of the dynamics that are embodied in patients’ movement across a complex healthcare system. Result: The results show that directed graphs are well suited to the task of depicting the way that the diverse components of the system are functionally coupled—or remain disconnected—by patient journeys. Conclusion: By setting the resolution on the graph topology visualization, important characteristics can be highlighted, including highly prevalent repeating sequences of service events readily interpretable by clinical subject matter experts. Moreover, this methodology provides a first step in addressing the challenge of locating potential operational problems for patients with complex issues engaging with a complex healthcare service system.

Developing a Program forAdvanced Physical Therapist Practice inAmputation Care.

Over the past 20 years, military medicine made greatstrides in the medical management of traumatically injured patients. Significant advancements were made in the treatment and rehabilitation after limb loss. These advancements can be attributed to the large number of complex patients presenting to military treatment facilities and the demand for medical professionals to provide care to patients with complex injuries and multiple traumatic amputations. The concern now is to maintain the skills needed to be prepared for the next conflict. To meet this demand, the Extremity Trauma and Amputation Center of Excellence (EACE) initiated the documentation of knowledge, skills, and abilities (KSAs) to ensure that the skill sets needed to treat this unique population are not lost. The EACE developed KSAs to sustain advanced clinical practice for physical therapists, occupational therapists, and prosthetists and is in the process of developing KSAs for orthotists and physical medicine physicians. The learning objectives [terminal and enabling learning objectives (TLOs and ELOs)] derived from each set of KSAs will drive curricula development for enduring education, residencies, and fellowships. This article describes the KSAs and learning objectives for advanced physical therapist competencies in amputation care. Clinical subject matter experts (SMEs) convened from the Department of Defense (DoD) Advanced Rehabilitation Centers (ARCs) to draft the initial KSAs. All experts had specific expertise in treating individuals with highly complex lower and upper limb amputation. In a quasi-Delphi methodology, the initial draft KSAs underwent five cycles of review and comment by an additional 15 DoD, Veterans Affairs, and civilian institution experts from clinical practice, education, and research. The consensus KSAs were then transcribed into learning objectives with collaboration between clinical subject matter experts and doctoral-level educators. The final program document has 21 instructional modules with 30 TLOs and 157 ELOs. The KSAs and the learning objectives describe the skills expected of an advanced practice physical therapist treating patients with traumatic limb loss. Weaknesses of this document include the focus on traumatic amputation and military specific needs. However, many of the central advanced practices are universal to all physical therapists working in amputation. Thus, this document should serve as a starting point and can evolve to include dysvascular, oncology, and other etiologies. To our knowledge, this is the first paper to describe the KSAs for the advanced practice physical therapist working with traumatic limb loss population. This work will form the framework for physical therapist advanced practice training programs.

Clusters of conditions among US service members diagnosed with mild TBI from 2017 through 2019.

Many US Military Service Members (SMs) newly diagnosed with mild Traumatic Brain Injury (mTBI) may exhibit a range of symptoms and comorbidities, making for a complex patient profile that challenges clinicians and healthcare administrators. This study used clustering techniques to determine if conditions co-occurred as clusters among those newly injured with mTBI and up to one year post-injury. We measured the co-occurrence of 41 conditions among SMs diagnosed with mTBI within the acute phase, one or three months post-mTBI diagnosis, and chronic phase, one year post-mTBI diagnosis. Conditions were identified from the literature, clinical subject matter experts, and mTBI care guidelines. The presence of conditions were based on medical encounters recorded within the military health care data system. Through a two-step approach, we identified clusters. Principal component analysis (PCA) determined the optimal number of clusters, and hierarchical cluster analyses (HCA) identified the composition of clusters. Further, we explored how the composition of these clusters changed over time. Of the 42,018 SMs with mTBI, 23,478 (55.9%) had at least one condition of interest one-month post-injury, 26,831 (63.9%) three months post-injury, and 29,860 (71.1%) one year post injury. Across these three periods, six clusters were identified. One cluster included vision, cognitive, ear, and sleep disorders that occurred one month, three months, and one year post-injury. Another subgroup included psychological conditions such as anxiety, depression, PTSD, and other emotional symptoms that co-occurred in the acute and chronic phases post-injury. Nausea and vomiting symptoms clustered with cervicogenic symptoms one month post-injury, but later shifted to other clusters. Vestibular disorders clustered with sleep disorders and headache disorders one-month post-injury and included numbness and neuropathic pain one year post-injury. Substance abuse symptoms, alcohol disorders, and suicidal attempt clustered one year post-injury in a fifth cluster. Speech disorders co-occurred with headache disorders one month and one year post-injury to form a sixth cluster. PCA and HCA identified six distinct subgroups among newly diagnosed mTBI patients during the acute and chronic phases post-injury. These subgroups may help clinicians better understand the complex profile of SMs newly diagnosed with mTBI.

Consideration of the emergency nurse practitioner as a population within the APRN Consensus Model: A SWOT analysis

After adoption of the 2008 Consensus Model for Advanced Practice Registered Nurse (APRN) Regulation, evolution of the nurse practitioner (NP) role and emergency NP (ENP) specialty has outpaced regulatory standards. Lack of uniformity among regulators, health insurance providers, and employers in acknowledging the ENP specialty has created barriers to practice and access to care. This article serves to identify potential outcomes if the ENP specialty was transitioned to a population within the Consensus Model of Regulation. A strengths, weaknesses, opportunities, and threats (SWOT) analysis methodology was used to assess ENP specialty current state, specifically focusing on the licensure, accreditation, certification, and education model for APRN regulation. The data were collected from peer-reviewed literature, clinical subject-matter experts, and academic and advanced practice executive leaders. Variances in ENP licensure, recognition, and acknowledgment among State Boards of Nursing leave the ENP specialty in a precarious position. For each of the strengths and opportunities that could exist in recognizing the ENP at the population level of the Consensus Model, there are abundant weaknesses and threats. Although full acknowledgment of the ENP specialty is lacking, regulatory implications are highly variable, and employers' understanding of the APRN educational model is limited, our findings reveal that the ENP specialty is an evolving role that deserves regulatory legitimization. Although ideal placement for the ENP within the Consensus Model remains to be determined, challenges and opportunities exist with both specialty and population options.

A Delphi study of rescue and clinical subject matter experts on the extrication of patients following a motor vehicle collision

BackgroundApproximately 1.3 million people die each year globally as a direct result of motor vehicle collisions (MVCs). Following an MVC some patients will remain trapped in their vehicle; these patients have worse outcomes and may require extrication. Following new evidence, updated multidisciplinary guidance for extrication is needed.MethodsThis Delphi study has been developed, conducted and reported to CREDES standards. A literature review identified areas of expertise and appropriate individuals were recruited to a Steering Group. The Steering Group formulated initial statements for consideration. Stakeholder organisations were invited to identify subject matter experts (SMEs) from a rescue and clinical background (total 60). SMEs participated over three rounds via an online platform. Consensus for agreement / disagreement was set at 70%. At each stage SMEs could offer feedback on, or modification to the statements considered which was reviewed and incorporated into new statements or new supporting information for the following rounds. Stakeholders agreed a set of principles based on the consensus statements on which future guidance should be based.ResultsSixty SMEs completed Round 1, 53 Round 2 (88%) and 49 Round 3 (82%). Consensus was reached on 91 statements (89 agree, 2 disagree) covering a broad range of domains related to: extrication terminology, extrication goals and approach, self-extrication, disentanglement, clinical care, immobilisation, patient-focused extrication, emergency services call and triage, and audit and research standards. Thirty-three statements did not reach consensus.ConclusionThis study has demonstrated consensus across a large panel of multidisciplinary SMEs on many key areas of extrication and related practice that will provide a key foundation in the development of evidence-based guidance for this subject area.

Prevalence of Comorbidities in Active and Reserve Service Members Pre and Post Traumatic Brain Injury, 2017-2019.

To understand the prevalence of comorbidities associated with traumatic brain injury (TBI) patients among active and reserve service members in the U.S. Military. Active and reserve SMs diagnosed with an incident TBI from January 2017 to October 2019 were selected. Nineteen comorbidities associated with TBI as identified in the literature and by clinical subject matter experts were described in this article. Each patient's medical encounters were evaluated from 6months before to 2years following the initial TBI diagnoses date in the Military Data Repository, if data were available. Time-to-event analyses were conducted to assess the cumulative prevalence over time of each comorbidity to the incident TBI diagnosis. We identified 47,299 TBI patients, of which most were mild (88.8%), followed by moderate (10.5%), severe (0.5%), and of penetrating (0.2%) TBI severity. Two years from the initial TBI diagnoses, the top five comorbidities within our cohort were cognitive disorders (51.9%), sleep disorders (45.0%), post-traumatic stress disorder (PTSD; 36.0%), emotional disorders (22.7%), and anxiety disorders (22.6%) across severity groups. Cognitive, sleep, PTSD, and emotional disorders were the top comorbidities seen within each TBI severity group. Comorbidities increased pre-TBI to post-TBI; the more severe the TBI, the greater the prevalence of associated comorbidities. A large proportion of our TBI patients are afflicted with comorbidities, particularly post-TBI, indicating many have a complex profile. The military health system should continue tracking comorbidities associated with TBI within the U.S. Military and devise clinical practices that acknowledge the complexity of the TBI patient.

A practical guide to applying the Delphi technique in mental health treatment adaptation: The example of Enhanced Problem-Solving Training (E-PST).

Expert consensus methods, such as the Delphi procedure, are commonly employed in consumer, education, and health services research. However, the utility of this methodology has not widely been described in relation to mental health treatment adaptation efforts. This gap is noteworthy given that evidence-based treatments are often modified in terms of core intervention content, method of delivery, and target populations. Expert consensus methods such as the Delphi procedure offer multiple practical benefits (e.g., flexibility, resource-efficiency) for psychologists who need to adapt existing treatments to meet new research and clinical practice needs. The purpose of this paper is to provide a brief overview of the Delphi procedure, and to offer a practical guide to using this method for treatment adaptation. An example is offered using our team's application of a three-round Delphi procedure to render content and context modifications to an existing problem-solving intervention to optimize its use with a new treatment population. Data were collected from Department of Veterans Affairs clinical subject matter experts. Round 1 utilized semi-structured interviews to determine necessary protocol features and modifications. Rounds 2-3 utilized a forced-choice survey and feedback loop to evaluate expert consensus. More than 91% of rated items reached consensus following Round 2, with the remainder following Round 3. Recommended modifications included minor structural and content edits, and re-balancing time allotments. We conclude that consensus methods may facilitate treatment adaptation efforts, enhance treatment feasibility, and promote content and ecological validity. Considerations for future Delphi-based treatment adaptations are offered.

Etiology of Microcephaly and Central Nervous System Defects during the Zika Epidemic in Colombia

To estimate the prevalence of microcephaly and central nervous system (CNS) defects during the Zika virus (ZIKV) epidemic in Colombia and proportion attributable to congenital ZIKV infection. Clinical and laboratory data for cases of microcephaly and/or CNS defects reported to national surveillance between 2015 and 2017 were reviewed and classified by a panel of clinical subject matter experts. Maternal and fetal/infant biologic specimens were tested for congenital infection and chromosomal abnormalities. Infants/fetuses with microcephaly and/or CNS defects (cases) were classified into broad etiologic categories (teratogenic, genetic, multifactorial, and unknown). Cases classified as potentially attributable to congenital ZIKV infection were stratified by strength of evidence for ZIKV etiology (strong, moderate, or limited) using a novel strategy considering birth defects unique or specific to ZIKV or other infections and laboratory evidence. Among 858 reported cases with sufficient information supporting a diagnosis of microcephaly or CNS defects, 503 were classified as potentially attributable to congenital ZIKV infection. Of these, the strength of evidence was considered strong in 124 (24.7%) cases; moderate in 232 (46.1%) cases; and limited in 147 (29.2%). Of the remaining, 355 (41.4%) were attributed to etiologies other than ZIKV infection (syphilis, toxoplasmosis, rubella, cytomegalovirus, herpes 1 and herpes 2 virusesonly, n=32 [3.7%]; genetic, n=16 [1.9%]; multifactorial, n=42 [4.9%]; unknown, n=265 [30.9%]). Fifty-eight percent of cases of microcephaly and/or CNS defects were potentially attributable to congenital ZIKV infection; however, the strength of evidence varied considerably. This surveillance protocol might serve as a model approach for investigation and etiologic classification of complex congenital conditions.

PCV58 DEFINING THROMBOEMBOLIC EVENTS USING ADMINISTRATIVE CLAIMS DATA

Through the Center for Biologics Evaluation and Research Biologics Effectiveness and Safety (BEST) Initiative, we sought to develop administrative claims-based definitions, referred to as algorithms, to facilitate identification of adverse events potentially associated with exposure to biologic products. The objectives of this study were to (1) develop algorithms for a series of thromboembolic events (TEEs), including pulmonary embolism (PE), deep vein thrombosis (DVT), and acute myocardial infarction (AMI), and (2) determine whether the 2015 transition to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) affected the frequency of TEE reporting. Authors conducted a literature review using PubMed. Findings were leveraged to develop initial algorithms that were mapped from the International Classification of Diseases, Ninth Revision, Clinical Modification to ICD-10-CM via forward–backward mapping using General Equivalence Mappings. Clinical subject matter experts reviewed draft algorithms. Each algorithm was characterized in the IBM® MarketScan® Research Databases using the IBM MarketScan Treatment Pathways tool. Descriptive statistics, including the annual frequency of diagnosis for each algorithm, were generated for 2014–2017. DVT was the most common TEE, with the annual number of individuals with a relevant diagnosis code ranging from 4.36 to 4.96/1,000 enrolled/year; this was followed by AMI (2.83–3.16 individuals/1,000 enrolled/year) and PE (2.26–2.41 individuals/1,000 enrolled/year). A qualitative assessment of annual reporting frequency suggests that the transition to ICD-10-CM did not substantially affect the proportion of the enrolled population receiving an AMI, DVT, or PE diagnosis. Three new ICD-based TEE algorithms were developed and—though not subject to validation—were applied to generate statistics on the frequency of reporting for each category for 2014–2017. Annual proportions showed no indication that the ICD-10-CM transition meaningfully affected the frequency of TEE reporting. This effort is intended to support subsequent epidemiologic safety and effectiveness studies of biologics.

Rapid Heuristic Evaluation: Ensuring Fast and Reliable Usability Support

The U.S. Department of Veterans Affairs (VA) Human Factors Engineering (HFE) office developed a usability testing method called “Rapid Heuristic Evaluation” (Rapid HE) that offers benefits to users of the Agile development process. Rapid HE addresses the need to combine fast, reliable usability support with feedback from clinical subject matter experts (SMEs) during the design and development of an electronic health record (EHR). The Rapid HE process leverages established EHR heuristics to accelerate wireframe review and approval, and merges a traditional heuristic evaluation (HE) with an expert review by two SMEs. Our application of Rapid HEs has maximized use of resources and minimized the amount of time needed to provide feedback during Agile development cycles. This paper describes the Rapid HE process, deviations from traditional HEs, and reports on data from 16 HEs that our group conducted on an EHR platform currently being developed by VA.

Impact of a Prospective Review Program for Reference Laboratory Testing Requests

To control the cost of reference laboratory testing, to ensure that its usage is medically appropriate, and to review the contribution of reference testing to patient care at our institution. A multidisciplinary institutional committee was convened to manage the utilization of reference testing. A subset of tests was designated to be reviewed in real time by a team of clinical pathologists in consultation with clinical subject matter experts. Twelve percent of testing requests, accounting for approximately 18% of send-out costs, were determined to be clinically unnecessary or would not produce actionable results at that point during that patient's care and were therefore not performed. This intervention, combined with insourcing of frequently requested tests, resulted in a reduction in the costs of reference testing to less than half of that predicted by the rate of growth from 2005 to 2009. Molecular diagnostic tests displayed a higher cost per test than other forms of testing but had a similar degree of clinical impact. Formal prospective review of reference laboratory testing requests resulted in substantial cost containment and improved the efficiency of patient care.

A review of pre-admission advanced airway management in combat casualties, Helmand Province 2013

ObjectivesAirway compromise is the third leading cause of potentially preventable combat death. Pre-hospital airway management has lower success rates than in hospital. This study reviewed advanced airway management focusing on...

The top clinical trial opportunities in therapeutic apheresis and neurology.

The National Heart, Lung, and Blood Institute, of The National Institutes of Health, convened the 2012 State-of-the-Science Symposium in therapeutic apheresis (TA) with the goals of identifying and prioritizing future research concept proposals to optimize the use of TA over the next decade. Six subcommittees, including neurology, were formed based on organ system, pathophysiology, and technology/special considerations. The subcommittees consisted of physicians, clinical subject matter experts, and basic scientists. Each subcommittee developed concept proposals that were presented, evaluated, and prioritized based on scientific importance, clinical significance, and feasibility. The neurology subcommittee developed eight concept proposals. The proposals include therapeutic plasma exchange (TPE) in neuromyelitis optica; TPE versus intravenous immunoglobulin (IVIG) in anti-muscle specific kinase associated myasthenia gravis, severe acute disseminated encephalomyelitis, and anti-NMDA encephalitis; extracorporeal photopheresis in relapsing remitting multiple sclerosis and polymyositis; fibrinogen/low-density lipoprotein apheresis in idiopathic sudden sensorineural hearing loss; and creation of a rare neurologic disease registry and biorepository. Key clinical research priorities to evaluate and optimize the use of TA on selected neurologic disorders exist. The research opportunities if addressed would provide evidence-based data to inform the care of patients with these selected neurologic diseases.

Planning a Continuing Education Course on Bariatric Nursing

This article provides an overview of how health educators and others can plan training sessions on bariatric nursing for nurses in both academic and practice settings. It gives practical, step-by-step advice on how to develop a continuing education experience and promote it to senior management staff who are responsible for funding both these programs and the salaries of staff who attend them. Although many administrators feel that designing training and educational programs comes almost intuitively to any experienced nurse, this work is best done by nurses who have some expertise in instructional systems design, in collaboration with clinical subject matter experts. This article guides the reader through some of the essential instructional systems design steps in developing an effective learning experience targeted at staff who care for bariatric patients.