Electronic Health Record Chart Research Articles

Clinical Adjudication of Outpatient Complications Reported in the U.S. News and World Report’s Urology Rankings

ObjectivesTo assess whether the US News and World Report (USNWR) Urology specialty ranking methodology accurately captures and classifies complications following elective outpatient urology procedures. MethodsWe conducted electronic health record chart review of n=80 elective, outpatient urology procedures with complications from 2019-2023 across four hospitals in our integrated US health system. We used the Solventum AM-PPC software and USNWR methodology to determine eligibility and measure complications. For each complication identified by the software, we assessed: 1.) Whether the procedure was performed by a urologist; 2.) Whether the adjudicator agreed with the complication type; and 3.) Whether the complication was a clinically-related sequelae of the index procedure. We reported Clavien-Dindo severity of each complication. Results: Our adjudication agreed on complication type in 62/80 (78%) complications, and 64/80 (80%) complications were clinically related to the index urology procedure. Combined, 57/80 (71%) complications were concordant on both complication type and clinical relatedness. However, 38/80 (48%) index procedures were conducted by interventional radiologists, not urologists. Furthermore, 11/80 (13.8%) complications were false positive urinary tract infections (UTIs). ConclusionsThe USNWR methodology for elective outpatient urology procedural complications showed reasonable clinical validity but detected several false positive UTIs. Further, USNWR should clarify the extent to which procedures performed by interventional radiologists belong in urology rankings.

Determining the Failure Rate of Direct Restorations-Chart Review versus Electronic Health Record Reports.

Amalgam and composite restorations are used to treat minor dental issues. University of Michigan, School of Dentistry Electronic Health Record (EHR) reports show a 2.31% failure rate for amalgam and 1.14% for composite. Our study aims to determine the true failure rates through manual EHR chart reviews. Patient data from the University of Michigan School of Dentistry were utilized-216 amalgam restorations from 2020 to 2022 and 350 composite restorations in 2021 were searched. We defined failure and retreatment as replacing a restoration with the same material and failure and alternate treatment as replacing restoration with an alternative treatment within one year. The failure rate refers to a combination of replacement with the same and alternative treatment material within one year. For Amalgam: 1.85% failed and were retreated; 7.87% failed and were received an alternate treatment. Composite: 9.71% failed and retreated; 2.86% failed and received alternate treatment. In total anterior composite: 10.5% retreated, 2.6% failed; posterior composite: 9.1% retreated, 3.0% failed. Our study revealed higher restoration failure rates than the reports extracted in the EHR. This highlights the need to foster a culture of precise documentation to align EHR reports with hand-search findings.

Opportunities to improve high-risk behavior screenings during well-child examinations.

Nurse practitioners serve an essential role in the completion of age-appropriate adolescent high-risk behavior screenings including tobacco/nicotine, alcohol, illicit drug use, and sexual activity during well-child examinations (WCEs). Midwestern adolescents demonstrate a suboptimal rate of engaging in annual preventative medical visits in comparison to national data. This mixed-methods quality improvement pilot sought to evaluate health care providers' beliefs, general clinic processes, and the overall quality of WCEs among adolescents aged 11-17 years in two midwestern primary care clinics. Quantitative data were obtained through queried reports and manual electronic health record chart audits. Qualitative data were obtained through focus group interviews. Interventional strategies included providing education to key stakeholders regarding data analysis findings indicating process deficiencies regarding adolescent WCEs. Project members championed integration of advanced practice nurses as leaders of change within urban, multisite tertiary health care systems. Results demonstrate that the lack of standardized assessment during an adolescent WCE can lead to fragmentation of high-risk behavior screenings. This quality improvement pilot demonstrates the need for nurse practitioners to be at the forefront of interprofessional committees advancing the implementation of evidence-based guidelines and practice improvement initiatives. Standardization of high-risk behavior screening as part of the WCE in adolescence provides the foundation for health promotion and chronic disease prevention spanning into adulthood.

Patient-specific comorbidities as prognostic variables for survival inmyelofibrosis.

Treatment decisions in primary myelofibrosis (PMF) are guided by numerous prognostic systems. Patient-specific comorbidities have influence on treatment-related survival and are considered in clinical contexts but have not been routinely incorporated into current prognostic models. We hypothesized that patient-specific comorbidities would inform prognosis and could be incorporated into a quantitative score. All patients with PMF or secondary myelofibrosis with available DNA and comprehensive electronic health record (EHR) data treated at Vanderbilt University Medical Center between 1995 and 2016 were identified within Vanderbilt's Synthetic Derivative and BioVU Biobank. We recapitulated established PMF risk scores (eg, Dynamic International Prognostic Scoring System [DIPSS], DIPSS plus, Genetics-Based Prognostic Scoring System, Mutation-Enhanced International Prognostic Scoring System 70+) and comorbidities through EHR chart extraction and next-generation sequencing on biobanked peripheral blood DNA. The impact of comorbidities was assessed via DIPSS-adjusted overall survival using Bonferroni correction. Comorbidities associated with inferior survival include renal failure/dysfunction (hazard ratio [HR], 4.3; 95% confidence interval [95% CI], 2.1-8.9; P= .0001), intracranial hemorrhage (HR, 28.7; 95% CI, 7.0-116.8; P= 2.83e-06), invasive fungal infection (HR, 41.2; 95% CI,7.2-235.2; P= 2.90e-05), and chronic encephalopathy (HR, 15.1; 95% CI, 3.8-59.4; P=.0001). The extended DIPSS model including all 4 significant comorbidities showed a significantly higher discriminating power (C-index 0.81; 95% CI, 0.78-0.84) than the original DIPSS model (C-index 0.73; 95% CI, 0.70-0.77). In summary, we repurposed an institutional biobank to identify and risk-classify an uncommon hematologic malignancy by established (eg, DIPSS) and other clinical and pathologic factors (eg, comorbidities) in an unbiased fashion. The inclusion of comorbidities into risk evaluation may augment prognostic capability of future genetics-based scoring systems.

Clinical manifestations of EVALI in adolescents before and during the COVID-19 pandemic.

E-cigarette, or vaping, product use-associated lung injury (EVALI) results from inhaling the aerosol of e-cigarettes and has similar clinical features to coronavirus disease 2019 (COVID-19). EVALI case counts since the declaration of the COVID-19 pandemic is unknown. A retrospective electronic health record chart review of adolescents hospitalized at one institution with EVALI was conducted. Clinical characteristics and hospital course of patients hospitalized during the pandemic were compared to those prepandemic. The clinical presentation of adolescents hospitalized prior-to (n = 19) and during the COVID-19 pandemic (n = 22) were similar with respect to constitutional, respiratory, and gastrointestinal symptoms. All patients hospitalized during the pandemic were tested for COVID-19 at least once. Only one patient had a positive SARS-CoV-2 RT-PCR test result. Thirty-oneout of 39 patients treated with corticosteroids had clinical improvement within 24 h (79%). Patients hospitalized during the pandemic had a shorter median length of stay (5 vs. 7 days, p < 0.01), and were less often discharged with home oxygen (1 vs. 6 patients, p = 0.04). Pulmonary function tests improved pre- to postcorticosteroid treatment and postcorticosteroid to follow-up. Eliciting a history of vaping in adolescents presenting with constitutional, respiratory, and gastrointestinal symptoms is important to identify EVALI cases, which have continued throughout the COVID-19 pandemic. A shorter length of stay with less need for mechanical ventilation and home oxygen in adolescents hospitalized during the pandemic may reflect increased familiarity with EVALI characteristics. Corticosteroids led to clinical and pulmonary function improvement.

Goals of Care Conversations Documented By an Embedded Emergency Department-Palliative Care Team During COVID.

Background: There has been growing interest around integrating palliative care (PC) into emergency department (ED) practice but concern about feasibility and impact. In 2020, as the COVID pandemic was escalating, our hospital's ED and PC leadership created a new service of PC clinicians embedded in the ED. Objectives: To describe the clinical work of the embedded ED-PC team, in particular what was discussed during goals of care conversations. Design: Prospective patient identification followed by retrospective electronic health record chart extraction and analysis. Settings/Subjects: Adult ED patients in an academic medical center in the United States. Measurements/Results: The embedded ED-PC team saw 159 patients, whose mean age was 77.5. Nearly all patients were admitted, 48.0% had confirmed or presumed COVID, and overall mortality was 29.1%. Of the patients seen, 58.5% had a serious illness conversation documented as part of the consult. The most common topics addressed were patient (or family) illness understanding (96%), what was most important (92%), and a clinical recommendation (91%). Clinicians provided a prognostic estimate in 57/93 (61.3%) of documented discussions. In the majority of cases where prognosis was discussed, it was described as poor. Conclusion: Specialist PC clinicians embedded in the ED can engage in high-quality goals of care conversations that have the potential to align patients' hospital trajectory with their preferences.

Simulated Electronic Health Record Chart Audit: A Relevant Clinical Activity.

Simulated Electronic Health Record Chart Audit: A Relevant Clinical Activity.

Missed pertussis diagnosis during co-infection with Bordetella holmesii.

The purpose of this study is to identify predictive factors associated with missed diagnosis of B. pertussis-B. holmesii co-infection by assessing the analytical performance of a commercially available multiplexed PCR assay and by building a prediction model based on clinical signs and symptoms for detecting co-infections. This is a retrospective study on the electronic health records of all clinical samples that tested positive to either B. pertussis or B. holmesii from January 2015 to January 2018 at Geneva University Hospitals. Multivariate logistic regression was used to build a model for co-infection prediction based on the electronic health record chart review. Limit of detection was determined for all targets of the commercial multiplexed PCR assay used on respiratory samples. A regression model, developed from clinical symptoms and signs, predicted B. pertussis and B. holmesii co-infection with an accuracy of 82.9% (95% CI 67.9-92.8%, p value = .012), for respiratory samples positive with any of the two tested Bordetella species. We found that the LOD of the PCR reaction targeting ptxS1 is higher than that reported by the manufacturer by a factor 10. The current testing strategy misses B. pertussis and B. holmesii co-infections by reporting only B. holmesii infections. Thus, we advocate to perform serological testing for detecting a response against pertussis toxin whenever a sample is found positive for B. holmesii. These findings are important, both from a clinical and epidemiological point of view, as the former impacts the choice of antimicrobial drugs and the latter biases surveillance data, by underestimating B. pertussis infections during co-infections.

De novo EGFR T790M mutations in a community-based oncology practice.

3146 Background: With the 2018 FDA approval of osimertinib for first-line treatment in EGFR-mutated lung cancers, the prevalence of acquired EGFR T790M mutations is expected to decrease, heightening the significance of de novo T790M mutations. Previous studies have reported a wide range of de novo T790M prevalence, and smaller retrospective studies have indicated that germline T790M may comprise the majority of de novo T790M mutations. Here, we assess the frequency of de novo T790M mutations in a community-based setting and report on germline T790M mutations occurring within this population. Methods: Patients with T790M-positive lung cancer were identified using Sarah Cannon’s clinicogenomics database containing information for patients treated within the Sarah Cannon research network. All T790M mutations were detected on tissue- and plasma-based NGS tests delivered as part of routine care. De novo and germline EGFR T790M status was determined via manual electronic health record chart review. When available, allele fraction and %cfDNA values were extracted from the structured NGS report and analyzed separately. Results: Of T790M-positive lung cancers with available pretreatment testing results, 36% (16/44) were confirmed to be T790M+ prior to EGFR TKI exposure; five of these patients received germline testing, and all five were confirmed to have originated in the germline. Two patients with germline T790M mutations detected on testing ordered by external providers were added to our de novo T790M+ patient analysis after chart review. Co-occurring EGFR mutations, including L858R, were detected in pre-TKI samples for 78% (14/18) of de novo T790M+ patients (Table). Co-occurring mutations in TP53, KRAS, PTEN, or RB1 were detected in pre-TKI samples of all patients without co-occurring EGFR mutations. EGFR C797S was observed after osimertinib treatment in one of four patients with post-TKI testing results. Of confirmed germline T790M+ cases with available allele frequencies, 100% (4/4) had allele fractions &gt;0.5 (tissue) and/or %cfDNA values &gt;50% (plasma). Average allele fraction and %cfDNA values were higher for de novo T790M mutations (allele fraction: 0.5 ± 0.2; %cfDNA: 40% ± 20%) than for acquired T790M mutations (allele fraction: 0.3 ± 0.2; %cfDNA: 2% ± 2%). Conclusions: Roughly one-third of T790M mutations detected in real-world settings occur before EGFR TKI exposure and may be associated with germline inheritance. Allele frequency may be a potential indicator of de novo T790M mutations in scenarios where pre-treatment data is not available. Future studies will investigate the impact of de novo T790M mutations on treatment response and evolution of resistance mechanisms in osimertinib-treated patients. [Table: see text]

Incidence of Sacral Osteomyelitis and Discitis After Minimally Invasive Sacrocolpopexy.

The incidence and associated risk factors for sacral osteomyelitis and sacral discitis after sacrocolpopexy remain unknown. The aim of this study was to determine the incidence of sacral osteomyelitis and discitis after minimally invasive sacrocolpopexy and their association with the method of sacral mesh fixation. This is a retrospective cohort study of consecutive minimally invasive sacrocolpopexies performed by 11 female pelvic medicine and reconstructive surgery board-certified surgeons from January 2009 to August 2019 within a single health system. Sociodemographic, procedure, and clinical variables were abstracted from the electronic health record (EHR). We then performed a confirmatory EHR interrogation, cross-referencing procedural codes for laparoscopic and robot-assisted sacrocolpopexy and diagnostic codes for sacral osteomyelitis and sacral discitis. The EHR chart review identified 1,189 women who underwent laparoscopic (55.2%) and robot-assisted (44.8%) minimally invasive sacrocolpopexy, all with polypropylene mesh. Median follow-up was 7.7 months (interquartile range, 0-49.8). Titanium helical tacks were used in 52.7% patients, sutures in 41.6%, and both in 5.6%. No cases (0%) of sacral osteomyelitis or discitis were identified by chart review. The system-wide EHR interrogation of procedural and diagnostic codes identified 421 additional procedures for a total of 1,610 minimally invasive sacrocolpopexies. Among these, there were no cases (0%) of osteomyelitis or discitis. Sacral osteomyelitis and discitis are rare early outcomes after minimally invasive sacrocolpopexy with an incidence of less than 1/1,000 cases. Given an absence of cases, we were unable to assess for an association between method of sacral attachment and sacral osteomyelitis and sacral discitis.

S0289 Utilization of Telemedicine for Colorectal Cancer Outreach During the COVID-19 Pandemic: COLOVID-19

INTRODUCTION: The United States is currently experiencing an unprecedented outbreak of the coronavirus. During the peak phase of the pandemic in order to conserve resources and minimize risk of transmission, many elective screening colonoscopies were cancelled. The quality team at our institute developed an educational program via telemedicine and internet—“COLorectal Outreach Via Internet and Dial-in—19 (COLOVID-19)” utilizing patient resources provided by ACG and ASGE. Our aim was to continue our colorectal cancer screening outreach initiative and provide an avenue for patients to reschedule screening colonoscopies. METHODS: A document about colon cancer screening with instructions for rescheduling procedures was prepared by a group of physicians and nurses (Figure 1). A list of cancelled screening colonoscopies was generated by the practice manager from March 23 to May 15, 2020. Nurses, fellows, physicians and practice staff provided outreach to patients whose screening colonoscopy was rescheduled. The checklist was shared as part of the patient’s online electronic health record (EHR) which allowed for two way conversation between the medical provider and patient. Any patients not reached via EHR received a telephone call and the check- list was also mailed. RESULTS: Figure 2 describes the algorithm of our workflow. We reached out to 871 patients whose screening colonoscopies were cancelled from March 23 to May 15, 2020. 274 patients did not have access to online EHR chart and received the COLOVID-19 point checklist via mail and telephone call. The remaining patients (N = 597) received the list via EHR and 286 patients confirmed receipt of the checklist via the EHR. Patients who did not confirm receipt of the checklist (N = 311) were contacted via telephone and 213 patients had the checklist mailed to them. In summary 44.1% of the patients received the COLOVID-19 via internet and 55.9% via telephone and mail. Figure 3 shows the results and patient comments. CONCLUSION: We developed the COLOVID-19 point checklist to ensure a continuum of education and communication with respect to colorectal cancer awareness and prevention during the time of the COVID-19 pandemic. Through this process, patients had adequate follow-up for cancelled screening colonoscopies and were not lost to follow-up. Patients expressed positive feedback and all procedures have been rescheduled to date.Figure 1.: COLOVID 19 Point Checklist.Figure 2.: Flow diagram for distribution of COVID-19 check list.Figure 3.: Patient outreach method and feedback on receiving COLOVID-19 checklist.

205: Effect of weight gain on delivery mode in obese women with normal estimated fetal weight

To study the effect of excessive gestational weight gain (EGWG) on the mode of delivery (MOD) and maternal outcomes in obese women with a normal estimated fetal weight (EFW) who delivered at term. A multi-center observational retrospective cohort study using electronic health record chart review of obese women who delivered at term from October 2016 to June 2019 in UPMC Pinnacle associated hospitals and had a fetal growth ultrasound within 3 weeks of delivery with an EFW within 2500 to 4500 grams. Obese women with normal EFW were compared on the basis of weight gain. EGWG was defined as weight gain of more than 20lbs during the pregnancy by the American College of Obstetrics and Gynecology. Weight gain of more than 20 pounds had no significant effect on MOD in obese women with a normal EFW. Obese women who had EGWG had a significantly lower pre-gravid body mass index (BMI) when compared to obese women with significantly higher pre-gravid BMI (p< 0.0001). Obese women who were delivered by cesarean section had a significantly higher BMI at the time of delivery when compared to the same group who had a vaginal delivery (p=0.0403). There was no significant difference on the MOD between women with class I, class II, and class III obesity. There was no significant difference in the demographics and co-morbidities between the study groups who delivered by cesarean section versus vaginal delivery. Maternal obesity and EGWG has been associated with adverse pregnancy outcomes, large for gestational age infants and cesarean delivery. To our knowledge, the relationship between EGWG in the setting of a normal EFW and MOD had not been previously reported. Our study shows that weight gain in excess of the 20lbs recommended for obese women (class I-III) had no significant effect on the MOD in the setting a normal EFW.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Improving Asthma in Pediatric Practice

Pediatric asthma is a significant public health problem. It is the third cause of pediatric hospitalizations, costing $20 billion in 2016. In the US, approximately 6 million children have asthma. Despite available guidelines, implementation is lagging with only 35 % of providers using guidelines. The question was does provider compliance of the NAEPP 2007 asthma guidelines improve through an electronic health record (EHR) template in a pediatric primary care practice?" A quality improvement project implemented an EHR template for pediatric asthma visits and provider education to support the compliance of following the NAEEP 2007 asthma guidelines. A retrospective EHR chart review of charts within the same seasonal time frame, ages 5-12yrs was done to determine documentation pre-and post-project implementation. The chi- square was used for statistical significance. Data reviewed were documentation of action plan, severity, adherence to follow-up appointment, prescribing of prevention medication, ED visits and hospitalizations, C-ACT score, spirometry use, education, and missed school days. Documentation of asthma action plan increased from 10 % to 74 % p = 0.001., spirometry rose from 4% to 32 % p =.011, asthma education increased from 60 % to 98% p=.000, follow up adherence rose from 60% to 98% p = .000 and asthma severity categorized improved from 32% to 100 % p=. 011. Statistical significance was shown in 7 out of the 8 quality measurements. The area of prescribing controller medication for persistent asthma showed clinical significance with 58% to 100% improvement, but was not statistically significant (p=.258) because clinical knowledge was present with the providers prior to the intervention on managing persistent asthma. Results support the hypothesis that an EHR template with evidence-based guidelines improved provider documentation of an asthma action plan, severity, follow-up, and prescribing control medication, ED visits, hospitalizations, missed school days, C-ACT score, spirometry and asthma education. View a PDF of this Poster Presentation

Implementing integrated behavioral health: Testing associations between shared clinical time and space and provider referrals.

Behavioral health provider (BHP) availability is widely acknowledged as an important factor in the effectiveness of an integrated care approach within primary care. However, there is little research providing evidence of the impact of BHP availability on physician uptake of integrated behavioral health (IBH) services. This quasi-experimental study examines whether shared clinical time and space with a BHP is associated with providers' number of standard IBH referrals and proportion of warm handoffs within total behavioral health (BH) referrals. Data are from 2 family medicine outpatient clinics with 1 shared, part-time BHP and were gathered across 4 months (2,847 unique patients served) using electronic health record chart review of patients referred for BH services. Results of a Poisson regression indicated greater shared time and space between BHP and providers is significantly associated with a greater number of providers' standard IBH referrals, χ²(df = 1, N = 15) = 13.67, p = .000. Results of general linear modeling indicate greater shared time and space is also associated with a greater proportion of warm handoffs (percentage of total referrals). A 1-unit increase in percentage of schedule overlap was associated with a 110% increase in likelihood of a family medicine provider making a warm handoff, Exp(β) = 2.10, p = .007. This exploratory study provides initial evidence to support the notion that shared time and space between BHPs and physicians is an essential component of effective integrated care. Future research is needed to evaluate how shared time and space impact the accessibility, adoption, and effectiveness of the BHP. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A Project to Improve Postpartum Depression Screening Practices Among Providers in a Community Women’s Health Care Clinic

ObjectiveThe purpose of this project was to improve health care providers’ postpartum depression (PPD) knowledge and screening practices with the implementation of a standardized screening tool. DesignThe plan–do–study–act model was used as a framework to measure and implement a practice change aimed at universal screening for PPD. Setting/Local ProblemHealth care providers’ screening practices for PPD were inconsistent and lacked use of a standardized screening tool at a southwestern U.S. community women’s health care clinic serving minority women of lower socioeconomic status. ParticipantsHealth care providers at a community women’s health care clinic. Intervention/MeasurementsA single educational in-service was presented to health care providers regarding preventive PPD screening practices and documentation recommendations. Measurements included pre- and post-education questionnaire results and electronic health record chart reviews. ResultsPPD screening documentation rates increased from 56% to 92.7% (p < .5). ConclusionPPD screening education for health care providers and the addition of EPDS criteria to the electronic health record were associated with increased screening rates for PPD at a community women’s health care clinic.

Golden Hour Protocol for Preterm Infants: A Quality Improvement Project.

Preterm infants are a vulnerable patient population, especially during the first hours of life. Hypothermia, hypoglycemia, and early-onset sepsis are common problems related to prematurity. Implementation of a Golden Hour protocol has been shown to improve outcomes for preterm infants. To evaluate the effectiveness of a Golden Hour protocol for infants born at less than 32 weeks' gestation on improving the admission process in a military care facility. Specific aims focused on temperature, time to initiation of intravenous (IV) fluids, time to administration of antibiotics, and time to close of the incubator top. A pre-/postdesign was used to compare outcomes from preimplementation to postimplementation. Predata were collected using electronic health record chart review and postdata were collected from the Neonatal Intensive Care Unit admission worksheet. Although we did not find statistical significance, we found that more infants had a temperature greater than 36.5°C within 1 hour of birth and decrease in time to initiation of IV fluids and antibiotics from preimplementation to postimplementation, which is clinically significant. Time to close of the incubator top remained greater than 1 hour. Implementation of a Golden Hour protocol provides a guide to caring for preterm infants during the first hour of life to improve patient outcomes. Involvement of key stakeholders and staff education are key to successful implementation. Researchers should examine long-term outcomes related to implementation of a Golden Hour protocol in future studies. Future quality improvement projects should include the effectiveness of similar protocols and address possible barriers.

The effect of electronic health record software design on resident documentation and compliance with evidence-based medicine.

This study aimed to determine the role of electronic health record software in resident education by evaluating documentation of 30 elements extracted from the American Academy of Ophthalmology Dry Eye Syndrome Preferred Practice Pattern. The Kresge Eye Institute transitioned to using electronic health record software in June 2013. We evaluated the charts of 331 patients examined in the resident ophthalmology clinic between September 1, 2011, and March 31, 2014, for an initial evaluation for dry eye syndrome. We compared documentation rates for the 30 evidence-based elements between electronic health record chart note templates among the ophthalmology residents. Overall, significant changes in documentation occurred when transitioning to a new version of the electronic health record software with average compliance ranging from 67.4% to 73.6% (p < 0.0005). Electronic Health Record A had high compliance (>90%) in 13 elements while Electronic Health Record B had high compliance (>90%) in 11 elements. The presence of dialog boxes was responsible for significant changes in documentation of adnexa, puncta, proptosis, skin examination, contact lens wear, and smoking exposure. Significant differences in documentation were correlated with electronic health record template design rather than individual resident or residents’ year in training. Our results show that electronic health record template design influences documentation across all resident years. Decreased documentation likely results from “mouse click fatigue” as residents had to access multiple dialog boxes to complete documentation. These findings highlight the importance of EHR template design to improve resident documentation and integration of evidence-based medicine into their clinical notes.

Examining predictors of utilization of an Interdisciplinary outpatient transitions of care service

Objective To determine the impact of need, enabling and predisposing factors on utilization of an interdisciplinary, postdischarge transitions of care (TOC) service. Methods This was a retrospective cohort study of patients discharged from an acute care hospital and scheduled for a TOC visit. Patients with a scheduled TOC appointment at the study clinic within 30 days of a hospital discharge from any of the three University of Pennsylvania Health System hospitals in Philadelphia between September 2013 and January 2015 were included in the study. Individual determinants of healthcare utilization from the Andersen model were extracted from the patients' electronic health record chart. Bivariate analyses were used to identify patient characteristics associated with utilizing the TOC service. A logistic regression model was used to identify independent predictors of TOC service utilization. Key findings TOC utilizers had higher Charlson Comorbidity Index (CCI) scores (OR 1.66, P < 0.01), greater number of internal medicine office visits (OR 1.20, P = 0.03) and took fewer medications (OR 0.89, P < 0.01) relative to non-utilizers. Conclusions Findings from this study can help healthcare administrators prioritize factors associated with the greatest impact on utilization with the ultimate goal of increasing utility of TOC services.

Development and Validation of an Electronic Health Record–Based Chronic Kidney Disease Registry

Chronic kidney disease (CKD) is increasing, and outcomes-related research from diverse health care settings is needed to target appropriate efforts and interventions. We developed an electronic health record (EHR)-based CKD registry at the Cleveland Clinic and validated comorbid conditions. Patients who had at least one face-to-face outpatient encounter with a Cleveland Clinic health care provider and (1) had two estimated GFR values <60 ml/min per 1.73 m(2) >90 days apart as of January 1, 2005 and/or (2) were patients with International Classification of Diseases-9 (ICD-9) diagnosis codes for kidney disease were included. Our registry includes 57,276 patients (53,399 patients met estimated GFR criteria and 3877 patients met ICD-9 diagnosis code criteria) as of March 2010. Mean age was 69.5 ± 13.4 years, with 55% women and 12% African Americans. Medicare is the primary insurer for more than one half of the study cohort. The κ statistics to assess the extent of agreement between the administrative dataset extracted from the EHR and actual EHR chart review showed substantial agreement (>0.80) for all conditions except for coronary artery disease and hypertension, which had moderate agreement (<0.60). Development of an EHR-based CKD registry is feasible in a large health system, and the comorbid conditions included in the registry are reliable. In addition to conducting research studies, such a registry could help to improve the quality of care delivered to CKD patients and complement the ongoing nationwide efforts to develop a CKD surveillance project.

American college of rheumatology quality indicators for rheumatoid arthritis: Benchmarking, variability, and opportunities to improve quality of care using the electronic health record

To measure how rheumatologists across our health system performed with the American College of Rheumatology (ACR) quality indicators (QIs) for rheumatoid arthritis (RA) and methotrexate (MTX) drug safety, and to develop opportunities for improvement. An electronic health record (EHR) review of 1,062 unique RA patients seen by 15 rheumatologists in a 1-year period was performed. Percentage of each QI met, reasons why the metric was not met, and performance of rheumatologists based on years of experience were evaluated. The percentage met was high for QI-2 (RA disease-modifying antirheumatic drug use; 94%), QI-3 (intervention if RA worse; 85%), and QI-4 (MTX risks discussion; 87%). Percentage met was lower for QI-1 (RA core data set; 69%), QI-5 (MTX baseline studies; 41%), and QI-6 (MTX followup studies; 46%). QI-1 and QI-5 were low due to most physicians missing a single test, and QI-6 was low because of few physicians driving the percentage down. Better QI performance was seen in rheumatologists with <or=10 years versus >10 years of experience for QI-1 (90% versus 64%; odds ratio [OR] 4.21, P = 0.004) and QI-3 (96% versus 82%; OR 4.47, P = 0.019). EHR chart review for this population required 179.3 hours. Measurement allows us to better understand the quality of care that we deliver. In this systematic benchmarking of the ACR QIs in a large RA cohort, performance was excellent in RA treatment-related QIs. Significant variability was noted in RA and MTX monitoring measures, which can be addressed using process redesign techniques.