Electronic Health Record Reminder Research Articles

Optimizing Protection Against HPV-Related Cancer: Unveiling the Benefits and Overcoming Challenges of HPV Vaccination.

Human papillomavirus (HPV) vaccine is an underutilized tool in cancer prevention. HPV vaccine completion rates in adolescents age 13 to 15 years remain low at 59%. The HPV vaccine can prevent more than 90% of cases of cancer caused by HPV, including cervical, oropharyngeal, anal, penile, vulvar, and vaginal. HPV vaccine is very safe and effective, as demonstrated by numerous large-scale studies. Practice-based strategies can improve vaccination rates, such as having providers give a strong presumptive recommendation for the vaccine, using motivational interviewing for hesitant families, and using electronic health record reminders to prompt providers to offer it, among other interventions. Offering HPV vaccine starting at age 9 years is another evidence-based strategy to improve HPV vaccine completion rates, which has been shown to be acceptable to both providers and parents. [Pediatr Ann. 2024;53(10):e372-e377.].

Factors Affecting Breast Cancer Screening in Ukraine

PURPOSE Breast cancer early detection in Ukraine and other low and middle-income countries (LMICs) often includes opportunistic screening. Evaluation of factors that affect screening is key to improving early detection. METHODS An online survey for primary care physicians (PCPs) was distributed through PCP-focused social media in Ukraine. Data were analyzed using descriptive statistics. RESULTS 435 PCPs from all regions of Ukraine completed the survey, including 389 (89.4%) women, 375 (86.2%) family medicine, 60 (13.8%) internal medicine physicians. 349 (80.2%) referred women for screening mammography. 252 (57.9%) conducted screening clinical breast exams (CBE), while 135 (31.0%) referred patients to mammalogists or 133 (30.6%) to gynecologists for CBE. Within one's practice, mammography was available for 81 (18.6%), mammalogists for 39 (9.0%), and gynecologists for 133 (30.3%). Breast cancer screening was prompted by MOH Order 504 for 281 (64%), family history 266 (61%), patient pathway guidelines 94 (21.6%), availability of subspecialists 78 (17.9%), and patient request 132 (30%). Reasons for not conducting CBE screening included insufficient experience 88 (20.2%), patients declining CBE 63 (14.5%), lack of time 59 (13.6%). Reasons for not conducting mammography screening included patients declining (11.7%) and absence of mammography (6.4%).). 350 (80.5%) were familiar with the Ministry of Health (MOH) Order 504, which describes eligibility criteria for breast cancer screening, and 291 (66.9%) used it to guide their screening practice. Others used US or European recommendations (62 (14.3%) and 115 (26.4%), respectively), and institution-specific patient pathways 117 (26.9%). Barriers to breast cancer screening included insufficient PCP training (53%) and experience (40%) and insufficient mammography availability (33%). Strategies for increasing breast cancer screening included improving collaboration between PCPs and oncologists 175 (40.2%), educational materials for patients 169 (38.9%), PCP education/training 168 (38.6%), automatic electronic health record reminders 150 (34.5%). CONCLUSION We identified important barriers and facilitators of breast cancer screening from the point of view of PCPs in Ukraine. Our results were limited by online convenience sampling.

Improving Documentation of Pain Reassessment after Pain Management Interventions in the NICU.

Neonates exposed to painful procedures require pain assessment and reassessment using nonverbal scales. Nurses perform initial assessments routinely, but reassessment is variable. The goal was to increase pain reassessments in neonates with a previous score of 4 or higher within 60 minutes from 50% to 75% within 12 months. After identifying key drivers, we tested several interventions using the IHI's Model for Improvement. The outcome measure was the rate of reassessments within 1 hour after scoring ≥4 on the Neonatal Pain Agitation and Sedation Scale (N-PASS). Duration of time between scoring and intervention was documented. Interventions included electronic health record (EHR) changes, direct communication with bedside nurses through text messages and emails, in-person education, and a yearly competency module. The process measure was the number of messages/emails to staff. Sedation scores were the balancing measure. Baseline compliance was 50% with significant variability. A centerline shift occurred after the first intervention. After the first four interventions in the following 3 months, a 29% total increase occurred. Overall time-lapse between reassessments decreased from 102 to 90 minutes. Overall sedation scores decreased from -2.5 during the baseline to -1.7 during the sustain period. The goal of 75% pain reassessments was achieved and sustained for two years. Automated tools such as the trigger report provided data that increased noncompliance visibility. Real-time and personalized reminders and education improved awareness and set the tone for culture change. Electronic health record reminders for reassessments and standardized annual education helped in sustaining change.

Evaluation of Strategies to Improve Uptake of Expedited Partner Therapy for Chlamydia trachomatis Treatment in Minnesota: A Decision Analytic Model.

Addressing provider concerns about expedited partner therapy (EPT) legality and its potential risks would result in the most partners treated for chlamydia.EPT alerts and electronic EPT prescriptions may also streamline partner treatment.Provider education about the legality of EPT and its potential risks and training in counseling patients on EPT could also increase uptake.

2066. Introduction of a Universal HIV Screening Electronic Health Record Alert at a Midwest Academic Health System

Abstract Background Universal human immunodeficiency virus (HIV) testing is recommended for patients ages 13-64 at least once by the Centers for Disease Control and Prevention. Screening lags behind these recommendations. Methods We performed an analysis of the current state of HIV screening at three university-based internal medicine and one internal medicine/pediatrics clinics serving counties with HIV prevalence in 2020 from 51/100,000 to 176/100,000. We completed a chart review to examine current screening practices and conducted an electronic survey of primary care providers inquiring about awareness of universal screening recommendations and barriers to screening. Based on this analysis, we implemented an automated electronic health record (EHR) reminder for HIV screening for patients aged 15-64 during health maintenance exams. Our primary outcome was the number of patients screened for HIV pre-intervention (2017-July 2021) and post-intervention (August 2021-December 2021). We used odds ratio to compare the proportion of tests which were false positive and true positive pre- vs post-intervention. To evaluate the effect of the intervention on total HIV tests ordered across the institution, we used control chart methodology. Results Survey response rate was 59% for residents (n=97) and 18% for faculty (n=29). 93% were aware of the screening recommendation. The most common barrier to screening was forgetting to screen (Figure 1). Pre-intervention, 25% of reviewed charts (n=4393) received recommended HIV screening. Post-intervention, HIV testing increased across the institution by 49% (Figure 2) and weekly testing was consistently three standard deviations above the mean compared to pre-intervention (Figure 3). The proportion of true positive tests decreased (p< 0.05). Figure 1.Common Reasons for Not Performing Universal HIV ScreeningFigure 2.Summary of HIV Testing 2017-2021Figure 3.Control Chart for HIV Testing by Week 2017-2021 Conclusion Implementation of an automated HIV screening EHR reminder increased HIV screening. The proportion of true positive tests decreased, likely due to the low prevalence of HIV in our community Disclosures All Authors: No reported disclosures.

"Lock to Live" for firearm and medication safety: Feasibility and acceptability of a suicide prevention tool in a learning healthcare system.

ObjectiveFew patients with suicide risk are counseled on lethal means safety by health providers. This study tested the feasibility of different delivery methods for Lock to Live (L2L), a web-based decision aid of safe storage options for firearms and medications.MethodsPatients reporting suicide ideation on the PHQ9 depression screener during outpatient health visits were included. Invitation messages to visit L2L were sent via combinations of email, text, Electronic Health Record (EHR) message, mailed letter, or provider referral, followed by a survey about storage behavior and acceptability. Provider interviews evaluated logistical considerations and acceptability.ResultsThe population-based method reached 2,729 patients and the best method (EHR message plus 2 email reminders) had 11% uptake (L2L visitation rate). Provider referral had small reach (14 patients) and 100% uptake (all visited). Provider interviews identified several strategies to promote uptake including: EHR reminders, provider training, quality metrics with accountability, a clearly communicated lethal means screening/counseling policy, and strong organizational leadership support.ConclusionDespite the low uptake for population-based (11%), far more patients with suicide risk were engaged in the L2L tool through population-based outreach than provider-referral over the same time frame.

An initiative to improve pneumococcal immunization counseling in children with nephrotic syndrome.

BackgroundImmunization is essential in preventing life-threatening pneumococcal infections in children with nephrotic syndrome. An additional 23-valent pneumococcal polysaccharide vaccine (PPSV23) series is required for children with nephrotic syndrome. Despite current practice guidelines, many children with nephrotic syndrome do not receive PPSV23.MethodsOur nephrology clinic conducted a quality improvement project to improve the overall rate of PPSV23 counseling to more than 70% within a 12-month period by applying several targeted interventions to raise providers’ awareness, improve communication with primary care providers, and increase provider adherence. Data was collected from the electronic health record (EHR), and monthly performance was tracked via monthly control charts and overall immunization counseling rate charts.ResultsWe increased adherence to PPSV23 vaccination counseling from a baseline of 12 to 86%. The first intervention that effectively increased the vaccine counseling rate from 12 to 30% was improving a provider’s awareness of the PPSV23 literature and vaccine guidelines. Other interventions included regular performance reviews at division meetings, creating an immunization protocol, posting performance charts on the office bulletin board, and unifying vaccine recommendation templates. Lastly, specific and timely EHR reminders improved the total counseling rate from 52 to 86% and maintained adherence until the completion of the project.ConclusionBridging the knowledge gap in provider awareness and using specific EHR reminders can improve adherence to PPSV23 counseling in children with nephrotic syndrome. Such interventions could be applied to similar groups of immunocompromised patients in whom additional vaccines are indicated.Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information. Supplementary InformationThe online version contains supplementary material available at 10.1007/s00467-021-05305-3.

Effect of Electronic Health Record Reminders for Routine Immunizations and Immunizations Needed for Chronic Medical Conditions.

Immunization reminders in electronic health records (EHR) provide clinical decision support (CDS) that can reduce missed immunization opportunities. Little is known about using CDS rules from a regional immunization information system (IIS) to power local EHR immunization reminders. This study aimed to assess the impact of EHR reminders using regional IIS CDS-provided rules on receipt of immunizations in a low-income, urban population for both routine immunizations and those recommended for patients with chronic medical conditions (CMCs). We built an EHR-based immunization reminder using the open-source resource used by the New York City IIS in which we overlaid logic regarding immunizations needed for CMCs. Using a randomized cluster-cross-over pragmatic clinical trial in four academic-affiliated clinics, we compared captured immunization opportunities during patient visits when the reminder was "on" versus "off" for the primary immunization series, school-age boosters, and adolescents. We also assessed coverage of CMC-specific immunizations. Up-to-date immunization was measured by end of quarter. Rates were compared using chi square tests. Overall, 15,343 unique patients were seen for 26,647 visits. The alert significantly impacted captured opportunities to complete the primary series in both well-child and acute care visits (57.6% on vs. 54.3% off, p = 0.001, and 15.3% on vs. 10.1% off, p = 0.02, respectively), among most age groups, and several immunization types. Captured opportunities for CMC-specific immunizations remained low regardless of alert status. The alert did not have an effect on up-to-date immunization overall (89.1 vs. 88.3%). CDS in this population improved captured immunization opportunities. Baseline high rates may have blunted an up-to-date population effect. Converting Centers for Disease Control and Prevention (CDC) rules to generate sufficiently sensitive and specific alerts for CMC-specific immunizations proved challenging, and the alert did not have an impact on CMC-specific immunizations, potentially highlighting need for more work in this area.

Improving Blood Pressure Accuracy in the Outpatient Adolescent Setting

Hypertension (HTN) is increasing in the pediatric population, and hypertensive children become hypertensive adults. Blood pressure (BP) is often overlooked due to factors including distrust in readings, lack of time in visits, and discomfort prescribing antihypertensive medications. The objective of our multistage, clinically based quality improvement project was to improve BP measurement and HTN diagnosis and intervention in adolescents. Study investigators performed interventions in an adolescent medicine clinic at Children's Hospital Colorado (ages 12-24 years), which included equipment inventory, mapping clinic processes, manual/automated BP training for staff, education of faculty/staff on guidelines, and creation/implementation of updated best practice alerts (BPAs) based on age-appropriate guidelines for stage 1, 2 HTN in patients younger/older 18years. With equipment updates, medical assistant manual BP certifications, educational sessions for faculty/staff, and creation of a BPA with instruction before the go-live date, confidence in using automated and manual BP measurements increased for faculty/staff. The number of unique patient visits presenting with elevated BPs decreased significantly in the postintervention period reflecting the education/training. Staff used the new order set minimally, but there was an increase in correct diagnoses of elevated BP and laboratory workup. Having appropriate equipment while introducing BP guideline education in the ambulatory setting with electronic health record reminders and utility of BPAs can decrease erroneous BP values saving providers and staff encounter time. Real-time alerts can aid in accurate diagnosis rates and improved intervention for youth with elevated BP readings. Providers still inconsistently interact with order sets despite such parameters.

Screening for Excessive Alcohol Consumption in Emergency Departments: A Nationwide Assessment of Emergency Department Physicians.

To assess current screening practices for excessive alcohol consumption, as well as perceived barriers, perceptions, and attitudes toward performing this screening among emergency department (ED) physicians. A brief online assessment of screening practices for excessive drinking was disseminated electronically to a representative panel of ED physicians from November 2016 to January 2017. Descriptive statistics were calculated on the frequency of alcohol screening, factors affecting screening, and attitudes toward screening. An online assessment was sent to a national panel of ED physicians. A panel of ED physicians who volunteered to be part of the American College of Emergency Physicians Emergency Medicine Practice Research Network survey panel. The primary outcome measures were the percentage of respondents who reported screening for excessive alcohol consumption and the percentage of respondents using a validated excessive alcohol consumption screening tool. Of the 347 ED physicians evaluated (38.6% response rate), approximately 16% reported "always/usually," 70% "sometimes," and 14% "never" screening adult patients (≥18 years) for excessive alcohol use. Less than 20% of the respondents who screened for excessive drinking used a recommended screening tool. Only 10.5% of all respondents (15.4% "always," 9.5% "sometimes" screened) received an electronic health record (EHR) reminder to screen for excessive alcohol use. Key barriers to screening included limited time (66.2%) and treatment options for patients with drinking problems (43.1%). Only 1 in 6 ED physicians consistently screened their patients for excessive drinking. Increased use of EHR reminders and other systems interventions (eg, electronic screening and brief intervention) could help improve the delivery of screening and follow-up services for excessive drinkers in EDs.

Randomized Clinical Trial of Inreach With or Without Mailed Outreach to Promote Hepatitis C Screening in a Difficult-to-Reach Patient Population.

Hepatitis C virus (HCV) treatment can significantly reduce the risk of liver-related mortality; however, many patients remain unaware of their infection in clinical practice. The aim of this study is to compare the effectiveness of inreach, with and without mailed outreach, to increase HCV screening and follow-up in a large, difficult-to-reach patient population. We conducted a pragmatic randomized clinical trial from August 2018 to May 2019 in a large safety-net health system. Patients born between 1945 and 1965 were randomly assigned (1:1) to inreach with an electronic health record reminder to providers (n = 6,195) or inreach plus mailed HCV screening outreach (n = 6,191) to complete HCV antibody screening. Outreach also included processes to promote HCV RNA testing among those with a positive HCV antibody and linkage to care among those with positive HCV RNA. The primary outcome was completion of HCV antibody testing within 3 months of randomization (ClinicalTrials.gov NCT03706742). We included 12,386 eligible patients (median age 60 years; 46.5% Hispanic, 33.0% Black, and 16.0% White). In intent-to-treat analyses, HCV screening completion was significantly higher among inreach-plus-outreach patients than inreach-alone patients at 3 months (14.6% vs 7.4%, P < 0.001) and 6 months (17.4% vs 9.8%, P < 0.001) after randomization. Among those who completed HCV screening within 6 months, a higher proportion of inreach-plus-outreach patients with positive antibody results completed RNA testing within 3 months than inreach-alone patients (81.1% vs 57.1%, respectively, P = 0.02); however, linkage to care within 3 months of HCV infection confirmation did not significantly differ between the 2 groups (48.1% vs 75.0%, respectively, P = 0.24). Among difficult-to-reach patients, a combination of inreach and mailed outreach significantly increased HCV screening compared with inreach alone. However, HCV screening completion in both arms remained low, highlighting a need for more intensive interventions.

Electronic Health Record Reminder Effect on Hepatitis C Antibody Screening.

In the United States, national guidelines recommend screening adults born between 1945 and 1965 for hepatitis C, but screening rates in this population continue to be low. We added a hepatitis C screening reminder to the Epic Electronic Health Record and educated physicians on the use of the Health Maintenance section in Epic. We assessed the effect of this intervention on the completion of screening hepatitis C antibody tests. We examined data from 2 years before and after the addition of the reminder. Completed hepatitis C antibody testing increased from 733 to 6502, and the rate of positive testing decreased from 5.9% to 2.0%. Implementing the electronic health record reminder and educating providers on the routine use of the Health Maintenance section increased hepatitis C screening for at risk adults.

Improving mammography through effective screening, brief intervention, and referral to treatment at a rural health center.

Screening mammography rates at a rural health center were below state rates, while the countywide rate of breast cancer was above the state and national rates. Only 25% of patients at the practice site received a screening mammogram within the last 2 years, and standing order usage was 25%. Evidence-based guidelines and decision aids were not used consistently. The aim was to increase the rate of screening mammograms and right care at a rural health center to 55% of eligible patients in 90 days. Implementation consisted of four 2-week plan, do, study, act cycles. Interventions included screening, brief intervention with patient engagement, referral to treatment with case management log tracking, and team engagement. Aggregate data were collected twice weekly. An electronic health record reminder for mammography screening, a patient mammography decision aid, a case management log, and weekly quality improvement team meetings were the four core interventions used for the project. Screening and identification improved by 40%, patient engagement improved by 30%, and case management for right care more than doubled. Overall, the combined mammography and right care rate improved by 40%. Team engagement reached 100% with survey scores for involvement rising to 78%. The results obtained indicate the tools and processes implemented effectively increased screening, patient engagement, and case management to improve mammography rates and right care.

Understanding the use of digital technology to promote human papillomavirus vaccination – A RE-AIM framework approach

ABSTRACT The human papillomavirus virus (HPV) vaccine is effective at preventing various cancers, but coverage falls short of targets that are needed for community protection. Here, we use the RE-AIM implementation framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) to understand how text, email, and electronic health record (EHR) reminders and social media campaigns can be used as part of policy and practice interventions to increase HPV vaccination. These technology-based interventions could be used together and mainstreamed into clinical and system-based practice to have the greatest impact. Of the interventions explored, text-based, email-based, and EHR reminders have the most evidence behind them to support their effectiveness. While there are several studies of promotion of the HPV vaccine on social media, more studies are needed to demonstrate their effects and better methods are needed to be able to attribute results to these interventions.

Improved Gout Outcomes in Primary Care Using a Novel Disease Management Program: A Pilot Study.

To pilot a primary care gout management improvement intervention. Two large primary care sites were selected: 1 underwent the intervention, the other, a control, underwent no intervention. The intervention consisted of engagement of intervention-site staff, surveys of provider performance improvement preferences, and onsite live and enduring online education. Electronic health record reminders were constructed. Both the intervention and control sites had 3 quality measures assessed monthly: the percentage of gout patients treated with urate-lowering therapy, the percentage of treated patients monitored with serum urate, and the percentage of treated patients at target serum urate ≤6.0 mg/dl. The intervention-site providers received monthly reports comparing their measures against their peers. By 6 months, the intervention site significantly improved all 3 gout performance measures. The percentage treated increased from 54.4% to 61.1% (odds ratio [OR] 1.19 [95% confidence interval (95% CI) 1.08-1.31]; P < 0.001), the percentage monitored increased from 56.1% to 79.2% (OR 1.52 [95% CI 1.24-1.87]; P < 0.001), and the percentage at goal increased from 26.85% to 43.3% (OR 1.43 [95% CI 1.16-1.77]; P < 0.001). At 6 months after intervention, gout patients at the intervention site were more likely to be monitored (79.2% versus 53.4% [OR 3.54 (95% CI 2.30-5.45)]; P < 0.001) and at goal (43.3% versus 28.3% [OR 1.99 (95% CI 1.33-2.96)]; P < 0.001) than control-site patients. Numbers treated did not significantly improve over the control site. A pilot multifaceted gout management program can significantly improve primary care gout management performance.

Adherence to Preventative Health Care Measures in Inflammatory Bowel Disease Patients Is Low

Introduction: Prior studies have shown that preventative health issues are neglected in patients with inflammatory bowel disease. In 2017, the American College of Gastroenterology (ACG) published comprehensive 14-point guidelines regarding preventive care measures (PCMs) in IBD. The adherence to these guidelines has not been assessed. We aimed to evaluate adherence to PCMs outlined by ACG in IBD patients at our center. Methods: We conducted retrospective quality improvement study including IBD patients who had received care at our gastroenterology outpatient clinics between September, 2017 to October, 2017. Baseline patient characteristics and data regarding adherence to preventative health care measures was noted. Results: A total of 94 patients were included. Mean age was 47.6 years and 34% were males. 49% of the patients had Crohn's disease (CD), while 51% had ulcerative colitis. 58.5% of the patients were on long-term steroids, while 45.7% and 44.6% of the patients were on immunomodulators and biologics respectively. Majority of the patients (88%) had a PCP, and 56.6% of the female patients were established with a gynecologist. Adherence with appropriate PCMs as indicated was: Influenza 58.5%, pneumococcal: 56.3%, herpes zoster 19.5%, varicella zoster 11.6%, meningococcal 100%, Tetanus, Diphtheria and Pertussis (Tdap) 55.3%, HAV: 58.5%, HBV 80.5%, HPV 80%, depression screening: 55.3%, melanoma screening: 30.8%. In women on immunosuppressive therapy, 51.6% underwent annual cervical cancer screening, and 33.3% of patients on immunomodulators had non-melanoma skin cancer screening. Bone mineral density testing was performed 67.2% of patients in whom it was indicated, and smoking cessation was advised to 76.9% of CD patients who used tobacco. Conclusion: Despite comprehensive guidelines, PCMs in IBD patients continue to be neglected. There continues to be debate whether preventative care in IBD is best addressed by PCP or gastroenterologists. Although our sample size is small, our results demonstrate significant room for improvement. There is a trend towards better preventive care in patients with IBD who have a PCP in addition to a gastroenterologist. Our next steps include: feedback to our physicians regarding adherence to PCMs, development of electronic health record reminders, and placing flyers in patient rooms. We plan to collect post-intervention data to assess if our interventions lead to improvement in preventive health care delivery to IBD patients.619_A Figure 1. Adherence to preventive care measures in patients with IBD619_B Figure 2. Comparison between gastroenterology fellow and faculty in regards to adherence to preventive care measures in IBD

Large Health Systems’ Prevention Guideline Implementation: A Qualitative Study

Health systems now employ more than half of U.S. physicians. They have the potential to affect primary care through decision support and financial incentives around clinical prevention guidelines. The processes by which they respond to and implement clinical guidelines remain largely unexplored. In 2015, the research team conducted and analyzed interviews with quality leaders from eight hospital-based systems and one physician organization which together employ >33,000 physicians and serve >15 million patients. Executives explained organizational processes to adapt, adopt, disseminate, and incentivize adherence to preventive services guidelines. Nearly all have a formal process for reviewing and refining guidelines, developing clinician support, and disseminating the approved guidelines. Internal and external factors like organizational structure, patient demographics, and payer contracts affect the review processes and resulting guideline adaptations. Challenges to guideline uptake include competing demands on clinician time and the absence of accurate and timely patient data in accessible and user-friendly formats. Interviewees reported that engaging clinicians in guideline review is critical to successful implementation. Electronic health record reminders represent the primary tool for guideline dissemination and reinforcement. Interviewees reported widespread use of performance monitoring and feedback to clinicians, with varying levels of success. Most organizations use financial incentives tied to performance for some of their clinicians, although details vary widely depending on network structures and contractual arrangements. Health systems play a critical intermediary role between guideline-developing organizations and practicing clinicians. Strengthening the adoption of guidelines requires attention to many factors beyond care delivery.

An Innovative Framework to Improve Teratogenic Medication Risk Counseling.

Health care providers in the Veterans Affairs system are caring for a growing number of women of childbearing age. Prior research shows that a significant number of women veterans are prescribed category D or X teratogenic medications. However, the majority do not receive teratogenic risk or contraceptive counseling. In order to improve teratogenic medication prescribing practices at the Veterans Affairs Pittsburgh Healthcare System, we developed a framework called TARCC to guide primary care providers through appropriate teratogenic risk counseling. The components of TARCC are teratogen (Are you prescribing a potential teratogen?), alternative (Did you consider a nonteratogenic alternative?), risks (Did you discuss the risks of the medication?), contraception (Did you discuss contraception?), and chart (Did you chart your discussion?). We incorporated TARCC into an electronic health record reminder. Additional probes, educational tools, and options to place consults and orders are included within the reminder. The Teratogen Pharmacy E-consult prompts a pharmacist to electronically review a patient's medications and provide recommendations regarding potential alternatives and discussions of risks and benefits. This article describes the development and implementation of the TARCC framework in a clinical reminder.

Pediatrician Use of Down Syndrome Health Supervision Guidelines

Objective: The primary care of children with Down syndrome (DS) requires close attention to specific medical vulnerabilities to maximize quality of life and prevent secondary disability. To help optimize adulthood outcomes for children with DS, the AAP Council on Genetics published health supervision guidelines to promote standardized care that adheres to the latest evidence based information. Our primary objective was to determine primary care pediatrician comfort, familiarity and frequency of referral to the 2011 AAP health supervision guidelines for children with DS. A secondary objective was to identify interventions that would improve compliance. Methods: A voluntary, self-administered e-mail survey was distributed to Washington State AAP members using Survey Monkey. The questionnaire targeted information regarding demographics, guideline knowledge, perceived barriers to guideline utilization and interventions to improve use. General pediatricians living in Washington State with self-reported past, current or expected future experience with the pediatric DS population were included. Results: Our response rate was 17% (N=161). Approximately 80% of pediatricians reported being comfortable using guidelines. About 20% of pediatricians were unfamiliar with the guidelines and do not refer to them. An additional 20% refer to the guidelines only sometimes. When asked a specific question regarding a guideline recommendation, 72% answered incorrectly. Over three-quarters of participants reported that electronic health record reminders would be the most beneficial. Conclusions: Opportunities to improve general pediatrician awareness and utilization of the DS guidelines exist. The most beneficial perceived intervention among pediatricians is guideline integration into the electronic health record. Studies measuring compliance and awareness of guidelines with a variety of interventions will be necessary in the future.

Diabetes Screening Reminder for Women With Prior Gestational Diabetes: A Randomized Controlled Trial.

To evaluate whether an electronic health record (EHR) reminder improves rates of screening for type 2 diabetes in women with prior gestational diabetes. We randomly allocated primary care providers (by clinic site) to a reminder for type 2 diabetes screening within the EHR or to usual care. Women with previous gestational diabetes mellitus were identified through an automated search of laboratory results and the problem list. We compared rates of screening during the study period (2010-2012) in women at intervention sites with those at control sites. With a sample size of 850 participants, we had 80% power to detect a 15% difference in screening rates. We included 847 individuals seen at a participating clinic during the study period, of whom 471 were at a reminder clinic and 376 were at a control clinic. A similar proportion of women were screened for type 2 diabetes in both groups (n=265, 56.3% of the reminder group compared with n=206, 54.8% of the control group, P=.67; adjusted odds ratio [OR] 1.04, 95% confidence interval [CI] 0.79-1.38). Patient characteristics associated with risk for diabetes including body mass index (adjusted OR per kg/m 1.05, 95% CI 1.01-1.08) and race (adjusted OR for nonwhite race 2.14, 95% CI 1.57-2.92) were significantly associated with screening. A simple EHR reminder did not increase the rate of diabetes screening in women with prior gestational diabetes mellitus. ClinicalTrials.gov, www.clinicaltrials.gov, NCT01288144. I.