Electronic Health Record Documentation Research Articles

Using ICD Codes Alone May Misclassify Overdoses Among Perinatal People

As perinatal drug overdoses continue to rise, reliable approaches are needed to monitor overdose trends during pregnancy and postpartum. This analysis aimed to determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ICD-9/10-CM codes for drug overdose events among people in the MATernaL and Infant clinical NetworK (MAT-LINK) with medication for opioid use disorder (MOUD) during pregnancy. People included in this analysis had electronic health record (EHR) documentation of MOUD and a known pregnancy outcome from January 1, 2014 through August 31, 2021. Data were analyzed during pregnancy through one year postpartum. CDC's drug overdose case definitions were used to categorize overdose based on ICD-9/10-CM codes. These codes were compared to abstracted EHR data of any drug overdose. Analyses were conducted between May 2023 and May 2024. Among 3,911 pregnancies with EHR-documented MOUD, the sensitivity of ICD-9/10-CM codes for capturing drug overdose during pregnancy was 32.7%, while specificity was 98.5%, PPV was 23.4%, and NPV was 99.0%. The sensitivity of ICD-9/10-CM codes for capturing drug overdose postpartum was 30.9%, while specificity was 98.4%, PPV was 25.9%, and NPV was 98.8%. The sensitivity and PPV of ICD-9/10-CM codes for capturing drug overdose compared to abstracted EHR data during the perinatal period was low in this cohort of people with MOUD during pregnancy, though the specificity and NPV were high. Incorporating other data from EHRs and outside the healthcare system might provide more comprehensive insights on nonfatal drug overdose in this population.

Cohort Profile: Baseline Characteristics of Veterans from Improving Veteran Access to Integrated Management of Back Pain (AIM-Back) - an Embedded Pragmatic, Cluster Randomized Trial in the United States.

AIM-Back is an embedded pragmatic clinical trial (ePCT) with cluster randomization designed to increase access and compare the effectiveness of two different non-pharmacological care pathways for low back pain (LBP) delivered within the Veteran Administration Health Care System (VAHCS). This manuscript describes baseline characteristics of AIM-Back participants as well as the representativeness of those referred to the AIM-Back program by sex, age, race, and ethnicity, relative to Veterans with low back pain at participating clinics. To be eligible for AIM-Back, Veterans were referred to the randomized pathway at their clinic by trained primary care providers (Referral cohort). Veterans from the Referral cohort that participated in the study included: 1) an Electronic Health Record (EHR) sample of Veterans enrolled in the program (i.e., attended initial AIM-Back visit with no consent required) and a Survey sample of Veterans that were consented for further study. Descriptive statistics for age, race, ethnicity, sex, high-impact chronic pain (HICP), a comorbidity measure, post-traumatic stress diagnosis (PTSD) and opioid exposure were reported for the Referral cohort and by sample; mean baseline PROMIS pain interference, physical function and sleep disturbance scores were reported by sample. Additional measures of pain, mental health and social risk were reported on the Survey sample. Participation to prevalence ratios (PPRs) were calculated for sex, age, race, and ethnicity by clinic to describe representativeness of the Referral cohort. Across 17 randomized primary care clinics, the Referral cohort included 2767 unique Veterans with n=1817 in the EHR sample, n=996 in the Survey sample and n=799 of the EHR sample (44%) were also in the Survey sample. High rates of HICP were observed in the EHR and Survey samples (>59%). Mean scores (SD) based on self-reported PROMIS Pain Interference (63.2 (6.8), 63.1 (6.6)) and PROMIS Physical Function (37.1 (5.3), 38.1 (5.8)) indicated moderate impairment in the EHR sample and Survey sample respectively. Approximately 10% of the EHR sample had documented opioid use in the year leading up to the AIM-Back referral. At most clinics, older Veterans (>=65 years) were underrepresented in the Referral cohort compared to those with LBP visits at clinics (PPRs < 0.8). The AIM-Back trial will conduct analysis to examine the comparative effectiveness of the two care pathways and identify individual characteristics that may improve responses to each pathway. The trial is expected to complete 12-month follow-up data collection by December 2024, with subsequent analyses and publications providing insights into optimizing non-pharmacological care for Veterans with LBP. NCT04411420 ( clinicaltrials.gov ). Strengths: Embedded features (e.g., EHR documentation and clinical staff serving as interventionist) of the AIM-Back trial have potential to facilitate implementation of these care pathways more broadly in Veteran's Health Administration clinics and in health systems outside the Veteran's Health AdministrationParticipating clinics were in 10 states providing regional geographic representation across the study.Trial was delivered within an integrated health system optimal for consistent documentation templates and data extraction across the trial sites.Limitations: Due to clinical personnel's role in participant recruitment, sample biases may exist in those referred to the program and/or those who agreed to participate in additional surveysThese findings may not be generalizable to older aged Veterans due to our lower enrollment of those 65+.

Electronic Health Record Documentation Burden Crowds Out Health Information Exchange Use By Primary Care Physicians.

Although electronic health record (EHR) documentation burden is known to be associated with reduced clinician well-being and burnout, it may have even worse unintended consequences if documentation work also crowds out other high-value EHR tasks. We examined this possibility by assessing the relationship between documentation burden and a high-value but optional EHR task: the use of health information exchange (HIE) to view patient records from outside organizations. Our study took advantage of an exogenous shock to documentation time: appointment no-shows. We found that documentation time had a strong impact on HIE use, with each additional hour spent documenting resulting in a 7.1percent reduction in the proportion of patients with an outside record viewed by the primary care physician seeing them that day. Our results point to the urgent need for policy makers to do more to reduce documentation burden.

Increasing resuscitation status-related goals of care discussions for older adults with severe mental illness in a Canadian mental health setting: a retrospective study

BackgroundOlder adults with severe mental illness, including advanced dementia (AD), within geriatric admission units (GAU) often prioritise comfort care, avoiding life-prolonging procedures including cardiopulmonary resuscitation (CPR). Pre-2019, hospital policy lacked...

Using Technology to Support Measurement-Based Care: Design and Implementation of the Measurement-Assisted Care Program.

The authors aimed to increase measurement-based care in an outpatient academic psychiatry service. The Measurement-Assisted Care program (MAC) was implemented as a clinical quality-improvement effort that included 4,665 unique patients and 176 clinicians over 12 months. The Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder scale (GAD-7), PTSD Checklist for DSM-5, and Brief Inventory of Thriving were automatically included in the patient electronic check-in process for new visits; the PHQ-9 and GAD-7 were included for return visits. Patient responses were automatically routed to clinicians' electronic health record inboxes and documentation templates. MAC was rolled out in two phases, and clinicians were surveyed about their use of MAC data 3-6 months after the start of the program. After implementation of MAC, PHQ-9 completion rates increased from 5% to 66% of visits for phase 1 and from 5% to 60% for phase 2. Post-MAC completion rates were higher for telehealth (70%) than for in-person (40%) visits. More than 90% of clinicians reported that MAC was useful with at least one of their three most recent patients, and 51% reported that it was useful with all three of their three most recent patients. Clinician adoption was high, with 78% reporting that they use MAC data to guide care. MAC increased the completion rate of patient-reported outcome measures, especially for telehealth visits. Clinicians reported that they frequently use and discuss MAC data with patients, implying that technology-supported workflows can help systems with high telehealth utilization capture and use patient-reported outcomes.

Improving implementation and team communication by integrating a cystic fibrosis transition readiness (CF R.I.S.E.) program into electronic health records.

The cystic fibrosis (CF) Responsibility. Independence. Self-care. Education. (R.I.S.E.) program was developed to provide assessment and education, supporting transition readiness for people with cystic fibrosis (pwCF). Lack of integration within electronic health records (EHR) was a barrier to implementation of CF R.I.S.E. University of Michigan was able to integrate CF R.I.S.E. into EHR. To improve implementation and EHR documentation of CF R.I.S.E. module completion by pwCF across two (CF) programs from baseline (10.5%) to 75% per month in 6 months (January through June 2023). Two CF programs utilized quality improvement (QI) methods and tools and ad hoc support by a CF Learning Network (QI) specialist. Eligibility included pwCF ≥16 years old seen in CF clinics who accepted CF R.I.S.E. Beginning January 2, 2023, programs met in biweekly, virtual meetings to discuss implementation. Deidentified data were collected monthly tracking modules completed by pwCF and number of team members engaging with CF R.I.S.E. and documenting in EHR. Data timelines were baseline (November-December 2022), project period (January-June 2023), and post-project (July-December 2023). Completion rates increased from baseline (10.5%) to 48% (range 33% to 81%) through December 2023. During the project, an average 7.7 team members completed an average 19.2 modules per month. Post-project, an average 8 team members completed an average 16.5 modules per month. This collaboration demonstrated how utilization of EHR allowed for successful CF R.I.S.E. improvement at both programs. Shared software utilization and QI initiatives may be a way to facilitate timely dissemination of best practices through learning health systems.

Oscillating US Department of Defense policies and medical record documentation of gender dysphoria in service members: an observational time-series analysis

BackgroundUnited States military policies regarding service by transgender service members have shifted several times within the past decade. The relationships between policy changes and electronic health record documentation of gender dysphoria, a current and historic policy requisite for gender affirming care receipt, in active duty service members remain unknown.MethodsBayesian estimator of abrupt change, seasonality, and trend models identified changepoints in the proportion of service members who had new and then historical medical record documentation consistent with gender dysphoria from January 2015 to August 2022. Changepoints were evaluated as they related to salient military policy-related events.ResultsApproximately 3,853 active duty and activated National Guard or Reserve service members received a documented diagnosis corresponding to gender dysphoria from January 2015 to August 2022. Four significant changepoints were identified across both time series. Salient historical events that occurred during the changepoint periods were identified for contextualization.ConclusionsClinical documentation of gender dysphoria oscillated with changes to policies and public statements by government leaders, which may in turn, impact military recruitment and retention. This study highlights the need for equitable policies that optimize the strength of a diverse military force. Equity-oriented monitoring is needed to continually examine the impact of military service policies on readiness and retention to support actionable, data-driven improvements to policies and their implementation.

LGBTQ+ Supportive and Inclusive Care Practices: Survey Data From the T1D Exchange Quality Improvement Collaborative

OBJECTIVE Living with type 1 diabetes is challenging, but more barriers exist when one also identifies as LGBTQ+ (lesbian, gay, bisexual, transgender, queer, or other gender-expansive identities). Acknowledging the importance of identifying this population and providing personalized care, the Health Resources and Services Administration mandated institutions to document sexual orientation and gender identity (SOGI) data. To understand the current state of SOGI documentation in the T1D Exchange Quality Improvement Collaborative, a survey assessing LGBTQ+ supportive and inclusive care practices was given to affiliated sites. RESEARCH DESIGN AND METHODS Thirty-three pediatric and 21 adult care centers were surveyed via Qualtrics. The survey included questions about their electronic health record documentation of patient-identified gender, pronouns, sexual orientation, and sex assigned at birth (SAAB). Care centers also reported on the legality of gender-affirming care in their municipalities, as well as their willingness to change SAAB after patients meet requirements. Fisher’s exact tests were used to evaluate response frequencies. RESULTS All 33 of the pediatric centers and 81% (17 of 21) of the adult centers responded to the survey. Sixty-four percent of pediatric centers had established strategies to support SOGI documentation, whereas only 50% of adult centers had implemented strategies. Some adult centers could not confirm whether they documented SOGI. Differences were seen between the pediatric and adult endocrinology centers in their documentation of gender identity (P = 0.04) and pronouns (P = 0.02). CONCLUSION Although most endocrinology centers documented gender identity and pronouns, fewer documented sexual orientation. Further work is needed to improve SOGI documentation and assess its impact on LGBTQ+ patients with diabetes.

Physical Restraint Use in Hospitalized Patients: A Study of Routinely Collected Health Records Data.

The use of restraints in hospitalized patients is associated with physical and psychological adversity for patients and staff. The minimization of restraint use is a key goal in the hospital setting. Reaching this goal requires an accurate assessment of existing patterns of use across clinical settings. This study reports the rate of physical restraints among patients hospitalized within a multi-entity healthcare network along with stratification by care context, diagnostic, and demographic factors, and examines the sensitivity and specificity of ICD-10 code Z78.1 "physical restraint status" for defining physical restraints relative to electronic health record (EHR) documentation. The EHR was used for a retrospective analysis of all adults hospitalized between 2017 and 2022. Hospitalized adults. Patient demographics, structured diagnostic information, care area, length of stay, and in-hospital mortality, Z78.1 coding for physical restraints, restraint documentation in orders and flowsheets. Among 742,607 hospitalizations, 6.3% (n=47,041) involved the use of physical restraint based on coding or EHR documentation. Treatment in the intensive care unit (ICU) included restraint in 39% of encounters whereas treatment outside the ICU included restraint use in 1.3% of encounters. Besides critical illness, demographic factors including increasing age (adjusted odds ratio (aOR)=1.21 [1.19-1.23]), male gender (aOR=1.56, [1.52-1.60]), unknown race (aOR=1.27 [1.19-1.35]), and preferred language other than English (aOR=1.24, [1.18-1.29]) were associated with higher odds of restraint utilization. As compared to EHR orders or documentation of restraint, the ICD-10 code for physical restraint had a sensitivity of 1.5% and a specificity of 99.99%. Among adults admitted to acute care hospitals, clinical, demographic, and operational factors were associated with increased odds of restraint, with care in the ICU associated with greatly increased odds of restraint. Research into restraint utilization using coded administrative claims data is likely limited by the sensitivity of physical restraint coding.

Respiratory syncytial virus (RSV) vaccine effectiveness against RSV-associated hospitalisations and emergency department encounters among adults aged 60 years and older in the USA, October, 2023, to March, 2024: a test-negative design analysis

Respiratory syncytial virus vaccines first recommended for use during 2023 were efficacious against lower respiratory tract disease in clinical trials. Limited real-world data regarding respiratory syncytial virus vaccine effectiveness are available. To inform vaccine policy and address gaps in evidence from the clinical trials, we aimed to assess the effectiveness against respiratory syncytial virus-associated hospitalisations and emergency department encounters among adults aged at least 60 years. We conducted a test-negative design analysis in an electronic health records-based network in eight states in the USA, including hospitalisations and emergency department encounters with respiratory syncytial virus-like illness among adults aged at least 60 years who underwent respiratory syncytial virus testing from Oct 1, 2023, to March 31, 2024. Respiratory syncytial virus vaccination status at the time of the encounter was derived from electronic health record documentation, state and city immunisation registries, and, for some sites, medical claims. Vaccine effectiveness was estimated by immunocompromise status, comparing the odds of vaccination among respiratory syncytial virus-positive case patients and respiratory syncytial virus-negative control patients, and adjusting for age, race and ethnicity, sex, calendar day, social vulnerability index, number of underlying non-respiratory medical conditions, presence of respiratory underlying medical conditions, and geographical region. Among 28 271 hospitalisations for respiratory syncytial virus-like illness among adults aged at least 60 years without immunocompromising conditions, vaccine effectiveness was 80% (95% CI 71-85) against respiratory syncytial virus-associated hospitalisations, and vaccine effectiveness was 81% (52-92) against respiratory syncytial virus-associated critical illness (ICU admission or death, or both). Among 8435 hospitalisations for respiratory syncytial virus-like illness among adults with immunocompromising conditions, vaccine effectiveness was 73% (48-85) against associated hospitalisation. Among 36 521 emergency department encounters for respiratory syncytial virus-like illness among adults aged at least 60 years without an immunocompromising condition, vaccine effectiveness was 77% (70-83) against respiratory syncytial virus-associated emergency department encounters. Vaccine effectiveness estimates were similar by age group and product type. Respiratory syncytial virus vaccination was effective in preventing respiratory syncytial virus-associated hospitalisations and emergency department encounters among adults aged at least 60 years in the USA during the 2023-24 respiratory syncytial virus season, which was the first season after respiratory syncytial virus vaccine was approved. The Centers for Disease Control and Prevention.

Addressing menopause symptoms in the primary care setting: opportunity to bridge care delivery gaps.

Menopause symptoms affect quality of life and financial well-being but are often unaddressed in primary care clinics. Therefore, we evaluated the extent of menopause symptom documentation in electronic health records (EHRs) by primary health care professionals. We retrospectively reviewed adult women who reported moderate or higher vasomotor symptoms on a Mayo Clinic survey conducted from March 1, 2021, through June 30, 2021. We then assessed adequacy of menopause symptom documentation in the EHRs of these women who had primary care visits during the survey period. We reviewed the percentage of documented vasomotor symptoms from May 1, 2019, through May 1, 2021. In the Mayo Clinic Health System-Northwest Wisconsin Region, 229 women self-reported moderate or higher vasomotor symptoms in the Mayo Clinic survey. Although only 23% of these women had vasomotor symptoms listed in the EHR clinical problem lists, 60% of these women had vasomotor symptoms documented in their clinic notes from the primary care visit. Approximately 6% of women reported hormone therapy use for management of menopause symptoms, and nearly 15% reported use of nonhormone prescription therapies for vasomotor symptoms. A greater proportion of women in our study had EHR documentation of bothersome menopause symptoms than those reported in other studies, but vasomotor symptoms remain generally untreated. We need better methods for identifying midlife women with bothersome menopause symptoms in primary care clinics so that appropriate treatment options, including hormone therapy, can be discussed and offered.

Bundling implementation strategies supports outcome measure adoption in stroke rehabilitation: preliminary findings

BackgroundOver 80% of people who experience a stroke present with residual impairment of the upper extremity, such as the shoulder, elbow, wrist, and hand. However, rarely do stroke rehabilitation practitioners (e.g., occupational therapists) use standardized outcome measures to objectively evaluate upper extremity function. Accordingly, the purpose of this project was to develop a bundle of implementation strategies that supports practitioners’ adoption of the Fugl-Meyer Assessment of the Upper Extremity in stroke rehabilitation practice.MethodsWe used tenets of Implementation Mapping to guide the development of our implementation strategy bundle. We partnered with one, large academic health system serving over 200 stroke patients annually through intensive rehabilitation care. Strategies were selected and developed through a multi-method process that included a review of the literature, qualitative input from our health system’s practitioners and managers, and expert consultation. We also specified the hypothesized implementation “mechanisms” our strategies intended to change. Practitioners’ adoption (yes/no) of the Fugl-Meyer Assessment was calculated by analyzing electronic health record documentation of the 6-month time frame before strategies were deployed compared to the 6-month time frame after deployment.ResultsPractitioners were exposed to the following implementation strategies to support Fugl-Meyer adoption: conduct educational meetings, prepare outcome measure champions, provide equipment, develop training materials, and adapt documentation systems. In the 6-months before deployment of our implementation strategies, practitioners implemented the Fugl-Meyer with 14.8% of stroke patients. In the six months after deployment, adoption of the Fugl-Meyer increased to 73.8% (p < .001).ConclusionsWhen systematically developed in collaboration with health system partners, a bundle of implementation strategies may support outcome measure adoption in stroke rehabilitation. Improving the use of standardized outcome measures is of paramount importance in stroke rehabilitation to objectively monitor patients’ progress or decline, to demonstrate the value of rehabilitation services for enhancing patients’ recovery, and to advocate for continued reimbursement for rehabilitation care. Future opportunities lie in further specifying the mechanisms through which implementation strategies are intended to work and how those mechanisms contribute to strategy effectiveness.Trial registrationNCT registration: NCT04888416; May 06, 2021.

Electronic health record system use and documentation burden of acute and critical care nurse clinicians: a mixed-methods study.

Examine electronic health record (EHR) use and factors contributing to documentation burden in acute and critical care nurses. A mixed-methods design was used guided by Unified Theory of Acceptance and Use of Technology. Key EHR components included, Flowsheets, Medication Administration Records (MAR), Care Plan, Notes, and Navigators. We first identified 5 units with the highest documentation burden in 1 university hospital through EHR log file analyses. Four nurses per unit were recruited and engaged in interviews and surveys designed to examine their perceptions of ease of use and usefulness of the 5 EHR components. A combination of inductive/deductive coding was used for qualitative data analysis. Nurses acknowledged the importance of documentation for patient care, yet perceived the required documentation as burdensome with levels varying across the 5 components. Factors contributing to burden included non-EHR issues (patient-to-nurse staffing ratios; patient acuity; suboptimal time management) and EHR usability issues related to design/features. Flowsheets, Care Plan, and Navigators were found to be below acceptable usability and contributed to more burden compared to MAR and Notes. The most troublesome EHR usability issues were data redundancy, poor workflow navigation, and cumbersome data entry based on unit type. Overall, we used quantitative and qualitative data to highlight challenges with current nursing documentation features in the EHR that contribute to documentation burden. Differences in perceived usability across the EHR documentation components were driven by multiple factors, such as non-alignment with workflows and amount of duplication of prior data entries. Nurses offered several recommendations for improving the EHR, including minimizing redundant or excessive data entry requirements, providing visual cues (eg, clear error messages, highlighting areas where missing or incorrect information are), and integrating decision support. Our study generated evidence for nurse EHR use and specific documentation usability issues contributing to burden. Findings can inform the development of solutions for enhancing multi-component EHR usability that accommodates the unique workflow of nurses. Documentation strategies designed to improve nurse working conditions should include non-EHR factors as they also contribute to documentation burden.

Implementation of a Secure Firearm Storage Program in Pediatric Primary Care

Increased secure firearm storage can reduce youth firearm injury and mortality, a leading cause of death for children and adolescents in the US. Despite the availability of evidence-based secure firearm storage programs and recommendations from the American Academy of Pediatrics, few pediatric clinicians report routinely implementing these programs. To compare the effectiveness of an electronic health record (EHR) documentation template (nudge) and the nudge plus facilitation (ie, clinic support to implement the program; nudge+) at promoting delivery of a brief evidence-based secure firearm storage program (SAFE Firearm) that includes counseling about secure firearm storage and free cable locks during all pediatric well visits. The Adolescent and Child Suicide Prevention in Routine Clinical Encounters (ASPIRE) unblinded parallel cluster randomized effectiveness-implementation trial was conducted from March 14, 2022, to March 20, 2023, to test the hypothesis that, relative to nudge, nudge+ would result in delivery of the firearm storage program to an additional 10% or more of the eligible population, and that this difference would be statistically significant. Thirty pediatric primary care clinics in 2 US health care systems (in Michigan and Colorado) were included, excluding clinics that were not the primary site for participating health care professionals and a subset selected at random due to resource limitations. All pediatric well visits at participating clinics for youth ages 5 to 17 years were analyzed. Clinics were randomly assigned in a 1:1 ratio to receive either the nudge or nudge+. Patient-level outcomes were modeled to estimate the primary outcome, reach, which is a visit-level binary indicator of whether the parent received both components of the firearm storage program (counseling and lock), as documented by the clinician in the EHR. Secondary outcomes explored individual program component delivery. A total of 47 307 well-child visits (median [IQR] age, 11.3 [8.1-14.4] years; 24 210 [51.2%] male and 23 091 [48.8%] female) among 46 597 children and 368 clinicians were eligible to receive the firearm storage program during the trial and were included in analyses. Using the intention-to-treat principle, a higher percentage of well-child visits received the firearm storage program in the nudge+ condition (49%; 95% CI, 37-61) compared to nudge (22%; 95% CI, 13-31). In this study, the EHR strategy combined with facilitation (nudge+) was more effective at increasing delivery of an evidence-based secure firearm storage program compared to nudge alone. ClinicalTrials.gov Identifier: NCT04844021.

Building Capacity of Community Health Centers to Improve the Provision of Postpartum Care Services Through Data-Driven Health Information Technology and Innovation.

Maternal morbidity and mortality remain significant challenges in the United States, with substantial burden during the postpartum period. The Centers for Disease Control and Prevention, in partnership with the National Association of Community Health Centers, began an initiative to build capacity in Federally Qualified Health Centers to (1) improve the infrastructure for perinatal care measures and (2) use perinatal care measures to identify and address gaps in postpartum care. Two partner health center-controlled networks implemented strategies to integrate evidence-based recommendations into the clinic workflow and used data-driven health information technology (HIT) systems to improve data standardization for quality improvement of postpartum care services. Ten measures were created to capture recommended care and services. To support measure capture, a data cleaning algorithm was created to prioritize defining pregnancy episodes and delivery dates and address data inconsistencies. Quality improvement activities targeted postpartum care delivery tailored to patients and care teams. Data limitations, including inconsistencies in electronic health record documentation and data extraction practices, underscored the complexity of integrating HIT solutions into postpartum care workflows. Despite challenges, the project demonstrated continuous quality improvement to support data quality for perinatal care measures. Future solutions emphasize the need for standardized data elements, collaborative care team engagement, and iterative HIT implementation strategies to enhance perinatal care quality. Our findings highlight the potential of HIT-driven interventions to improve postpartum care within health centers, with a focus on the importance of addressing data interoperability and documentation challenges to optimize and monitor initiatives to improve postpartum health outcomes.

Abstract MP11: Evaluation of a Remote Patient Monitoring Hypertension Program with Telehealth Pharmacist Management in Nephrology Clinic Patients

Introduction: Remote patient monitoring (RPM) and physician-pharmacist collaborative models have potential in improving hypertension control. Herein, we report the effectiveness of a community based, self-measured blood pressure (SMBP) RPM program on BP control and healthcare utilization in a largely rural health system. Methods: A multidisciplinary team developed a self-measured blood pressure (SMBP) RPM program in central and northeast PA using a virtual platform with bluetooth-connected BP devices targeting patients with BP ≥140/90 mmHg seen in nephrology clinics. From 3/2022 to 9/2022, high BP notifications were transmitted to nephrologists. After 9/2022, BP notifications were transmitted first to pharmacists, who co-managed BP through collaborative practice agreements via telehealth. We captured pharmacist interventions by reviewing electronic health record documentation. Changes in SMBP over time and the effect of pharmacist interventions were analyzed using mixed effects models. All-cause hospitalizations and emergency room (ER) visits were compared in 6-month pre/post-enrollment periods. Results: A total of 205 patients (mean age 62.3y, clinic BP 146/84, 3.1 BP classes, 48% female, 53% CKD) were enrolled into the program and had ≥ 6 months follow-up data. SMBP control &lt;140/90 improved from 30% during week 1 to 67% at 6 months and 74% at 12 months. Overall, systolic SMBP improved over the first 6 months with stronger effect on patients with higher baseline BP (baseline BP ≥150/100 mmHg: -3.3 mmHg/month (95% CI: -3.5, -3.1); baseline 140-149/90-99: -2.4 (95% CI: -2.6, -2.1) mmHg/month; baseline &lt;140/90: -0.6 (-0.9, -0.4) mmHg/month). Pharmacist telehealth encounters were documented in 65% of patients; 46% had a BP medication adjustment; 37% had new BP medication classes, including 9% mineralocorticoid receptor antagonist. Pharmacist medication intervention was associated with greater decline in systolic BP over time (-1.3 mmHg/month; 95% CI: -1.6, -1.1). Comparing the 6 months pre vs. post-enrollment, patients experienced a reduction in hospitalizations (6.0% vs. 0%; Exact Mcnemar p=0.0005) and no difference in ER visits (14.9% vs. 12.9%; p=0.6). Conclusion: Participation in a nephrologist-pharmacist SMBP RPM program was associated with improvement in BP control and reduced hospitalizations. Future efforts are underway to refine delivery of this program for the largest impact on improving BP control.

Physician EHR Time and Visit Volume Following Adoption of Team-Based Documentation Support

Physicians spend the plurality of active electronic health record (EHR) time on documentation. Excessive documentation limits time spent with patients and is associated with burnout. Organizations need effective strategies to reduce physician documentation burden; however, evidence on team-based documentation (eg, medical scribes) has been limited to small, single-institution studies lacking rigorous estimates of how documentation support changes EHR time and visit volume. To analyze how EHR documentation time and visit volume change following the adoption of team-based documentation approaches. This national longitudinal cohort study analyzed physician-week EHR metadata from September 2020 through April 2021. A 2-way fixed-effects difference-in-differences regression approach was used to analyze changes in the main outcomes after team-based documentation support adoption. Event study regression models were used to examine variation in changes over time and stratified models to analyze the moderating role of support intensity. The sample included US ambulatory physicians using the EHR. Data were analyzed between October 2022 and September 2023. Team-based documentation support, defined as new onset and consistent use of coauthored documentation with another clinical team member. The main outcomes included weekly visit volume, EHR documentation time, total EHR time, and EHR time outside clinic hours. Of 18 265 physicians, 1024 physicians adopted team-based documentation support, with 17 241 comparison physicians who did not adopt such support. The sample included 57.2% primary care physicians, 31.6% medical specialists, and 11.2% surgical specialists; 40.0% practiced in academic settings and 18.4% in outpatient safety-net settings. For adopter physicians, visit volume increased by 6.0% (2.5 visits/wk [95% CI, 1.9-3.0]; P < .001), and documentation time decreased by 9.1% (23.3 min/wk [95% CI, -30.3 to -16.2]; P < .001). Following a 20-week postadoption learning period, visits per week increased by 10.8% and documentation time decreased by 16.2%. Only high-intensity adopters (>40% of note text authored by others) realized reductions in documentation time, both for the full postadoption period (-53.9 min/wk [95% CI, -65.3 to -42.4]; 21.0% decrease; P < .001) and following the learning period (-72.2 min/wk; 28.1% decrease). Low adopters saw no meaningful change in EHR time but realized a similar increase in visit volume. In this national longitudinal cohort study, physicians who adopted team-based documentation experienced increased visit volume and reduced documentation and EHR time, especially after a learning period.

Improving electronic health record documentation and use to promote evidence-based pediatric care.

Electronic health records (EHRs) often lack the necessary functionalities to support the full implementation of national clinical guidelines for pediatric care outlined in the American Academy of Pediatrics Bright Futures Guidelines. Using HealthySteps (HS), an evidence-based pediatric primary care program, as an exemplar, this study aimed to enhance pediatric EHRs, identify facilitators and barriers to EHR enhancements, and improve data quality for delivering clinical care as part of HS implementation and evidence building. Three HS sites-each differing in location, setting, number of children served, and mix of child insurance coverage-participated in the study. Sites received technical assistance to support data collection and EHR updates. A comprehensive evaluation, including a process evaluation and outcomes monitoring, was conducted to gauge progress toward implementing study data requirements over time. Data sources included administrative records, surveys, and interviews. All sites enhanced their EHRs yet relied on supplemental data systems to track care coordination. Sites improved documentation of required data, demonstrating reductions in missing data and increases in extractable data between baseline and follow-up assessments. For example, the percentage of missing social-emotional screening results ranged from 0% to 8.0% at study conclusion. Facilitators and barriers to EHR enhancements included organizational supports, leadership, and capacity building. With significant investment of time and resources, practices modified their EHRs to better capture services aligned with HS and Bright Futures. However, more scalable digital solutions are necessary to support EHR updates to help drive improvements in clinical care and outcomes for children and families.

A human centered design approach to define and measure documentation quality using an EHR virtual simulation.

Electronic health record (EHR) documentation serves multiple functions, including recording patient health status, enabling interprofessional communication, supporting billing, and providing data to support the quality infrastructure of a Learning Healthcare System. There is no definition and standardized method to assess documentation quality in EHRs. Using a human-centered design (HCD) approach, we define and describe a method to measure documentation quality. Documentation quality was defined as timely, accurate, user-centered, and efficient. Measurement of quality used a virtual simulated standardized patient visit via an EHR vendor platform. By observing and recording documentation efforts, nurse practitioners (NPs) (N = 12) documented the delivery of an Age-Friendly Health System (AFHS) 4Ms (what Matters, Medication, Mentation, and Mobility) clinic visit using a standardized case. Results for timely documentation indicated considerable variability in completion times of documenting the 4Ms. Accuracy varied, as there were many types of episodes of erroneous documentation and extra time in seconds in documenting the 4Ms. The type and frequency of erroneous documentation efforts were related to navigation burden when navigating to different documentation tabs. The evaluated system demonstrated poor usability, with most participants scoring between 60 and 70 on the System Usability Scale (SUS). Efficiency, measured as click burden (the number of clicks used to navigate through a software system), revealed significant variability in the number of clicks required, with the NPs averaging approximately 13 clicks above the minimum requirement. The HCD methodology used in this study to assess the documentation quality proved feasible and provided valuable information on the quality of documentation. By assessing the quality of documentation, the gathered data can be leveraged to enhance documentation, optimize user experience, and elevate the quality of data within a Learning Healthcare System.

Disposition and Follow-up for Low-Risk Febrile Infants: A Secondary Analysis of a Multicenter Study.

American Academy of Pediatrics guidelines recommend that febrile infants at low risk for invasive bacterial infection be discharged from the emergency department (ED) if primary care provider (PCP) follow-up occurs within 24 hours. We aimed to (1) assess the association between having electronic health record (EHR) documentation of a PCP and ED disposition and (2) describe documentation of potential barriers to discharge and plans for post-discharge follow-up in low-risk febrile infants. We conducted a secondary analysis of a multicenter, cross-sectional study of low-risk febrile infants. Descriptive statistics characterized ED disposition on the basis of the day of the visit, EHR documentation of PCP, scheduled or recommended PCP follow-up, and barriers to discharge. Most infants (3565/4042, 90.5%) had EHR documentation of a PCP. Compared with discharged infants, a similar proportion of hospitalized infants had EHR documentation of PCP (90.3% vs 91.2%, P = .47). Few infants (1.5%) had barriers to discharge documented. Of the 3360 infants (83.1%) discharged from the ED, 1544 (46.0%) had documentation of scheduled or recommended 24-hour PCP follow-up. Discharged infants with weekday visits were more likely than those with weekend visits to have documentation of scheduled or recommended 24-hour follow-up (50.0% vs 35.5%, P < .001). Most infants had a documented PCP, yet fewer than half had documentation of a scheduled or recommended 24-hour follow-up. A dedicated focus on determining post-ED care plans that are safe and patient-centered may improve the quality of care for this population.