Electronic Medical Record Era Research Articles

Predictive model and risk analysis for coronary heart disease in people living with HIV using machine learning

ObjectiveThis study aimed to construct a coronary heart disease (CHD) risk-prediction model in people living with human immunodeficiency virus (PLHIV) with the help of machine learning (ML) per electronic medical records (EMRs).MethodsSixty-one medical characteristics (including demography information, laboratory measurements, and complicating disease) readily available from EMRs were retained for clinical analysis. These characteristics further aided the development of prediction models by using seven ML algorithms [light gradient-boosting machine (LightGBM), support vector machine (SVM), eXtreme gradient boosting (XGBoost), adaptive boosting (AdaBoost), decision tree, multilayer perceptron (MLP), and logistic regression]. The performance of this model was assessed using the area under the receiver operating characteristic curve (AUC). Shapley additive explanation (SHAP) was further applied to interpret the findings of the best-performing model.ResultsThe LightGBM model exhibited the highest AUC (0.849; 95% CI, 0.814–0.883). Additionally, the SHAP plot per the LightGBM depicted that age, heart failure, hypertension, glucose, serum creatinine, indirect bilirubin, serum uric acid, and amylase can help identify PLHIV who were at a high or low risk of developing CHD.ConclusionThis study developed a CHD risk prediction model for PLHIV utilizing ML techniques and EMR data. The LightGBM model exhibited improved comprehensive performance and thus had higher reliability in assessing the risk predictors of CHD. Hence, it can potentially facilitate the development of clinical management techniques for PLHIV care in the era of EMRs.

Surviving in the Electronic Era: My Top EMR Hacks.

With many pediatric orthopaedic surgeons spending 3 or even more days a week in clinic, a thorough understanding of the ever-changing electronic medical record is paramount to providing excellent clinical care, overall job satisfaction, and minimizing clinician burnout. Here we provide 5 tips to optimize clinic workflow for the busy pediatric orthopaedic surgeon in the electronic medical record era.

WITHDRAWN: Teaching electronic medical record (EMR) data discipline to clinical trainees: A Canadian pilot study

This article has been withdrawn: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been withdrawn at the request of the editor and publisher. The publisher regrets that an error occurred which led to the premature publication of this paper. This error bears no reflection on the article or its authors. The publisher apologizes to the authors and the readers for this unfortunate error.

148 Typing Speed and Accuracy as Neurocognitive Measures of Emergency Medicine Resident Physician Fatigue

Fatigue impairs performance and productivity and escalates the risk of accidents and injuries. An objective tool to screen for physician fatigue would promote a culture of safety. Typing is an important task in the electronic medical record era. Typing speed and accuracy has been used as a neurocognitive screening tool for fatigue. This study assessed the impact of shift and time of day on emergency physician typing speed and accuracy.

An Asthma Specialist's Consult Letter: What Do Parents Think About Receiving a Copy?

ObjectiveWritten summaries about visits with general practitioners’ have influenced increased patient knowledge, satisfaction, recollection, and compliance, and strengthened the doctor–patient relationship. All previous studies about this communication pre-dated the electronic medical record (EMR) era, and none examined views from parents of children with asthma. We explored parents’ perceptions about receiving a hard copy summary Letter immediately following the visit, with the pediatric asthma specialist about findings and the care plan for their child.MethodsA Parent Advisory Council helped inform this pilot study, an observational cross-sectional electronic survey. Each Letter included a comprehensive summary of the child’s visit with the specialist.ResultsPrevious findings from patients about the benefits of receiving this Letter were strongly supported by data from 51 participants. Interestingly, more than 54% of respondents preferred receiving a hard copy Letter over an electronic copy, and 98% wanted other clinicians to adopt this practice.ConclusionParents of children with asthma value and want timely written information of this nature from other clinicians.Practice ImplicationsThese results can influence further asthma research to promote a change in the perceptions of clinicians, parents, and patients about timely access to health information in the EMR era.

Clinician-Dermatopathologist Communication via the Requisition Form in the Era of Electronic Medical Records: A Review of the Literature

Background: There are shortcomings in the quality and accuracy of submitted clinical information on skin biopsy requisition forms (SBRFs). Most SBRFs are completed via electronic medical records (EMR), and the effect of this on the work flow and the quality of submitted clinical information must be evaluated to identify targets in clinician-dermatopathologist communication for improvement.Objective: This review of the literature explored how SBRFs are currently handled by clinicians in the context of EMR, barriers to effective clinician-dermatopathologist communication, and suggestions for improvement.Methods: A literature search was conducted on Medline, Cinahl, and Scopus including the keywords of dermatology*, dermapatholog*, dermatopathology*, and requisition*. 20 articles were retrieved. 17 articles were included from this search and from cross-referencing articles.Results: This review reaffirmed the inadequacy of clinical information provided to dermatopathologists. Standardization of and formal education in completing SBRFs, along with dermatopathologist access to information and images via shared EMR may improve histopathologic interpretation of specimens and allow for cost-effective patient care.Limitations: This review was restricted to the English language. Previous studies have primarily been retrospective study designs and survey studies.Conclusion: The development of user-friendly standardized SBRFs with validated criteria are necessary. Clinician awareness of how to appropriately convey information and terminology on the SBRF may significantly improve the work flow of both clinicians and dermatopathologists and patient outcomes.

2337. Health Outcomes in Congenital Cytomegalovirus, a Systematized and Unbiased Approach in the Electronic Medical Record Era

BackgroundThere is limited data on the indirect and non-medical costs associated with congenital cytomegalovirus (cCMV). Attempts to predict the economic impact of disease often rely on secondary analyses of large private databases, and may not capture the full spectrum of a disease. The granularity of billing codes in the Electronic Medical Record (EMR) make it possible to track health outcomes over time, however, with over 80,000 unique codes in ICD-10, selecting the appropriate codes requires specific content knowledge and can lead to bias in categorization. The Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT)® provides physicians a tool to find specific ICD-10 on the basis of semantic terms. These terms can be used to build disease state-specific clusters of ICD-10 codes by which to study the economic impact of any disease, including this potentially devastating congenital infection.MethodsUsing a series of data parsing and processing scripts written in SAS V9.4 (Cary, NC), we extracted the diagnosis codes for 190 patients seen in our Congenital Cytomegalovirus Clinic at Texas Children’s Hospital in Houston, Texas. This data were consolidated into a relational database of clinical information. Through a second program we developed, clusters of ICD-10 codes were imputed from the SNOMED-CT® on the basis of semantic terms associated with cCMV (e.g., “hearing problem,” “developmental disability,” “neurological problem”).ResultsA total of 190 patients have been seen in our clinic with an ICD-10 diagnosis of CMV infection, 144 of these had cCMV, and 102 of these were born after 1/1/2008 (the inception date of our EMR). 60% of these patients were Caucasian (21% Hispanic), and 25% African American. 54 (53%) had hearing deficits, 17 (16%) had hearing aids, and 55 (54%) had developmental abnormalities. The average time (in years) to development of specific deficits are shown in Figure 1.ConclusionThe spectrum of disease of cCMV is broad and has been well studied in the past. The EMR gives us the potential to further study this disease in finer detail and identify rates of disease progression by mining the ICD-10 codes associated with these patients throughout time. These results should prove invaluable for generating cost-models for the economic impact of cCMV. Disclosures All authors: No reported disclosures.

Updating HIPAA for the electronic medical record era.

With advances in technology, patients increasingly expect to access their health information on their phones and computers seamlessly, whenever needed, to meet their clinical needs. The 1996 passage of the Health Insurance Portability and Accountability Act (HIPAA), modifications made by the Health Information Technology for Economic and Clinical Health Act (HITECH), and the recent 21st Century Cures Act (Cures) promise to make patients' health information available to them without special effort and at no cost. However, inconsistencies among these policies' definitions of what is included in "health information", widespread variation in electronic health record system capabilities, and differences in local health system policies around health data release have created a confusing landscape for patients, health care providers, and third parties who reuse health information. In this article, we present relevant regulatory history, describe challenges to health data portability and fluidity, and present the authors' policy recommendations for lawmakers to consider so that the vision of HIPAA, HITECH, and Cures may be fulfilled.

Impact of ED Scribes in a Residency Program

Background and Hypothesis: In the electronic medical record era, clerical documentation has become a significant source of burden in the emergency department (ED). Medical scribes have been advocated as a method to reduce clerical documentation burden while improving physician productivity and satisfaction. The impact of scribes in a non-academic ED setting has been found to be beneficial, and a small survey suggested resident physicians found scribes to be a valuable fatigue-mitigation strategy. The goal of this study was to assess the impact of ED scribes on residents, including time burden of documentation, signals of emotional impact that contribute to burnout, and learning/teaching opportunities. 
 Experimental Design or Project Methods: This observational time motion analysis assesses scribe impact on emergency medicine residents. Observations were pseudo-randomized in a 1:1 fashion to shifts without or with scribes. Trained observers tracked the activity of upper level residents in the high acuity section of a busy urban county ED for 4 hours of each shift. At the end of each shift, residents self-reported post-shift documentation time and completed a survey assessing residents’ perception of their shift and the impact of scribes. 
 Results: Residents reported that scribes improved their overall experience during their shift. They also reported that scribes reduced documentation time (0:11:33 [Symbol]0:04:24 v. 0:08:56 [Symbol]0:05:36) and allowed them to better connect with and care more for their patients (9.6 [Symbol]0.8 v. 8.7[Symbol]1.3). 
 Conclusion and Potential Impact: Scribes improved emergency medicine residents’ perceptions of their educational experience and reduced symptoms of burnout during shifts.

Standardizing and optimizing institutional-level documentation in the electronic medical record era.

155 Background: Although electronic medical records (EMR) offer numerous potential benefits, there are significant challenges to balance high quality patient care and clinical efficiency with the rising demands of required documentation. Our objective was to propose and implement a strategy to standardize and optimize EMR documentation. Methods: An EMR taskforce was created within our institution’s radiation oncology (RO) department consisting of representatives of the clinical staff and EMR coders. To optimize clinical documentation, disease-site specific consult templates were created using EMR standard data elements and personalized drop down menus (Smartlists). Meetings were held with the billing department for template review and with the analytics team to begin automated data extraction into research databases. Quality metrics such as the average number of clinic visits billed at levels 4 or 5 (B45) and the average number of hours per visit (AHV) were compared in different clinics within a 6-month pre- and post- template implementation time period. Results: Within 3 months of establishing the taskforce, 32 RO disease-specific templates were created and distributed for usage in clinic. Optimized template features include consistent cancer staging, standardized oncologic history entry, usage of macros for patients’ symptoms for multiple provider verification, imbedded disease-specific protocol list to improve patient screening and enrollment, and multiple Smartlists for common treatment recommendations. In the GI Clinic, B45 increased from 49.3 to 61.4 per month and similar trends were seen in the Thoracic Clinic (B45, 51.4 to 85.2 per month). The AHV decreased in both the GI (21 to 10 hours) and Thoracic (22 to 13 hours) clinics, showing a significant added value to use of standard documentation. Conclusions: EMR systems can be challenging to navigate; however, they also present a unique opportunity to optimize clinical and research efficiency if used properly. The implementation of standard documentation in our department led to significant improvement in clinical efficiency. Further efforts are being made to adopt these changes on an institutional-wide level.

308 - Obtaining Patient Reported Outcome Data in the Era of Electronic Medical Records

308 - Obtaining Patient Reported Outcome Data in the Era of Electronic Medical Records

Applying the Seattle Heart Failure Model in the Office Setting in the Era of Electronic Medical Records

Prediction models such as the Seattle Heart Failure Model (SHFM) can help guide management of heart failure (HF) patients, but the SHFM has not been validated in the office environment. This retrospective cohort study assessed the predictive performance of the SHFM among patients with new or pre-existing HF in the context of an office visit.Methods and Results:SHFM elements were ascertained through electronic medical records at an office visit. The primary outcome was all-cause mortality. A "warranty period" for the baseline SHFM risk estimate was sought by examining predictive performance over time through a series of landmark analyses. Discrimination and calibration were estimated according to the proposed warranty period. Low- and high-risk thresholds were proposed based on the distribution of SHFM estimates. Among 26,851 HF patients, 14,380 (54%) died over a mean 4.7-year follow-up period. The SHFM lost predictive performance over time, with C=0.69 and C<0.65 within 3 and beyond 12 months from baseline respectively. The diminishing predictive value was attributed to modifiable SHFM elements. Discrimination (C=0.66) and calibration for 12-month mortality were acceptable. A low-risk threshold of ∼5% mortality risk within 12 months reflects the 10% of HF patients in the office setting with the lowest risk. The SHFM has utility in the office environment.

Application of a Natural Language Processing Algorithm to Asthma Ascertainment. An Automated Chart Review.

Difficulty of asthma ascertainment and its associated methodologic heterogeneity have created significant barriers to asthma care and research. We evaluated the validity of an existing natural language processing (NLP) algorithm for asthma criteria to enable an automated chart review using electronic medical records (EMRs). The study was designed as a retrospective birth cohort study using a random sample of 500 subjects from the 1997-2007 Mayo Birth Cohort who were born at Mayo Clinic and enrolled in primary pediatric care at Mayo Clinic Rochester. Performance of NLP-based asthma ascertainment using predetermined asthma criteria was assessed by determining both criterion validity (chart review of EMRs by abstractor as a gold standard) and construct validity (association with known risk factors for asthma, such as allergic rhinitis). After excluding three subjects whose respiratory symptoms could be attributed to other conditions (e.g., tracheomalacia), among the remaining eligible 497 subjects, 51% were male, 77% white persons, and the median age at last follow-up date was 11.5 years. The asthma prevalence was 31% in the study cohort. Sensitivity, specificity, positive predictive value, and negative predictive value for NLP algorithm in predicting asthma status were 97%, 95%, 90%, and 98%, respectively. The risk factors for asthma (e.g., allergic rhinitis) that were identified either by NLP or the abstractor were the same. Asthma ascertainment through NLP should be considered in the era of EMRs because it can enable large-scale clinical studies in a more time-efficient manner and improve the recognition and care of childhood asthma in practice.

Electronic Medical Record Use and Satisfaction Among Pediatric Orthopaedic Surgeons.

Electronic medical record (EMR) use among pediatric orthopaedic surgeons has evolved substantially within the past decade. In response to the Patient Protection and Affordable Care Act, large hospitals and tertiary pediatric medical centers rapidly acquired and implemented EMRs with uncertainty as to the potential impact on patient care and operational efficiency of subspecialists. This study reviews the background and regulatory framework for Meaningful Use of EMR and assesses the current landscape of EMR utilization by pediatric orthopaedic surgeons. In 2015, the Practice Management Committee distributed a survey regarding EMR use and satisfaction to members of the Pediatric Orthopaedic Society of North America. Survey responses from 324 members were used to analyze levels of satisfaction by EMR platform and practice type and to consider drivers of satisfaction or dissatisfaction of end users. Although there were no differences in overall satisfaction based on vendor or practice type, significant differences were noted for 5 specific parameters of satisfaction, including: usefulness of templates, efficiency of practice workflow, information services support, number of logon events, and speed of the system. A user/vendor map is provided to facilitate networking among providers and groups utilizing common EMR platforms to help bring about rational improvements in EMR functionality for the future. Substantial effort needs to be made to improve subspecialty-specific EMR documentation, order entry, research tools, and clinical workflows to enhance the processes of care for children with orthopaedic conditions in the era of EMR. Level IV.

Applying the Seattle Heart Failure Model at an Office Visit in the Era of Electronic Medical Records

Applying the Seattle Heart Failure Model at an Office Visit in the Era of Electronic Medical Records

System Safety in Healthcare

Electronic Medical Records (EMR) are the digital version of paper charts. They are the electronic record of an individual’s health-related information that is created, gathered, managed, and consulted by licensed clinicians and staff [Refs. 1-3]. This article will focus on some of the challenges of health record integration between often disparate systems — internally, across a mix of systems, or externally, such as entities ranging from federal and state agencies, insurance companies, physician practices, medical facilities and pharmacies. The challenges of data collection, assimilation and integration remain at the forefront of our electronic medical record era [Refs. 1, 6-9]. Seamlessly moving information across disparate information systems becomes even more challenging when the data involves confidential medical information.

Customized electronic alerts to boost pneumococcal vaccinations in high risk cancer patients.

e18227 Background: Streptococcus pneumoniae remains a leading cause of serious illness, including bacteremia, meningitis, and pneumonia among adults in the United States. Approximately 10% of all patients with invasive pneumococcal disease die of their illness, but case-fatality rates are higher for immunocompromised adults including cancer patients. Current Center for Disease Control (CDC) guidelines recommend routine use of 13-valent (Prevnar 13) and 23-valent (Pneumovax 23) pneumococcal vaccines (PV) for immunocompromised patients. We conducted a quality improvement (QI) project utilizing our electronic medical record (EMR) system to improve PV compliance (PVC) rates in our patients. Methods: We created automatic reminders called best practice alerts (BPA) and linked them to a smart order set within our EMR that appeared upon opening patient charts. The smart set ordered the correct vaccine in sequence based on CDC guidelines. From August 2015- January 2017, we implemented this BPA for one of six hematology providers and the remaining providers were provided with verbal guidelines and reminders to administer PV to their patients. Results: At baseline only 22% of 3000 hematology patients within the practice had received PV. The pilot provider with the BPA linked to a smart order set within the EMR improved PVC within his patients from 23% to 66%. Providers who were just given verbal guidelines improved PVC from an average of 22% to 45%. The difference in the improvement between the pilot provider and the reference group is 21% (p &lt; 0.001). Conclusions: In an EMR era, we took advantage of the tools within our system to improve PVC rates. BPA linked to a smart order set within the EMR provided better means of improving PVC than verbal prompts in high-risk immunocompromised patients. Additionally, the increase in PVC throughout the hematology practice is due to primary care providers using similar reminders within the same EMR. The PV BPA will be conducted as a standard of care in our clinic and will be expanded to oncology patients as well.

Assessment of Asthma Progression Determined by Natural Language Processing to Improve Asthma Care and Research in the Era of Electronic Medical Records

Assessment of Asthma Progression Determined by Natural Language Processing to Improve Asthma Care and Research in the Era of Electronic Medical Records

8-5 電子カルテ時代の呼吸器内視鏡検査(シンポジウム8 安全で高度なBronchoscopyを目指して)

8-5 電子カルテ時代の呼吸器内視鏡検査(シンポジウム8 安全で高度なBronchoscopyを目指して)

Automated Chart Review for Asthma Ascertainment: An Innovative Approach for Asthma Care and Research in the Era of Electronic Medical Record

Automated Chart Review for Asthma Ascertainment: An Innovative Approach for Asthma Care and Research in the Era of Electronic Medical Record