Electronic Medical Record Tools Research Articles

A Framework for the Administration of Anti-amyloid Monoclonal Antibody Treatments in Early-Stage Alzheimer's Disease.

The US Food and Drug Administration (FDA) approval of lecanemab for early-stage Alzheimer's disease (AD) represents an exciting new chapter in the management of neurodegenerative disease, but likewise presents numerous clinical, technical, and financial logistical challenges for both academic and non-academic medical institutions hoping to administer this drug. Minimal resources exist that provide guidance for establishing and maintaining a lecanemab treatment program at the institutional level. The current report aims to provide healthcare institutions a framework for the planning, onboarding, and longitudinal treatment of AD with anti-amyloid monoclonal antibody treatments. We present an implementation study involving three stages: (1) feasibility assessment, (2) operations and going live, and (3) monitoring assessment. We found that implementation of lecanemab in clinical practice was feasible due to the assignment of an enterprise-wide project manager to facilitate the planning phase, a cost analysis showing that lecanemab was financially sustainable, and the development of electronic medical record tools to support operational efficiency.

Nurse-Led Cardiac Rehabilitation Care Coordination Program: Improving Functional Outcomes for Patients Through Automatic Referral and Effective Care Coordination.

The aim of this investigation was to evaluate the impact of automated cardiac rehabilitation (CR) referral and nurse care coordination on patient and program outcomes. Specifically, the aim was to identify whether differences exist in physical and psychological function at CR Phase 2 enrollment and completion and CR Phase 2 participation and completion for hospitalized patients who receive in-person CR nurse visits versus phone consultation. Using a retrospective pre-/post-intervention descriptive design, a purposive sampling technique was used to select groups with matching clinical attributes. Dates were selected to mitigate the impact of COVID-19 on CR program enrollment and completion. Data were abstracted from the patient electronic medical record, telemetry documentation, and CR referral tracking tool. Patient descriptors included age, sex, cardiac diagnosis/procedure (post-coronary artery bypass graft surgery, myocardial infarction, percutaneous coronary intervention, heart failure, and aortic valve repair and replacement) and cardiac risk stratification category. Patient functional outcomes included the 6-min walk test and metabolic equivalents of task levels for functional capacity; psychological function was measured by the Patient Health Questionnaire assessment. Program outcomes included discharge to CR Phase 2 enrollment, CR sessions, and completion. Each group had 52 patients. Age was 64 ± 12yr, 68% were male. Perhaps indications for CR included coronary artery bypass graft surgery (44%), myocardial infarction (19%), percutaneous coronary intervention (20%), heart failure (10%), aortic valve repair and replacement (8%). Cardiac risk was low in 30%, intermediate in 65%, and high in 5%. The post-intervention group compared with the pre-intervention group had a shorter discharge to CR Phase 2 enrollment (35 ± 18 d vs 41 ± 28 d, P = .078) and significantly fewer sessions required for CR completion. Automated CR referral and nurse care coordination visits for hospitalized patients decreased the transition period between CR Phase 1 and 2. Patients were physically and psychologically prepared for earlier CR Phase 2 enrollment and successfully completed the program in fewer days than the pre-intervention group.

Enhanced Scheduling to Improve Resident Continuity in a Family Medicine Teaching Clinic.

Continuity of care is a core concept at the heart of primary care practices. Increased patient-provider continuity of care is associated with better satisfaction scores, better clinical outcomes, decreased hospitalizations and emergency department utilization, improved completion of preventive health services, adherence to medical treatment plans, and improved show rates. Compared to traditional outpatient practices, resident teaching clinics traditionally have lower rates of continuity and face unique challenges in improving continuity given the curricular demands, complex scheduling, and high turnover of providers. The objective of our study was to assess the impact of front office training and new electronic medical record (EMR) scheduling protocols on resident continuity in a family medicine teaching clinic. From July 2021 through May 2022, optimized scheduling through a provider search function in the EMR was implemented in a family medicine teaching clinic. We compared the monthly continuity rates between corresponding months in the prior year and the intervention year. Over an 11-month implementation process, continuity for resident physicians increased from 36.4% to 64.6% (χ2=675.41, P<.001) using EMR tools and scheduling search functions to improve and sustain continuity over the study period. This intervention to enhance continuity in a family medicine residency clinic led to rapid and sustained improvement in provider continuity. This result demonstrates that optimization of EMR scheduling with tools and protocols can improve overall continuity. This scheduling process can likely be applied to clinical sites for residency programs across disciplines.

Patient Portal Use and Risk of Readmissions in Decompensated Cirrhosis: Retrospective Study.

Patient portals are a common electronic medical record tool that allow for the asynchronous exchange of health information between patients and their health care teams. Patients can leverage patient portals to perform tasks such as viewing test results, reviewing clinical notes, and messaging their health care team. The impact of patient portal use on clinical outcomes in cirrhosis is unknown. In this study, we evaluated the relationship between patient portal use patterns and readmissions in cirrhosis. We identified 131 patients with decompensated cirrhosis with an index cirrhosis-related admission between May 1, 2018, and May 1, 2019. We then examined patient portal enrollment and use data during the 6-month period preceding the study period. Portal functions evaluated included sending a message, reading a message, and reading a test result. Use was categorized as active (sending a message) and passive (reading a message or test result) and was further stratified as no, moderate, or frequent use based on the frequency of portal function use compared to the mean. The primary outcomes were 90-day and overall readmissions, adjusted for age, model for end-stage liver disease-sodium, alcohol-related cirrhosis etiology, ascites, and hepatic encephalopathy. Portal functions assessed included sending a message, reading a message, and reading a result; the total number of times a portal function was performed was divided by the number of months the patient was enrolled in the patient portal during the 6-month period. The study population was 50.4% (66/131) female, with a mean age of 58 years. Enrollment in the patient portal was 63.4% (83/131), and there was no significant difference in enrollment based on clinical or demographic characteristics. For the entire cohort, 14.5% (19/131) and 22.1% (29/131) of patients were moderate and frequent active users, respectively. Of those enrolled in the patient portal, 97.6% (81/83) of patients were moderate or frequent passive users for both reading a message and reading a test result. Moderate active users had less 90-day readmissions (odds ratio 0.77, 95% CI 0.60-1.00) and overall readmissions (subdistribution hazard ratio 0.42, 95% CI 0.21-0.84), compared to nonactive users. There was no relationship between readmissions and passive use. Passive use of the patient portal is very high but is not associated with the risk of readmissions in people with decompensated cirrhosis. However, moderately active use of the patient portal is associated with a reduced risk of readmissions. Further work is needed to identify possible confounders and refine key use behaviors that may be protective with regard to the risk of readmission in this population.

Abstract 17246: Using Alerts vs Automated Tools to Better Document CHADS2-VASc Scores in Patients Hospitalized With Atrial Fibrillation

Introduction: Atrial fibrillation (Afib) is the most common cardiac arrhythmia in the United States and a significant burden on our healthcare system. Currently as many as six million people in the United States carry a diagnosis of Afib, with that number likely increasing as our population ages and our methods of detection improve. Accurate diagnosis and risk stratification are imperative as these patients may have stroke rates as high as 20% annually. Comprehensive documentation of the CHADS2-VASc score can better determine the need for Anticoagulation for patients hospitalized with Afib Hypothesis: What is the rate of recording of CHADS2-VASc scores in patients admitted to House Staff and Hospitalist teams and what interventions would lead to better data gathering: a best practice alert or an automated diagnosis tool in the Electronic Medical Record (EMR). Methods: At The University of Chicago Medical Center, attendings on the cardiology service and hospitalists documented CHADS2-VASc without intervention. Then the response rate was measured after implementing a best practice alert, or soft stop dialog box in the EMR. Later for Hospital Medicine teams, an auto diagnosis tool, a hard stop auto-generated in the note, was added to the EMR. Results: Over the course of three years (January 2018 to December 2021) CHADS2-VASc score was charted an average of 1% of the time for hospitalists and 7% of the time for House Staff Cardiology. After implementing the EMR Best practice alert (January 2022 to January 2023 for House Staff and January 2022 to November 2022 for Hospitalists) these rates increased to 19% (p <0.0001) for the hospitalist team and 54% for the House Staff Cardiology team (p<0.00001). With the Auto diagnosis tool (November 2022 to January 2023) the rate increased from 19% to 56% (p <1x10 -7 ) Conclusions: As our data shows, CHADS2-VASc scores recording rates remained low among both cardiology and medicine attendings. However, an EMR generated alert increased responses while an auto diagnosis tool increased documentation even more. This demonstrates the effectiveness of EMR tools. This improvement in adherence should also lead to better rates of prescribing Anticoagulation to patients with higher risk.

Implementation of a Multipronged Intervention to Improvement Inpatient Sickle Cell Disease Care

Introduction: Over the decades, many interventions have been used to improve care for patients with Sickle Cell Disease (SCD). There are 19 whole lifespan SCD centers, 30 pediatric SCD centers, and 28 adult SCD centers compared to 6,129 hospitals and over 220 children's hospitals in the US. The number of providers is insufficient to meet the needs of patients with SCD. Caring for patients without a dedicated Comprehensive SCD Center, such as our institution, can be challenging. Therefore, we developed a framework to leverage expertise in hematology, internal medicine, and emergency medicine to improve SCD patient care processes. In these settings, filling the gap in SCD care requires a multipronged creative approach that is implemented over time in a stepwise fashion. This allows time to adapt the intervention to the local medical system for more enduring change. This project looks at the longitudinal interventions that have occurred at the University of Chicago (UC) to address SCD care and discusses procedures to achieve successful implementation. Methods: In the first step, we identified the key stakeholders to determine the system's needs and goals (Table 1). This involved clinicians and staff who were interested in improving care for patients with SCD. The second step involved stakeholders creating a plan after analyzing the current care. Multipronged interventions were developed and implemented (see Figure 1 for a timeline and list of interventions). The final steps involved provider training. Furthermore, we tracked the progress of our interventions using the Electronic Medical Record (EMR). An EMR review was performed from 7/17/22 to 6/13/23 to evaluate our utilization. Descriptive statistics and Chi-Square were used to evaluate the data. This project was formally determined to be quality improvement and was therefore not overseen by the Institutional Review Board. Results: Regarding the first step, our task force comprises a large multidisciplinary group (see Table 1 for a full list). Next, it was important that we implement sustainable and useful systems (see Figure 1). In the review period, 154 patients were admitted 488 times. The SPP was used or viewed 134 times. Seventy-nine percent (122/154) of admitted patients had an IPP that was used, viewed, or created during their admission. Since the opening of the SCD Day clinic, there have been a total of 1045 SCD-related encounters, with an average of 36 patients a month or 1.7 patients a day. When comparing the review period to the same time in the prior year, the inpatient hydroxyurea protocol did not significantly improve the use of the medication. Hydroxyurea use changed from 64% to 65% of admissions and 65% to 68% of admitted patients. The inpatient SCD consult service received new consult requests in 44% of SCD admissions (214 total times). Lastly, over 100 hospitalists, resident physicians, inpatient teaching team physicians, and hematology physicians were educated along the way regarding changes in our system. Discussion: With time and a multipronged approach, achieving change in a large medical system is possible. The largest hurdle to overcome is funding. This is why our initial interventions focused on the implementation of EMR tools such as SPP, IPP, and educating providers. Though there was an up-front time cost, once completed, these interventions could be iterated on easily. It was not until 2022, that dedicated funding for a consult service could be secured. Having a large multidisciplinary team allows for creative ideas, dividing of tasks, accountability, and expertise in implementation. This does come with a limitation as it is harder to implement changes the larger the group becomes. Thus, a balance of members is vital. Frequent provider education is paramount in disseminating and improving the changes that are in the system. The plan, do, study, act model is a staple in quality improvement. It is important that there is foresight in developing a model to track the quality of care. The EMR's tools should be maximized to aid clinicians as efficiently as possible. Conclusion: Making large changes without funding or an institutional push can be challenging. Small incremental grassroots changes may be necessary until additional funding has been negotiated and secured. Meeting and exchanging ideas as a team and establishing pathways for improvement is a viable initial step.

The transition tightrope: Optimizing post-discharge care for acute leukemia patients.

323 Background: Patients with acute leukemia who are discharged after a hospitalization are at high risk of complications and increased risk of readmissions. We reviewed discharge plans at an academic cancer center and found a gap of inconsistently scheduled follow-up appointments after discharge, and we sought to improve the transition of care for this population. Methods: Utilizing A3 methodology, we focused on ensuring acute leukemia patients had a follow-up visit in the clinic or infusion treatment area within 5 days of discharge, which was the timeline supported by literature review. Our improvement team performed a Gemba walk in November 2021 to observe discharge planning and outpatient follow-up appointment scheduling processes, and we mapped root causes of poor care transitions on a fishbone diagram. Many of the coordinated steps required for a seamless discharge and acceptance into outpatient care were not consistently performed. We utilized a pareto chart to stratify root causes and narrowed in on 3 key drivers: 1) standard process for discharge communication between in- & out-patient teams; 2) access to schedulers to secure appointments; and 3) escalation pathways when no appointment slots were available. We introduced 3 interventions: a direct phone line for the inpatient team to contact the infusion area schedulers for post-discharge appointments, an escalation pathway when schedules appeared fully booked, and a discharge navigator flowsheet in our electronic medical record (EMR) to anticipate discharge needs and facilitate standardized, efficient communication. Results: As a result of our interventions, the percentage of patients with an outpatient follow-up visit within 5 days increased from 61% to 94% between January and May 2022. Streamlining communication pathways (e.g., an automated EMR message to schedulers and a direct phone line for urgent escalation) led to initial improvements in timely follow-up visits. The EMR discharge navigator facilitated upstream identification of post-discharge needs and directed communication to the appropriate infusion area and clinic pools to schedule appointments. The discharge navigator continues to be used in the hematology service; one year after its launch, the EMR tool is utilized in 38% of all hematology discharges. Conclusions: Timely outpatient follow-up to address acute symptoms is a key method to decrease readmission risk, but inconsistent scheduling practices presented barriers at our cancer center. Instituting standardized scheduling protocols in the EMR and escalation pathways enabled nearly all our patients with acute leukemia to secure outpatient visits within 5 days of discharge. We are building on these initial efforts to disseminate and sustain utilization of the tool for all hematology and oncology patients in our center.

Harnessing Electronic Medical Record Tools to Provide Proceduralist Feedback on Pediatric Endoscopy Quality Metrics.

In 2022, the Pediatric Endoscopy Quality Improvement Network published quality metrics related to pediatric endoscopy. We utilized electronic medical record (EMR) tools to collect pediatric endoscopy quality metrics (PEQM) and to standardize proceduralist feedback. EMR tools were created to capture and display PEQM: (1) an endoscopy documentation template, (2) nursing documentation of events during endoscopy for timed calculations, and (3) a data dashboard. Dashboard metrics provided individualized PEQM feedback relative to group performance and ideals where available. Utilization of the endoscopy documentation tools and data dashboard was measured. Utility was assessed using a survey based on the Technology Adoption Model. Adoption of documentation tools has been nearly universal with positive survey outcomes. Robust dashboard visualization has been demonstrated. Use of EMR documentation tools standardized PEQM collection. Future capture and sharing of common PEQM data across institutions could help determine PEQM benchmarks.

Analysis of Telestroke Usage in Rural Critical Access Emergency Departments.

Introduction: Telestroke is an effective strategy to increase appropriate stroke treatments among patients in resource-limited environments. Despite the well-documented benefits of telestroke, there is limited literature regarding its utilization. The purposes of this study are: (1) determine the percentage of potential stroke patients who generate a telestroke consult in rural critical access hospitals (CAHs) and (2) validate an electronic medical record (EMR)-derived report as a stroke screen. Methods: This retrospective chart review analyzed patients presenting between September 1, 2020 and February 1, 2021 to three CAHs. Visits with triage complaints suggesting acute ischemic stroke (AIS)/transient ischemic attack (TIA) were pooled for analysis using an EMR-derived report. Patients with confirmed AIS/TIA at discharge over this period were used to validate the EMR tool. Results: The EMR report pooled 252 possible AIS/TIA visits out of 12,685 emergency department visits for analysis. It had a specificity of 98.78% and sensitivity of 58.06%. Of the 252 visits, 12.7% met telestroke criteria and 38.89% received telestroke evaluation. Among these, a definite diagnosis of AIS/TIA was made in 92.86%. Of the remaining population who met criteria but didn't undergo consultation, 61.11% were diagnosed with AIS/TIA at discharge. Conclusion: This study provides novel characterization of stroke presentations and telestroke in rural CAHs. The EMR-derived report is a reasonable tool to concentrate potential AIS/TIA cases for review and resource allocation but is not sensitive enough to detect stroke as a stand-alone tool. The majority (56%) of eligible patients did not undergo telestroke consultation. Future studies are critical to further understand reasons contributing to this.

Improving Hepatitis B Screening at Family Health Centers Using Quality Improvement and Electronic Medical Record Tools.

Chronic hepatitis B viral (HBV) infection is associated with significant morbidity and mortality with endemic areas carrying most of the global burden of HBV disease. Current HBV screening rates in the United States are suboptimal. We aimed to improve HBV screening rates at regional family health centers serving high-risk refugee populations by 20% over 2 years. We used quality improvement (QI) methodology and implemented interventions providing electronic medical record (EMR)-enabled HBV screening tools within known clinical workflows. EMR tools captured country-of-origin data to identify persons from HBV-endemic regions with provision of a laboratory order set to ensure performance of appropriate HBV screening tests. The project was initiated prior to the COVID pandemic but continued during the pandemic with imposed social isolation measures. We nevertheless demonstrated 4 statistical process control chart shifts and achieved our QI smart aim. Further, we demonstrated a high HBV detection rate (8.2%-12.8%) among persons identified for screening.

Using a Provincial EMR Program to Increase Guideline Utilization in Diabetes

eDOCSNL (Newfoundland) is implementing a guidelines-based set of electronic medical record (EMR) tools for documentation and practice management. We will examine how an intuitive EMR tool set can influence guidelines-based practice and improve patient outcomes.

Improving performance status documentation using an electronic medical record tool.

309 Background: Performance status (PS) is used regularly in oncology care to select appropriate cancer treatment, track changes in level of functioning, and determine clinical trial eligibility. In addition, the American Society of Clinical Oncology (ASCO)/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards requires that on each clinical encounter, staff performs and documents a patient assessment that includes 8 elements; one of which is PS. Currently, little instruction is provided on how to utilize and record a more standardized criteria, such as PS with either ECOG or Karnofsky scores, in the electronic medical record (EMR) which results in suboptimal documentation. We assessed documentation of PS before and after implementation of a tool within the EMR at our outpatient cancer center. Methods: Using the Plan-Do-Study-Act (PDSA) technique, a quality improvement project was developed to determine if our center was consistent with the ASCO/ONS guidelines. An EMR tool was developed that enabled clinicians to standardize PS documentation within an encounter via population of a flowsheet to improve compliance. Clinicians were educated on guidelines and utilization of the PS tool and data was collected pre- and post- implementation. A survey was developed and administered to assess PS tool use and to learn of any barriers to implementation. Based on survey results, we created a reminder tip sheet for clinicians to utilize the PS tool; a subsequent chart review was completed. Results: In a random pre-study 50 chart review, 0% of encounters in our lung and breast clinic had PS documented. At the time of pre-tool implementation, due to the lack of a retrievable flowsheet, we did not obtain a reliable PS documentation percentage. After education and tool implementation, 2481 random encounters were evaluated of which 315 encounters (12.6%) documented PS and used the PS tool. A total of 7 (35%) clinicians completed the survey: 4 physicians and 3 advanced practice registered nurses. Of those who responded, 57% used the PS tool, 71% used a note template with ECOG PS embedded, and 85.7% were willing to alter their note template to incorporate ECOG PS. Barriers identified included: limited time, workflow constraints and redundant documentation. After tip sheet implementation, 66% of encounters documented PS; however, only 6 out of those 33 encounters (18%) documented PS using the PS EMR tool. Conclusions: Documentation support tools help facilitate care and enable measurement of guideline concordance, but once implemented it can be challenging to maintain adherence. Although this study improved overall PS documentation (0 to 66%), we were only able to demonstrate a 6% increase in the use of our PS documentation tool. While PS tool implementation was feasible, adoption of the additional tool was not universal. We aim to gather additional clinician input to improve PS documentation completion and guideline adherence.

Utilization of the Khorana score (KS) by hematology/oncology clinicians in the ambulatory setting.

31 Background: Patients with cancer are at an increased risk for venous thromboembolism (VTE). Though cancer-associated thrombosis is a major cause of mortality in patients, only second to disease progression, the optimal use of primary prophylaxis remains a clinical challenge. The KS, developed in 2008, is a validated tool to identify patients at low, intermediate, and high-risk for VTE. At the UConn Health Neag Comprehensive Cancer Center, we created a survey and administered it amongst our clinicians to assess KS knowledge and documentation practices. Methods: We conducted a 3-part quality improvement study that included a pre- and post-intervention retrospective chart review of eligible patients with cancer to examine rates of KS documentation. Eligibility included patients with cancer initiating a new chemotherapy. We excluded patients on anticoagulation, multiple myeloma, brain/central nervous system tumors, and patients in the Department of Corrections. The interventions included: 1) 9-question survey to assess clinician knowledge and utilization of KS; 2) KS education presented at a clinician meeting; 3) an electronic medical record (EMR) tool implemented to standardize KS documentation; and 4) reminder KS tip sheet created for clinicians. Descriptive statistics were used in data analysis. Results: Of 50 documented encounters, 40 met study criteria, with none having KS documentation. In a pre-tool implementation survey sent to 24 clinicians, of whom 20 had participated, 70% were physicians, 30% were advanced practice registered nurses (APRN), and 60% reported being in practice for 5 years or less. Most (90%) reported not using KS; only 10% reported being unfamiliar with the KS while 65% reported only sometimes talking to patients about VTE risk. Of the 10% of clinicians that did document KS, it was reported that they “document in the narrative of [the] note when appropriate.” The highest barriers to documentation were reported as “time constraints with extra documentation” and “not enough guidance.” Post-EMR tool implementation, a total of 58 of 99 (58.5%) encounters met study criteria and 1 KS was documented (1.7%). Conclusions: KS is underutilized in ambulatory clinical settings partly due to a lack of education and awareness despite availability of national guidelines which reflect the importance of primary VTE prophylaxis evaluation in all patients with cancer. This study demonstrates a continued deficiency in our clinical practice. We aim to further identify barriers and methods for improvement of KS documentation and VTE risk assessments. Additionally, a referral process is planned for all at-risk patients to enhance patient care, decrease hospital visits related to VTE, and attempt to reduce health-care costs related to VTE care.

Standardizing the Evaluation and Management of Necrotizing Enterocolitis in a Level IV NICU.

Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outcomes. This quality improvement project aimed to decrease variation in the evaluation and management of NEC in a Level IV NICU. A multidisciplinary team investigated institutional variation in NEC management and developed a standardized guideline and electronic medical record tools to assist in evaluation and management. Retrospective baseline data were collected for 2 years previously and prospectively for 3.5 years after interventions. Outcomes included the ratio of observed-to-expected days of antibiotics and nil per os (NPO) on the basis of the novel guidelines and the percentage of cases treated with piperacillin/tazobactam. Balancing measures were death, surgery, and antifungal use. Over 5.5 years, there were 124 evaluations for NEC. Special cause variation was noted in the observed-to-expected antibiotic and NPO days ratios, decreasing from 1.94 to 1.18 and 1.69 to 1.14, respectively. Piperacillin/tazobactam utilization increased from 30% to 91%. There were no increases in antifungal use, surgery, or death. Variation in evaluation and management of NEC decreased after initiation of a guideline and supporting electronic medical record tools, with fewer antibiotic and NPO days without an increase in morbidity or mortality. A quality improvement approach can benefit patients and decrease variability, even in diseases with limited evidence-based standards.

LB916 The war on melanomaTM: A statewide public health initiative

Melanomas are visible on the skin, making melanoma a good model to test the effectiveness of educational strategies on early detection. The War on MelanomaTM is a statewide, education-based, prospective, controlled, public health study. It tests the hypothesis that a broad education campaign, coupled with risk-stratified screening recommendations, will lower statewide melanoma mortality rates and stage of disease at diagnosis, and improve the public’s melanoma-specific knowledge, attitudes, and self-skin examination behaviors relative to control states (primary outcomes). There is little direct data to show that skin screening reduces death due to melanoma. To address this data gap, we have targeted the lay population, patients, skin service professionals, primary care providers, and melanoma experts throughout the state using education and technology. Our experimental design tailors outreach based on each population’s varying knowledge and risk levels. Outreach to the lay community includes mass print, social media, radio and television public service announcements, billboard advertisements, high school curricula, and screening education of rural and Indian reservation communities. Outreach to over 40,000 licensed skin care professionals (e.g., hair, massage, aesthetician industries, etc.) incorporates an educational toolkit with pre- and post-education assessments and is supplemented with home dermoscopy devices (SKLIP) and client access to store-and-forward e-visits with dermatology. A separate educational toolkit for over 4000 primary care providers has been promoted and is supplemented with provision of SKLIP devices, virtual dermoscopy webinars, access to e-consults with dermatology, and electronic medical record tools. A Skin Imaging and Technology Center has been created for expert care of the highest-risk patients. This proof-of-principle public health experiment will provide data that may support a shift of health care resources away from late-stage heroic measures into early detection.

Real-world evidence of a successful biosimilar adoption program.

Biosimilars have introduced new opportunities to reduce the disproportionately high US healthcare spending on biologic medications. This article describes strategic utilization management program initiatives designed to promote biosimilar utilization, reduce biologic drug costsand increase sustainability in a USnonprofit health system. Key components of these biosimilar utilization management program initiatives included expedited procedures to evaluate and establish the formulary status of biosimilars, enhanced contracting negotiations, specially designed electronic medical record tools to guide physician prescribing, payer coverage analysis, evaluations of biologic-utilization trendsand financial performance analysis. Within 2years (2019-2020), this program has resulted in savings of USD$26.9million for Providence St Joseph Health and biosimilar adoption rates that greatly exceed the USnational average.

Minimizing the "Kitchen Sink" Approach: De-implementation of Unnecessary Care for Patients with Anaphylaxis in a Pediatric Emergency Department.

Introduction:Epinephrine is the only medication that prevents morbidity and mortality in anaphylaxis. Systemic corticosteroids and H2 receptor antagonists (H2RA) may benefit select cases but are not universally indicated. This study aims to de-implement the universal use of steroids and H2RAs and emphasize epinephrine-focused care for children with anaphylaxis during acute care visits. The study aims to reduce steroid and H2RA use from 81% and 60%, respectively, to 30% by December 2019.Methods:The primary outcome measures were the percent of patients receiving steroids and H2RAs in the emergency department (ED) or urgent care (UC). Process measure was the frequency of intravenous (IV) line placement. Balancing measures were ED/UC length of stay, admission rate, and ED/UC return visit rate. In addition, a multidisciplinary team designed the following interventions: (1) anaphylaxis clinical pathway to emphasize epinephrine-focused care, outline criteria for second-line therapies and a provider guideline for ED/UC observation; (2) standardize unit-based anaphylaxis medication kits; (3) optimize electronic medical record tools, including order sets and discharge instructions to be concordant with guideline recommendations.Results:The study included 870 patients. There was special cause variation in the use of steroids (81%–33%) and H2RAs (60%–11%), ED/UC Length of stay decreased (6.2–5.0 hours). There was no special cause variation in admission rates or ED/UC return visit rates.Conclusion:Universal use of systemic steroids and H2RAs can be safely de-implemented in pediatric patients with anaphylaxis using quality improvement methods.

Sustainability of Palliative Care Principles in the Surgical Intensive Care Unit Using a Multi-Faceted Integration Model.

Objective(s): Understanding patient goals of care is essential in any setting, and especially so in an urban, safety net trauma centers' Surgical Intensive Care Units (SICU). This underscores the need for implementation of palliative care principles and practices, such as identification of surrogate decision makers, goals-of-care discussions, and CPR directives, in the SICU. Methods: A pragmatic, quality improvement study utilizing a retrospective, pre- and post-intervention continuum analysis. Interventions included a surgeon champion, resident education, and an electronic medical record template, called the Advanced Care Planning (ACP) Note, for use on daily rounds. We reviewed the charts of all adults admitted to the SICU before, during, and after these interventions to identify the incidence of surrogate decision maker documentation by SICU residents. Results: There was an early and enthusiastic adoption in ACP note utilization by SICU residents over the study period. Rates of documenting surrogate decision makers increased throughout the study period (p < 0.0001). Having an ACP note in the chart was associated with significantly higher rates of documented surrogate decision makers (p < 0.0001). Conclusions: Through the integration of targeted education, standardization of an electronic medical record tool for palliative care documentation, and incorporation of palliative care goals into daily rounding ICU checklists, we significantly increased identification of surrogate decision makers in the SICU of our urban Level One trauma center. Chart review from one year post-intervention showed sustained commitment to the use of the ACP note and identification of surrogate decision makers.

Social Determinants of Health Screening by Preclinical Medical Students During the COVID-19 Pandemic: Service-Based Learning Case Study.

BackgroundThe inclusion of social determinants of health is mandated for undergraduate medical education. However, little is known about how to prepare preclinical students for real-world screening and referrals for addressing social determinants of health.ObjectiveThis pilot project’s objective was to evaluate the feasibility of using a real-world, service-based learning approach for training preclinical students to assess social needs and make relevant referrals via the electronic medical record during the COVID-19 pandemic (May to June 2020).MethodsThis project was designed to address an acute community service need and to teach preclinical, second-year medical student volunteers (n=11) how to assess social needs and make referrals by using the 10-item Social Determinants of Health Screening Questionnaire in the electronic health record (EHR; Epic platform; Epic Systems Corporation). Third-year medical student volunteers (n=3), who had completed 6 clinical rotations, led the 2-hour skills development orientation and were available for ongoing mentoring and peer support. All student-patient communication was conducted by telephone, and bilingual (English and Spanish) students called the patients who preferred to communicate in Spanish. We analyzed EHR data extracted from Epic to evaluate screening and data extracted from REDCap (Research Electronic Data Capture; Vanderbilt University) to evaluate community health workers’ notes. We elicited feedback from the participating preclinical students to evaluate the future use of this community-based service learning approach in our preclinical curriculum.ResultsThe preclinical students completed 45 screening interviews. Of the 45 screened patients, 20 (44%) screened positive for at least 1 social need. Almost all of these patients (19/20, 95%) were referred to the community health worker. Half (8/16, 50%) of the patients who had consultations with the community health worker were connected with a relevant social service resource. The preclinical students indicated that project participation increased their ability to assess social needs and make needed EHR referrals. Food insecurity was the most common social need.ConclusionsPractical exposure to social needs assessment has the potential to help preclinical medical students develop the ability to address social concerns prior to entering clinical clerkships in their third year of medical school. The students can also become familiar with the EHR prior to entering third-year clerkships. Physicians, who are aware of social needs and have the electronic medical record tools and staff resources needed to act, can create workflows to make social needs assessments and services integral components of health care. Research studies and quality improvement initiatives need to investigate how to integrate screening for social needs and connecting patients to the appropriate social services into routine primary care procedures.

Digital health interventions for osteoporosis and post-fragility fracture care.

The growing burden from osteoporosis and fragility fractures highlights a need to improve osteoporosis management across healthcare systems. Sub-optimal management of osteoporosis is an area suitable for digital health interventions. While fracture liaison services (FLSs) are proven to greatly improve care for people with osteoporosis, such services might benefit from technologies that enhance automation. The term ‘Digital Health’ covers a variety of different tools including clinical decision support systems, electronic medical record tools, patient decision aids, patient apps, education tools, and novel artificial intelligence (AI) algorithms. Within the scope of this review are AI solutions that use algorithms within health system registries to target interventions. Clinician-targeted, patient-targeted, or system-targeted digital health interventions could be used to improve management and prevent fragility fractures. This review was commissioned by The Royal Osteoporosis Society and Bone Research Academy during the production of the 2020 Research Roadmap (https://theros.org.uk), with the intention of identifying gaps where targeted research funding could lead to improved patient health. We explore potential uses of digital technology in the general management of osteoporosis. Evidence suggests that digital technologies can support multidisciplinary teams to provide the best possible patient care based on current evidence and to support patients in self-management. However, robust randomised controlled studies are still needed to assess the effectiveness and cost-effectiveness of these technologies.