Epic Electronic Medical Record Research Articles

CONNECT: Coordinating Options for Neurovascular Patients Needing Electrophysiology Consults and Treatments

Background and Purpose Though Event Monitors (EM) and Implantable Loop Recorders (ILR) are prevalent in stroke workups, complex processes to obtain placement of these device might result in delays. Our aim was to determine if the CONNECT (Coordinating Options for Neurovascular patients Needing Electrophysiology Consults and Treatments) pathway could improve Stroke-to-Electrophysiology (EP) communications, increase EM and ILR device placements prior to discharge, shorten placement time, and preserve satisfaction. Methods We assessed device placements when an EP consult was obtained [Pre-CONNECT (5/1/21-4/30/22), CONNECT (5/1/22-4/30/23)] for patients with stroke. In the Pre- period, consults were sent via EPIC electronic medical record (EMR), with additional direct communication when desired. In the CONNECT period, the pathway and module allowed for immediate communication between services. Outcomes included case rate, times, length of stay, and satisfaction. Hospital reports detailed Order to Activation (O-A) days. EM report review was used to obtain O-A time. Clinician satisfaction was assessed using Qualtrics survey. Patient satisfaction was assessed with Hospital Consumer Assessment of Health care Clinicians and Systems (HCAHPS) survey. Man-Whitney U test was used. Results 78 patients were included (30EM(38.5%), 48ILR(61.5%)). Age was 68 years ( P = 0.58). For ILRs, inpatient placements prior to discharge increased (3Pre vs 51 CONNECT; P < 0.0001) as did outpatient placements (5 vs 16; P = 0.02). Order to Activation (O-A) time savings were significant for ILR overall (32 days vs 1 day; P = 0.03) and for Inpatient EM (13 days vs 3 days; P = 0.003). Time for consultant to view was 4 min and to respond was 6 min. Devices were placed at a median 6 hrs 32 min (EM: 4 hrs 19 min; ILR:7 hrs36 min). All (12/12) clinicians preferred the technique. Patient satisfaction improved on 13/19 (68%) questions. Conclusions There was a 1600% increase in ILR placements prior to discharge that was associated with the time period that the CONNECT process was in place. The robust improvement in ILR placements prior to discharge, high satisfaction, ease of use, closed loop communication, and respect for autonomy allowing more organic parallel discussions with patients improved clinician workflow which could potentially improve future risk reduction strategies.

Assessing the implementation of a tertiary care comprehensive pediatric asthma education program using electronic medical records and decision support tools

Background Self-management education is integral for proper asthma management. However, there is an accessibility gap to self-management education following asthma hospitalizations. Most pediatric patients and their families receive suboptimal or no education. Objective To implement a comprehensive pediatric asthma education program and evaluate subsequent self-management knowledge in patients as well as behavior change outcomes reflected in the frequency of asthma related repeat emergency department visits and hospitalization. The program implementation was informed by the Knowledge to Translation Action Framework and the i-PARIHS model for quality improvement and involved several iterative stages. Methods We implemented a comprehensive asthma education program for the families of all children 0-18 years old who had been admitted for an asthma exacerbation to the Children’s Hospital of Eastern Ontario (CHEO), beginning on April 1, 2018. The program was adapted to the stages of the Knowledge Translation to Action Framework including undertaking an environmental scan, expert stakeholder feedback, reviews, addressing barriers, and tailoring the intervention, along with evaluating knowledge and health outcomes. Education was delivered over 1-2 h in personalized individual or small group settings, within 4 wk of hospital discharge. All education was provided by registered nurses or respiratory therapists who were also certified asthma educators. The EPIC electronic medical record was used to facilitate referral and scheduling of asthma education sessions, and to track subsequent acute asthma visits. We compared the frequency of a repeat asthma emergency department (ED) visit or hospitalization within 1-year following an initial asthma hospitalization for children who would have received comprehensive asthma education, to a historical cohort of children who were hospitalized between April 9, 2017 – Apr 8, 2018, and did not receive asthma education. Results The program had a high enrollment, capturing nearly 75% of the target population. Most families found the program to be acceptable and reported increased knowledge of how to manage asthma. We identified a crude overall 54% reduction in repeat hospitalizations among children 1 year after implementation of the asthma education program (i.e. 10.2% (23/225) repeat hospitalization rate pre- implementation versus 4.8% (11/227) post-implementation). In adjusted time-to event analysis, this reduction was prominent at 3 months among those who received comprehensive asthma education, relative to those who did not, but this improvement was not sustained by 1 year (HR =1.1, 95% CI =0.55- 2.05; p-value = 0.6). Discussion Although we did not find long-term improvements in ED visits, or hospitalizations, in children of caregivers who participated in comprehensive asthma education, the asthma education program holds potential given that most patients found it to be acceptable and that it increased asthma management knowledge. A future asthma education program should include multiple sessions to ensure that the knowledge and behavior change will be sustained, leading ultimately to long-term reductions in repeat ED visits and hospitalizations.

Chemotherapy Care Companion: Enhancing cancer care through digital remote monitoring.

1636 Background: Oncology patients often encounter preventable acute issues prompting the need for proactive monitoring and management. To manage disease and therapy complications, Ochsner Health developed Chemotherapy Care Companion (CCC) for remote monitoring of treatment patients. This abstract highlights the feasibility of digital remote monitoring (DRM) in managing oncologic patient care, while increasing patient satisfaction and reducing patient events and healthcare costs. Methods: Starting in January 2021, patients initiating an oral or intravenous cancer treatment with an active Ochsner portal account and smartphone became eligible. Providers can manually enroll patients via an order set and receive enrollment reminders within the Epic electronic medical record (EMR). Patients receive a digital WiFi-enabled monitoring scale, blood pressure cuff, and ear thermometer, at no cost. Patients are reminded via phone alerts to take vitals at 9am and 3pm, along with a daily questionnaire. The data is transmitted wirelessly to the EMR, where abnormal vital signs or questionnaire responses trigger escalations sent to an Epic in-basket pool. During clinic hours, advanced practice providers (APPs) review and intervene, utilizing embedded urgent care slots for same-day access. In August 2022, a patient satisfaction survey comprising of nine questions was distributed to all enrolled patients. Results: A retrospective analysis was conducted from September 2022 to August 2023 including 722 participants, 7,360 escalations and 668 interventions. Patient compliance reached 62%, defined as submitting at least 50% of daily vitals. The most common interventions were related to hypertension, hypotension, weight changes, and questionnaire responses. Regarding questionnaire responses, diarrhea, pain, fever, and dizziness were the mostly frequently triaged. Data analytics revealed that CCC led to a 5.9% decrease in emergency room visits, a 41.7% decrease in the rate of inpatient hospital admissions, and a 32.3% improvement in the inpatient length of stay compared to non-enrolled patients. Extrapolating this data across 5,500 oncology patients within our hospital system, CCC could prevent 172 ER visits, 914 inpatient hospital admissions and 2,006 hospital days. The survey (131 responses) revealed high satisfaction with CCC: over 80% felt a sense of security, 90% were overall satisfied, and more than 90% would recommend CCC. Conclusions: Findings highlight the value of integrating DRM in cancer care, showcasing its ability to reduce healthcare costs and optimize resource utilization while enhancing patient care and satisfaction. Moreover, the study underscores the high patient satisfaction and engagement with DRM, bolstering its feasibility and acceptance in oncology care. Further investigation is warranted to explore the financial benefits for hospitals, insurance companies, and pharmaceutical companies.

Ocular screening for chronic graft-versus-host disease in patients with allogeneic hematopoietic stem cell transplant

ObjectiveThis study investigates ocular manifestations of graft-versus-host disease in patients following allogeneic hematopoietic stem cell transplantation (HSCT) at the University of Texas Medical Branch (UTMB). Preferred practice pattern guidelines are proposed for ocular graft-versus-host disease (oGHVD) detection. MethodsThe Epic electronic medical record database at UTMB was screened using International Classification of Diseases, Tenth Revision (ICD-10), codes for bone marrow transplants, stem cell transplants, and complications of bone marrow transplants and stem cell transplants. We identified 50 patients with the ICD-10 codes that were seen at UTMB between 2000 and 2021. Patients who received an HSCT and follow-up care with UTMB were included in this study. Thirty-eight patients met the inclusion criteria, whereas 12 patients were excluded because they had no diagnosis of HSCT or did not follow-up with UTMB. ResultsOf the 38 patients in our cohort, 23.7% (n = 9) were noted to have oGVHD. As many as 89% of the patients with oGVHD presented with an ocular surface disease including keratoconjunctivitis sicca, meibomian gland dysfunction, and dry eye syndrome. Systemic GVHD also was found in 44% of the patients with oGVHD. Only 29% (n = 11) of the study population had referrals to ophthalmology. Most referrals (55%) were made within 1 year of getting the HSCT. None of the patients in our cohort received an ocular screening before HSCT. ConclusionsMany post-HSCT patients lack routine ophthalmic care. Regularly assessing post-HSCT patients for early signs and symptoms of oGVHD may limit adverse outcomes. Management of oGVHD should involve a multidisciplinary team approach.

Associations Between Interleukin-6 (IL-6) and the Outcomes of Post-acute Sequelae of COVID-19 (PASC): An EPIC Electronic Medical Record System Retrospective Study (P11-13.003)

Associations Between Interleukin-6 (IL-6) and the Outcomes of Post-acute Sequelae of COVID-19 (PASC): An EPIC Electronic Medical Record System Retrospective Study (P11-13.003)

Quality improvement project to reduce medicare 1-day write-offs due to inappropriate admission orders

BackgroundWe identified that Stanford Health Care had a significant number of patients who after discharge are found by the utilization review committee not to meet Center for Mediare and Medicaid Services (CMS) 2-midnight benchmark for inpatient status. Some of the charges incurred during the care of these patients are written-off and known as Medicare 1-day write-offs. This study which aims to evaluate the use of a Best Practice Alert (BPA) feature on the electronic medical record, EPIC, to ensure appropriate designation of a patient’s hospitalization status as either inpatient or outpatient in accordance with Center for Medicare and Medicaid services (CMS) 2 midnight length of stay benchmark thereby reducing the number of associated write-offs.MethodWe incorporated a best practice alert (BPA) into the Epic Electronic Medical Record (EMR) that would prompt the discharging provider and the case manager to review the patients’ inpatient designation prior to discharge and change the patient’s designation to observation when deemed appropriate. Patients who met the inclusion criteria (Patients must have Medicare fee-for-service insurance, inpatient length of stay (LOS) less than 2 midnights, inpatient designation as hospitalization status at time of discharge, was hospitalized to an acute level of care and belonged to one of 37 listed hospital services at the time of signing of the discharge order) were randomized to have the BPA either silent or active over a three-month period from July 18, 2019, to October 18, 2019.ResultA total of 88 patients were included in this study: 40 in the control arm and 48 in the intervention arm. In the intervention arm, 8 (8/48, 16.7%) had an inpatient status designation despite potentially meeting Medicare guidelines for an observation stay, comparing to 23 patients (23/40, 57.5%) patients in the control group (p = 0.001). The estimated number of write-offs in the control arm was 17 (73.9%, out of 23 inpatient patients) while in the intervention arm was 1 (12.5%, out of 8 inpatient patient) after accounting for patients who may have met inpatient criteria for other reasons based on case manager note review.ConclusionThis is the first time to our knowledge that a BPA has been used in this manner to reduce the number of Medicare 1-day write-offs.

Determining Adherence to Inhaled Corticosteroids From the Epic Electronic Medical Record

OBJECTIVE Often we call the patient’s pharmacy to obtain a refill history to assess inhaled corticosteroid (ICS) adherence. The purpose of this project was to determine the accuracy of refill histories for ICS (with or without long-acting beta agonist) listed in Epic’s Medication Dispense History. METHODS We evaluated 61 patients and used data from 38 who met the following criteria: 1) under the care of the UF Pediatric Severe Asthma Clinic; 2) taking the same dose of the same ICS product for 6 months before the patient’s last clinic visit; and 3) having data available from the pharmacy where the last ICS prescription was electronically sent. We called the pharmacies to obtain a verbal report of their refill record. Then, we compared the number of refills reported to the number listed in Epic’s records using a Wilcoxon matched-pairs signed-ranks test. RESULTS Of the 293 refill dates listed in Epic, 157 were duplicates, giving a 54% error. After deleting duplicates, the mean (SD) number of refills listed in Epic was 3.6 (2.0) compared with 3.3 (2.0) in pharmacies over a period of 6 months (p < 0.0001). After removing duplicates Epic correctly reported the total number of refills for 30 of the 38 patients (78.9%). Seven of the remaining patients had more refills listed in Epic while 1 patient had more refills dispensed. CONCLUSION This study indicates that our version of Epic over-reports refills thus limiting assessment of adherence. In contrast, absence of refills in Epic is a clear indication of poor adherence.

Acceptability and Feasibility of a Smartphone-Based Real-Time Assessment of Suicide Among Black Men: Mixed Methods Pilot Study.

Suicide rates in the United States have increased recently among Black men. To address this public health crisis, smartphone-based ecological momentary assessment (EMA) platforms are a promising way to collect dynamic, real-time data that can help improve suicide prevention efforts. Despite the promise of this methodology, little is known about its suitability in detecting experiences related to suicidal thoughts and behavior (STB) among Black men. This study aims to clarify the acceptability and feasibility of using smartphone-based EMA through a pilot study that assesses the user experience among Black men. We recruited Black men aged 18 years and older using the MyChart patient portal messaging (the patient-facing side of the Epic electronic medical record system) or outpatient provider referrals. Eligible participants self-identified as Black men with a previous history of STB and ownership of an Android or iOS smartphone. Eligible participants completed a 7-day smartphone-based EMA study. They received a prompt 4 times per day to complete a brief survey detailing their STB, as well as proximal risk factors, such as depression, social isolation, and feeling like a burden to others. At the conclusion of each day, participants also received a daily diary survey detailing their sleep quality and their daily experiences of everyday discrimination. Participants completed a semistructured exit interview of 60-90 minutes at the study's conclusion. In total, 10 participants completed 166 EMA surveys and 39 daily diary entries. A total of 4 of the 10 participants completed 75% (21/28) or more of the EMA surveys, while 9 (90%) out of 10 completed 25% (7/28) or more. The average completion rate of all surveys was 58% (20.3/35), with a minimum of 17% (6/35) and maximum of 100% (35/35). A total of 4 (40%) out of 10 participants completed daily diary entries for the full pilot study. No safety-related incidents were reported. On average, participants took 2.08 minutes to complete EMA prompts and 2.72 minutes for daily diary surveys. Our qualitative results generally affirm the acceptability and feasibility of the study procedures, but the participants noted difficulties with the technology and the redundancy of the survey questions. Emerging themes also addressed issues such as reduced EMA survey compliance and diminished mood related to deficit-framed questions related to suicide. Findings from this study will be used to clarify the suitability of EMA for Black men. Overall, our EMA pilot study demonstrated mixed feasibility and acceptability when delivered through smartphone-based apps to Black men. Specific recommendations are provided for managing safety within these study designs and for refinements in future intervention and implementation science research. RR2-10.2196/31241.

Abstract B107: Disparities in lung cancer screening rates: A retrospective observational study

Abstract Introduction: Lung cancer is a leading cause of cancer deaths worldwide. Despite advances in cancer care, the low five-year survival rate for lung cancer is due to late-stage diagnoses. Early detection through lung cancer screening is vital for improving patient outcomes. However, racial disparities persist, with Black individuals experiencing higher rates and advanced stages of the disease. This retrospective study assessed racial and gender disparities in lung cancer screening rates among different racial groups at WakeMed Health and Hospital outpatient primary care clinics. Study design: The study utilized data from the lung cancer screening registry, focusing on the period between Jan 1st 2017 and May 15th 2023. The data was obtained from the EPIC electronic medical record system and exported to Excel. We implemented filters to narrow down the patient population that met the U.S. Preventive Services Task Force inclusion criteria for lung cancer screening. Eligible patients for lung cancer screening are those aged 50 to 80 years, either current smokers or individuals who quit smoking within the past 15 years and have a smoking history of at least 20 pack years. The study focused on three racial groups: Asian, Black, and White populations. Results: Among the 2,098 patients who met the inclusion criteria, 15.5% were Black (n=326), 0.01% were Asian (n=23), and 83.4% were White (n=1,749). The screening rates for lung cancer were calculated for each racial group. The Asian population had a screening rate of 26% (6 out of 23 patients), the Black population had a rate of 32% (103 out of 326 patients), and the White population had a rate of 31% (543 out of 1,749 patients). Among the Asian population, the screening rate for Asian males was 20% (4 out of 20 patients), while for Asian females, it was relatively higher at 67% (2 out of 3 patients). For the Black male population, the screening rate was 31% (52 out of 167 patients), while among females, it was 32% (51 out of 159 patients). Among the White population, white males were screened at a rate of 33% (313 out of 962 patients), while among females, it was slightly lower at 29% (230 out of 787 patients). Conclusion: The findings reveal no significant difference in lung cancer screening rates between racial groups or genders. Caution must be exercised when interpreting the findings for the Asian population due to the small sample size. Further research using a larger and more diverse dataset is necessary to draw more robust conclusions regarding potential disparities in lung cancer screening rates. This study underscores the importance of improving overall lung cancer screening rates, as the majority of the eligible population did not receive screening. Efforts will be made to implement interventions that enhance lung cancer screening rates, ensuring timely detection and improving patient outcomes. Addressing disparities in lung cancer screening access and utilization is crucial for achieving equitable healthcare and reducing the burden of lung cancer on vulnerable populations. Citation Format: Giuseppina Jacob, Amanpreet Dhaliwal, Praveen Namireddy. Disparities in lung cancer screening rates: A retrospective observational study [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B107.

Discordant indirect immunofluorescence compared to multiplex bead immunoassay in ANCA associated vasculitides, a retrospective analysis

Abstract Based on the revised 2017 international consensus on testing for anti-neutrophil cytoplasmic antibodies (ANCA) in granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), we conducted a retrospective analysis to assess whether testing algorithm modification would be appropriate in our laboratory. Currently, at our institution, the primary screening method for ANCA associated vasculitides (AAV) remains indirect immunofluorescence (IIF), which is reflexed to immunoassay (IA) for confirmation. IA is performed by multiplex bead technology to detect anti-myeloperoxidase (MPO) and anti-proteinase 3 (PR3) antibodies. We reviewed cases from January 1, 2021, to November 30, 2022 using Softlab (laboratory information system) with the aim to find discordant results between IIF and IA (IIF-positive and IA-negative, and IA-positive and IIF-negative). We limited our analysis to in-house patients with clinical information available (EPIC electronic medical record). 204 cases met the criterion for positive IIF and negative IA (positive IA defined as index value >0.9), of which 5% were close to the cut off index value (0.7-0.9). 64% of these 204 patients were never concordant in results available for review (IIF-positive, IA-negative). Potential confounding factors for these never concordant cases include 44% historically or concurrently ANA-positive (10% with clinical diagnosis of lupus), 11% with inflammatory bowel disease, and 10% with an underlying ophthalmologic diagnosis, both overlapping with positive ANA. Notably 36% of the patients who were IIF negative over this period had historically positive MPO or PR3 testing, and the current testing window may reflect higher sensitivity of IIF methods, which in this population includes index values near cutoff but definitionally negative. In contrast, of 247 cases with IA-positive results, 51 cases were discordant with IIF results (IA-positive, IIF-negative). 57% of the discordant cases had a historical diagnosis of AAV who were receiving treatment or in remission. 34% of these AAV discordant cases were near the cut off index value (1.0-1.2). Furthermore, we found that all patients with a clinical diagnosis of AAV were monitored by serial laboratory testing at varying frequency, which included IIF with titers and IA (at least once). As there are no explicit guidelines for laboratory testing to monitor AAV patients, it is unclear whether ordering both assays is of clinical utility in management. With advantages of efficiency and faster turnaround time, IAs may be considered as the primary screening method. In our patient population, we did not identify patients who were IIF-positive only with clinically meaningful disease. Although there may be clinical scenarios that warrant to perform both assays simultaneously, for those with GPA and MPA we conclude that it may be appropriate to transition to use IAs as the primary screening method and use IIF as a confirmatory assay, which may not need to be repeated if positive once.

Social Determinants of Health (SDoH) Scores for Adolescent and Young Adults (AYAs) at a Public Safety-Net Teaching Hospital: A Retrospective Cohort Analysis

Introduction The majority of AYAs, ages 15-39, are treated outside of major academic centers and recent data suggests inferior outcomes for these patients. Social determinants of health play an important role in the outcomes for AYAs due to longer duration of survival, less established social networks, diminished support systems, and financial toxicity. Here we report SDoH data from self-reported screening questionnaires in the EPIC electronic medical record (EMR). The purpose of this study was to examine differences in SDoH between AYAs and older adults from diagnosis of hematological malignancy through 5 years at a nonprofit public safety-net health system in Cleveland, Ohio. Methods Using a retrospective cohort design, patients with hematological malignancies (acute/chronic leukemia, lymphoma, myelodysplastic syndrome, myeloproliferative neoplasms, etc.) identified in the EMR by ICD code, were assigned two groups, AYAs (15-39) and older adults (>39 years of age). Social determinants of health data screenings for Alcohol Use, Depression, Financial Resource Strain, Food Insecurity, and Transportation Needs were evaluated beginning at malignancy diagnosis through 5 years. Scores for each item rated from 0 to 3 based on 3 questions pertaining to each item. Data was stratified by low scores (0 to 1) and high scores (2 to 3) and cumulative incidence was obtained at timepoints of diagnosis (-7 to +7 days), and annually through year 5 from diagnosis. Statistical significance was performed using Kruskal-Wallis chi square analysis and odds ratios (OR). Results A total of 1710 patients with 11010 screens were identified from days 7 prior to diagnosis to 12070 after diagnosis. Any positive score (score of 1 to 3) was obtained in 93% of AYA screens and 95% of >39 years of age screens. To further investigate the degree of positivity of SDoH screen, scores were stratified by low (0 to 1) and high (2 to 3). At initial diagnosis, no statistical difference between AYAs and >39 years was found (x 2=0.97, p=0.3251). A statistical difference was seen for cumulative incidence at all timepoints after diagnosis: 1 year x 2=9.23, p=.0024; 2 years x 2=15.86, p=0.0001; 3 years x 2=18.58, p<0.00001; 4 years x 2=25.47, p<0.00001; 5 years x 2=25.32, p<0.00001 (table 1). Odds ratios (with 95% CI) were statistically significant at all timepoints after diagnosis: 1 year 2.06 (1.28-3.13), p=0.0029; 2 years 1.77 (1.21-2.58), p=0.0031; 3 years 1.97 (1.44-2.69), p=<0.0001; 4 years 2.07 (1.55-2.76), p=<0.0001; 5 years 1.94 (1.49-2.53), p=<0.0001, (figure 1). Most prominently positive were self-reported depression screens in AYAs at 1 year (x 2=6.54, p=0.0105), 2 years (x 2=16.35, p=.0001), 3 years (x 2=21.42, p<0.00001), 4 years (x 2=19.09, p<0.00001), 5 years (x 2=26.86, p<0.00001). Lastly, we assessed annual incidences for total SDoH screens which showed significance at 1 year (x 2=8.73, p=.0031), 3 years (x 2=11.04, p=.0009), and 4 years (x 2=7.96, p=.0048) but not at 2 or 5 years (x 2=1.17, p=0.2798 and x 2=1.40, p=0.2373, respectively). Conclusions Within a highly vulnerable population at a public safety-net hospital, AYAs with hematological malignancies had a statistically significant higher proportion of self-reported Alcohol Use, Depression, Financial Resource Strain, Food Insecurity, and Transportation Needs versus older adults. While no statistical difference existed at time of diagnosis, a larger proportion of high-risk scores were seen beginning at 1 year after diagnosis through 5 years after diagnosis. In addition, odds ratios were most prominent at 1 year and 4 years after diagnosis possibly suggesting a higher social toxicity seen by AYAs in active treatment and survivorship. Specific attention should be given to mental health services for AYAs throughout treatment and prospective observation studies should be done in order to confirm the observed results. In addition, further research is needed to assess the role of hospital setting type (academic, county, community) and presence of an AYA program on social determinants of health for AYAs as well as implementation of social interventions that may mitigate these outcomes.

Optimizing Preoperative Iron Deficiency Anemia in Patients Undergoing Cardiac Surgery

Background: Preoperative anemia is common in patients undergoing cardiac surgery, with iron deficiency being the most common cause of anemia in these patients. Patients who are anemic in the preoperative setting have worse perioperative outcomes than patients with normal hemoglobin levels including higher rates of red cell transfusions, acute kidney injury, increased length of stay, and increased mortality. At the University of Virginia (UVA) Medical Center, there was no institutional process in place to identify and treat iron deficiency anemia in patients planned to undergo cardiac surgery. Objective: The UVA Perioperative Blood Management Committee is a newly-formed multidisciplinary group consisting of members from the departments of Hematology, Anesthesiology, Thoracic and Cardiovascular Surgery, Perfusion, and Blood Bank who work together to improve perioperative patient outcomes and blood product utilization. We set out to implement a testing algorithm with the purpose of improving the proportion of anemic patients undergoing cardiac surgery who have iron studies performed in the outpatient setting, thereby improving the percentage of patients receiving intravenous (IV) iron preoperatively. Methods: We adapted two published perioperative treatment algorithms (Lin, Hematology Am Soc Hematol Educ Program 2019; Munting and Klein, Anaesthesia 2019) which recommend iron therapy in patients with hemoglobin < 13 g/dL, ferritin < 100 µg/L, and/or transferrin saturation < 20% for our cardiac surgery preoperative clinic. In November 2022, we implemented a reflex test within Epic electronic medical record that automatically sent ferritin, iron, and transferrin for patients with hemoglobin < 13 g/dL to evaluate for iron deficiency. Patients meeting parameters for iron deficiency (ferritin < 30 ng/mL and/or transferrin saturation < 20%) were then scheduled for iron infusions. We compared the percentage of patients undergoing testing for iron deficiency, as well as the percentage of anemic patients receiving iron infusion preoperatively, to those from a six month period prior to our start date. Results: Between May 31, 2022 and October 31, 2022, 19% of cardiac surgery patients at UVA with hemoglobin values < 13 g/dL had iron studies drawn in the three months prior to surgery. After implementing outpatient reflex iron testing, that number increased to 42% between November 2022 and May 2023 (p < 0.001). In the six months prior to implementation, four iron deficient cardiac surgery patients received preoperative IV iron an average of one day prior to surgery. Between November 1, 2022 and May 29, 2023, fifteen patients received IV iron an average of 5.7 days prior to surgery. The patients who received IV iron had lower rates of blood transfusions than anemic patients who did not receive IV iron (53% vs. 65%) and fewer units of blood transfused per patient who received blood (3.1 vs. 5.7). Conclusions: Results from the first seven months of this project suggest that using a standardized testing methodology in the outpatient setting can increase the uptake of iron testing and thereby treatment of iron deficiency anemia in the preoperative setting. Patients who received IV iron had lower rates of blood transfusions and received fewer units of blood on average than anemic patients who did not receive IV iron. We next plan to implement an iron testing strategy in cardiac surgery inpatients to further improve rates of iron testing and iron infusions in this population. We have created an IRB-approved database to study more patient-centered outcomes such as acute kidney injury, stroke, length of stay, readmissions, and mortality to determine if we can detect a measurable impact from IV iron administration in our patient population.

Utilisation and impact of predict prostate on decision-making among clinicians and patients in a specialist tertiary referral centre: A retrospective cohort study.

Patients with intermediate-risk prostate cancer are faced with the decision of whether to undergo radical treatment. Decision-making aids, such as Predict Prostate, can empower both clinicians and patients to make treatment decisions with personalised information, but their impact on multi-disciplinary team (MDT) decision-making and uptake of radical treatment remains unknown. The objective of this study is to assess the utilisation and utility of Predict Prostate in informing treatment decisions for patients with intermediate-risk prostate cancer. A retrospective cohort study was conducted in Cambridge University Hospitals (CUH) of patients referred to the prostate cancer specialist multi-disciplinary team (pcSMDT) and robotic prostatectomy clinic (ROPD) between September 2019 and August 2021 for consideration of radical prostatectomy (RARP). Data on patient characteristics, use of PredictProstate and management decisions were collected from the Epic electronic medical record (EMR) of 839 patients, of whom 386 had intermediate-risk prostate cancer. The use of Predict Prostate at the pcSMDT increased in the second half of the study period (34.5% vs. 23.8%, p< 0.001). The use of Predict Prostate was associated with an increased likelihood of attending ROPD for men with CPG2 prostate cancer (OR =2.155, 95% CI =1.158-4.013, p= 0.015) but a reduced likelihood of proceeding with RARP for men with CPG2 (OR =0.397, 95% CI =0.209-0.753, p= 0.005) and CPG3 (OR =0.305, 95% CI =0.108-0.861, p= 0.025) prostate cancer. Our study showed that the use of Predict Prostate for patients with intermediate-risk prostate cancer is associated with increased attendance at specialist surgical clinic and a reduced chance of undergoing radical prostate surgery.

Hypertension and Related-Disorders in Hodgkin Lymphoma Patients Identified from Epic Cosmos System

Recent advancements in Hodgkin lymphoma (HL) treatment have significantly improved disease-free survival rates. However, survivors face a higher burden of long-term comorbidities and non-oncologic mortality compared to their peers. Studying survivorship has been challenging due to the time required for comorbidities to develop, patient loss to follow-up, variable disease-specific treatments, and variations across age groups of survivors. In this context, the Cosmos system offers a validated population-based informatics approach to establishing observational relationships between therapy and longitudinal non-oncologic outcomes, with the potential to enhance clinical care. Cosmos, a data science tool based on the Epic Electronic Medical Record (EMR) system, utilizes a HIPAA-defined limited centralized data set from various US health care systems. At the time of this submission, the data set encompasses 152,450,619 patients. A query population of 89,963 HL patients with more than one face-to-face encounter within any two-year period during the query interval was established. Validated associated ICD-10 diagnoses were assessed within the Cosmos system. The query revealed that HL patients had a median age of 56, with a male predominance (51.8%), and 35% were diagnosed between the ages of 15 and 39. Staging information was available for only 10% of patients. The most common comorbid diagnoses defined by ICD-10 were essential hypertension (45.4%), hyperlipidemia (36.1%), anemia (32.1%), GERD (32.1%), shortness of breath (31.4%), fatigue (30.1%), non-HL (30%), cough (26.3%), and anxiety (25.6%). Further assessment of hypertension and associated disorders was conducted by querying Epic grouper terms in comparison to the general Cosmos population. The HL population had a higher prevalence of hypertension (46.1% vs. 24.5%), chronic kidney disease (14.9% vs. 5%), hypertensive renal disease (10.1% vs. 3.1%), hyperlipidemia (44% vs. 21.1%), coronary artery disease (20.7% vs. 6.2%), ischemic or unspecified stroke (4.4% vs. 1.6%), and myocardial infarction (9.6% vs. 2.8%). Notably, death dates were documented for 12.5% of the HL population (compared to 3% in the general Cosmos population), but cause of death information was limited (0.028%). EMR informatics presents a powerful tool for rapidly generating real-time observational data, which can inform focused studies and interventions. Such data is crucial for understanding trends in treatment-related morbidity and mortality in diseases like HL, which can impact future health in survivorship. This study suggests that hypertension and related disorders may be more prevalent in the HL population compared to the general Cosmos population, warranting further directed study and validation in the future.

Post-hospitalization oncology workflow implementing LACE+ score to stratify and reduce readmissions at Lyndon B. Johnson safety-net hospital.

56 Background: Patients with cancer visit the emergency room (ER) and are hospitalized frequently. Contributing factors may include uncontrolled symptoms (cancer- or treatment-related), caregiver fatigue, concerns about the cancer, and difficulty accessing healthcare elsewhere. It is estimated that nearly 50% of ER and hospital visits by advanced cancer patients may be avoidable. This may represent unmet needs in oncology outpatient care and counseling. The LACE+ index is a validated clinical tool available within EPIC electronic medical record system to predict the risk of 30-day readmission. Here we used LACE+ score, common concerns and demographics observed among cancer patients readmitted to Lyndon B. Johnson Hospital (LBJ), a safety-net hospital in Texas, to determine potential contributors and implement interventions to reduce unplanned admissions. Methods: Retrospective data of ER visits and hospitalizations among cancer patients at LBJ were collected from 6/2022-12/2022. Data included comorbidities, cancer diagnosis and therapy, indication for visit, acuity on arrival, additional visits within 30 days, primary language, and LACE+ score. Descriptive statistics were used to guide intervention(s) to reduce hospital readmission. Specifically, these results led to the development of a triaging system based on LACE+ score to arrange timely post-hospital follow-up in the oncology clinic. Our findings also led to translation of AskMyNurse resources to Spanish. Results: Our group identified 61 oncology patients who had visited the ER or been hospitalized at LBJ from 6/2022-12/2022. From this cohort, 90% had been hospitalized or visited an ER within the past 30 days. LACE+ scores were consistently elevated within this group and visits were largely related to their cancer. Additionally, about 66% spoke primarily Spanish. Presently, oncology patients who are discharged from LBJ Hospital are having follow-up arranged in the clinic by means of risk stratification by their LACE+ score. Those with the highest score are seen the earliest after discharge. At this visit, in addition, AskMyNurse resources are now provided in Spanish. Collection of post-intervention data is ongoing to evaluate whether hospital readmission rates are effectively reduced. Conclusions: Cancer patients, especially those with language barriers and in the context of a safety-net hospital, are a particularly vulnerable group. The ability to triage and accurately identify patients at most risk of adverse post-hospitalization outcomes may help direct proper counseling, cancer treatment, and symptom management in the outpatient setting. Here our group proposes a feasible risk stratification tool using the LACE+ score on EPIC to allow for timely post-hospital follow-up and reduce 30-day hospital readmission.

Abstract PO-010: Operationalizing the health care system electronic medical record to create head and neck cancer research and screening databases

Abstract Introduction: A “living” prospective database for tracking patient outcomes and creating clinical trial screening populations would be useful for head and neck multidisciplinary teams and can be translated to innumerable populations of interest. The database should be rapidly accessible, economical, accurate, and transcend the typical 5-year length of grants. We hypothesized we could construct such a database and piloted the concept using patients within our head and neck cancer active surveillance population. This population consists of patients at high risk for the development of primary and secondary oral carcinoma over 20 years. A second goal was identifying subjects for oral leukoplakia studies and construction of genomic atlases. Methods: Through the University of Minnesota Clinical and Translational Sciences Institute (CTSI), we performed an IRB interrogation of our patient population in the EPIC electronic medical record (EMR) of 4,496 unique patients seen by the senior author and identified 1,375 unique deidentified patient records representing individuals with likely preneoplastic lesions. Our approach included 30 International Classification of Disease (ICD) 9 and 10 codes corresponding to 120 unique mucosal head and neck precancerous lesion descriptors. Information included typical demographic and risk data, laboratory, pathology, and possible staging data. All curated data were stored on CTSI servers with direct access to data analysis software. Results: The ICD 9 and 10 codes queried encompass 36 low risk, 16 moderate/low risk, 8 moderate/high risk, and 55 high risk lesion codes. 25/30 of the queried ICD 9 and 10 codes (&amp;gt;12,000 instances) were identified in the 4,496 patients queried, encompassing 1,375 unique patients, with most patients harboring multiple ICD codes. We identified 464 patients with diagnosed high risk lesions, 346 with moderate/high risk lesions, 692 with moderate/low risk lesions, and 728 with low-risk lesions. Several research functions in the EMR were identified to construct screening lists. From IRB approval to obtaining the data set from the CTSI, this process requires fewer than 24 hours of combined labor, minimal cost, and did not require manual chart abstraction. Conclusions: From our preliminary success in curating a dataset of patients diagnosed with high-risk oral lesions, we conclude that utilization of ICD 9 and 10 codes as inclusion criteria represents an efficient and simple way for busy practitioners to screen large amounts of clinical data for study populations of interest (&amp;gt;1 × 106 EMR). We will develop quality assurance and improvement measures to audit data accuracy. Further expansion of this work will apply similar algorithmic dataset curation to medical records acquired from clinicians beyond the current study population. Critically, this process could be used for a variety of conditions to develop comprehensive longitudinal databases to examine both retrospective and prospective outcomes, provided an ICD 9 or 10 code exists for the condition and coding is accurate and consistent. Citation Format: Lindsey Mortensen, Alexander J. Dwyer, Beverly R. Wuertz, Frank G. Ondrey. Operationalizing the health care system electronic medical record to create head and neck cancer research and screening databases [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Innovating through Basic, Clinical, and Translational Research; 2023 Jul 7-8; Montreal, QC, Canada. Philadelphia (PA): AACR; Clin Cancer Res 2023;29(18_Suppl):Abstract nr PO-010.

Evaluating the accuracy and efficacy of an electronic medical record alert to identify paediatric patients with low-risk febrile neutropenia

BackgroundPoint-of-care decision support, embedded into electronic medical record (EMR) workflows, has the potential to improve efficiency, reduce unwarranted variation and improve patient outcomes. A clinical-facing best practice advisory (BPA) in the Epic EMR system was developed to identify children admitted with low-risk febrile neutropenia (FN) who should be considered for treatment at home after a brief inpatient stay. We evaluated the accuracy and impact of this BPA and identify areas for improvement. MethodsThe low-risk FN BPA was co-designed with key-stakeholders and implemented after a one-month testing phase. Mixed methodology was used to collect and analyse data. The sensitivity and positive predictive value of the BPA was calculated using FN episodes captured in a prospectively collected database. Overall effectiveness was defined as the proportion of alerts resulting in completion of a FN risk assessment flowsheet. ResultsOver the 12-month period 176 FN episodes were admitted. Overall, the alert had poor sensitivity (58%) and positive predictive value (75%), failing to trigger in 62 (35%) episodes. In the episodes where the alert did trigger, the alert was frequently dismissed by clinicians (76%) and the overall effectiveness was extremely low (3%). Manual review of each FN episode without a BPA identified important design limitations and incorrect workflow assumptions. DiscussionGiven the poor sensitivity and limited impact on clinician behaviour the low-risk BPA, in its current form, has not been an effective intervention at this site. While work is ongoing to enhance the accuracy of the BPA, alternative EMR workflows are likely required to improve the clinical impact.

Descriptive and Concordance Data for Asynchronous Teledermatology Consultations for Dermatitis: A Retrospective Study.

Background: Implementation of teledermatology for assessing dermatitis patients provides comparable diagnostic and management outcomes to in-person visits, but studies on consumer to physician asynchronous teledermatology (eDerm) consults submitted by patients in large dermatitis cohorts are limited. The objective of this study was to retrospectively assess associations of eDerm consults with diagnostic accuracy, management, and follow-up in a large cohort of dermatitis patients. Methods: One thousand forty-five eDerm encounters between April 1, 2020, and October 29, 2021, recorded in the University of Pittsburgh Medical Center Health System Epic electronic medical record were reviewed. Descriptive statistics and concordance were analyzed using chi-square. Results: Asynchronous teledermatology modified/changed treatment in 97.6% of cases and had the same diagnosis between teledermatology and in-person follow-up in 78.3% of cases. Patients following up in the time line requested were more likely to follow-up in person (61.2% vs. 43.8%) than those who did not. Patients with intertriginous dermatitis (p = 0.003), preexisting conditions (p = 0.002), who required follow-ups (<0.0001), and moderate-high severity scores of 4-7 (p = 0.019) were more likely to follow up in the time line requested. Limitations: Lack of similar in-person visit data did not allow us to compare descriptive and concordance data between eDerm and clinic visits. Conclusions: eDerm offers a quick accessible solution to provide comparable dermatologic care for patients with dermatitis.

Increasing COVID-19 vaccine adherence within an immunocompromised patient population in a community practice.

e18714 Background: Patients receiving antineoplastic therapy are at increased risk of severe illness and death from COVID-19. Vaccination against COVID-19 is an effective strategy to prevent serious complications of the disease. Because immunocompromised patients may have a blunted immune response to COVID-19 vaccinations, the CDC recommends these patients receive an additional vaccine dose. CDC recommendations serve as a guideline for optimal care of hematology/oncology patients, and within which we demonstrate a quality improvement project to promote community education and assess vaccination rates. Methods: Through Epic electronic medical record (EMR) reporting, we identified 250 immunocompromised patients who had not completed their primary COVID-19 vaccination series or booster and initiated antineoplastic therapy between 12/1/2020- 12/1/2021 at a community-based oncology practice in Michigan. Patients were provided an electronic patient portal letter detailing vaccination recommendations, information on how to obtain vaccination, and a survey inquiring if patients were more likely to become vaccinated after the educational intervention. 204 patients received electronic letters and 46 patients (without portal access) were sent a letter via the US postal service. Three months post intervention, we evaluated for change in COVID vaccination status, hospitalization, death rates, and patient preferences regarding vaccination. Results: Three months post intervention, a total of 44 patients responded to the survey (39 electronically and 5 via mail). The overall improvement in vaccination rate was 10.4%. Using Fisher’s exact test, we found a statistically significant difference (p = 0.002) in vaccination rates between survey responders compared to non-responders. Vaccination rates increased by 25.0% in survey responders, compared to 7.3% in patients who did not respond. During the study period, 13 patients contracted COVID-19 (1/13 vaccinated), and one patient required hospitalization due to COVID-19 (unvaccinated). No deaths due to COVID-19 were reported. Patients’ most cited reasons for declining vaccination were concerns regarding vaccination safety and lack of understanding of the CDC recommendations. Conclusions: Our study highlights the EMR as an effective means to provide community education about COVID-19 vaccination. Limitations include delayed outreach to patients without electronic patient portal access or with infrequent patient portal use. Nonetheless, our quality study design serves as a model for other implementations of electronic community outreach in oncology patients. Future directions will assess long-term vaccination rates and outcomes in these immunocompromised patients.

Characterizing Functional Tics (P11-11.014)

<h3>Objective:</h3> To assess the characteristics of patients presenting with functional tics (FT) at two different pediatric neurology sites. A subaim was to assess for differences in presentations of FT between cisgender versus non-binary or transgender youth. <h3>Background:</h3> In the years between 2020 and 2022, coinciding with the COVID-19 pandemic, we have seen a large increase in the incidence of functional tics in adolescents (ages 12–18 years). Understanding how FT differs from tic disorders and whether FT presents differently among gender identity groups may help to better identify FT in individuals. <h3>Design/Methods:</h3> We conducted a systematic chart review at two different sites using the Epic Electronic Medical Record System of the Pediatric Neurology Departments at Strong Memorial Hospital in Rochester, NY (UR) and at Atrium Health Wake Forest Baptist in Winston-Salem, NC (WF). <h3>Results:</h3> There were 83 subjects, 37 of whom were patients at UR and 46 at WF. The average age of onset of FT was 13.6 years old with 5% male, 70% female, 12% transgender female-to-male, 13% nonbinary or gender fluid. At onset, 76% of patients had complex tics, 45% had abusive behavior, 73% had motor tics which localized below the neck, and 55% had contextual or specific triggers to tics. 37% endorsed exposure to tics by social media or peers. The two most common co-occurring conditions were anxiety (69%) and depression (51%). There was no significant difference in phenomenology of FT in cisgender versus non-binary or transgender youth. <h3>Conclusions:</h3> Functional tics were more common in adolescent females and were associated with more complex presentation at onset than tic disorders. There was no significant difference in age of onset, symptomatology, and treatment of FT in cisgender versus non-binary or transgender youth. <b>Disclosure:</b> Miss Nguyen has nothing to disclose. Mr. Wang has nothing to disclose. Dr. Vermilion has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Neurogene. The institution of Dr. Vermilion has received research support from Tourette Association of America, American Academy of Neurology and American Brain Foundation. Dr. Martindale has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Tourette Association of America. The institution of Dr. Martindale has received research support from Tourette Association of America.