Epic Electronic Medical Record Research Articles

Anticipatory Ear Pain Counseling at a 12-15 Month Preventive Care Visit for Low Income Children

Background: Determine the usefulness of ear pain anticipatory counseling for young children with public health plans to reduce visits for acute otitis media (AOM) and shift visits from urgent care/emergency department (UC/ED) settings to primary care clinic (PCC) settings. Methods: We documented the AOM visit distribution and incidence rates by setting according to race/ethnicity from the EPIC electronic medical record system for 12 months following the enrollment of eligible 12-15 month old children in a single blind randomized control trial of ear pain counseling. Results: Among the 310 children enrolled in the study, 30.6% of participants had at least 1 AOM visit and 4.5% had 3 or more AOM visits. The overall incidence was 490 AOM visit episodes per 1000 child years with rates of 232 in PCC and 226 in UC/ED settings. The difference in the proportion of Hispanic children with at least 1 AOM visit (33.5% 52/155) compared to Non-Hispanic children (24% 25/106) approached significance (p=0.08). The counseling intervention did not reduce the proportion of children with at least 1 AOM visit (counseling: 29.0%: 45/155; control: 32.3% 50/155 p=0.54); the proportion of children with 3 or more AOM visits (counseling: 5.8%: 9/155; control: 3.2% 5/155 p=0.41); or the AOM visit incidence rates (counseling: 471; control: 510) and did not shift AOM visits from the UC/ED to PCC setting. Conclusions: Anticipatory ear pain counseling in a hospital based PCC serving children enrolled in public plans does not reduce PCC or UC/ED AOM visit incidence rates.

739: Postpartum health service utilization by mothers of infants admitted to neonatal intensive care

Mothers of infants admitted to the neonatal intensive care unit (NICU) must recover from birth while attending to a critically ill infant. These mothers also have higher rates of chronic disease and perinatal complications than mothers of well babies (MWB). We sought to quantify postpartum health utilization by NICU mothers, compared with MWB. We conducted a retrospective cohort study of mothers delivering liveborn infants at North Carolina Women's Hospital between 7/1/2014 and 6/30/2016. MWB were defined as mothers of infants not admitted to the NICU. NICU mothers were defined as mothers with one or more infants admitted to the NICU. We further subtyped NICU mothers into two groups: Mothers of medically fragile infants (MMFI), defined as NICU length of stay ≥3 days, and mothers of transiently ill infants (MTII), defined as NICU stays <3 days. We ascertained postpartum health service utilization through encounter data recorded in the UNC Health System Epic Electronic Medical Record (EMR) between discharge from the birth hospitalization and 12 weeks postpartum. We used Poisson regression to compare encounter counts and by encounter type, adjusting for mode of delivery, race/ethnicity, payer status, and maternal age. When differences were found between NICU mothers and MWB, we further compared utilization for MMFI vs. MTII. During the study period, 6849 mothers met criteria for inclusion, of whom 5768 were MWB, 743 were MMFI, and 338 were MTII,. Of these 6849 women, 4349 had at least one encounter in the UNC system during the 12-week postpartum period, comprising 9540 encounters. In crude analyses, NICU mothers were more likely to experience each type of encounter, compared with MWB (Table). In adjusted analyses, utilization rates remained significantly higher for NICU mothers for all encounter types other than emergency room visits. Exclusion of women without any postpartum encounters in the UNC Health System did not materially change our results. When we compared MTII with MMFI, we found that MTII had higher rates of outpatient office visits (adj RR 1.29, 95% CI 1.07-1.55) and psychiatry visits (adj RR 1.63, 95% CI 1.13-2.35). Mothers of NICU infants utilize health care at a higher rate in the postpartum period, compared with MWB.

1945. Making the EMR Work for You: Modifications to Epic to Improve Management of Outpatient Parenteral Antibiotic Therapy (OPAT) Patients

BackgroundOur institution uses Epic as its electronic medical record (EMR), and managing the complex needs of OPAT patient’s has been challenging and also time-consuming with our EMR. It became imperative that the EMR be modified to capture all OPAT patients and manage them efficiently. We describe the development of EMR tools to facilitate OPAT management.MethodsThe infectious diseases (ID) physician and pharmacist identified multiple ways in which OPAT patient care could be improved by modifying the EMR. In 2016, a multidisciplinary team at URMC created software modifications in Epic to meet the needs of the OPAT program.ResultsA shared system list and communication tools used by ID physicians, nurses, and pharmacists were created. As soon as an inpatient is identified as an OPAT discharge, an OPAT “Plan of care” note is created by an ID fellow, note is sent to the OPAT team members (OPAT nurse, nurse practitioner, and ID pharmacist) and the patient is added to the shared list. An order set was built to facilitate accurate electronic prescribing of antimicrobials, supplies for home infusions, and pertinent laboratory tests. The order set sends an automatic message to OPAT team members, a back-up method for identifying OPAT patients. A comprehensive patient report, the “OPAT monitoring” view, was designed to facilitate patient care. The view displays OPAT relevant data from multiple sections of the patient chart onto one screen (ID notes, laboratory results, medications, appointments, free text box, etc.) without entering each patient’s chart. These EMR modifications significantly reduced the time needed for weekly case reviews and facilitates more efficient management of 90–100 patients weekly.ConclusionModifications made to the Epic EMR at our institution have improved patient safety and efficiency of the OPAT program. Fewer patients are missed, patient monitoring is enhanced, clinician time is saved, and ordering is more accurate. Physician satisfaction was improved by creating tools that were designed with workflow efficiency in mind. These modifications were independent of and predate the recommendations made in the Epic “OPAT setup and support guide,” and provide more enhancements for efficient patient management, and could easily be made by other Epic users.Disclosures All authors: No reported disclosures.

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS AND CLOSTRIDIUM DIFFICILE INFECTIONS AMONG PENICILLIN-ALLERGIC PATIENTS IN A UNIVERSITY HOSPITAL

Introduction Following penicillin skin testing and oral challenge, up to 90% of individuals reporting a PCN allergy are not found to be allergic. Patients with a PCN “allergy” are exposed to more and broader antibiotics, increasing their risk of developing antibiotic-associated and antibiotic-resistant infections. In this study, we compare the prevalence of Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile infections among patients with a reported PCN allergy to that of PCN non-allergic patients. Methods In this retrospective study, PCN-allergic and control cohorts were created using the EPIC electronic medical record (EMR) database to investigate patients admitted to a university hospital between 2014-2017. Discharge diagnoses were extracted by ICD-10 codes. The primary outcome included infections with C. difficile and MRSA. The secondary outcome was hospital length of stay (LOS). We compared the two groups controlling for differences through a set of confounders. Results The rate of MRSA infection was significantly increased among PCN-allergic patients compared to PCN non-allergic patients (0.69% vs 0.21%, pC. difficile infection was increased among PCN-allergic patients compared to controls, but only among males (14% vs 2%, p Conclusions A diagnosis of penicillin “allergy” increases one's likelihood of developing antibiotic-resistant infections. One limitation is that data extraction relies on diagnosis codes entered into the EMR, which is largely provider-dependent. This research suggests that verifying PCN allergy can improve antibiotic stewardship and patient outcomes.

Mobile device access to electronic patient portals in oncology: Potential implications for patient and practice experiences.

179 Background: Mobile devices provide individuals with rapid and frequent access to electronic patient portals. How patients use this growing and widespread technology to review test results and communicate with providers is not known. Methods: Retrospective study of patients enrolled in the MyChart electronic health portal associated with the EPIC electronic medical record in the Harold C. Simmons Comprehensive Cancer Center. We recorded type of portal access according to year and patient characteristics. Associations between patient characteristics and type of portal access were tested using Mann-Whitney test, Chi-square test, and linear Gaussian regression models. Results: Since the availability of mobile access in 2012, 2,524 patients accessed MyChart from a mobile device at least once, accounting for 291,526 mobile logins. The proportion of patients with mobile MyChart logins increased from 4% in 2012 to 13% in 2017 ( P= 0.004). Among these patients, the proportion of logins from mobile devices increased from 22% to 72% ( P&lt; 0.001). Mobile access occurred more frequently among younger ( P&lt; 0.001), black ( P= 0.002), and Hispanic ( P= 0.004) patients. In 2017, among patients who accessed MyChart from mobile devices at least once, those under age 40 years used the mobile application for over 90% of logins; those over age 60 years used the mobile application for 65% of logins. Black and Hispanic patients who used mobile MyChart access did so for approximately 80% of logins, compared to 70% of logins for non-Hispanic white patients. Before 2012, patients who went on to use mobile access averaged about five more logins per year than did mobile application never-users. While login frequency increased for both groups, the change was far greater for mobile application users. After 2012, total portal login frequency increased approximately 110% among patients who used mobile access, compared to 25% among non-users ( P&lt; 0.001). Conclusions: Mobile access to electronic health portals has increased patient portal use, particularly among traditionally underserved populations. How this widely and immediately available technology impacts patient and practice experiences warrants further study.

A SINGLE COMMUNITY CENTER UNBLINDED CROSS-SECTIONAL STUDY ON SPIROMETRY OR PULMONARY FUNCTION TEST UTILITY OF PATIENTS INCLUDED IN THE COPD REGISTRY AT TERTIARY CARE COMMUNITY HOSPITAL

SESSION TITLE: Obstructive Lung Diseases 1 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Spirometry or pulmonary function testing is required for the diagnosis of chronic obstructive pulmonary disease yet this practice is often not followed. An academic satellite tertiary care community hospital analyzed the effects of provider education on utilization of spirometry and deficiencies in the COPD registry. METHODS: An un-blinded cross sectional observational study quantified the summit educational intervention on provider practice while refining the COPD registry. By using filters and billing codes to clarify missing data, the EPIC electronic medical record applied data monitoring of compliance of formal COPD diagnoses with testing. RESULTS: In July 2017, the COPD registry at our hospital had 7,264 people involved. The number of pulmonary function tests were 1,795 before August 2017. In February 2018, there are 6858 people involved in the COPD registry and 1,932 have pulmonary function testing on file. The utilization of lung function testing has improved from 24% to 38% usage since the summit educational intervention. CONCLUSIONS: In conclusion, our hypothesis described that the pulmonary testing adherence percentage would increase after the educational summit meeting on lung function testing and COPD diagnosis while concurrently purifying the COPD registry. These results are possibly reflective of a typical community hospital practice. The accuracy of registry is important to report reliable mortality and readmissions data to Centers of Medicare & Medicaid Services. CLINICAL IMPLICATIONS: Chronic Obstructive Pulmonary Disease is pervasive in southwest Michigan. “Symptomatic COPD affects more than 5 percent of the adult population, is the fourth leading cause of death, and the twelfth leading cause of morbidity in the United States.” Patients are often added to the to the Chronic Obstructive Pulmonary Disease registry without formal diagnosis. Spirometry is required to make the diagnosis of COPD. The Global Initiative of Chronic Obstructive Lung Disease states FEV1/FVC ratio is necessary to describe the disease process. The spirometry measurements are the foundation for staging the disease according to GOLD criteria. Doctor Ferguson further proved trending the patients spirometry measurements was beneficial in reducing mortality. Interventions from primary care spirometry “Reduced the relative risk of exacerbations by 20 to 25 percent and the absolute risk by 5 to 6 percent.” In our community, spirometry is underutilized. Standard practice should be 100% compliance but as Dr. Bolton showed, spirometry usage is at 85.6% for COPD diagnosis and management. An area wide Summit educational seminar was held in July to address this utilization issue. This research is aimed to quantify the change made to the COPD registry including spirometry performed, patients remaining without spirometry, incorrect diagnosis and labeling and verification of registered members. DISCLOSURES: No relevant relationships by Brittany Haines, source=Web Response No relevant relationships by Furqan Shoaib Siddiqi, source=Web Response

Electronic medical record: data collection and reporting for spinal cord injury.

Presentation of implementation of International Spinal Cord Injury (SCI) Data Sets, International Standards for Neurological Classification of SCI (ISNCSCI), and other structured SCI tools in to the Electronic Medical Record (EMR) Epic. To describe the implementation of SCI tools in Epic at Rigshospitalet, University of Hospital, Capital Region of Denmark, and the ambitions for the future development of SCI related structured data and their reporting in the Epic EMR to be able to standardize data collection to facilitate research within institutions and collaboratively with other institutions locally and globally. Denmark and United States of America. The general content of the EMR Epic and the SCI-specific structured data implemented are described as well as the tools for reporting. The ISNCSCI is made available via access to http://isncscialgorithm.azurewebsites.net/. After filling in the test data on the website, one can save the completed form as an image within the patient's chart. The International SCI Core Data Set and 13 International SCI Basic Data Sets (Table 1) are nearly completely implemented in the Danish version of Epic as SmartForms. In addition, 14 functional measures, including the Spinal Cord Independence Measure III, are implemented as flowsheets (Table 2). The possibility of entering international recognized structured data into the EMR gives better possibility for data sharing across SCI centers worldwide. Gianna Maria Rodriguez, Stacey Cohen, and Fin Biering-Sørensen are users of Epic, but have no economic relationship with Epic. Kelly Tausk and Josh Martin are employees of Epic.

Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing

Reliance on prescription opioids for postprocedural analgesia has contributed to the opioid epidemic. With the implementation of electronic medical record (EMR) systems, there has been increasing use of computerized order entry systems for medication prescriptions, which is now more common than handwritten prescriptions. The EMR can autopopulate a default number of pills prescribed, and 1 potential method to alter prescriber behavior is to change the default number presented via the EMR system. To investigate the association of lowering the default number of pills presented when prescribing opioids in an EMR system with the amount of opioid prescribed after procedures. A prepost intervention study was conducted to compare postprocedural prescribing patterns during the 3 months before the default change (February 18 to May 17, 2017) with the 3 months after the default change (May 18 to August 18, 2017). The setting was a multihospital health care system that uses Epic EMR (Hyperspace 2015 IU2; Epic Systems Corporation). Participants were all patients in the study period undergoing 1 of the 10 most common operations and discharged by postoperative day 1. The default number of opioid pills autopopulated in the EMR when prescribing discharge analgesia was lowered from 30 to 12. Linear regression estimating the change in the median number of opioid pills and the total dose of opioid prescribed was performed. Opioid doses were converted into morphine milligram equivalents (MME) for comparison. The frequency of patients requiring analgesic prescription refills was also evaluated. There were 1447 procedures (mean [SD] age, 54.4 [17.3] years; 66.9% female) before the default change and 1463 procedures (mean [SD] age, 54.5 [16.4] years; 67.0% female) after the default change. After the default change, the median number of opioid pills prescribed decreased from 30 (interquartile range, 15-30) to 20 (interquartile range, 12-30) per prescription (P < .001). The percentage of prescriptions written for 30 pills decreased from 39.7% (554 of 1397) before the default change to 12.9% (183 of 1420) after the default change (P < .001), and the percentage of prescriptions written for 12 pills increased from 2.1% (29 of 1397) before the default change to 24.6% (349 of 1420) after the default change (P < .001). Regression analysis demonstrated a decrease of 5.22 (95% CI, -6.12 to -4.32) opioid pills per prescription after the default change, for a total decrease of 34.41 (95% CI, -41.36 to -27.47) MME per prescription. There was no statistical difference in opioid refill rates (3.0% [4 of 135] before the default change vs 1.5% [2 of 135] after the default change, P = .41). Lowering the default number of opioid pills prescribed in an EMR system is a simple, effective, cheap, and potentially scalable intervention to change prescriber behavior and decrease the amount of opioid medication prescribed after procedures.

Distress prevalence and associated risk factors within the urothelial cancer population.

526 Background: Prevalence of distress has been estimated as high as 40% in some cancer populations, but minimal literature exists regarding distress in bladder cancer patients. Distress has been linked with multiple negative clinical outcomes, with the Commission on Cancer now requiring standardized distress screening for cancer program accreditation. The purpose of this study is to identify prevalence of distress, associated clinical risk factors and psychosocial referral trends in the urothelial cancer population. Methods: This was a retrospective review of distress screening outcomes in bladder cancer patients seen in oncology outpatient clinic at an academic medical center between January 1, 2016-October 1, 2017. Established oncology patients are screened for distress every 30 days using the Patient Health Questionnaire-9 (PHQ-9) and/or the NCCN Distress Thermometer (DT). Questionnaires are completed on an electronic tablet at the time of check-in and linked to the Epic electronic medical record in real time. A data capture program was used to query screening outcomes and identify those who met the threshold scores (PHQ-9 &gt; 8, DT &gt; 4). Results: Of 153 patients with a primary diagnosis of bladder, 81 (53%) completed the PHQ-9 (n = 67) or NCCN distress thermometer (n = 16). The overall incidence of distress was 13.6% with an average score of 12.3 on PHQ-9 (n = 10) and 9 on DT (n = 1). Of the patients with elevated distress, there were 7 males and 4 females with an average age of 64 and 77, respectively. All were either married or widowed. Metastasis was documented in 45%. Five were on an antidepressant and only one had mood disorder previously documented in the history. Social work referral occurred for 73% of the patients. One patient had elevated distress in the 6 months subsequent to diagnosis. Of the seven now deceased patients, all had elevated distress within 6 months of death. Conclusions: At 13.6%, the prevalence of distress in urothelial cancer patients was less than that in general oncology. Metastatic disease and female gender were risk factors while documentation of a psychiatric condition was not. One unexpected finding was that all now deceased patients had endorsed elevated distress within 6 months of death.

Implementation of a virtual vascular clinic with point-of-care ultrasound in an integrated health care system

ObjectiveUsing secured videoconferencing technologies, telemedicine may replace traditional clinic visits, save patients' time and travel, and improve use of limited surgeon and facility resources. We report our initial experience of the remote clinical encounter (RCE) by evaluating vascular surgery patients. MethodsIn this proof-of-concept pilot study, we conducted telemedicine evaluations of vascular patients at a tertiary care institution from October 2015 to August 2016. Patients were offered synchronous virtual visits from a surgical provider in lieu of an in-person visit. We used Skype for Business (Microsoft, Redmond, Wash) over secured networks for patient-provider interaction, clinical data entry in the Epic electronic medical record (Epic Systems Corporation, Verona, Wisc) for documentation, and established satellite facilities with existing vascular laboratories for imaging and laboratory testing. We evaluated feasibility, demographics, encounter type, and satisfaction of the patient through web-based questionnaires. ResultsDuring a 10-month period, 41 women and 14 men with an average age of 57 years (range, 29-79 years) underwent 82 RCEs. There were 43 white (78.1%), 9 black (16.3%), 1 Asian (1.8%), and 2 Middle Eastern (3.6%) patients. Diagnoses included both arterial (aneurysm, carotid, and occlusive disease) and venous (deep venous thrombosis and varicose vein) disease. Among the 82 RCEs, visit types included 15 new patients, 30 postoperative visits, and 37 follow-up visits. Ultrasound imaging was performed in conjunction with the RCE in 74 patients (90.2%). Most patients (57%) had multiple RCEs during the study period. All 55 patients responded to the satisfaction questionnaire; 91% stated that they would highly recommend a virtual physician encounter to a friend or colleague, and all of the respondents found their encounter more convenient than having a traditional office visit. All patients thought that they were able to communicate clearly with the provider, and overall quality responses were overwhelmingly positive. ConclusionsSecured virtual visits can be conducted using commercially available hardware and software solutions. Synchronous telemedicine with point-of-care ultrasound is effective in evaluating common vascular conditions. Virtual care may be used for management of patients with chronic vascular disease.

947: Using electronic medical record data to quantify racial and ethnic differences in pain management following cesarean birth

Racial disparities in pain management have been documented in health care settings. We sought to evaluate associations between patient race and ethnicity and pain management following cesarean birth. We conducted a retrospective cohort study of mothers following cesarean birth at North Carolina Women's Hospital between 7/1/2014 and 6/30/2016. Maternal pain scores (0-10) and medication administration were documented in Epic Electronic Medical Record (EMR) as part of routine clinical care. We used these data to determine frequency of pain assessment, pain scores, and administration of opiate analgesia from 0 to 48 hours postpartum (PP). Opiates administered were converted to 5 mg oxycodone tablet equivalents (OTE). We excluded from our sample women who received general anesthesia, were in the intensive care unit after delivery, were currently treated with methadone or buprenorphine, or received ≥2 opiate prescriptions during antenatal care. We used chi square tests to compare prevalence of severe pain, indexed by pain scores > 7, and linear regression models to compare OTE administered by maternal race/ethnicity, adjusting for insurance status, primary language, age, and primiparity. P values <0.05 were considered statistically significant. 1,970 women underwent cesarean section during the study period, of whom 1,776 met inclusion criteria. EMR records included 32,361 pain assessments and 13,989 opiate doses administered from 0-48 hours after c-section. The number of pain assessments differed by race-ethnicity, with the highest number of assessments for non-Hispanic white women (Table, p<.001). Mean pain scores were highest for non-Hispanic black women (Figure), and these women were most likely to have at least one pain assessment >7/10, whereas Asian women were the least likely (chi square p < .001). Although non-Hispanic black women reported higher pain scores, they received less opiate analgesia than non-Hispanic white women (OTE mean, [se] 0-24h PP: 7.0 [0.3] vs. 8.1 [0.3]; 24-48h PP: 7.8 [0.5] vs 8.7 [0.5], p<.001), as did Asian, Hispanic and other women, adjusting for insurance, language, age, and primiparity. We found racial differences in pain scores and administration of opiates. EMR data can be leveraged to identify differences in care delivery that may contribute to health disparities.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Trends in pediatric urologic consultations in a tertiary care hospital setting

There is growing interest in the general activities of a pediatric urologist, whose specialty remains young in the spectrum of modern, organized medicine. Unplanned activities, which are more commonly referred to as consultations, can represent significant additional workload for the urologist seeing scheduled clinic patients or completing elective operative cases. This study sought to better understand the practice patterns surrounding inpatient consultations of pediatric urology, and to describe patterns in reasons, timing, patient and service factors that may lead to patient intervention. Consultations at a tertiary care center were prospectively tracked using a consult note template with embedded data collection fields directly within the Epic electronic medical record. Bivariate and multivariate logistic regression were used to predict need for intervention. A total of 351 eligible consultations were completed during the 15-month study period. A total of 174 (50%) consultations originated from the emergency department, with 26% of those having been transferred from another institution (Figure). Consults occurred more frequently at the beginning of the week than at the end of the week (R2=0.7545) and at the end of the day rather than the beginning (R2=0.2504). Of these consults, 36% required an intervention, defined as bedside procedure, operative procedure or study in interventional radiology. Factors associated with intervention on multivariate analysis included consultation from the emergency department, pertinent radiologic or laboratory findings, and consultation after hours. With the introduction of subspecialty certification in pediatric urology there has been growing concern about a shift in the number and type of consultations seen by pediatric urology. Unlike prior examinations of pediatric urology consultation, the present study recorded diagnoses that appeared to more commonly result in urology consultation than in the past, such as testicular torsion. It highlighted a small subset of children with medical complexity and who were frequently admitted to the hospital, and accounted for nearly one fifth of all consultations. Repeat consultations underscored a need for ongoing education of the family, primary care and emergency department providers, and other services who interface with complex patients with ongoing healthcare needs. The pediatric urology service averaged about one formal consultation per day, with the most common diagnoses being hydronephrosis, urinary tract infection, urolithiasis, testicular torsion, and retention. One third of consults required intervention. Improved understanding of pediatric urology consultation would be helpful to facilitate physician education and improve service efficiency in the hospital setting.

Creation and Validation of an Automated Algorithm to Determine Postoperative Ventilator Requirements After Cardiac Surgery

In medical practice today, clinical data registries have become a powerful tool for measuring and driving quality improvement, especially among multicenter projects. Registries face the known problem of trying to create dependable and clear metrics from electronic medical records data, which are typically scattered and often based on unreliable data sources. The Society for Thoracic Surgery (STS) is one such example, and it supports manually collected data by trained clinical staff in an effort to obtain the highest-fidelity data possible. As a possible alternative, our team designed an algorithm to test the feasibility of producing computer-derived data for the case of postoperative mechanical ventilation hours. In this article, we study and compare the accuracy of algorithm-derived mechanical ventilation data with manual data extraction. We created a novel algorithm that is able to calculate mechanical ventilation duration for any postoperative patient using raw data from our EPIC electronic medical record. Utilizing nursing documentation of airway devices, documentation of lines, drains, and airways, and respiratory therapist ventilator settings, the algorithm produced results that were then validated against the STS registry. This enabled us to compare our algorithm results with data collected by human chart review. Any discrepancies were then resolved with manual calculation by a research team member. The STS registry contained a total of 439 University of California Los Angeles cardiac cases from April 1, 2013, to March 31, 2014. After excluding 201 patients for not remaining intubated, tracheostomy use, or for having 2 surgeries on the same day, 238 cases met inclusion criteria. Comparing the postoperative ventilation durations between the 2 data sources resulted in 158 (66%) ventilation durations agreeing within 1 hour, indicating a probable correct value for both sources. Among the discrepant cases, the algorithm yielded results that were exclusively correct in 75 (93.8%) cases, whereas the STS results were exclusively correct once (1.3%). The remaining 4 cases had inconclusive results after manual review because of a prolonged documentation gap between mechanical and spontaneous ventilation. In these cases, STS and algorithm results were different from one another but were both within the transition timespan. This yields an overall accuracy of 99.6% (95% confidence interval, 98.7%-100%) for the algorithm when compared with 68.5% (95% confidence interval, 62.6%-74.4%) for the STS data (P < .001). There is a significant appeal to having a computer algorithm capable of calculating metrics such as total ventilator times, especially because it is labor intensive and prone to human error. By incorporating 3 different sources into our algorithm and by using preprogrammed clinical judgment to overcome common errors with data entry, our results proved to be more comprehensive and more accurate, and they required a fraction of the computation time compared with manual review.

An EPIC Hierarchical Data Collection Schema to Assess Contraceptive Counseling in Primary Care [24A

INTRODUCTION: In 2011 the Institute of Medicine designated contraceptive counseling and provision an essential service. Electronic medical record (EMR) systems provide large volumes of clinical data but the quality of this data varies, especially when no billing, lab or prescription is given. As part of a quality improvement initiative, we sought to develop a reliable algorithm using EPIC EMR to measure rates of contraception counseling at outpatient primary care sites. METHODS: We constructed an initial hierarchical data collection schema using prescription data, ICD and CPT codes, and text searching, in this order. We refined the schema through an iterative validation process including three cycles of manual chart review. We applied the schema to eight outpatient urban family medicine, general obstetrics and gynecology, and family planning sites affiliated with one academic medical center. RESULTS: From August 2015 to May 2016, the eight sites averaged 2500 unique monthly visits by women aged 14-45. Among visits where contraception counseling and/or provision was documented, 18.6% were captured by prescriptions, 8.9% by ICD and CPT codes, and 69.7% by text search. Among visits where contraceptive counseling was documented but no method was provided, 15.7% were captured by diagnosis codes and 84.3% by text search. CONCLUSION: This hierarchical data collection schema allowed us to obtain robust measures of contraception counseling and provision in primary care practices. Inclusion of text search in addition to prescription and ICD/CPT coding is crucial for data accuracy and comprehensiveness. This schema could be adapted by other EPIC EMR users interested in real-time quality assessment.

Treatment of locally advanced parotid malignancies with parotidectomy and temporal bone resection

PurposeIn this study we review our institution's experience and outcomes with temporal bone resection and parotidectomy in the treatment of advanced parotid malignancies. MethodsPatients undergoing lateral temporal bone resection and parotidectomy from 2007–2013 were identified in the EPIC electronic medical record. Primary tumor location, staging, surgical procedure, and patient demographic and outcome data were collected retrospectively. ResultsFifteen patients underwent combined temporal bone resection and parotidectomy for parotid malignancy. Carcinoma ex-pleomorphic and squamous cell carcinoma were the most common pathologies. Two year disease free survival was 40%. Distant metastases were the most common site of disease recurrence. Only nodal disease was predictive of reduced disease free survival, though pre-operative facial paralysis showed a trend towards significance. Margin status and operating for recurrent tumor did not influence outcome in our series. ConclusionLocal and regional tumor controls are attainable with combined skull base approaches to advanced parotid malignancies. Unfortunately these cases have a high rate of distant recurrence despite negative margins and local control.

Implementation of Epic Beaker Clinical Pathology at Stanford University Medical Center.

To provide an account of implementation of the Epic Beaker 2014 clinical pathology module at Stanford University Medical Center and highlight strengths and weaknesses of the system. Based on a formal selection process, Stanford selected Epic Beaker to replace Sunquest as the clinical laboratory information system (LIS). The rationale included integration between the LIS and already installed Epic electronic medical record (EMR), reduction in the number of systems and interfaces, and positive patient identification (PPID). The build was significantly customized and included a first of its kind Epic-to-Epic interface. This was due to the clinical laboratory serving two hospitals (pediatric and adult) with independent instances of Epic. Test turnaround times showed improvement from historical baselines, mostly because of the implementation of PPID. PPID also resulted in significant reduction in mislabeled specimens. Epic 2014 Beaker clinical pathology is a viable LIS with adequate functionality for a large academic center. Strengths include PPID and integration with the EMR. Integration provides laboratory users with ready access to the patient's relevant clinical history to assist releasing of results and gives physician and nurse providers sophisticated add-on ordering and specimen collection workflows. Areas that could use further development include specimen aliquoting, quality control reporting, and maintenance tools.

A Novel Electronic Medical Record-Based Workflow to Measure and Report Colonoscopy Quality Measures.

When I was in private practice, pulling adenoma detection rates (ADRs) by physician was easy. In 2007, we developed a method to calculate ADRs, which was a bit cumbersome but effective, and we began tracking them by physician. We provided every partner with his or her ADR as part of a package of quarterly performance metrics. By 2009, we had incorporated endoscopy and pathology into our electronic medical record (EMR) so ADR analysis became automatic. This allowed us to begin publishing our results on our website and ultimately in peer-reviewed journals (Clin Gastroenterol Hepatol 2009;7:1335–1340 and Gastroenterology 2015;149:952–957). I then moved to an academic medical center where the enterprise-wide EMR (Epic) did not interface with either our endoscopy reporting software or pathology results, and all hope of routine ADR measurement vanished. Everyone working in similar situations can relate to my frustration. In this month’s Road Ahead column, Leiman and colleagues provide a straightforward method to extract ADRs from an Epic EMR. While this still requires physician input, it helps those of us in large health systems measure what is important in our ongoing efforts to reduce the incidence of colon cancer.

An Educational Campaign Combined with an Electronic Alert Improved Sepsis Process Measures

Electronic alerts from electronic medical records systems have obvious promise but can be a hassle (NEJM JW Emerg Med Dec 2015 and Ann Emerg Med 2015; [e-pub]). Investigators compared sepsis process and outcome measures before (111 patients) and after (103 patients) an emergency department intervention that involved an educational campaign and a new pop-up alert in the hospital's Epic electronic medical record system. An alert …

Evaluating the epic electronic medical record system: A dichotomy in perspectives and solution recommendations

ObjectivesElectronic Medical Record (EMR) systems have become an integral part of patient care, in both inpatient and outpatient settings. The objective of this paper is to propose a set of recommendations on how the Epic EMR system can be used to improve patient care. To this end, we present findings on the use of the Epic EMR system in the University of Virginia (UVa)׳s Health System. Target audienceHealthcare organizations implementing electronic medical record systems and health technology managers. MethodsFace-to-face interviews with 30 of UVa׳s hospital personnel and others in the Epic department at UVa. Results and conclusionsThree key areas are discussed to determine the feasibility of improvement including a decrease in medical errors and the resulting parallel improvement in patient safety, inter-disciplinary collaboration, and a decrease in the overall cost of healthcare. We identified many discrepancies between the Epic EMR system’s intended use, and the workaround system that clinicians have used to document patient care. In addition, we discuss a dichotomy in perspectives amongst the Health System and Technology Services department at UVa, and healthcare staff end users, with regard to the intended functionality and the usability of the Epic EMR system. In light of our findings, we provide a set of recommendations on how to decrease the gap between the intended and actual use of EMR systems, in general

Emergency department (ED) utilization and hospital admission rates among oncology patients at a large academic center and the need for improved urgent care access.

19 Background: In the US, 30% of the total cancer expenditure is spent in the last year of life and 55% of this is spent on inpatient care. For patients with advanced cancer, most hospitalizations arise from expected disease progression. With the ultimate goal reducing hospital admissions at the Smilow Cancer Hospital at Yale New Haven, we sought to understand our patterns of ED referral, hospital admission, and length-of-stay. Methods: An analysis of all oncology patients coming to the Yale New Haven Hospital (YNHH) ED was performed by executing reports through our EPIC electronic medical record. We looked at a 5-month time frame from January 1, 2014, through May 31, 2014. Results: A total of 391 oncology patients from each of our disease groups presented to the ED and 90% were admitted. Mean length of stay (LOS) was 6.74 days. 62% of patients arrived during the hours of 9:00AM-5:00PM. The average daily cost per admission was $1886 per day/ $12,711.64 for the mean hospitalization (largely spent on nursing, pharmacy, and laboratory). At least 50% of these presentations could have been addressed in the ambulatory setting including but not limited to dehydration, abdominal pain and failure-to-thrive. Conclusions: Despite a 6-day/wk ambulatory oncology practice, our patients are presenting to the ED during standard daytime hours resulting in admission and prolonged length-of-stay. We will launch a same-day visit program with access to urgent palliative care consultation, pharmacy and infusion chairs. We will treat dehydration, nausea, vomiting, pain, DVT, and other urgent presentations. This cultural change will require education of physicians, nurses, staff, patients and caregivers. We estimate that a 50% reduction in admissions would yield a cost savings of approximately $6 million annually. [Table: see text]