Epic Systems Research Articles

Understanding the perceived role of electronic health records and workflow fragmentation on clinician documentation burden in emergency departments.

Understand the perceived role of electronic health records (EHR) and workflow fragmentation on clinician documentation burden in the emergency department (ED). From February to June 2022, we conducted semistructured interviews among a national sample of US prescribing providers and registered nurses who actively practice in the adult ED setting and use Epic Systems' EHR. We recruited participants through professional listservs, social media, and email invitations sent to healthcare professionals. We analyzed interview transcripts using inductive thematic analysis and interviewed participants until we achieved thematic saturation. We finalized themes through a consensus-building process. We conducted interviews with 12 prescribing providers and 12 registered nurses. Six themes were identified related to EHR factors perceived to contribute to documentation burden including lack of advanced EHR capabilities, absence of EHR optimization for clinicians, poor user interface design, hindered communication, increased manual work, and added workflow blockages, and five themes associated with cognitive load. Two themes emerged in the relationship between workflow fragmentation and EHR documentation burden: underlying sources and adverse consequences. Obtaining further stakeholder input and consensus is essential to determine whether these perceived burdensome EHR factors could be extended to broader contexts and addressed through optimizing existing EHR systems alone or through a broad overhaul of the EHR's architecture and primary purpose. While most clinicians perceived that the EHR added value to patient care and care quality, our findings underscore the importance of designing EHRs that are in harmony with ED clinical workflows to alleviate the clinician documentation burden.

Successful Implementation of Workflow-Embedded Clinical Pathways During the COVID 19 Pandemic.

Clinical pathways have been found effective for improving adherence to evidence-based guidelines, thus providing better patient outcomes. As coronavirus disease-2019 (COVID-19) clinical guidance changed rapidly and evolved, a large hospital system in Colorado established clinical pathways within the electronic health record to guide clinical practice and provide the most up-to-date information to frontline providers. On March 12, 2020, a system-wide multidisciplinary committee of specialists in emergency medicine, hospital medicine, surgery, intensive care, infectious disease, pharmacy, care management, virtual health, informatics, and primary care was recruited to develop clinical guidelines for COVID-19 patient care based on the limited available evidence and consensus. These guidelines were organized into novel noninterruptive digitally embedded pathways in the electronic health record (Epic Systems, Verona, Wisconsin) and made available to nurses and providers at all sites of care. Pathway utilization data were analyzed from March 14 to December 31, 2020. Retrospective pathway utilization was stratified by each care setting and compared with Colorado hospitalization rates. This project was designated as a quality improvement initiative. Nine unique pathways were developed, including emergency medicine, ambulatory, inpatient, and surgical care guidelines. Pathway data were analyzed from March 14 to December 31, 2020, and showed that COVID-19 clinical pathways were used 21 099 times. Eighty-one percent of pathway utilization occurred in the emergency department setting, and 92.4% applied embedded testing recommendations. A total of 3474 distinct providers employed these pathways for patient care. Noninterruptive digitally embedded clinical care pathways were broadly utilized during the early part of the COVID-19 pandemic in Colorado and influenced care across many care settings. This clinical guidance was most highly utilized in the emergency department setting. This shows an opportunity to leverage noninterruptive technology at the point of care to guide clinical decision-making and practice.

A Comparison of Intubation and Airway Complications Between COVID-19 and Non-COVID-19 Critically Ill Subjects.

Introduction The number of subjects infected with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) throughout the western hemisphere increased exponentially in the later months of 2020.With this increase in infection, the number of subjects requiring advanced ventilatory support increased concomitantly.We decided to compare the survival rates between coronavirus disease 2019 (COVID-19) subjects versus non-COVID-19 subjects undergoing intubation in the intensive care unit (ICU).We hypothesized that COVID-19 subjects would have lower rates of survival post-intubation. Methods We screened all subjects admitted to the adult critical care unit between January 2020and June 2020 to determine if they met the inclusion criteria.These subjects were required to be spontaneously ventilating upon admission and eventually required intubation.Subjects were selected from our electronic health record (EHR) system EPIC© (Epic Systems, Verona, WI) through a retrospectiveICU admission analysis.We identified and included 267 non-COVID-19 subjects and 56 COVID-19 subjects.Our primary outcome of interest was intubation-related mortality.We defined intubation mortality as unexpected death (within 48 hours of intubation).Our secondary outcomes were the length of stay in the ICU, length of time requiring ventilator support, and proportion of subjects requiring tracheostomy placement. Results Compared to non-coronavirus disease (COVID) subjects, COVID subjects were more likely to be intubated for acute respiratory distress.COVID subjects had longer stays in the ICU and longer ventilator duration than non-COVID subjects.COVID-positive subjects had a decreased hazard ratio for mortality (HR = 0.42, 95% CI: 0.20-0.87, P < 0.05) and increased chances of survival compared to non-COVID subjects. Conclusions We showed therates of intubation survival were no different between the COVID and non-COVID groups.We attribute this finding to intubation preparation, a multidisciplinary team approach, and having the most experienced provider lead the intubation process.

A Therapeutic Approach to Primary Hyperparathyroidism: A Collaborative Evaluation Between Endocrinology and Surgery.

Introduction Primary hyperparathyroidism (PHPT) is a disorder in which one or more parathyroid glands overproduce parathyroid hormone, leading to hypercalcemia. It may present with symptoms likeconstipation, abdominal pain, psychiatric complaints as well as signs of nephrolithiasis, and osteoporosis that may need surgical treatment. PHPT is often underdiagnosed and undertreated. Our study aimed to review hypercalcemia in a single center to evaluate forundiagnosed PHPT. Methods A group of 546 patients from Southwest Virginia was selected using the EMR Epic (Epic Systems, Verona, USA)who had adiagnosis of hypercalcemia in the previous six months.Charts were manually reviewed, and patients were excluded based on the lack of hypercalcemia as well as previous testing of parathyroid hormone (PTH) levels. One hundred and fifty patients were excluded because of a lack of documented hypercalcemia. Letters were sent to the patients advising the patients to discuss whether a PTH would be indicated with their primary care provider (PCP). These patients' charts were re-examined six months later and a determination of whether a PTH level was performed as well as any referrals explicitly for hypercalcemia or PHPT was done. Results A total of 20 (5.1%) patients had a new PTH test during the time assessed. Of these patients, five received referrals to surgical treatment and six received referrals to endocrinology for treatment (no patients received referrals to both). Of those who obtained a PTH level, 50% of them had significantly elevated PTH levels consistent with the diagnosis of primary hyperparathyroidism. An additional 45% had levels of parathyroid hormone that were in the normal range but or most likely inappropriately normal for the concurrent level of calcium. Only one patient (5%) had a suppressed PTH level. Conclusion The impact of an intervention on clinician evaluation and treatment of patients with hypercalcemia has been previously tested and shown to be beneficial. In this study, the method of directly sending a letter to patients yielded clinically significant results, with 20 patients out of 396 (5.1%) having a PTH level tested. A majority had an overt or suspected parathyroid disease, and out of them, 11 underwent referral for treatment.

Automated electronic health registry-based hepatitis Bscreening.

Electronic population health tools may offer novel ways to screen for chronic hepatitis B (CHB), but efficacy of these approaches is currently unknown. We utilized an electronic population health module within Epic Systems to create registries of patients who were at risk for CHB, but never completed a hepatitis B surface antigen (HBsAg) test. For the pilot, hepatitis B testing was bulk ordered to compare an intervention and control clinic prior to dissemination of CHB screening throughout our health system. The intervention clinic increased screening by 556% (95% CI 363%-851%) versus an increase of 190% (95% CI 146%-248%) in the control clinic (p<.0001) after 1 year. Health system-wide, we expanded the screening program to 11 Northern California clinics across 3 counties, involving 4,545 at-risk patients and increased HBsAg completion by 824% (95% CI 724%-939%) compared to baseline. Automated, registry-based methods significantly increased completion of CHB screening.

Physician Note Composition Patterns and Time on the EHR Across Specialty Types: a National, Cross-sectional Study.

The burden of clinical documentation in electronic health records (EHRs) has been associated with physician burnout. Numerous tools (e.g., note templates and dictation services) exist to ease documentation burden, but little evidence exists regarding how physicians use these tools in combination and the degree to which these strategies correlate with reduced time spent on documentation. To characterize EHR note composition strategies, how these strategies differ in time spent on notes and the EHR, and their distribution across specialty types. Secondary analysis of physician-level measures of note composition and EHR use derived from Epic Systems' Signal data warehouse. We used k-means clustering to identify documentation strategies, and ordinary least squares regression to analyze the relationship between documentation strategies and physician time spent in the EHR, on notes, and outside scheduled hours. A total of 215,207 US-based ambulatory physicians using the Epic EHR between September 2020 and May 2021. Percent of note text derived from each of five documentation tools: SmartTools, copy/paste, manual text, NoteWriter, and voice recognition and transcription; average total and after-hours EHR time per visit; average time on notes per visit. Six distinct note composition strategies emerged in cluster analyses. The most common strategy was predominant SmartTools use (n=89,718). In adjusted analyses, physicians using primarily transcription and dictation (n=15,928) spent less time on notes than physicians with predominant Smart Tool use. (b=-1.30, 95% CI=-1.62, -0.99, p<0.001; average 4.8 min per visit), while those using mostly copy/paste (n=23,426) spent more time on notes (b=2.38, 95% CI=1.92, 2.84, p<0.001; average 13.1 min per visit). Physicians' note composition strategies have implications for both time in notes and after-hours EHR use, suggesting that how physicians use EHR-based documentation tools can be a key lever for institutions investing in EHR tools and training to reduce documentation time and alleviate EHR-associated burden.

Documentation dynamics: Note composition, burden, and physician efficiency.

To analyze how physician clinical note length and composition relate to electronic health record (EHR)-based measures of burden and efficiency that have been tied to burnout. Secondary EHR use metadata capturing physician-level measures from 203,728 US-based ambulatory physicians using the Epic Systems EHR between September 2020 and May 2021. In this cross-sectional study, we analyzed physician clinical note length and note composition (e.g., content from manual or templated text). Our primary outcomes were three time-based measures of EHR burden (time writing EHR notes, time in the EHR after-hours, and EHR time on unscheduled days), and one measure of efficiency (percent of visits closed in the same day). We used multivariate regression to estimate the relationship between our outcomes and note length and composition. Physician-week measures of EHR usage were extracted from Epic's Signal platform used for measuring provider EHR efficiency. We calculated physician-level averages for our measures of interest and assigned physicians to overall note length deciles and note composition deciles from six sources, including templated text, manual text, and copy/paste text. Physicians in the top decile of note length demonstrated greater burden and lower efficiency than the median physician, spending 39% more time in the EHR after hours (p< 0.001) and closing 5.6 percentage points fewer visits on the same day (p< 0.001). Copy/paste demonstrated a similar dose/response relationship, with top-decile copy/paste users closing 6.8 percentage points fewer visits on the same day (p< 0.001) and spending more time in the EHR after hours and on days off (both p< 0.001). Templated text (e.g., Epic's SmartTools) demonstrated a non-linear relationship with burden and efficiency, with very low and very high levels of use associated with increased EHR burden and decreased efficiency. "Efficiency tools" like copy/paste and templated text meant to reduce documentation burden and increase provider efficiency may have limited efficacy.

Abstract 13575: Utilizing Electronic Health Record Alerts to Increase Prescription of Lipid Lowering Therapies in Patients Admitted With Acute Coronary Syndromes

Introduction:Patients who present to the hospital with acute coronary syndromes (ACS) often have poor control of cardiac risk factors. Multiple studies have demonstrated that lipid lowering therapy is not appropriately initiated or intensified in these patients.Hypothesis:We hypothesized that an interruptive alert delivered via the electronic medical record would increase the initiation and intensification of lipid lowering therapies.MethodsUsing Epic EHR (Epic Systems, Verona, WI), an interruptive alert was designed to trigger upon opening the patient’s chart when the patients were admitted with an ICD code that indicated an ACS (i.e., STEMI, NSTEMI, or Unstable Angina). The alert included an order set to obtain a cholesterol panel or if a cholesterol panel had already been collected it would be displayed and suggest modifications to the patient’s current medication regimen. These alterations included statin intensification or the addition of ezetimibe.ResultsBetween September 1, 2021 and May 30, 2022 172 unique patients were identified. The mean age was 64.8 ±13.8 years, 64.5% were male, 74% were white, and 12% were black. The identified patients had multiple comorbidities including cerebrovascular disease (23%), heart failure (47%), peripheral vascular disease (30%), and being a current or former smoker (53%). The triggered order set had a direct effect on 42 (24%) patients, with 10 initiating ezetimibe and 32 having their statins intensified. The most common indicated reason for overriding the alert (n=99) was not meeting criteria. Of these 99 patients, 4 were ultimately started on ezetimibe, 57 had their statin intensified, and 23 were appropriately excluded (including patients with type II myocardial infarctions who were not the target of this intervention). Of note, 15 patients should have received intensified therapy but had their alert over ridden.ConclusionsThis targeted alert led to direct intensification of lipid lowering therapy in 24% of ACS patients with an additional 35% of patients identified by the alert also having therapeutic intensification. This alert will remain in place to allow for further assessment of its effects and can be easily translated to other clinical systems.

Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events.

The purpose of this study was to evaluate perioperative medication-related incidents (medication errors (MEs) and/or adverse medication events (AMEs)) identified by 2 different reporting methods (self-report and direct observation), and to compare the types and severity of incidents identified by each method. We compared perioperative medication-related incidents identified by direct observation in Nanji et al's 2016 study[1] to those identified by self-report via a facilitated incident reporting system at the same 1046-bed tertiary care academic medical center during the same 8-month period. Incidents, including MEs and AMEs were classified by type and severity. In 277 operations involving 3671 medication administrations, 193 MEs and/or AMEs were observed (5.3% incident rate). While none of the observed incidents were self-reported, 10 separate medication-related incidents were self-reported from different (unobserved) operations that occurred during the same time period, which involved a total of 21,576 operations and approximately 280,488 medication administrations (0.004% self-reported incident rate). The distribution of incidents (ME, AME, or both) did not differ by direct observation versus self-report methodology. The types of MEs identified by direct observation differed from those identified by self-report (P = .005). Specifically, the most frequent types of MEs identified by direct observation were labeling errors (N = 37; 24.2%), wrong dose errors (N = 35; 22.9%) and errors of omission (N = 27; 17.6%). The most frequent types of MEs identified by self-report were wrong dose (N = 5; 50%) and wrong medication (N = 4; 40%). The severity of incidents identified by direct observation and self-report differed, with self-reported incidents having a higher average severity (P < .001). The procedure types associated with medication-related incidents did not differ by direct observation versus self-report methodology. Direct observation captured many more perioperative medication-related incidents than self-report. The ME types identified and their severity differed between the 2 methods, with a higher average incident severity in the self-reported data.

Optimizing outpatient oncology consult workflow using time-driven activity-based costing: Efficiency and financial impacts.

9 Background: Clinical efficiency is a key component of value-based healthcare, patient satisfaction, staff burnout, and institutional operational capacity. The objective of this study was to identify clinic inefficiencies using time driven activity-based costing (TDABC) and evaluate the implementation of a new clinical workflow in high volume, outpatient radiation oncology clinics. Methods: We conducted an IRB-approved quality improvement study in the Gastrointestinal (GI), Genitourinary (GU), and Thoracic Radiation (TRO) Oncology departments at a large academic cancer center and four additional network sites (HALs). TDABC methodology was used to create process maps and optimize consult workflow. Patient encounter metrics were captured utilizing a real-time status function in the electronic medical record (Epic Systems). Anonymous patient satisfaction telephone surveys were administered to patients at the HALs. Hourly wages were determined based on 2021 U.S. Bureau of Labor Statistics. Pre- vs post-implementation metrics were compared using the Mann-Whitney U test. Results: Consult data for 1328 patients pre-intervention and 1234 post-intervention across all sections was included. Median overall cycle time was reduced by 21% in GI (19 min, p &lt; 0.001), 18% in GU (16 min, p &lt; 0.001), and 12% in HALs (9 min, p &lt; 0.001). The median interval between rooming and being seen by the attending physician decreased by 13% in GI (7 min, p &lt; 0.001), 16% in GU (9 min, p &lt; 0.001), 21% in TRO (10 min, p &lt; 0.001), and 9% in HALS (4 min, p &lt; 0.005). For each consult, there was a median financial savings of $29 for GI, $24 for GU, $5 for TRO, and $14 for HALs per consult. From patient satisfaction surveys (95/177), 99% of patients reported their providers spent adequate time with them, 85% reported their appointment began on time, and 91% reported being seen by a care provider in a timely manner. Conclusions: TDABC is a successful method to identify opportunities to improve clinical efficiency. Implementing workflow changes based upon these findings led to substantial reduction in overall encounter cycle times and patient wait times across multiple departments. Furthermore, patient satisfaction was high and there were significant financial savings with the new workflow. These findings may also have implications for reducing staff burnout and expanding clinical capacity across the magnitude of clinical enterprise.[Table: see text]

S1480 Clinical Burden of Electronic Health Record Use Amongst Gastroenterology Providers Associated With Differences in Sex, Provider Subspecialty, and Provider Training

Introduction: The electronic health record (EHR) has increased time spent outside of face-to-face encounters, with higher EHR burden associated with differences in provider sex, specialty, and rates of burnout. However, the EHR burden specific to gastroenterology (GI) providers is not fully understood. Methods: Measures of EHR use calculated through Epic Systems were retrospectively collected for GI providers from a tertiary referral center during a 6-month period starting January 1, 2021. Primary measures used to characterize EHR use included time spent performing clinical review, documentation, and in-basket management as well as quantification of efficiency, messaging, and time logged into the EHR, including time outside regularly scheduled hours (5:30 p.m. to 7:00 a.m. and weekends). EHR use patterns were compared across provider sex, sub-specialty (inflammatory bowel disease [IBD], motility/irritable bowel syndrome, advanced endoscopy [AE], and esophagus [ESO]), and training (physician vs non-physician provider [NPP]). Data was analyzed in aggregate using t-tests and analysis of variance with post-hoc Boniferri correction. Results: Data from 33 providers compromising 3,743 clinic days and 16,572 appointments was collected. Overall, 69.7% (23/33) were physicians, 30.3% (10/33) NPPs and 48.5% (16/33) were women, with women comprising all NPPs. Comparing EHR burden across sexes, women spent more daily time in clinical review than men (42.4 minutes vs 26.0, P = 0.02), though this result lost statistical significance when excluding NPPs. Comparing sub-specialties, IBD specialists spent more daily time in clinical review per appointment than AEs or ESOs (13.7 minutes vs 3.9 and 3.7, respectively; P < 0.001) yet had higher efficiency scores compared to these sub-specialties (P < 0.001). Compared to AEs, IBD specialists spent more overall daily time in the EHR (131.5 minutes vs 39.7, P < 0.005) as well as more daily time outside of regular work hours (60.0 minutes vs 8.9, P < 0.01). Comparing provider training, NPPs spent more daily time in the in-basket (P = 0.03), clinical review (P = 0.02), and overall EHR (P < 0.001) than physicians. Additionally, NPPs received more patient medical advice request messages per day than physicians (P = 0.03). Conclusion: IBD specialists and NPPs have an increased EHR burden. More work is needed to better understand sex, sub-specialty, and training-based differences in workload to combat factors contributing to provider burnout.

The challenge of DrEaMing in a digital world

Background: After the introduction of Electronic Health Record Systems (EHRS) (EPIC systems) in 2019, our Drinking, Eating, and Mobilising (DrEaMing) outcomes for prostatectomy patients had deteriorated when compared with historical PQIP data.1 This project therefore aimed to reintegrate these principles using the EHRS to increase pathway adherence.

Improving routine use of clinical pathway decision support through EMR integration.

432 Background: There has been an explosive growth in oncology with an evolution of precision oncology based on molecular profiling. Providing evidence-based, high quality, equitable care is a foundational mission for Kaiser Permanente (KP). Thus, KP created a systematic approach toward oncology care pathways that incorporated organizational leadership, structured participation and feedback, novel integration of clinical decision support (CDS) tools, and evaluation of efficacy, safety, and value. Our goal was to make it easy and preferable for physicians to access clinical decision support for every patient, every time. Methods: KP’s inter-regional oncology chiefs, supported by relevant teams in evidence analysis, pharmacy, and other clinical specialties, convened monthly meetings in 10 oncology sub-specialties to synthesize evidence and create care pathways for priority conditions. The pathways are published to KP’s Clinical Library (CL), a trusted, curated resource of clinical knowledge guidance and tools, available via KP’s Epic Systems electronic medical record (EMR). The pathways are represented as intuitive, graphical, clickable process diagrams, with additional clinical content available as hover text. CL uses standard Epic interfaces to receive contextual information when accessed from a patient encounter. When the physician browses the CL oncology pathway and selects a treatment recommendation, CL returns to the EMR with the specific treatment plan queued up for ordering. We began initial deployment of these inter-regional pathways in Feb 2020. We combined EMR data with CL data to understand the impact of this clinical decision support. Results: We experienced dramatic uptake of oncology clinical pathways despite offering minimal training and no external incentives. KP orders over Beacon treatment plans annually in the clinical conditions supported by our pathways. In the first quarter of deployment, clinicians ordered 9% of these protocols through clicking on CDS in CL. Over the course of 2 years, we saw pathway-based ordering grow to over 75% of eligible patients. Conclusions: We find that we have made considerable progress toward our goal of having physician users consult clinical pathways decision support before ordering oncology drug treatment protocols. As with all clinical guidance, we would not expect 100% of patients to follow the recommendation, due to clinical variation and co-morbidity, but we find that by making clinical pathways easily accessible and actionable within normal clinical workflow, physicians are consulting the latest evidence in their treatment.

Multiple Sclerosis and MyChart Messaging: A Retrospective Chart Review Evaluating Its Use.

Understanding patterns of MyChart (Epic Systems Corporation) messaging has the potential to alter clinical practice. However, because most research evaluating its use has been conducted in limited contexts, utilization patterns in patients with multiple sclerosis (MS) remain unclear. We characterized factors associated with high rates of MyChart messaging for patients with MS at an academic outpatient clinic. We performed a retrospective cross-sectional analysis of 439 patients in our center's database. Inclusion criteria were 1 or more clinic visits and MS diagnosis. We extracted demographic data, disease-specific characteristics, and MyChart messaging information. Of the patients in the database, 324 (74%) were MyChart users. MyChart users were more often younger (mean ± SD age, 50.1 ± 12.6 vs 55.0 ± 13.7 years; P < .001), had shorter mean ± SD duration since diagnosis (11.9 ± 8.3 vs 15.8 ± 10.8 years; P = .0013), had lower mean ± SD Patient-Determined Disease Steps scale scores (2.8 ± 2.3 vs 3.5 ± 2.5; P = .0107), and were more likely to be using high-efficacy disease-modifying therapies (χ2 1,323 = 6.7; P = .009). Messaging rates correlated positively with total number of unique medications (R = 0.17; P = .003) and negatively with age (R = -0.11; P = .018). Although previous research has implicated arm-hand disability and impaired vision as barriers to patient portal use, these findings suggest the relationship between MS-specific disease burden and MyChart utilization is also a function of underlying medical complexity beyond physical disability. These data may serve as groundwork for investigations in other disease-specific settings and for quality improvement research to mitigate these high rates in at-risk patients to optimize provider time investment, clinic productivity, and patient safety and minimize health care provider burnout.

Assessing the impact of patient access to clinical notes on clinician EHR documentation.

Recent policy changes have required health care delivery organizations provide patients electronic access to their clinical notes free of charge. There is concern that this could have an unintended consequence of increased electronic health record (EHR) work as clinicians may feel the need to adapt their documentation practices in light of their notes being accessible to patients, potentially exacerbating EHR-induced clinician burnout. Using a national, longitudinal data set consisting of all ambulatory care physicians and advance practice providers using an Epic Systems EHR, we used an interrupted time-series analysis to evaluate the immediate impact of the policy change on clinician note length and time spent documenting in the EHR. We found no evidence of a change in note length or time spent writing notes following the implementation of the policy, suggesting patient access to clinical notes did not increase documentation workload for clinicians.

Enter and Discuss Orders and Prescriptions (EPA 4): A Curriculum for Fourth-Year Medical Students.

Order entry, entrustable professional activity (EPA) 4, is one of several EPAs that residency program directors identify as a weakness for PGY 1 residents. A multispecialty survey of program directors indicated that only 69% of interns could be trusted to enter and discuss orders and prescriptions without supervision. To address this gap, we developed a formative workshop for fourth-year medical students. Prior to the start of their subinternships, 366 fourth-year medical students engaged in an order entry workshop. Students performed chart reviews on electronic standardized patients within an educational electronic health record (EHR), placed admission orders, customized order sets, responded to safety alerts, utilized decision support tools, and incorporated high-value care considerations. Students used expert-validated rubrics to assess the quality of their admission orders and participated in a facilitated group discussion on key learning points. Finally, students participated in order entry, with all orders requiring cosignature by a supervising physician, during their clinical rotations. Students reported their confidence with order entry before and after the workshop and after the clinical rotation. One hundred seventeen students completed the pre- and postworkshop surveys, and 99 went on to complete the postcourse evaluation. Students showed a statistically significant increase in their confidence level following the workshop. Order entry is a critical, complex skill that requires deliberate instruction. This curriculum, which leverages the features of an educational EHR, can facilitate instruction, practice, and confidence gains regarding order entry prior to further application of these skills in the clinical environment.

#41 Manual Validation of an Automated Tool to Extract Blood Culture and Susceptibility Data from the Electronic Health Record for Children with Acute Myeloid Leukemia

Abstract Background Children with acute myeloid leukemia (AML) receive high-intensity chemotherapy to achieve durable remission. AML chemotherapy causes bone marrow suppression resulting in vulnerability to infection, most frequently bloodstream infections (BSI). While the most commonly described organisms include Gram-negative pathogens and streptococci, the epidemiology and resistant profile of these pathogens can change. It is important to monitor the epidemiology of these infections over time to inform clinical care. Previously capture of these microbiology data required laborious manual chart reviews that are often done intermittently and with variable accuracy, limiting the impact of the results. We sought to develop and validate an automated process for extracting blood culture results, including antimicrobial susceptibility profiles for positive results from the electronic health record (EHR). Method An automated tool to extract blood culture results from the EHR (Epic Systems, Verona WI) was developed using SQL (Structured Query Language). The tool was applied to the EHR of all children with newly diagnosed AML treated at the Children’s Hospital of Philadelphia from January 1, 2011 to December 31, 2020, regardless of subsequent relapse and treatment. Data from all blood cultures (including standard, fungal, mycobacterial, and subacute bacterial endocarditis blood cultures) were captured. Manual chart review was performed by an Infectious Diseases physician to abstract the same blood culture results to determine accuracy of the automated extraction tool. The manual abstraction was considered the gold standard. The BSI epidemiology of AML patients during this time period were described to illustrate the utility of this tool. Results There were 91 children with newly diagnosed AML who received chemotherapy during the study period. Of the collected 3,150 cultures obtained and resulted, 206 (6.5%) were positive. There were 37 distinct pathogens identified (Table 1). Of positive cultures, 114 (55.3%) were reflexed to antimicrobial susceptibility testing (AST) per institutional standards. In total, 1,427 AST results were captured in the automated tool. Manual validation confirmed that concordance between the automated abstraction and chart review was 100% for the organisms grown on culture and accurately identified all AST results. The majority of organisms were Gram-positive. The most frequently identified species was Streptococcus mitis/oralis, found in 40/206 (19.4%) of positive cultures (Table 1). Of S. mitis/oralis that underwent AST, only 8/21 (38.1%) were susceptible to penicillin. Escherichia coli was the most common Gram-negative pathogen. Candida spp. accounted for 9.3% of detected pathogens, with C. krusei identified most commonly. Conclusion We developed and automated tool to extract blood culture results from the EHR of children and adolescents with AML at a single center. This tool was manually validated and found to be 100% accurate. This tool has the ability to efficiently capture the BSI epidemiology of a specific patient population at high risk for BSI. Further work is needed to confirm the accuracy of this tool at more centers. Implementation at other sites will allow this tool to be employed for various purposes including large, multicenter epidemiology research studies or quality improvement projects.

Standardization of toxicity related dose modification in oncology electronic health record (EHR).

e18616 Background: Inappropriate antineoplastic drug dosing can cause excessive toxicities or impaired efficacy. Chemotherapy dose delays and reduced dose intensity are common in community oncology practices[1]. Electronic tools can improve quality and safety of chemotherapy. Methods: A quality improvement project to standardize toxicity related dose modifications was initiated in January 2021. A dose modification section was created in BEACON (Epic Systems, Verona, WI) chemotherapy protocols. Dose modifications used in primary source studies were added to the protocols (Table, illustrative). An embedded link to relevant section of the study protocol allowed detailed review. Similarly, a link to the relevant CTCAE grading was embedded for reference. A user experience survey was conducted in August 2021 to evaluate adoption and perceived utility. Results: Dose modifications recommendations have been introduced in 104 protocols to date. Of the 70 survey respondents, there were 18 physicians and 5 advance practice providers, remainder being oncology nurses and pharmacists. Pre-implementation, 29% (8/27) of respondents whose role required performing dose modifications indicated using personal clinical judgement for hematological toxicity related dose modifications. 34% (9/26) did the same for non-hematological toxicities. Post-implementation, 87% respondents indicated awareness of the recommendations. 47% indicated that recommendations saved timed and 60% found these useful. 7.2% felt recommendations were impractical for clinical use. Conclusions: Embedding evidence-based dose modification recommendations into EHR based treatment protocols is feasible with widespread user adoption. References Denduluri, N., et al., Dose Delays, Dose Reductions, and Relative Dose Intensity in Patients With Cancer Who Received Adjuvant or Neoadjuvant Chemotherapy in Community Oncology Practices. J Natl Compr Canc Netw, 2015. 13(11): p. 1383-93. Illustrative Dose Modification Table. Reference Links 1. Grothey et al. Dose Modifications 2. CTCAE Grading. Refer to Reference Link for Detailed Instructions. Decrease Oxaliplatin and 5 FU one dose level for ANC&lt;1000, platelets &lt;50,000, Grade 4 diarrhea Decrease 5 FU one dose level for Grade 3 diarrhea, Grade 3 or 4 mucositis Decrease Oxaliplatin one dose level for Grade 2 neurotoxicity persisting between treatments, Grade 3 neurotoxicity resolving to &lt;/= Grade 2 between treatments Discontinue Oxaliplatin for Grade 3 neurotoxicity persisting between treatments, Grade 4 neurotoxicity.[Table: see text]

Electronic capture of cancer-related distress in a community oncology program.

1577 Background: Cancer related distress can be seen in as many as one in two patients. Many organizations such as the Commission on Cancer require distress screening. National Comprehensive Cancer Network (NCCN) distress thermometer is a common tool used for screening. We studied feasibility of embedding the NCCN thermometer into oncology electronic health record (EHR) for routine patient care. We concurrently studied feasibility of using a mobile health tool for serial evaluation of cancer related distress. Methods: A flowsheet containing NCCN distress thermometer questions was created in Epic EHR (Epic Systems, Verona, WI). Oncology nurses used the flowsheet for routine patient assessment. Patients with distress level ≥ 4 answered additional questions. Ancillary care providers such as palliative care nurses or social workers addressed the identified needs by providing appropriate ‘services’. A field to capture these interventions was created. We also adapted our previously reported web based mobile tool [1] for monitoring cancer distress. Patients rated their distress on a 1-10 scale and highlighted the distress domain (physical, emotional, practical, family). Distress level ≥ 4 generated a color-coded flag for provider review and intervention. Data from both electronic tools was periodically analyzed to inform patient care and quality improvement. Results: Between January and December 2021, Epic EHR based distress flowsheet collected 28,594 distinct responses in 911 patients. 57.4%, 14.9%, 14.1%, 9.4% and 2.3% of the responses were in the physical, emotional, practical, familial and spiritual domains respectively. ‘Other’ responses were 1.4%. Cumulative frequency of non-physical problems was 42.5%. 1819 ‘services’ were provided with 357 emotional, 351 work, 351 housing, 350 transportation and 350 financial need-based interventions. Of 1231 patients who used the distress scale and provided additional comments, 315 (25.5%) had distress levels ≥ 4. The mobile tool captured 849 unique patient responses to the distress question between April 2020 and February 2022. Distress level ≥ 4 was flagged by 281 unique patients (33.09%). Average distress level was 2.7. Emotional domain problems generated the greatest distress level followed by family, physical and practical problems in decreasing order. Conclusions: We demonstrate feasibility of electronic capture of cancer related distress to facilitate holistic patient care in a community-based oncology program. EHR based and mobile tool distress evaluations generated concordant results. Distress caused by emotional, practical and familial domain problems was nearly as frequent and often more severe than distress caused by physical problems, underscoring the need for comprehensive cancer care.

Tracking procedure outcomes using Epic SmartText and SmartData Elements following minor dermatologic procedures in the ambulatory setting

To the Editor: In 2017, the Department of Dermatology, Duke University, employed a template-generating electronic health record tool to collect variables related to surgical site infections (SSIs) following minor dermatologic procedures, including shave biopsies, punch biopsies, excisions, and electrodessication and curettages in the ambulatory setting. This system uses SmartText (a registered trademark of Epic Systems Corporation) with embedded SmartData Elements (SDEs) through Epic-based electronic health records. Our initiative aimed at improving the documentation of adverse outcomes, such as SSIs, wound bleeding, and wound dehiscence, reducing inconsistency in charting, and facilitating tracking in compliance with the Joint Commission on Accreditation of Healthcare Organizations, specifically regarding the Ongoing Professional Practice Evaluation and SSI tracking standards. 1 What are the key elements needed to meet the ongoing professional practice evaluation (OPPE) requirements? The Joint Commission. https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/medical-staff-ms/000001500/Date accessed: February 1, 2022 Google Scholar ,2 Surgical site infections (SSI): surveillance and resources. The Joint Commission. Posted September 25, 2017. Accessed February 1, 2022. https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/infection-prevention-and-control-ic/000002155/ Google Scholar Additionally, our SmartText simplifies documentation at postprocedural follow-up appointments and enables rapid, user-friendly data entry and analysis, offering a springboard for research projects while minimizing manual data extraction requirements.