Exam Room Research Articles

Eim®-on Campus Solution

PURPOSE: At Florida Gulf Coast University (FGCU) we have leveraged the Exercise is Medicine® - On Campus (EIM®-OC) solution to create cross campus partnerships among, Campus Recreation (CR), Student Health Services (SHS), Office of Service Learning and Civic Engagement (SL), and the Department of Rehabilitation Sciences (RS) to facilitate student learning, health promotion, and research. This abstract’s aim is to share the EIM®@FGCU framework & baseline data. METHODS: Phase 1 of the study was designed to build the collaborative framework and created a paperless data collection method. Mobile tablets were installed in SHS exam rooms to collect baseline data while patients were awaiting providers. In additional, exercise is a vital sign at all SHS visits and a procedure/referral code for the [email protected] referral program(October 2015). Questionnaires are updated annually to capture additional data on the current programs being offered. During the summer of 2015, Exercise Science (ES) Students created a campus wide marketing campaign to promote physical activity. The campaign includes: a social media arm (in partnership with CR), a monthly activity (ranging from Adaptive Recreation Day to the Great American Smoke Out), and promotion program that is delivered through campus housing. ES Students design and implement the monthly events as part of an ongoing SL project. RESULTS: Between March and May 2015, 142 students on campus (6.6% response rate) completed the International Physical Activity Questionnaire assessing their baseline physical activity level which showed that 33% of the students at FGCU do not meet the minimum American College of Sports Medicine recommendation for physical activity. Overwhelmingly, the SL events have broadened the ES students experience and allowed them additional avenues to practice clinical skills. Campus Recreation has submitted the videos produced as part of [email protected] to their national meeting, and SHS is using [email protected] as part of their ongoing quality improvement metric for accreditation. CONCLUSIONS: Through improvement of the campus community health, EIM-OC can improve ES student learning and faculty research agendas. This project is funded by an internal, inter-professional grant from the College of Health Professions and Social Work at Florida Gulf Coast University.

Multidisciplinary approach to introducing new technologies and reconstructive surgeries in diagnosis and treatment of neoplastic diseases of the female reproductive organs

Multidisciplinary approach that comprises the passing the examination in the exam room with the Pap test, questionnaires, ultrasound or digital mammography screening (MS) according to the age is a promising way of solving the problems with the visual localization of cancer, in particular with the reproductive organs. A minimally invasive removal technology that helped to determine the nature of tumor pathologies and remove those potentially dangerous hotbeds at the same time, was an important component of this secondary prevention system. Organ preserving and reconstructive surgeries (to our knowledge to 38,8% of patients with breast cancer and 95% of patients with vulvar cancer and vulvar dysplasia) have a positive effect not only on women’s life quality, but also become a good motivation for regular women’s screening in the region. Nothing is more convincing than the vivid example and “word of mouth”. A multidisciplinary approach to solving problem with the help of different specialists helped to reduce mortality rates for breast cancer by 30,03 ± 2,1% compared with 2009 (after the introduction of reconstructive surgery) and vulvar cancer by 83,3 ± 5,7% in comparison with 2005 (after the introduction of reconstructive surgery) at the continuing trend of increasing incidence rate. Cytological screening for dysplasia and early forms of cervical cancer needs a serious adjustment in accordance with the WHO recommendations and per capita accounting used in Russia.

Examination of the Acute Abdomen in Children

The history and physical examination (H&P) on a child with an acute abdomen is an opportunity to build a solid relationship with the child and parents. Building confidence and trust under fraught circumstances requires a genuine affection for children, and sympathy for the anxiety of the parents. Arrival of a surgeon is a signal that the illness is serious and not likely to respond to the usual remedies. The surgeon therefore must have a gentle, unhurried approach. Obtaining the history should be non-directive and allow both parent and child to describe the entire timeline of the illness without interruption. The physical examination should be done without hurting the child, first observing how the child moves about in bed and undresses, then having the child control palpation by holding the examiner’s hand and pulling it away should undue pain be elicited. Even though a diagnosis and a plan for surgery may already have been made, exiting the exam room after the H&P to review lab and radiological images gives the family time to regroup information. The diagnosis and decision for operation require simple and direct explanations that communicate patience, have a tone of reassurance, and affirm repeatedly that parents understand what is being said. The message is that surgery is a shared decision, and safety and the child’s wellbeing always foremost. To the child three points have to be paramount: They won’t feel pain during or after the procedure; after the operation they will feel better; and they won’t be alone. The goal is to build a trusting relationship so that the child has some calm in departing to the operating room and the parents willingly see them leave.

Abstract 143: Development of a Novel Electronic Preventative Cardiology Decision Aid

Objectives: Few contemporary electronic decision aids have been designed and evaluated rigorously in the realm of preventative cardiology. Our aim was to develop and test a web-based decision aid that: 1) effectively conveys information on cardiovascular disease risk as well as therapies that modify that risk, 2) improves decisional quality, and 3) is able to be efficiently implemented. Methods: We utilized the Internal Patient Decision Aid Standards (IPDAS) collaboration development process as a framework for the creation of our patient decision aid (PtDA). We conducted a literature review and convened a focus group of experts to identify risk prediction models and interventions to be included in our PtDA. Based on this, we used the AHA/ACC Pooled Cohort Risk Assessment Equations to estimate risk and included the following interventions as risk modifiers: smoking cessation, dietary modification, weight loss, exercise (grouped as healthy living options), statin therapy, and aspirin therapy. Additionally, we included evidence-based estimates on the most common side effects of aspirin and statin therapies. We then designed a web-based decision aid (located at http://demo.heartriskreport.com , username and password “innovation”). We then completed several rounds of mixed-methods alpha testing of our PtDA with patients (n=36) consisting of quantitative surveys (incorporating elements of the Control Preferences Scale and the Decisional Conflict Scale) as well as semi-structured in-person interviews. Standardized patient scenarios were utilized. Finally, we surveyed 7 national experts in the field of preventative cardiology on the accuracy and usability of our PtDA. Results: The majority (92%, 33/36) of patients wished to incorporate elements of shared decision making processes when considering their care. Patients estimated risk 20 % points different from risk determined by validated calculators prior to using the PtDA. After using the PtDA, the patients’ estimation differed by less than one point from actual risk. The majority of patients knew which healthy living (94% of patients, 34/36) and medication (86% of patients, 31/36) options were available. Similarly, most patients knew the benefits of healthy living (89%, 32/36) and medication (86%, 31/36) options. The majority of patients understood the risks of medication options (89%, 32/36). In terms of feedback from our external experts (n=7), 100% of experts felt the PtDA was useful, accurate, and comprehensible to patients. All experts felt they would utilize the PtDA with their own patients. The majority of experts felt the PtDA would be best used in an exam room with a patient (67%, 4/7) and felt that the primary physician would be the best provider to review the PtDA with a patient (86%, 6/7). Conclusions: Our PtDA is highly usable and effective in conveying information regarding cardiovascular risk and common therapies to patients.

Abstract A33: Promoting screening mammography in an American Indian community in Oklahoma: The Native Women's Health Project

Abstract Background: The stagnant breast cancer mortality rates and the increased number of younger American Indian (AI) women who are being diagnosed with breast cancer indicate that breast cancer remains an important public health issue among the AI community. This 4-year study is a continuation of two preliminary studies at a rural tribal clinic in Oklahoma. In the first study, we developed a culturally-sensitive survey of mammography screening practices and beliefs, entitled Women's Health Survey (WHS), based on the Theory of Planned Behavior. In the second study, we identified the salient mammography screening beliefs held by AI women. The results led to the development of a Logic Model of mammography screening behavior, involving both clinical and community components, which guided intervention development. In the current study, we implemented the intervention and evaluated its efficacy via Community-based Participatory Research. Methods: A Community Steering Committee (CSC) was formed. The priority population consisted of AI women without a history of breast cancer who lived in the target region between the ages of 52-74 years, and who have not had a screening mammogram within the last 2 years. The study had four aims: 1) Conduct a needs and resource assessment of the priority population, 2) Utilize the needs and resource assessment data to develop a community-driven intervention program, 3) Pilot-test and refine the intervention, and 4) Evaluate the intervention using a one-group pre- and post-evaluation design and mixed research methodology. A modified version of the WHS was used as the evaluation tool. Results: The results of the formative research (Aim 1) indicated that: a) AI women lack knowledge of mammograms, b) Fatalistic attitudes toward breast cancer exist among AI women, c) Many AI women prefer a holistic approach to their health, d) Physicians influence women's screening mammography decisions, and e) Social modeling is an important motivating factor. Using a prioritization process through the CSC and data triangulation, we concluded that the intervention would center on the concepts of social modeling, physician recommendation, breast cancer fatalism, and lack of knowledge about mammography screening. The Logic Model was finalized, educational intervention materials were developed, and alliances were built with regional grassroots initiatives (Aim 2). The intervention included four main strategies: a) Structured communication between medical practitioner and patient about screening mammography; b) Receipt of a breast cancer brochure and subsequent follow-up letter from the medical provider; c) Participation in a breast cancer discussion group at a community setting by using the Freire (raising consciousness) approach; and d) Receipt of a congratulatory bracelet upon receipt of a mammogram. Based on the evaluation results (Aim 4), the intervention is feasible despite its complexity; however, process evaluation revealed a shallow implementation of the clinic component. Almost half of the research participants (N=21) received a future mammogram, indicating moderate program success. Focus group research (N=4) showed that the participants became more conscious of their health and more vocal in discussing breast cancer with their friends and family. Moreover, sustainable environmental changes were introduced at the tribal clinic including a bulletin board poster on mammography and a screening mammography algorithm located in the exam rooms. Conclusions: Designing, implementing and evaluating a theory-based culturally-sensitive multi-component intervention on mammography screening within a Native American community is an exciting, yet challenging process. Replications of the current study with a bigger sample size and a controlled, comparative evaluation design are needed to further establish the efficacy of the intervention. Citation Format: Eleni L. Tolma, Kimberly Engelman, Cara Thomas, Stephanie Joseph, Julie Stoner, Ji Li, Norma Neely. Promoting screening mammography in an American Indian community in Oklahoma: The Native Women's Health Project. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A33.

Improving the quality of the consenting and education process for patients starting on oral oncology medications.

82 Background: Oral oncology medication prescribing is on the rise nationwide. Given that these medications are self-administered, drug compliance is a concern. Appropriate patient education directly impacts drug adherence. Prior to the process improvement initiative in our community based medical oncology clinic, implied consent was obtained while educating patients on side effects and written informed consent was documented 0% of the time. This creates a patient safety and risk management problem. Methods: Our clinic implemented a new process for consenting and educating patients starting on new oral oncology medications from April – October 2015. The plan/do/study/act performance improvement technique was utilized. A new consent form was created for oral oncology medications meeting ASCO/ONS safety standards. The consent and education packets were placed centrally in the office and coincided with an initiative to improve consenting for IV chemotherapy. Providers were in-serviced to contact the nurse prior to patients exiting clinic to initiate the new prescription and begin the patient education process. Reminder checklists were placed in exam rooms to trigger the provider to communicate with nursing staff. Outcome measures included data on the percent of patients with written informed consent in health record and percent of patients with patient education handouts in health record prior to drug start. Data on percent of patients for whom the provider notified nurse prior to end of clinic visit were collected as a balance measure. Results: Over a 6 month period, 101 consecutive patients initiated on oral oncology drugs were included in the data analysis. The baseline mean improved from 0% to 75% for obtaining written informed consent (p chart, 3 sigma). The baseline mean improved from 37% to 80% for documenting patient education in health record prior to oral oncology medication start (p chart, 3 sigma). Conclusions: There was significant improvement in obtaining written informed consent and providing patient education prior to oral oncology drug start after implementation of new clinic processes.

Improving early childhood literacy and school readiness through Reach Out and Read (ROR) program.

Reach out and Read program (ROR) prepares young children to succeed in school by partnering with physicians and training them in handing out age appropriate books and to counsel parents...

A System-Theoretic Approach to Modeling and Analysis of Mammography Testing Process

Mammography is the standardized testing process for early detection of breast cancer. In this paper, a system-theoretic method based on a Markov chain model is presented to analyze such processes. Specifically, the general testing process in a single exam room is formulated using a Markov chain model. To resolve the dimensionality issue, an iteration method, referred to as shared resource iteration, is introduced to analyze the scenarios of two or more exam rooms. Formulas to evaluate the patient length of stay and staff efficiency are developed. The extension to non-Markovian scenarios is also investigated and an empirical formula is proposed. The experimental results indicate that such a method results in a high accuracy of performance estimation. A case study at a breast imaging center of the University of Wisconsin Medical Foundation is presented to illustrate the applicability of the model. In addition, the impact of patient volume increase is also studied, which shows that a capacity increase is necessary to accommodate the high demand.

“I found another to admire”: The Thing of the Female Body in William Carlos Williams’s Medical Narratives

I'll die before I've said my fill on women.-William Carlos Williams, / Wanted to Write a Poem (1958)I.Critics have long since established the exceptionality of the figure of the woman in Williams's poetry. Indeed, in his foundational literary biography of Williams, Paul Mariani devotes a whole chapter to the concept of Williams's Woman: not specific women, not even women's bodies, but the abstracted ideal of the woman. Appearing throughout Williams's literary career as Kora, Core, Persephone, the Beautiful Thing, the radiant gist, and the Egyptian goddess of history Mut, the abstracted is always the object of Williams's pursuit of an authentically American voice, language, and poetics. As previous Williams criticism has noted, Williams's formulation of his muse as either a goddess or an otherwise disembodied force suggests that this woman is not derived from a specific woman, but an abstracted ideal that Williams imagines as a specifically feminine energy.1Does-or can-Kora have a body? This article argues that the assumption that Williams's Kora cannot have a body is as fallacious as the assumption that Williams's Woman should be read separately from the women who appear in mundane, vulnerable, and compromising positions in his fiction and poetry. Through my analysis of the short stories the The with the Pimply Face and Comedy Entombed: 1930 and the take off your clothes moment from Paterson Book Three, I argue that the women Williams observes in their homes and in his exam room are a part of his search for the new order, embodiments of the American ideal that is at the heart of his understanding of medicine, sex, and modernity.At the center of Williams's descriptions of his modernism-as well as of critical readings of Williams's work-is the thing, the object that should be read for its own sake, without which there can be ideas in poetry. In closing the Autobiography, Williams writes: That is the business. Not to talk in vague categories but to write particularly, as a physician works, upon a patient, upon the before him, in the to discover the (A 391). In this formulation, Williams's differentiation between the and the suggests the same ideology that is behind the thing and the idea in his assertion no ideas but in things (P 6). By comparing the poet's business to the work of the doctor, Williams suggests that a key avenue by which the writer can move from the particular to the universal is the body.As his short stories based on his experiences in medical practice would suggest, a large percentage of the patients worthy of literary representation were his female patients: women and young girls who often attracted Williams's attention as a doctor. And yet, at the same time, Williams's doctor-narrator often noted an extra attraction to these women. He admired them. He fell for them. He noted their well-formed bodies. These sometimes seemingly misplaced moments of attraction that accompanied narratives of medical diagnosis have often lead critics to read this attraction as erotic in nature, a problematic violation of the doctor/patient relationship. Throughout the latter half of the twentieth century,literary critics like R.F. Dietrich and Marjorie Perloff, have used psychoanalytic and feminist literary theory in order to establish the troubling sexual politics inherent in Williams's treatment of the female patients in his medical narratives.2 Other readings of these stories, however, emphasize the redeeming aspects of the doctors' interest in their patients: the narrator of The Use of Force can ultimately diagnose Mathilda's dyptheria and potentially save her; in Girl with a Pimply Face, the doctor cures her acne; in A Night in June, the narrator ultimately chooses to allow the patient to labor naturally, rather than administer pituitrin to speed the delivery so he can return home sooner. …

Principles to Leveraging Point-of-Care Testing to Improve Outpatient Performance Measures

hospital stays. With this shift in the market, the performance and quality of patient outcomes in the outpatient setting is a key focus in pay-for-performance models. Accountable care organizations (ACO), the Centers of Medicare and Medicaid Services (CMS) and other organizations such as the National Committee for Quality Assurance (NCQA) are focusing heavily on outpatient performance metrics to gauge the quality of health care being delivered. This shift to outpatient care, and more integrated, process driven models of care has provided a common ground for the laboratory and other ancillary departments to the overall delivery of care. Many of the quality measures include performance standards around diagnostics testing to ensure patient outcomes are optimized, and clinical standards are applied. This provides a unique opportunity for clinical laboratories to impact not only the quality of care, but how it is delivered. Much of the application of point-of-care testing (POCT) has been centered on speed, and being able to provide patient education. However, POCT has benefits far beyond merely providing a faster result, and when applied correctly can help to improve performance measures. Properly integrating POCT into clinical practice is the key obstacle in leveraging it to improve performance measure scores. The application of 6 core principles can help to transform POCT from just a device and a result, to an integrated care and delivery solution. These principles are standardize, make clinically relevant, enhance accountability, simplify, process improvement, and engage patients. Many labs may shy away from POCT testing due to increase regulatory pressures, but applying these concepts actually helps to more effectively control and standardize the use of POCT. Standardization is the first step in effectively utilizing POCT in the outpatient setting, many approaches utilized in the past included standardized training and procedures. While effective they lack the ability to integrate the device within the delivery of care. Complementing traditional methods of standardization with a collaborative practice agreement is key for integrating POCT into the delivery of care. These agreements are a fixture in practice management and hospital administration, they help direct privileges, clinical guidelines and practice guidelines. Creating collaborative practice agreements regarding the use of specific POCT equipment in clinical care provides a way to help standardize, and ensure that the device is used as intended. These agreements also hold more weight and sway with clinicians, and help to enhance accountability. These agreements also ensure that the use of POCT is made clinically relevant by establishing set guidelines for treatment, applying the same risk factors, and standardizing patient education across multiple practices. In doing so you help to increase patient’s perceptions surrounding provider communication and shared decision making, which are key performance measures in the outpatient setting. The laboratory thrives on compliance and accountability, it is paramount in ensuring laboratory results are consistent and of high quality. Accountability is often something laboratories struggle with in their POCT programs. Developing accountability starts with standardization, utilizing a collaborative practice agreement can help to standardize and enhance accountability around qualifications, training, oversight and testing privileges. Providing a singular source to both standardize compliance, and hold individuals accountable to abide by the proper standards. Additionally collaborative practice agreement requirements are a focus in the credentialing process for positions, thus aiding in ensuring qualified personnel are performing and resulting POCT. The collaborative practice agreement helps to also lay the ground work for the remaining key principles of, simplify, process improvement, and engage the patient. These principles will have the most impact on outpatient performance measures. The principles of simplifying and process improvement may seem as if they are one in the same, but each takes a different perspective when aiming to improve performance measures. With simplifying how we utilize POCT, we are looking from the patient’s perspective. Developing a process that is simple for the patient increases the likelihood of patient compliance, and patient compliance is a key factor to improving performance measures. A key factor in simplifying the process for the patient is the location in which testing is being performed. Many labs and practices will use pointof-care devices in the most obvious location, the physician office or exam room. While this is an obvious point-of-care, there are many

Migrant encounters in the clinic: Bureaucratic, biomedical, and community influences on patient interactions with front-line workers

Ethnographic research on the clinical encounter has focused almost exclusively on what happens in exam rooms—particularly patient-provider interactions—leaving much to be understood about other actors within the clinic. As part of a larger ethnographic study examining the impact of colonialism, transnational migration, discrimination, and gender relations on Chuukese migrant women's reproductive and sexual health outcomes in Guam, I conducted eight months of participant observation in three publicly funded health clinics, 24 interviews with health care workers, and 15 life-history interviews with Chuukese women between September 2012 and February 2014. Findings demonstrated differential treatment of Chuukese patients by front-line workers (FLWs), who engaged in “boundary work” with these patients. Further, care varied by clinic space and the actors in that space. This differential treatment and variation in care impacted Chuukese women's access to and experiences with health care in Guam. Utilizing the concept of “deservingness,” this analysis unpacks how FLWs, like Lipsky's “street-level bureaucrats,” are influenced by bureaucratic, biomedical, and community hierarchies, all contributing to differential patient treatment. This study concludes by calling for more integrated analyses of clinical environments which utilize Lipsky's concept to include community narratives of “deservingness” and incorporate the influence of clinic and community stratification.

APA Joins Call for Reform of ‘Meaningful Use’ Program

APA and other medical organizations are urging CMS to focus on promoting interoperability and innovation as vendors respond to the demands of physicians and hospitals to progress past the current program where vendors must meet check-the-box requirements.

Physicians refer patients to MTM pharmacists at Fairview

Physicians refer patients to MTM pharmacists at Fairview

Improving Documentation Timeliness: A "Brighter Future" for the Electronic Medical Record in Resident Clinics.

Electronic medical records have many observed benefits but may cause work disruption, resulting in delayed documentation completion. The purpose of this project was to improve compliance with institutional standards of documentation of well child checks for residents and attendings without increasing stress. This project was completed at Children's Hospital Primary Care Clinic at Vanderbilt, which is staffed by 74 residents, supervised by 17 attendings. A longitudinal observational study using convenience sampling for the last full week of each month from October 2010-January 2012 was planned. Baseline documentation completion rates were assessed, then age-specific, structured data-entry forms were introduced beginning in March 2011. Run charts were created for completion data for all clinic visits in the sample. Physician self-report of satisfaction with and stress related to documentation was assessed through pre- and postintervention surveys. Data were derived for an average of 231 patient visits per month. The median percentage of documentation or attestations completed within the institutional standards increased from 54.7% to 78.9% for residents and from 38.2% to 83.5% for attendings. Physicians reporting high satisfaction with documentation increased from 20.5% to 85.7% (P < .01) for residents and from 11.1% to 76.9% (P < .01) for attendings. Residents reporting high stress with documentation decreased from 59.1% to 28.6% (P < .02). Use of age-specific, structured data-entry forms achieved marked improvement in documentation timeliness, but there is still room for improvement. The authors are now teaching computer-based documentation in exam rooms and instituting accountability measures.

Strategizing EHR use to achieve patient-centered care in exam rooms: a qualitative study on primary care providers.

Electronic health records (EHRs) have great potential to improve quality of care. However, their use may diminish "patient-centeredness" in exam rooms by distracting the healthcare provider from focusing on direct patient interaction. The authors conducted a qualitative interview study to understand the magnitude of this issue, and the strategies that primary care providers devised to mitigate the unintended adverse effect associated with EHR use. Semi-structured interviews were conducted with 21 healthcare providers at 4 Veterans Affairs (VAs) outpatient primary care clinics in San Diego County. Data analysis was performed using the grounded theory approach. The results show that providers face demands from both patients and the EHR system. To cope with these demands, and to provide patient-centered care, providers attempt to perform EHR work outside of patient encounters and create templates to streamline documentation work. Providers also attempt to use the EHR to engage patients, establish patient buy-in for EHR use, and multitask between communicating with patients and using the EHR. This study has uncovered the challenges that primary care providers face in integrating the EHR into their work practice, and the strategies they use to overcome these challenges in order to maintain patient-centered care. These findings illuminate the importance of developing "best" practices to improve patient-centered care in today's highly "wired" health environment. These findings also show that more user-centered EHR design is needed to improve system usability.

Abstract 15697: Fingertip-Based Monitoring of Vascular Reactivity and Endothelial Function: A Three-Way Comparison of Testing Modalities

Introduction: In recent years fingertip-based measurement of vascular reactivity and endothelial function using a 5-min arm-cuff reactive hyperemia protocol has become a clinical tool for clinicians to evaluate patients in the exam room. Our group previously introduced Digital Thermal Monitoring (DTM) as a simple, easy and operator-independent test that measures vascular reactivity and endothelial function by monitoring fingertip temperature. Recently we developed fingertip photoplethysmography (PPG). In this study, we performed a simultaneous comparison of the three methods to evaluate their similarities and dissimilarities. Hypothesis: We hypothesized that PPG correlates strongly with PAT and could be used as a replace. Methods: Cuff-induced reactive hyperemia protocol (5 min. baseline, 5 min. ischemia, 5 min. post deflation) tests were performed with simultaneous recording of signals from PAT Pressure sensors (on index finger), DTM temperature sensors (3rd finger), and PPG photoelectric sensors (4th finger). A total of 39 tests were performed on 17 individual subjects. Signal data were analyzed, cross correlated, and graphed using Excel software and MATLAB functions. Results: As shown in Figure below, all three modalities showed similar patterns. Analyses of data during reactive hyperemia phase showed the strongest correlation between PPG and PAT (mean crosscorr = 0.79), compared to PAT and DTM (mean crosscorr = 0.64) and PPG and DTM (mean crosscorr = 0.49). Conclusions: DTM, PPG, and PAT signals are well correlated. The strong correlation between PPG and PAT suggests they can be used interchangeably.

Pediatric decision support using adapted Arden Syntax.

Pediatric guidelines based care is often overlooked because of the constraints of a typical office visit and the sheer number of guidelines that may exist for a patient's visit. In response to this problem, in 2004 we developed a pediatric computer based clinical decision support system using Arden Syntax medical logic modules (MLM). The Child Health Improvement through Computer Automation system (CHICA) screens patient families in the waiting room and alerts the physician in the exam room. Here we describe adaptation of Arden Syntax to support production and consumption of patient specific tailored documents for every clinical encounter in CHICA and describe the experiments that demonstrate the effectiveness of this system. As of this writing CHICA has served over 44,000 patients at 7 pediatric clinics in our healthcare system in the last decade and its MLMs have been fired 6182,700 times in "produce" and 5334,021 times in "consume" mode. It has run continuously for over 10 years and has been used by 755 physicians, residents, fellows, nurse practitioners, nurses and clinical staff. There are 429 MLMs implemented in CHICA, using the Arden Syntax standard. Studies of CHICA's effectiveness include several published randomized controlled trials. Our results show that the Arden Syntax standard provided us with an effective way to represent pediatric guidelines for use in routine care. We only required minor modifications to the standard to support our clinical workflow. Additionally, Arden Syntax implementation in CHICA facilitated the study of many pediatric guidelines in real clinical environments.

Quality Improvement Measures in Hepatitis C Screening and Management in an Inner City Community Health Clinic

Introduction: In late 2013, a law was signed into effect in New York State mandating with few exceptions that providers offer Hepatitis C (HCV) screening to all patients born between 1945-1965. As practitioners in an inner-city community health clinic treating an underserved population, we have undertaken quality assessment/quality improvement (QA/QI) measures to determine how our facility is performing, and identified several areas for improvement in screening and management of HCV. Methods: We identified appropriate subjects through a search of our electronic medical record (EMR) for all patients born between 1945-1965, who visited our facility in the 2014 calendar year with no prior HCV data on record. We then identified whether any screening for HCV was performed, and if positive, whether a viral load was obtained. For positive viral loads, we looked if genotyping and alpha fetal protein (AFP) levels were ordered. We also assessed whether newly diagnosed HCV patients had hepatitis A and B serology or vaccinations, as well as HIV status. Results: Of the 1609 patients in the appropriate age-range seen during the 2014 calendar year and not previously screened for HCV, 29.6% (477) were screened for HCV antibodies. Of those screened, 8.8% (42) tested positive (29 male, 13 female). 86% (36) of these patients had a viral load, and of those with positive viral loads (22), 68% (15) had AFP levels, and 77% (17) had genotyping. The most common genotype found was 1a, followed by 1b and 3a. Hepatitis A and B serology was either checked or previously known for 64% (27) and 90% (38) of all positive screens respectively. HIV status was identified for 88% (37) of all positive screens. Conclusion: This is the first QI project undertaken at our facility dealing with HCV, and our data revealed many areas for improvement. Simple best practices to implement include posting guidelines for screening and diagnostic algorithms in exam rooms for providers. With our IT department we can create bundle lab orders on our EMR to standardize the ordering process, as well as alerts for missing tests when the chart is opened. Our positive screening rate suggests more community outreach is needed. This data provides a starting point for ongoing improvement; our goal is to examine data on treatment rates as well. Only 3 patients received HCV treatment at our facility in 2014. As Medicaid plans have begun covering more oral treatment regimens, there is opportunity for us to identify and treat a greater number of appropriate patients.

Identifying Patient Door-to-Room Goals to Minimize Left-Without-Being-Seen Rates.

IntroductionEmergency department (ED) patients in the leave-without-being-seen (LWBS) group risk problems of inefficiency, medical risk, and financial loss. The goal at our hospital is to limit LWBS to <1%. This study’s goal was to assess the influence on LWBS associated with prolonging intervals between patient presentation and placement in an exam room (DoorRoom time). This study’s major aim was to identify DoorRoom cutoffs that maximize likelihood of meeting the LWBS goal (i.e. <1%).MethodsWe conducted the study over one year (8/13–8/14) using operations data for an ED with annual census ~50,000. For each study day, the LWBS endpoint (i.e. was LWBS <1%: “yes or no”) and the mean DoorRoom time were recorded. We categorized DoorRoom means by intervals starting with ≤10min and ending at >60min. Multivariate logistic regression was used to assess for DoorRoom cutoffs predicting high LWBS, while adjusting for patient acuity (triage scores and admission %) and operations parameters. We used predictive marginal probability to assess utility of the regression-generated cutoffs. We defined statistical significance at p<0.05 and report odds ratio (OR) and 95% confidence intervals (CI).ResultsUnivariate results suggested a primary DoorRoom cutoff of 20′, to maintain a high likelihood (>85%) of meeting the LWBS goal. A secondary DoorRoom cutoff was indicated at 35′, to prevent a precipitous drop-off in likelihood of meeting the LWBS goal, from 61.1% at 35′ to 34.4% at 40′. Predictive marginal analysis using multivariate techniques to control for operational and patient-acuity factors confirmed the 20′ and 35′ cutoffs as significant (p<0.001). Days with DoorRoom between 21–35′ were 74% less likely to meet the LWBS goal than days with DoorRoom ≤20′ (OR 0.26, 95% CI [0.13–0.53]). Days with DoorRoom >35′ were a further 75% less likely to meet the LWBS goal than days with DoorRoom of 21–35′ (OR 0.25, 95% CI [0.15–0.41]).ConclusionOperationally useful DoorRoom cutoffs can be identified, which allow for rational establishment of performance goals for the ED attempting to minimize LWBS.

Human Factors Research and Design Trends for the Modern Exam and Hospital Room

Although much research has been conducted on the impact of the electronic health record (EHR) and health information technology (HIT) on provider-patient interaction, challenges persist on how to effectively integrate these tools into healthcare environments, while maintaining patient-centered care. Panelists will present and discuss their experience relating to: the introduction of new technology and how it changes the nature of work; the positive impact of greater focus on the patient; the nature of interruptions and strategies to reduce their negative impact; enhancing the workflow of medication ordering; and designing collaborative spaces considering all relevant stakeholders (patient care team, patients, family members). These topics represent some of the latest human factors research and design trends with a common goal: advancing the design of the modern healthcare environment, with consideration of the additional complexity introduced by evolutionary changes in clinical information systems and HIT.