Existing Electronic Medical Record Research Articles

Implementation of a pediatric early warning score tool in a pediatric oncology Ward in Palestine

BackgroundPediatric Early Warning Scores (PEWS) are nurse-administered clinical assessment tools utilizing vital signs and patient signs and symptoms to screen for patients at risk for clinical deterioration.1–3 When utilizing a PEWS system, which consists of an escalation algorithm to alert physicians of high risk patients requiring a bedside evaluation and assessment, studies have demonstrated that PEWS systems can decrease pediatric intensive care (PICU) utilization, in-hospital cardiac arrests, and overall decreased mortality in high income settings. Yet, many hospital based settings in low and lower middle income countries (LMIC) lack systems in place for early identification of patients at risk for clinical deterioration.MethodsA contextually adapted 16-h pediatric resuscitation program included training of a PEWS tool followed by implementation and integration of a PEWS system in a pediatric hematology/oncology ward in Beit Jala, Palestine. Four PDSA cycles were implemented post-implementation to improve uptake and scoring of PEWS which included PEWS tool integration into an existing electronic medical record (EMR), escalation algorithm and job aid implementation, data audits and ward feedback.ResultsFrequency of complete PEWS vital sign documentation reached a mean of 89.9%. The frequency and accuracy of PEWS scores steadily increased during the post-implementation period, consistently above 89% in both categories starting from data audit four and continuing thereafter. Accuracy of PEWS scoring was unable to be assessed during week 1 and 2 of data audits due to challenges with PEWS integration into the existing EMR (PDSA cycle 1) which were resolved by the 3rd week of data auditing (PDSA cycle 2).ConclusionsImplementation of a PEWS scoring tool in an LMIC pediatric oncology inpatient unit is feasible and can improve frequency of vital sign collection and generate accurate PEWS scores.Contribution to the literatureThis study demonstrates how to effectively implement a PEWS scoring tool into an LMIC clinical setting.This study demonstrates how to utilize a robust feedback mechanism to ensure a quality program uptake.This study demonstrates an effective international partnership model that other institutions may utilize for implementation science.

IT'S ABOUT TIME: IMPROVING COMPLIANCE IN THE ONE-HOUR SEPSIS BUNDLE USING A MODIFIED ELECTRONIC MEDICAL RECORD ALERT PROMPTING A NURSING DRIVEN PROTOCOL

SESSION TITLE: Education, Research, and Quality Improvement Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Sepsis and septic shock are life-threatening illnesses that affect more than 20 million patients. Early recognition of sepsis is vital for reducing morbidity and mortality as each hour of delay in antibiotics increases mortality by 8%. We implemented a simplified computerized alert system triggering a nursing driven protocol aimed at timely intervention, which we hypothesized would improve the speed of resuscitation and compliance with the 1-hour sepsis bundle. METHODS: A modified algorithm was built into our existing electronic medical record (EMR) system firing a systemic inflammatory response (SIRS) alert if 3 of the following criteria were met: heart rate ≥ 91 bpm, respiratory rate ≥ 21 bpm, temperature < 36 C or ≥38.4 C, or WBC <4k or ≥12.1k. A SEPSIS alert would fire if 2 SIRS criteria plus 1 of the following signs of organ dysfunction were met: lactate ≥ 2.1 mmol/L, systolic blood pressure < 90mmHg or mean arterial pressure < 65mmHg, bilirubin ≥ 2.1 mg/dL, platelet count < 100,000, INR > 1.5 (not on Coumadin), or creatinine ≥ 2 mg/dL without known chronic kidney disease. Once an alert was fired and infection was suspected, the nursing staff was electronically prompted to draw a lactic acid level, initiate a 500ml crystalloid bolus, and collect blood cultures. These nursing interventions were initiated autonomously before the evaluation of an emergency department (ED) provider. Pediatric (<age 18), trauma, or obstetric patients were excluded. We analyzed data from April through October 2019 for all the SIRS/Sepsis alerts. Full compliance of the 1-hour sepsis bundle meant obtaining blood cultures, drawing a lactate level, and initiating antibiotics and intravenous fluids within 1 hour of the EMR trigger. Monthly comparisons were analyzed using a two-sample t-Test. RESULTS: Of the 1900 alerts, 587 patients met the inclusion criteria. Compliance with the sepsis bundle at 1-hour was evaluated by comparing alerts from April 2019 through October 2019. In April, the 1-hour sepsis bundle was met in 25.5% of the patients. In October, the 1-hour sepsis bundle was met in 69.8% of the patients. This represents a compliance improvement of 44.3% (P=<0.01). Length of stay was also reduced by 1 day (P=0.5). The major improvement was observed in the timely administrations of intravenous fluids with a reduction of 83 minutes (P=0.003) and antibiotic administration with a reduction of 73 minutes (P=0.001). CONCLUSIONS: Our hospital compliance with the 1-hour sepsis bundle has steadily improved each month since the introduction of the EMR alert and with reinforcement of the nursing driven protocol. A concerted effort between the nursing staff, pharmacy, ED providers and prompt the recognition of sepsis have been the key in improving the 1-hour sepsis bundle. Given our success, we plan on expanding this project beyond the ED to all adult hospital units. CLINICAL IMPLICATIONS: This resident champion quality improvement project has helped steadily improve our hospital compliance in the 1-hour sepsis bundle since the introduction of the EMR alert and with reinforcement of the nursing driven protocol aimed at improving timely sepsis resuscitation. DISCLOSURES: No relevant relationships by Marium Asad, source=Web Response No relevant relationships by Kristine Galang, source=Web Response No relevant relationships by Mohsen Saadat, source=Web Response No relevant relationships by Kimberley Stephania Yescas Garibay, source=Web Response

Improving Transfusion Safety in the Operating Room With a Barcode Scanning System Designed Specifically for the Surgical Environment and Existing Electronic Medical Record Systems: An Interrupted Time Series Analysis.

Manual processes for verifying patient identification before blood transfusion and documenting this pretransfusion safety check are prone to errors, and compliance with manual systems is especially poor in urgent operating room settings. An automated, electronic barcode scanner system would be expected to improve pretransfusion verification and documentation. Audits were conducted of blood transfusion documentation under a manual paper system from January to October 2014. An electronic barcode scanning system was developed to streamline transfusion safety checking and automate documentation. This system was implemented in 58 operating rooms between October and December 2014, with follow-up compliance audits through December 2015. The association of barcode scanner implementation with transfusion documentation compliance was assessed using an interrupted time series analysis. Anesthesia providers were surveyed regarding their opinions on the electronic system. In mid-2016, the scanning system was modified to transfer from the Metavision medical record system to Epic OpTime. Follow-up analysis assessed performance of this system within Epic during 2017. In an interrupted time series analysis, the proportion of units with compliant documentation was estimated to be 19.6% (95% confidence interval [CI], 10.7-25.6) the week before scanner implementation, and 74.4% (95% CI, 59.4-87.4) the week after implementation. There was a significant postintervention level change (odds ratio 10.80, 95% CI, 6.31-18.70; P < .001) and increase in slope (odds ratio 1.14 per 1-week increase, 95% CI, 1.11-1.17; P < .001). After implementation, providers chose to use the new electronic system for 98% of transfusions. Across the 2 years analyzed (15,997 transfusions), the electronic system detected 45 potential transfusion errors in 27 unique patients, and averted transfusion of 36 mismatched blood products into 20 unique patients. A total of 69%, 86%, and 88% of providers reported the electronic system improved patient safety, blood transfusion workflow, and transfusion documentation, respectively. When providers used the barcode scanner, no transfusion errors or reactions were reported. The scanner system was successfully transferred from Metavision to Epic without retraining staff or changing workflows. A barcode-based system designed for easy integration to different commonly used anesthesia information management systems was implemented in a large urban academic hospital. The system allows a single user with the assistance of a software system to perform and document pretransfusion safety verification. The system improved transfusion documentation compliance, averted potential transfusion errors, and became the preferred method of blood transfusion safety checking.

1930. Developing an Electronic Medical Record System to Monitor Patients on Outpatient Parenteral Antibiotic Therapy at an Academic Medical Center

BackgroundOutpatient parenteral antibiotic therapy (OPAT) is an integral part of infectious disease (ID) management. The IDSA OPAT guidelines stress the importance of monitoring outcomes and safety assessment, yet there is no prescribed method to execute this process. There is limited published data on effective OPAT monitoring strategies in the US healthcare system.MethodsTo monitor and measure outcomes of patients on OPAT, our multi-disciplinary re-design team built a tracking system and database into the existing electronic medical record (EMR). A data entry form, called an “episode of care (EOC),” is completed in the EMR by the ID physician at the time of consultation (see figure). Data include: consultant’s name, discharge location, antibiotic type, duration of treatment, lab monitoring recommendations, and outpatient (OP) follow-up visit date. This information automatically populates three items: the hospital interagency referral, a dashboard for active monitoring by outpatient providers, and a database for quality metric analysis. Outcomes measured include emergency room (ER) visits 30-days post discharge, 30-day re-admission rates, clinic no -show rates, and adverse events. Patients discharged on IV antibiotics with no EOC (i.e., no ID oversight) were also identified.ResultsIn a 6-month period after the initiation of the new tracking system at our institution, 515 patients were discharged from the hospital on OPAT with an EOC. An additional 197 were discharged on IV antibiotics and no EOC. Of the patients with an EOC 25.5% had an ED visit within 30 days of discharge, and 19% had a 30-day re-admission from time of discharge. There were 20 adverse events related to antibiotic therapy documented (9 laboratory abnormalities, 6 antibiotic side-effects, 3 line complications, 1 episode of clostridium difficile, and 1 incorrect/missed antibiotic). Nineteen patients had a no-show to their first ID follow-up appointment.ConclusionWe demonstrate the feasibility of integrating a tracking system for patients on OPAT into a pre-existing EMR and creating a database for assessment of outcomes. We also identify a significant number of patients discharged without ID oversight, revealing missed opportunities for ID input in these cases. Disclosures All authors: No reported disclosures.

A Service-Oriented Model for Personal Health Records

ABSTRACT Personal health records (PHRs) have received widespread attention as a tool for people to store and manage their own or their family’s health records. Today PHRs are provided by a variety of players, including health care systems or hospitals, health plans, employers, and technology vendors. Traditional PHR systems are institution specific and have not been concerned with the interoperability and privacy of PHRs when interacting with other systems. The paper reported here seeks to address this challenge by presenting a service-oriented model for PHRs. In this study, we examine the challenges faced in the integration of existing electronic medical record (EMR) systems and health information exchanges (HIEs). We then propose a service-oriented model for integrating PHR and EMR systems. Furthermore, we analyze the services in SOA and explore the potential of service-oriented personal health cloud. We present a practical case study to verify and validate our the proposed approach. We conclude by discussing practical and policy implications and future research directions.

Improving cancer treatment handoffs: Wilmot Cancer Institute’s (WCI) ASCO Quality Training Program experience.

139 Background: Ineffective handoffs contribute to gaps in patient care and medication errors, jeopardizing patient safety and leading to poor quality of care. Ineffective handoffs accounted for 59% of reported medication events at WCI Infusion Center. The completion rate of WCI’s existing electronic medical record (EMR) based free text handoff note for patients treated with anti-cancer therapy on the same day as a clinic visit was 32%. The project aim is to create an effective EMR integrated treatment handoff tool and establish standard workflow processes to ensure optimal communication among WCI providers for improved patient safety and quality of care. Methods: We convened a multidisciplinary team to develop an efficient and safe treatment handoff tool. WCI nurses were surveyed to evaluate the baseline state of the handoff process. Tool development was performed over a series of phases, including creation of a project charter and aim statement, outlining current workflow process, identifying gaps and limitations in the process, identifying potential causes of ineffective hand-off and using a Pareto chart to prioritize them. Utilizing the Situation-Background-Assessment-Recommendation framework, an EMR-integrated handoff tool with standardized workflow process was developed, along with an educational plan for the tool. Results: 52% (N = 22/42) of nurses found the current handoff note to be ineffective at preventing errors and 48% (N = 20/42) identified incomplete or missing information as a significant factor for ineffective communication. Other barriers identified included poor note design, lack of standardization in workflow and variation in note use. During the 1 week implementation of the new handoff tool, the utilization rate was 100% (N = 32) with completion rate of 41% (13 of 32). Further data collection is ongoing and nursing perception of the new tool will be evaluated at 3 months. Conclusions: Multidisciplinary stakeholders’ guided development and implementation of an EMR-integrated treatment handoff tool to optimize the communication between cancer care providers during patient transition is associated with improvement in handoff tool utilization and communication.

EMR Innovation: Implementing Pharmacy Workflows Across A Multihospital Health System

EMR Innovation: Implementing Pharmacy Workflows Across A Multihospital Health System

Research and Development of Semantics-based Sharable Clinical Pathway Systems.

The clinical pathway (CP) as a novel medical management schema is beneficial for reducing the length of stay, decreasing heath care costs, standardizing clinical activities, and improving medical quality. However, the practicability of CPs is limited by the complexity and expense of adding the standard functions of electronic CPs to existing electronic medical record (EMR) systems. The purpose of this study was to design and develop an independent clinical pathway (ICP) system that is sharable with different EMR systems. An innovative knowledge base pattern was designed with separate namespaces for global knowledge, local knowledge, and real-time instances. Semantic web technologies were introduced to support knowledge sharing and intelligent reasoning. The proposed system, which was developed in a Java integrated development environment, achieved standard functions of electronic CPs without modifying existing EMR systems and integration environments in hospitals. The interaction solution between the pathway system and the EMR system simplifies the integration procedures with other hospital information systems. Five categories of transmission information were summarized to ensure the interaction process. Detailed procedures for the application of CPs to patients and managing exceptional alerts are presented by explicit data flow analysis. Compared to embedded pathway systems, independent pathway systems feature greater feasibility and practicability and are more advantageous for achieving the normalized management of standard CPs.

SMART Careplan System for Continuum of Care

ObjectivesThis paper describes the integrated Careplan system, designed to manage and utilize the existing Electronic Medical Record (EMR) system; the system also defines key items for interdisciplinary communication and continuity of patient care.MethodsWe structured the Careplan system to provide effective interdisciplinary communication for healthcare services. The design of the Careplan system architecture proceeded in four steps-defining target datasets; construction of conceptual framework and architecture; screen layout and storyboard creation; screen user interface (UI) design and development, and pilot test and step-by-step deployment. This Careplan system architecture consists of two parts, a server-side and client-side area. On the server-side, it performs the roles of data retrieval and storage from target EMRs. Furthermore, it performs the role of sending push notifications to the client depending on the careplan series. Also, the Careplan system provides various convenient modules to easily enter an individual careplan.ResultsCurrently, Severance Hospital operates the Careplan system and provides a stable service dealing with dynamic changes (e.g., domestic medical certification, the Joint Commission International guideline) of EMR.ConclusionsThe Careplan system should go hand in hand with key items for strengthening interdisciplinary communication and information sharing within the EMR environment. A well-designed Careplan system can enhance user satisfaction and completed performance.

Adverse drug reactions for CAM and conventional drugs detected in a network of physicians certified to prescribe CAM drugs.

Within recent years, the increasing popularity of complementary and alternative medicine (CAM) has led health care authorities to focus on the safety of these drugs. One reason for the low awareness of adverse drug reactions (ADRs) associated with CAM might be that users and physicians believe that there are no risks associated with CAM drugs. Recent studies have shown that ADRs are under-reported and are considered a leading cause of morbidity and mortality. The Evaluation of Anthroposophical Medicine (EvaMed) Pharmacovigilance Network was formed in 2004 at the Havelhoehe Research Institute in Berlin and is composed of 38 CAM physicians located in 12 of the 16 federal states in Germany for the purpose of using EvaMed data to evaluate the prescribing patterns, effectiveness, and safety of CAM therapies. To describe and quantify the volume and severity of ADRs for CAM and conventional (CON) drugs in a proprietary database created from prescriptions and patient data of primary care CAM physicians who participate in the EvaMed Network. This was a prospective, multicenter, observational study based on the ADR reports and electronic prescription data of 38 individual physicians (21 general practitioners, 9 pediatricians, 4 internists, 2 gynecologists, 1 dermatologist, and 1 neurologist) participating in the EvaMed Network. In addition to standard medical education, all physicians had 5 years practical experience and an additional qualification for anthroposophic medicine, which is a subcategory of CAM. All 38 physicians documented ADRs deemed serious, defined as life threatening or resulting in death, disability/incapacity, or inpatient hospital days. Due to the time-consuming nature of documenting ADRs, only a subgroup of 7 physicians (4 in general practice and 1 each in internal medicine, pediatrics, and gynecology) agreed to report both nonserious and serious ADRs. Therefore, the incidence and frequency of ADRs were evaluated in this subgroup. The study period was January 2004 through June 2009. ADRs were documented by the physicians using an electronic case report form in the EvaMed software, which was linked to the physicians' existing electronic medical record (EMR) systems and incorporated into their daily routines to avoid missing data or double entries. The participating physicians were compensated €15 (approximately US$20) for each ADR report. All ADR reports were monitored at the Havelhoehe Research Institute by 2 physicians who evaluated patient characteristics, present visit diagnosis, target drugs, associated drug classes and type of drugs, type of ADR, actions taken for the ADR, and outcome of the ADR. There were 1,018,626 drugs (54.8% CAM) prescribed by the 38 physicians for 88,431 patients, and 412 ADRs reported for 389 patients; 124 (30.1%) ADRs were for CAM drugs. The majority were reported in children (69.2%, n = 285) and females (56.3%, n = 232). All serious ADRs (n = 14) were associated with CON drugs. In the subgroup of 7 physicians who agreed to report all ADRs, a total of 327 serious and nonserious ADRs were reported for 392,243 prescribed drugs (0.08%) and for 308 of 25,966 patients (1.2%). ADRs were reported for 241 of 16,032 children (aged 17 years or younger; 1.5%) versus 67 of 9,934 adults (0.7%). Of the 327 total ADRs, 10 (3.1%) were serious. There were 95 ADRs for 213,900 CAM prescriptions (4.4 per 10,000) versus 232 for 178,343 CON prescriptions (13.0 per 10,000). The CAM drug with the highest frequency of ADRs was Pelargonium sidoides root (0.21%, 4 of 1,940 prescriptions). The most frequently reported ingredient in CAM was ivy leaves with an ADR frequency of 0.17% (n = 11 of 6,575 prescriptions). The most reported drug connected with ADRs was amoxicillin (1.36%, n = 31 of 2,276 prescriptions). The most common ADR medical management was withdrawal of the drug (82.3% overall, 83.9% CAM, 81.6% CON). A sample of 38 CAM physicians reported the occurrence of at least 1 ADR for 0.4% of treated patients in a 5.5-year study period. There were no serious ADRs reported for CAM drugs. In a subsample of 7 physicians who agreed to report all nonserious and serious ADRs, 1.2% of patients experienced at least 1 ADR; rates of ADRs per 10,000 prescriptions were 4.4 for CAM drugs and 13.0 for CON drugs.

EMR Management System for Patient Pulse Data

The purpose of this study is to build an integrated medical information system for effective database management of clinical information and to improve the existing Electronic Medical Record (EMR)-based system that is currently being used in hospitals. The integrated medical information system of hospitals consists of an Order Communication System (OCS), Picture Archiving Communication System (PACS), and Laboratory Information System (LIS), as well as Electronic Medical Record (EMR). It is designed so that remote health screening and patient data search can be accessed through a high speed network-even in remote areas-in order to effectively manage data on medical treatment that patients received at their respective hospitals. The existing oriental treatment system is one in which the doctor requires the patient to visit the hospital in person, so as to be able to check the patient's pulse and measure it with his hand for proper diagnosis and treatment. However, due to the recent development of digitalized medical measurement equipment, not only can doctors now check a patient's pulse without touching it directly, but the measured data are computerized and stored into the database as the electronic obligation record. Thus, even if a patient cannot visit the hospital, proper medical treatment is available by analyzing the patient's medical history and diagnosis process in the remote area. Furthermore, when a comprehensive medical testing center system including the people medical examination and diverse physical examination is established, the quality of medical service is expected to be improved than now.

Exploring clinician adoption of a novel evidence request feature in an electronic medical record system

The research evaluated strategies for facilitating physician adoption of an evidence-based medicine literature request feature recently integrated into an existing electronic medical record (EMR) system. This prospective study explored use of the service by 137 primary care physicians by using service usage statistics and focus group and survey components. The frequency of physicians' requests for literature via the EMR during a 10-month period was examined to explore the impact of several enhanced communication strategies launched mid-way through the observation period. A focus group and a 25-item survey explored physicians' experiences with the service. There was no detectable difference in the proportion of physicians utilizing the service after implementation of the customized communication strategies (11% in each time period, P=1.0, McNemar's test). Forty-eight physicians (35%) responded to the survey. Respondents who had used the service (n=19) indicated that information provided through the service was highly relevant to clinical practice (mean rating 4.6, scale 1 "not relevant"-5 "highly relevant"), and most (n=15) reported sharing the information with colleagues. The enhanced communication strategies, though well received, did not significantly affect use of the service. However, physicians noted the relevance and utility of librarian-summarized evidence from the literature, highlighting the potential benefits of providing expert librarian services in clinical workflow.

Detaillierte Erfassung von Inanspruchnahme, Morbidität, Erkrankungsverläufen und Ergebnissen durch episodenbezogene Dokumentation in der Hausarztpraxis innerhalb des Projekts CONTENT

Billing data for individual patients from General Practice surgeries can be used to analyse primary care utilisation. Making these data available for research and controlling purposes of the German health care system is vital for health services research. Due to the predominant billing purposes, German routine data are unlikely to yield a realistic and differentiated picture of primary care. The General Practice morbidity research network CONTENT (CONTinuous morbidity registration Epidemiologic NeTwork) was established as part of the primary care research grant of the German Federal Ministry of Research and Education. As opposed to other available German routine health care data, the project is designed around episodes of care as the ordering principle of primary care. An episode-based registration integrates the elements reason for encounter, result of the encounter and medical procedure across the quarterly billing timeframe. The use of the International Classification of Primary Care (ICPC) in the CONTENT project supports a specific adaptation to documentation in primary care. As opposed to the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD), ICPC was especially developed for primary care purposes. An episode-based registration and an appropriate classification are prerequisites for a realistic and detailed picture of morbidity and services provided in primary care. An existing electronic medical record (EMR) was extended with domain-specific modules in order to meet the requirements of episode-based registration. The resulting database has already yielded analyses that were impossible to achieve from German routine health care data. Further analyses will subsequently be based on the continuously expanding database and have the potential to shed light on complex epidemiological and health economics research questions. First results point in the direction that the new mode of data collection, in contrast to routinely entered data, features the potential for a more detailed assessment concerning utilisation of medical services, morbidity, course of illness and outcomes in the context of primary care.

A computer-based medical record system and personal digital assistants to assess and follow patients with respiratory tract infections visiting a rural Kenyan health centre

BackgroundClinical research can be facilitated by the use of informatics tools. We used an existing electronic medical record (EMR) system and personal data assistants (PDAs) to assess the characteristics and outcomes of patients with acute respiratory illnesses (ARIs) visiting a Kenyan rural health center.MethodsWe modified the existing EMR to include details on patients with ARIs. The EMR database was then used to identify patients with ARIs who were prospectively followed up by a research assistant who rode a bicycle to patients' homes and entered data into a PDA.ResultsA total of 2986 clinic visits for 2009 adult patients with respiratory infections were registered in the database between August 2002 and January 2005; 433 patients were selected for outcome assessments. These patients were followed up in the villages and assessed at 7 and 30 days later. Complete follow-up data were obtained on 381 patients (88%) and merged with data from the enrollment visit's electronic medical records and subsequent health center visits to assess duration of illness and complications. Symptoms improved at 7 and 30 days, but a substantial minority of patients had persistent symptoms. Eleven percent of patients sought additional care for their respiratory infection.ConclusionEMRs and PDA are useful tools for performing prospective clinical research in resource constrained developing countries.