Medical Electronic Health Record Research Articles

Analgesic regimens administered to older adults receiving skilled nursing facility care following hip fracture: a proof-of-concept federated analysis

BackgroundAlthough a majority of patients in the U.S. receive post-acute care in skilled nursing facilities (SNFs) following hip fracture, large-sample observational studies of analgesic prescribing and use in SNFs have not been possible due to limitations in available data sources. We conducted a proof-of-concept federated analysis of electronic health records (EHRs) from 11 SNF chains to describe analgesic use during hip fracture post-acute care.MethodsWe included residents with a diagnosis of hip fracture between January 1, 2018 and June 30, 2021 who had at least one administration of an analgesic. Use of analgesics was ascertained from EHR medication orders and medication administration records. We quantified the proportion of residents receiving analgesic regimens based on the medications that were administered up to 100 days after hip fracture diagnosis. Plots visualizing trends in analgesic use were stratified by multiple resident characteristics including age and Alzheimer’s Disease and Related Dementias (ADRD) diagnosis.ResultsThe study included 23,706 residents (mean age 80.5 years, 68.6% female, 87.7% White). Most (~ 60%) residents received opioids + APAP. Monotherapy with APAP or opioids was also common. The most prevalent regimens were oxycodone + APAP (20.1%), hydrocodone + APAP (15.8%), APAP only (15.1%), tramadol + APAP (10.4%), and oxycodone only (4.3%). During the study period, use of APAP-only increased, opioids-only decreased, and opioids + APAP remained stable. Use of APAP-only appeared to be more prevalent among individuals aged > 75 years (versus ≤ 75 years) and those with ADRD (versus without).ConclusionsWe successfully leveraged federated SNF EHR data to describe analgesic use among residents receiving hip fracture post-acute care.

Elevating Patient Engagement: Implementing EHR-Integrated Medication Reminders for Kidney Transplant Patients.

Digital health can enhance self-management of patients such as usage of medication reminders, thereby improving health outcomes. However, for successful implementation of such interventions, integration with the electronic health record (EHR) is useful. We evaluated the implementation of an integrated patient portal medication reminder tool in kidney transplant patients. Overall, 40.5% of the patients agreed that integrated EHR medication reminders assisted them in taking their medication on time.

Allergen skin test responses in broad U.S. asthma population in those with and without rhinitis.

Background: Asthma and allergic rhinitis are pathologically interlinked conditions. Despite skin testing (ST) being pivotal for evaluating allergic sensitization, U.S. data that date back to 1960s on ST reactivity patterns in subjects with asthma remain sparse. Objective: The purpose of this study was to elucidate seasonal, perennial ST responses, and their relationship with asthma severity, early versus late onset disease, and immunoglobulin E (IgE) levels. Methods: Five hundred patients with asthma were randomly selected from the National Jewish Health electronic medical record over a 3-year span. Demographic, clinical, and allergen ST reactivity data for a battery of seasonal and perennial allergens were procured, including total IgE levels, asthma onset, and severity, by using t-tests, χ² tests, and Analysis of Variance (ANOVA), patterns of reactivity were assessed for overall, seasonal, and perennial allergens in relation to IgE levels, asthma onset, and severity. Results: Of the 500 patients, 398 were analyzed. 63.3% were women, 50.1% had adult-onset asthma, and 86.1% had rhinitis; 75.3% tested positive to one or more allergens, with men demonstrating higher overall (p = 0.039) and perennial (p = 0.035) sensitization. ST reactivity varied based on the presence of rhinitis for seasonal (p = 0.028) but not perennial (p = 0.733) allergens. Asthma severity was not significantly associated with ST reactivity (p > 0.10). ST positivity for perennial (p < 0.001) but not seasonal (p = 0.128) allergens was higher in childhood-onset asthma versus adult-onset asthma despite both groups having a large percentage of reactors. Elevated IgE levels correlated with ST reactivity (p < 0.01). Conclusion: Our study represents a unique comprehensive evaluation of ST reactivity in a U.S. asthma population, which is lacking in the literature, when factoring in asthma onset, severity, and IgE levels. Our findings underscore the importance of allergen sensitization in asthma, regardless of severity, concurrent rhinitis symptoms, or asthma onset, which challenge some of the prevailing assumptions about the relationship between allergen sensitization and asthma onset.

Using Electronic Health Records and Linked Claims Data to Assess New Medication Use and Primary Nonadherence in Rheumatology Patients.

The objective of this study was to determine the proportion of new medication prescriptions observed in electronic health records (EHR) that represent true incident medication use, accounting for undocumented previous prescriptions (prevalent medication use) and failure to initiate treatment (primary nonadherence) with linked administrative claims data as the reference standard. Using single-specialty rheumatology EHR data from more than 700 community practices in the United States linked to administrative claims data, we identified first (index) EHR prescriptions and assessed the positive predictive value (PPV) of different EHR-derived new user definitions to identify true incident use (no prior claims). We then assessed how often index EHR prescriptions that met a definition of new use resulted in primary nonadherence (no subsequent claims). Overall, 12,405 index EHR prescriptions were identified with PPVs of 0.59 to 0.67 for true incident use. PPVs increased to 0.76 to 0.85 by excluding medications listed during the EHR medication reconciliation process and further increased to 0.87 to 0.93 by requiring ≥12 elapsed months since the first rheumatology office visit. Primary nonadherence at three months was observed in 33% to 38% overall and varied substantially by medication class, ranging from 15% to 23% for conventional synthetic disease-modifying antirheumatic drugs (DMARDs) to 54% to 64% for targeted synthetic DMARDs. New DMARD use was accurately distinguished from prevalent use with EHR prescriptions and simple new user definitions that include current medications collected during medication reconciliation. Primary nonadherence was frequent and varied by DMARD class. This has important implications for epidemiologic studies using EHR data and for optimal delivery of clinical care.

Beyond Hospital-Level Aggregated Data: A Methodology to Adapt Clinical Data From the Electronic Health Record for Nursing Unit-Level Research.

Studies of nurse staffing frequently use data aggregated at the hospital level that do not provide the appropriate context to inform unit-level decisions, such as nurse staffing. Describe a method to link patient data collected during the provision of routine care and recorded in the electronic health record (EHR) to the nursing units where care occurred in a national dataset. We identified all Veterans Health Administration acute care hospitalizations in the calendar year 2019 nationwide. We linked patient-level EHR and bar code medication administration data to nursing units using a crosswalk. We divided hospitalizations into segments based on the patient's time-stamped location (ward stays). We calculated the number of ward stays and medication administrations linked to a nursing unit and the unit-level and facility-level mean patient risk scores. We extracted data on 1117 nursing units, 3782 EHR patient locations associated with 1,137,391 ward stays, and 67,772 bar code medication administration locations associated with 147,686,996 medication administrations across 125 Veterans Health Administration facilities. We linked 89.46% of ward stays and 93.10% of medication administrations to a nursing unit. The average (standard deviation) unit-level patient severity across all facilities is 4.71 (1.52), versus 4.53 (0.88) at the facility level. Identification of units is indispensable for using EHR data to understand unit-level phenomena in nursing research and can provide the context-specific information needed by managers making frontline decisions about staffing.

Implementing pharmacist-prescriber collaboration to improve evidence-based anticoagulant use: a randomized trial

BackgroundDirect oral anticoagulant medications are commonly used to treat or prevent thrombotic conditions, such as pulmonary embolism, deep vein thrombosis, and atrial fibrillation. However, up to 10–15% of patients receiving these medications get unsafe doses based on a patient’s kidney or liver function, potential interactions with other medications, and indication for taking the medication. Alert systems may be beneficial for improving evidence-based prescribing, but can be burdensome and are not currently able to provide monitoring after the initial prescription is written.Methods/designThis study will improve upon existing alert systems by testing novel medication alerts that encourage collaboration between prescribers (e.g., physicians, nurse practitioners, physician assistants) and expert pharmacists working in anticoagulation clinics. The study will also improve upon the existing alert system by incorporating dynamic long-term monitoring of patient needs and encouraging collaboration between prescribers and expert pharmacists working in anticoagulation clinics. Incorporating state-of-the-art user-centered design principles, prescribing healthcare providers will be randomized to different types of electronic health record medication alerts when a patient has an unsafe anticoagulant prescription. We will identify which alerts are most effective at encouraging evidence-based prescribing and will test moderators to tailor alert delivery to when it is most beneficial. The aims of the project are to (1) determine the effect of notifications targeting existing inappropriate DOAC prescriptions; (2) examine the effect of alerts on newly prescribed inappropriate DOACs; and (3) examine changes in the magnitude of effects over time for both the new prescription alerts and existing prescription notifications for inappropriate DOACs over the 18-month study period.DiscussionFindings from this project will establish a framework for implementing prescriber-pharmacist collaboration for high-risk medications, including anticoagulants. If effectively implemented at the more than 3000 anticoagulation clinics that exist nationally, hundreds of thousands of patients taking direct oral anticoagulants stand to benefit from safer, evidence-based healthcare.Trials registrationNCT05351749.

Establishing a pharmacy revenue integrity team: A blueprint for increasing pharmacy's role in health-system revenue cycle.

An increasing focus on driving margin has pushed health-system pharmacy departments to find new ways of generating new or protecting existing revenue. At UNC Health, a dedicated pharmacy revenue integrity (PRI) team has been operating since 2017. This team has been able to significantly reduce revenue loss from denials, increase billing compliance, and improve revenue capture. This article provides a framework for establishing a PRI program and reports results generated from it. The activities of a PRI program can be grouped into 3 main pillars: minimizing revenue loss, optimizing revenue capture, and ensuring billing compliance. Minimizing revenue loss is accomplished primarily through management of pharmacy charge denials and can be an ideal first step in establishing a PRI program due to the tangible value generated. Optimizing revenue capture involves a combination of clinical expertise and understanding of billing operations to ensure medications are being billed and reimbursed appropriately. Finally, ensuring billing compliance, including ownership of the pharmacy charge description master and maintenance of electronic health record medication lists, is vital in preventing charge and reimbursement errors. Successfully bringing traditional revenue cycle functions into the department of pharmacy can be a daunting task but provides significant opportunities to create value for a health system. Key factors to the success of a PRI program include robust data access, hiring individuals with financial and pharmacy expertise into PRI positions, strong relationships with the existing revenue cycle teams, and a progressive model that allows for incremental expansion of services.

High-Throughput Assessment of Real-World Medication Effects on QT Interval Prolongation: Observational Study.

Drug-induced prolongation of the corrected QT interval (QTc) increases the risk for Torsades de Pointes (TdP) and sudden cardiac death. Medication effects on the QTc have been studied in controlled settings but may not be well evaluated in real-world settings where medication effects may be modulated by patient demographics and comorbidities as well as the usage of other concomitant medications. We demonstrate a new, high-throughput method leveraging electronic health records (EHRs) and the Surescripts pharmacy database to monitor real-world QTc-prolonging medication and potential interacting effects from demographics and comorbidities. We included all outpatient electrocardiograms (ECGs) from September 2008 to December 2019 at a large academic medical system, which were in sinus rhythm with a heart rate of 40-100 beats per minute, QRS duration of <120 milliseconds, and QTc of 300-700 milliseconds, determined using the Bazett formula. We used prescription information from the Surescripts pharmacy database and EHR medication lists to classify whether a patient was on a medication during an ECG. Negative control ECGs were obtained from patients not currently on the medication but who had been or would be on that medication within 1 year. We calculated the difference in mean QTc between ECGs of patients who are on and those who are off a medication and made comparisons to known medication TdP risks per the CredibleMeds.org database. Using linear regression analysis, we studied the interaction of patient-level demographics or comorbidities on medication-related QTc prolongation. We analyzed the effects of 272 medications on 310,335 ECGs from 159,397 individuals. Medications associated with the greatest QTc prolongation were dofetilide (mean QTc difference 21.52, 95% CI 10.58-32.70 milliseconds), mexiletine (mean QTc difference 18.56, 95% CI 7.70-29.27 milliseconds), amiodarone (mean QTc difference 14.96, 95% CI 13.52-16.33 milliseconds), rifaximin (mean QTc difference 14.50, 95% CI 12.12-17.13 milliseconds), and sotalol (mean QTc difference 10.73, 95% CI 7.09-14.37 milliseconds). Several top QT prolonging medications such as rifaximin, lactulose, cinacalcet, and lenalidomide were not previously known but have plausible mechanistic explanations. Significant interactions were observed between demographics or comorbidities and QTc prolongation with many medications, such as coronary disease and amiodarone. We demonstrate a new, high-throughput technique for monitoring real-world effects of QTc-prolonging medications from readily accessible clinical data. Using this approach, we confirmed known medications for QTc prolongation and identified potential new associations and demographic or comorbidity interactions that could supplement findings in curated databases. Our single-center results would benefit from additional verification in future multisite studies that incorporate larger numbers of patients and ECGs along with more precise medication adherence and comorbidity data.

VIONE: An Innovative Electronic Health Record Medication Optimization Methodology

VIONE methodology is an award winning, USA based patient safety project that transformed our national landscape with High Reliability Organization (HRO) concepts. VIONE’s clinical, academic, research, leadership, modern technology tools achieve sustainable reductions and optimization of Potentially Inappropriate Medications (PIM) and adverse outcomes such as hospitalizations, falls, death, clinical waste, etc.

1274. Implementation of Pharmacist-led Medication Reconciliation in Older PLHIV

Abstract Background Older (age ≥ 50) people living with HIV (PLHIV) have a higher prevalence of non-AIDS associated comorbidities and polypharmacy. Optimal care requires accurate knowledge of the number and types of medications older PLHIV take. Most providers use the electronic health record (EHR) to obtain this information, despite reported inaccuracy in other cohorts. Recent efforts have focused on engaging pharmacists to assist with EHR medication reconciliation. This abstract describes the results of a pilot study of phone-based, pharmacist-driven EHR medication reconciliation. Methods Older PLHIV reported via an online questionnaire the number of prescription medications they took, with response options ranging from “0” to “11 or more.” Then, a clinic-based pharmacist called each participant to review the daily and prn prescription medications they were taking. Finally, a physician reviewed EHR pharmacy data to count the number of daily and prn prescription medications listed. Wilcoxon rank sum tests compared the medians between the phone review, the self-reported questionnaire, and the EHR review. Results Forty participants were offered the intervention, and 26 (65%) were reachable by phone and agreed. Of those, the mean age was 61 years (range 51-73), 89% were male, 67% were White, and the mean number of self-reported comorbid conditions was 11.7 (SD=7.7). In 25/26 (96%) cases, both the number and type of HIV medications in the EHR matched what the pharmacist verified on the phone call. Median number of non-HIV medications are reported in Table 1. Assuming that pharmacist phone calls provided the most accurate data, the EHR overestimated the number of non-HIV medications by 5 medications (P = 0.01), whereas patients’ self-report underestimated by 1.5 medications (P &amp;lt; 0.01). Conclusion Among older PLHIV, EHR pharmacy data significantly overestimated, and patient self-report significantly underestimated, the number of non-HIV prescription medications. Phone-based, pharmacy-driven medication reconciliation improved upon both EHR-based and self-reported medication accuracy. Based on these findings, future interventions designed to decrease polypharmacy in older PLWHIV can rely upon pharmacist-led, phone-based outreach to ensure that baseline medication information is accurate. Disclosures Maile Y. Karris, MD, Gilead Sciences: Grant/Research Support|Gilead Sciences: I have received honorarium to speak at conferences|ViiV Healthcare: Grant/Research Support Peter J. Mazonson, MD, MBA, ViiV Healthcare: Grant/Research Support Lucas Hill, PharmD, AAHIVP, Gilead Sciences: Speakers Bureau Emily Huang, MPH, ViiV Healthcare: Grant/Research Support Jeff Berko, MPH, ViiV Healthcare: Grant/Research Support.

Pharmacist-managed multistep order transmittal for electronic specialty prescriptions reduces represcribing burden in ambulatory clinics: A retrospective cohort pilot study.

BACKGROUND: Specialty medications pose unique prescribing challenges, including complexities with drug dosing and safety monitoring, need for prior authorization and patient financial assistance, use of payer-mandated specialty pharmacies, and special requirements for storage and handling. These challenges can lead to higher rates of represcribing for specialty clinic providers, who may be operating with inadequate information or limited resources. Multistep order transmittal (MSOT) is an electronic medical record (EMR) prescription work queue functionality used by a specialty pharmacy service to support select ambulatory clinics. OBJECTIVE: To explore the relationship between an MSOT specialty pharmacy support service and represcribing burden of specialty medications for providers in an ambulatory care setting. METHODS: A retrospective cohort pilot study was performed before and after MSOT implementation. Prescription data were queried from Sanford Health's EMR for patients who were electronically issued at least 1 prescription for an injectable biologic medication at a dermatology and rheumatology clinic. The pre-intervention group included index prescriptions prescribed between October 1, 2017, and June 20, 2018. The post-intervention group included index prescriptions prescribed between October 1, 2018, and June 20, 2019. Retrospective EMR review was completed to identify any prescriptions that were represcribed and the reason for represcribing. The primary outcome was the rate of represcribing. Secondary endpoints explored reason for represcribing, when it occurred. Nominal data were compared using Pearson's chi-square tests. Regressions were performed to account for potential confounders. RESULTS: The pre-intervention group included 880 index biologic prescriptions, and the post-intervention group included 941 index biologic prescriptions. The aggregate represcribing rate decreased from 12.73% in the pre-intervention group to 9.56% in the postintervention group (P = 0.03). Represcribing directly by providers as a result of needing to modify the destination pharmacy decreased significantly from 6.25% of the pre-intervention group to 0.64% of the post-intervention group (P < 0.01). However, represcribing due to patient preferences and prescribing errors increased significantly between the pre- and post-intervention groups, with patient preferences increasing from 0.91% to 2.55% (P = 0.01) and prescribing errors from 0.68% to 1.70% (P = 0.05), respectively. Represcribing due to provider preferences and payer restrictions remained similar between groups. CONCLUSIONS: Within 2 ambulatory care clinics in an integrated health care system, the use of pharmacist-managed MSOT reduced overall represcribing burden. The need to represcribe owing to wrong destination pharmacy was nearly eliminated, while appropriate represcribing to accommodate patient preferences and correct prescribing errors increased. DISCLOSURES: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to disclose.

Developing Clinical Prediction Models Using Primary Care Electronic Health Record Data: The Impact of Data Preparation Choices on Model Performance.

To quantify prediction model performance in relation to data preparation choices when using electronic health records (EHR). Cox proportional hazards models were developed for predicting the first-ever main adverse cardiovascular events using Dutch primary care EHR data. The reference model was based on a 1-year run-in period, cardiovascular events were defined based on both EHR diagnosis and medication codes, and missing values were multiply imputed. We compared data preparation choices based on (i) length of the run-in period (2- or 3-year run-in); (ii) outcome definition (EHR diagnosis codes or medication codes only); and (iii) methods addressing missing values (mean imputation or complete case analysis) by making variations on the derivation set and testing their impact in a validation set. We included 89,491 patients in whom 6,736 first-ever main adverse cardiovascular events occurred during a median follow-up of 8 years. Outcome definition based only on diagnosis codes led to a systematic underestimation of risk (calibration curve intercept: 0.84; 95% CI: 0.83-0.84), while complete case analysis led to overestimation (calibration curve intercept: -0.52; 95% CI: -0.53 to -0.51). Differences in the length of the run-in period showed no relevant impact on calibration and discrimination. Data preparation choices regarding outcome definition or methods to address missing values can have a substantial impact on the calibration of predictions, hampering reliable clinical decision support. This study further illustrates the urgency of transparent reporting of modeling choices in an EHR data setting.

Considerations for observational study design: Comparing the evidence of opioid use between electronic health records and insurance claims.

Pharmacoepidemiology studies often use insurance claims and/or electronic health records (EHR) to capture information about medication exposure. The choice between these data sources has important implications. We linked EHR from a large academic health system (2015-2017) to Medicare insurance claims for patients undergoing surgery. Drug utilization was characterized based on medication order dates in the EHR, and prescription fill dates in Medicare claims. We compared opioid use documented in EHR orders to prescription claims in four time periods: 1) Baseline (182 days before surgery); 2) Perioperative period; 3) Discharge date; 4) Follow-up (90 days after surgery). We identified 11 128 patients undergoing surgery. During baseline, 34.4% (EHR) versus 44.1% (claims) had evidence of opioid use, and 56.9% of all baseline use was reflected only in one data source. During the perioperative period, 78.8% (EHR) versus 47.6% (claims) had evidence of use. On the day of discharge, 59.6% (EHR) versus 45.5% (claims) had evidence of use, and 51.8% of all discharge use was reflected only in one data source. During follow-up, 4.3% (EHR) versus 10.4% (claims) were identified with prolonged opioid use following surgery with 81.4% of all prolonged use reflected only in one data source. When characterizing opioid exposure, we found substantial discrepancies between EHR medication orders and prescription claims data. In all time periods assessed, most patients' use was reflected only in the EHR, or only in the claims, not both. The potential for misclassification of drug utilization must be evaluated carefully, and choice of data source may have large impacts on key study design elements.

Impaired SARS-CoV-2 mRNA Vaccine Antibody Response in Chronic Medical Conditions: A Real-World Analysis

Impaired SARS-CoV-2 mRNA Vaccine Antibody Response in Chronic Medical Conditions: A Real-World Analysis

Is Electronic Health Record Safety a Paradox?

Is Electronic Health Record Safety a Paradox?

Abstract 12176: Oral Anticoagulant Therapy Following Single-Lead ECG Screening Among Older Patients With Atrial Fibrillation: The VITAL-AF Trial

Introduction: A substantial proportion of patients with atrial fibrillation do not take oral anticoagulants (OAC). Point of care ECG testing at primary care visits may prompt reassessment of OAC eligibility in patients with AF. Methods: VITAL-AF (NCT035115057) was a cluster-randomized trial of AF screening using single-lead handheld electrocardiograms within 16 primary care practices affiliated with Massachusetts General Hospital. The goal of VITAL-AF was to screen for undiagnosed AF. For pragmatic reasons the trial included all individuals aged ≥ 65 years, including those with an established diagnosis of AF. We evaluated screening uptake among prevalent AF patients in the screening arm, OAC initiation among both screening and control patients with prevalent AF, and OAC initiation by screening result (adjusted for stroke/bleed risk factors compared to all patients not screened). OAC use was identified using electronic health record medication lists during the 1-year prior to and following a patient’s study index visit. Results: Prevalent AF was present in 2,250 patients (75% on OAC) in the screening arm and 2,343 patients (76% on OAC) in the control arm. 90% of patients in the screening arm were screened at least once during the study period (mean 2.4 times screened). 31.5% had a “Possible AF” and 17.2% had an “Unclassified” automated algorithm screening result during their first screening encounter (40.1% “Possible AF” and 27.4% “Unclassified” during any encounter). Overall, OAC initiation was similar among prevalent AF patients from the screening arm and control arm ( Table ). OAC initiation was higher among screened patients who had a “Possible AF” automated result (Adjusted Odds Ratio 1.14, 95% CI: 1.05-1.24). Conclusions: Point of care cardiac rhythm assessment was not associated with significant changes in the use of OAC in patients with a history of AF. However, screened patients not on OAC who had a positive single-lead ECG were more likely to initiate OAC.

Validation of EHR medication fill data obtained through electronic linkage with pharmacies.

BACKGROUND: Recent linkages between electronic health records (EHRs) and pharmacy data hold opportunity for up-to-date assessment of medication adherence at the point of care. OBJECTIVE: To validate linked EHR-pharmacy data, which can be used for point-of-care interventions for concordance with insurance claims data for patients in a large health care delivery system. METHODS: We performed a retrospective cohort study of adult patients with an active antihypertensive medication order and seen as outpatients between August 25, 2019, and August 31, 2019. Pharmacy fill information was obtained from the EHR via linkages with Surescripts pharmacy and pharmacy benefit manager data, as well as from insurance claims available at our institution. We matched antihypertensive medication fills observed in the linked EHR-pharmacy database with available fills in the insurance claims database and calculated the percentage of medication fills that were available in each database. We estimated medication adherence using proportion of days covered in the linked EHR-pharmacy database and in the insurance claims database. RESULTS: Of 26,679 patients with hypertension, 23,348 (87.5%) had at least 1 antihypertensive medication fill recorded in the linked EHR-pharmacy database. Of 1,501 patients matched with the insurance database and with a documented medication fill, a fill was present for 1,484 (98.9%) and 1,259 (83.9%) patients in the linked EHR-pharmacy and insurance databases, respectively. Of 12,109 medication fills recorded in the insurance data, we found an overlap of 11,060 (91.3%) fills with the linked EHR-pharmacy database. The linked EHR-pharmacy database also contained 18,232 of 19,281 (94.6%) medication fills present in either database. Measured medication adherence was higher for patients when based on linked EHR-pharmacy data compared with insurance claims data (42% vs 30%, P < 0.001). CONCLUSIONS: Linked EHR-pharmacy data captured medication fills for the vast majority of patients and resulted in higher estimates of adherence than insurance claims. Our results suggest that pharmacy fill data available in the EHR have sufficient reliability to be used for point-of-care assessment of medication adherence. DISCLOSURES: This study was supported by grant R01HL155149 from the National Heart, Lung, and Blood Institute. Allen Thorpe provided funding for the NYU Langone Health Learning Health System Program, which helped fund this project. The authors have nothing to disclose.

Association of Hospital Public Quality Reporting With Electronic Health Record Medication Safety Performance

Despite billions spent in public investment, electronic health records (EHRs) have not delivered on the promise of large quality and safety improvement. Simultaneously, there is debate on whether public quality reporting is a useful tool to incentivize quality improvement. To evaluate whether publicly reported feedback was associated with hospital improvement in an evaluation of medication-related clinical decision support (CDS) safety performance. This nonrandomized controlled trial included US hospitals that participated in the Computerized Provider Order Entry (CPOE) Evaluation Tool in the Leapfrog Hospital Survey, a national quality reporting program that evaluates safety performance of hospital CDS using simulated orders and patients, in 2017 to 2018. A sharp regression discontinuity design was used to identify the association of receiving negative feedback with hospital performance improvement in the subsequent year. Data were analyzed from January through September 2020. Publicly reported quality feedback. The main outcome was improvement from 2017 to 2018 on the Leapfrog CPOE Evaluation Tool, using regression discontinuity model estimates of the association of receiving negative publicly reported feedback with quality improvement. A total of 1183 hospitals were included, with a mean (SD) CPOE score of 59.3% (16.3%) at baseline. Hospitals receiving negative feedback improved 8.44 (95% CI, 0.09 to 16.80) percentage points more in the subsequent year compared with hospitals that received positive feedback on the same evaluation. This change was driven by differences in improvement in basic CDS capabilities (β = 8.71 [95%CI, 1.67 to 18.73]) rather than advanced CDS (β = 6.15 [95% CI, -9.11 to 26.83]). In this nonrandomized controlled trial, publicly reported feedback was associated with quality improvement, suggesting targeted measurement and reporting of process quality may be an effective policy lever to encourage improvement in specific areas. Clinical decision support represents an important tool in ensuring patient safety and decreasing adverse drug events, especially for complex patients and those with multiple chronic conditions who often receive several different drugs during an episode of care.

Analysis of provider-generated revenue and impact on medication reconciliation from a pharmacist-led chronic care management service

BackgroundPublished data on pharmacist-provided chronic care management (CCM) services is limited, particularly for programs led by community-based pharmacists. ObjectiveThe objective was to quantify the total revenue generated from a community pharmacist-led CCM service, including CCM billing and appointment referrals. A second objective was to identify the types and frequencies of medication discrepancies identified during medication reconciliation. Practice descriptionRealo Drugs is a group of 18 independent community pharmacies serving eastern North Carolina. Practice innovationExploration of revenue generated from a community pharmacist-led CCM service. Evaluation methodsThis retrospective analysis assessed interventions completed by pharmacists between April 1, 2018 through June 30, 2019. Data was extracted from the electronic health record (EHR), including revenue generated from CCM billing codes, appointment referrals made by the pharmacist resulting in a completed in-office appointment, and which patients received medication reconciliation. The types and frequencies of medication discrepancies were documented, including medication no longer being used by the patient, medication omission, and strength or dose mismatch. Descriptive statistics were used to analyze data. ResultsOver 15 months with a total of 112 patients, a total of $26,148 was generated from CCM services, representing an average of $15.56 per patient per month. The majority (approximately 80%) of the revenue was generated from noncomplex patient encounters. Of the 239 medication reconciliations completed, 609 medication discrepancies were identified. The majority of medication discrepancies (67%) were categorized as “patient no longer takes medication listed on EHR medication list.” The second most common discrepancy was “patient takes medication not listed on the EHR medication list” (22%), followed by “strength/dose mismatch” (10%). ConclusionThese data can demonstrate to provider partners the sources of revenue that can be provided through CCM services. In addition to revenue, pharmacists can positively impact patient care through identification of medication discrepancies through medication reconciliation.

977. Bacterial STI Diagnoses as Missed Opportunities for HIV Pre-Exposure Prophylaxis

BackgroundNew HIV diagnoses in the United States have remained stagnant while the incidence has increased among certain groups; additional efforts towards HIV prevention are needed. Most adults who could benefit from HIV Pre-Exposure Prophylaxis (PrEP) in the United States are not receiving it. Many of these individuals present for healthcare visits for bacterial sexually transmitted infection (STI), an indication for PrEP in both men who have sex with men (MSM) and heterosexual individuals; we sought to characterize these visits and identify missed opportunities for PrEP prescription to inform future PrEP expansion efforts.MethodsA retrospective chart review was conducted for all healthcare encounters of adult patients newly diagnosed with a bacterial STI within the UC Davis Health electronic medical record between January 1, 2017 and December 31, 2017. A bacterial STI was defined as a positive test result for gonorrhea, chlamydia, or syphilis. Patients were excluded if they had HIV, were pregnant or a prisoner, or if they were a woman or heterosexual man with a positive test result for chlamydia (not an indication for PrEP per CDC guidelines). Patient demographic, clinical, and visit-specific data were recorded; characteristics were described using frequencies for categorical variables, and median and quartiles for quantitative variables.Results205 encounters for bacterial STI were identified as potential opportunities for PrEP. The majority of PrEP candidates presented to the emergency department for their STI (44%), while 40% and 16% of encounters occurred in outpatient and inpatient settings, respectively. The majority of PrEP candidates were not offered PrEP within 6 months of their encounter for STI (86%). Of the 14% of PrEP candidates who were offered PrEP within 6 months of their STI diagnosis, the majority had presented to the outpatient setting for their STI (93%).ConclusionVisits to the emergency department for bacterial STI represent a disproportionate missed opportunity for PrEP discussion & prescription. Future PrEP expansion efforts should address emergency department visits as opportunities for linkage to PrEP and/or PrEP prescription.Disclosures All Authors: No reported disclosures