Hospital Electronic Health Record Research Articles

Taipei Medical University Clinical Research Database: a collaborative hospital EHR database aligned with international common data standards

ObjectiveThe objective of this paper is to provide a comprehensive overview of the development and features of the Taipei Medical University Clinical Research Database (TMUCRD), a repository of real-world data...

Efficacy of post-operative X-rays after operatively treated ankle fractures: What is their role?

ObjectiveThe utility of routine post-operative imaging in clinically asymptomatic patients is unclear. We sought to determine how frequently X-rays following operatively treated ankle fractures result in a change in management. DesignRetrospective cohort study conducted with hospital electronic health record SettingSingle level 1 trauma center in major urban city. Patients/Participants193 patients with operatively treated ankle fractures at our institution between January 2020 and December 2021. Main Outcome MeasuresPatient radiographs were categorized as surveillance X-rays and clinically indicated X-rays. Changes in management were defined as alteration in follow-up, deviation from standard post-operative protocols, or revision surgery. A logistic regression was performed looking at factors predicting whether an X-ray changes management. A cost analysis was also performed looking at the financial implications of asymptomatic surveillance of ankle fractures. Results438 post-operative X-rays were found and included in analysis. Of these, 391 were considered surveillance X-rays and 47 clinically indicated. 23 X-rays were determined to have resulted in changes in management (18 clinically indicated, 5 taken in asymptomatic patients). The number of management changing X-rays was significantly higher in the clinically indicated group (p < 0.0001). The only factor associated with whether an X-ray changed management was whether the patient was symptomatic at the visit (p < 0.0001). Asymptomatic surveillance X-rays cost our institution 21,825.62 USD per year. ConclusionsRadiographs in clinically asymptomatic patients with operatively managed ankle fractures have a low likelihood of changing management. Such imaging represents costs to the healthcare system, increased time for patients during clinic visits, and radiation exposure. The use of screening radiographic studies remains commonplace because the risk of delayed diagnosis is great, and the goal of any surgeon should be the swift identification of complications in order to minimize patient morbidity. Future surveillance protocols should consider the findings of this and other studies on the use of screening radiographs and strike a careful balance between minimizing unnecessary imaging, maximizing early complication detection, and ensuring a personalized approach towards patient-level factors to optimize care and efficiency for both patient and health system. Level of EvidenceLevel III

Development and validation of a clinical decision support system to prevent anticoagulant duplications

Background and ObjectiveUnintended duplicate prescriptions of anticoagulants increase the risk of serious adverse events. Clinical Decision Support Systems (CDSSs) can help prevent such medication errors; however, sophisticated algorithms are needed to avoid alert fatigue. This article describes the steps taken in our hospital to develop a CDSS to prevent anticoagulant duplication (AD). MethodsThe project was composed of three phases. In phase I, the status quo was established. In phase II, a clinical pharmacist developed an algorithm to detect ADs using daily data exports. In phase III, the algorithm was integrated into the hospital's electronic health record system. Alerts were reviewed by clinical pharmacists before being sent to the prescribing physician. We conducted a retrospective analysis of all three phases to assess the impact of the interventions on the occurrence and duration of ADs. Phase III was analyzed in more detail regarding the acceptance rate, sensitivity, and specificity of the alerts. ResultsWe identified 91 ADs in 1641 patients receiving two or more anticoagulants during phase I, 70 ADs in 1696 patients in phase II, and 57 ADs in 1576 patients in phase III. Mean durations of ADs were 1.8, 1.4, and 1.1 calendar days during phases I, II, and III, respectively. In comparison to the baseline in phase I, the relative risk reduction of AD in patients treated with at least two different anticoagulants during phase III was 39% (RR: 0.61, CI: 0.44–0.85). A total of 429 alerts were generated during phase III, many of which were self-limiting, and 186 alerts were sent to the respective prescribing physician. The acceptance rate was high at 97%. We calculated a sensitivity of 87.4% and a specificity of 87.9%. ConclusionThe stepwise development of a CDSS for the detection of AD markedly reduced the frequency and duration of medication errors in our hospital, thereby improving patient safety.

Syndromic surveillance of population-level COVID-19 burden with cough monitoring in a hospital emergency waiting room.

Syndromic surveillance is an effective tool for enabling the timely detection of infectious disease outbreaks and facilitating the implementation of effective mitigation strategies by public health authorities. While various information sources are currently utilized to collect syndromic signal data for analysis, the aggregated measurement of cough, an important symptom for many illnesses, is not widely employed as a syndromic signal. With recent advancements in ubiquitous sensing technologies, it becomes feasible to continuously measure population-level cough incidence in a contactless, unobtrusive, and automated manner. In this work, we demonstrate the utility of monitoring aggregated cough count as a syndromic indicator to estimate COVID-19 cases. In our study, we deployed a sensor-based platform (Syndromic Logger) in the emergency room of a large hospital. The platform captured syndromic signals from audio, thermal imaging, and radar, while the ground truth data were collected from the hospital's electronic health record. Our analysis revealed a significant correlation between the aggregated cough count and positive COVID-19 cases in the hospital (Pearson correlation of 0.40, p-value < 0.001). Notably, this correlation was higher than that observed with the number of individuals presenting with fever (ρ = 0.22, p = 0.04), a widely used syndromic signal and screening tool for such diseases. Furthermore, we demonstrate how the data obtained from our Syndromic Logger platform could be leveraged to estimate various COVID-19-related statistics using multiple modeling approaches. Aggregated cough counts and other data, such as people density collected from our platform, can be utilized to predict COVID-19 patient visits related metrics in a hospital waiting room, and SHAP and Gini feature importance-based metrics showed cough count as the important feature for these prediction models. Furthermore, we have shown that predictions based on cough counting outperform models based on fever detection (e.g., temperatures over 39°C), which require more intrusive engagement with the population. Our findings highlight that incorporating cough-counting based signals into syndromic surveillance systems can significantly enhance overall resilience against future public health challenges, such as emerging disease outbreaks or pandemics.

Clinicians' Attitudes Toward Electronic Health Records in Saudi Arabia.

This study explored physicians' and nurses' attitudes towardan electronic health record (EHR) system and examined the features and factors that clinicians associated with the implementation of EHR systems. A self-administered anonymous questionnaire with high reliability and validity was adopted from existing research to gather clinicians' attitudes towardthe EHR system implemented at King Khalid UniversityHospital, one of the biggest hospitals in Riyadh, Saudi Arabia. A total of 438 questionnaire responses were received from the participants; 240 of them were physicians and 198 were nurses. The participants had a mean age of 43.7 years (standard deviation (SD) 17.1), 213 (52.7%) were femaleand 207 (47.3%) were male. Most participants (424, 96.8%) had one or more years of experience using computers, and a majority (304, 69.4%) had one or more years of experience using EHR systems.Most physicians and nurses (214, 89.5%vs. 174, 87.9%) were satisfied with their hospital's EHR systemand felt that the system was highly usable and had the potential to improve communication between staff, facilitate easy storage of and access to informationand lead to improved health outcomes for patients. The study found positive attitudes among clinicians concerning the quality of training and education around the new system (178, 74.2%of physiciansvs. 142, 71.7%of nurses; p > 0.05) and towardleadership during the transition to HER (222, 92.5%vs. 183, 92.4%). On the other hand, a majority of nurses reported that the EHR system took longer to use and increased their workload compared with the previous analogue system (115 (47.9%) vs. 133 (67.2%); p ≤ 0.01and 46.7% vs. 112 (64.1%)). A large majority of physicians and nurses surveyed (214(89.2%) vs. 167 (84.3%)) stated that clinicians should be consulted in the design of such systems as a way to maximise the potential benefits of EHRand mitigate extra workload demands. Most clinicians expressed overall satisfaction with the EHR system, but there were some areas of dissatisfaction among the respondents, such as increasing workload and stress among nurses. There is scope for further research to continue to explore physicians' and nurses' attitudes towardEHRsand for future experimental studies that examine the impact of EHRs on clinician workloads, patient health outcomesand quality of care.

Peg-asparaginase associated toxicities in children with acute lymphoblastic leukemia: A single-center cross-sectional study

BackgroundLeukemia is the most prevalent type of cancer affecting children, representing approximately 35% of cancer diagnoses in Saudi Arabia. Notably, significant improvement in the overall survival and cure rates for pediatrics with acute lymphoblastic leukemia (ALL) has been attributed to adding asparaginase to the chemotherapy regimen. However, the administration of these agents may lead to a multifactorial range of toxicities that often alter treatment outcomes. ObjectiveThe study aimed to characterize the prevalence of common toxicities related to polyethylene glycol (PEG) asparaginase in children aged 0–14 years diagnosed with ALL. Additionally, it assessed the types of toxicities associated with intravenous (IV) and intramuscular (IM) administration of Peg-asparaginase. MethodIt was an observational retrospective cross-sectional study. Data was extracted from the hospital's electronic health record (EPIC). Using EPIC, we reviewed medical charts of all pediatric patients below 14 years old diagnosed with ALL who received at least one dose of PEG-asparaginase between January 2020 and March 2023. The toxicity grading was based on the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE). ResultsOne hundred and ninety-one patients with ALL were included in the study. Overall, 79 toxicity episodes were experienced by the study patients. Anaphylaxis/hypersensitivity (36.7%) and hepatotoxicity (31.6%) were the most prevalent toxicities reported, followed by pancreatitis and hyperglycemia (12.7% each). According to the CTCAE grading, approximately 70% of toxicities were categorized as Grade 3 and 4. Notably, 60% of the events occurred during the induction and consolidation phase of therapy. Interestingly, there was no significant difference in rates of toxicities between patients receiving IV or IM PEG-asparaginase. ConclusionThe distribution of toxicities highlighted in our study aligns with findings from previously published studies. Furthermore, multivariate analysis indicated that patients with high-risk ALL and T-ALL were more likely to develop toxicities compared to other forms of ALL.

How far back do we need to look to capture diagnoses in electronic health records? A retrospective observational study of hospital electronic health record data

ObjectivesAnalysis of routinely collected electronic health data is a key tool for long-term condition research and practice for hospitalised patients. This requires accurate and complete ascertainment of a broad range...

USING HOSPITAL ELECTRONIC HEALTH RECORDS TO DETERMINE FRAILTY WITH THE PICTORIAL FIT-FRAIL SCALE

Abstract Hip fractures are common in older adults, particularly those that are frail. There is no “gold standard” tool to measure frailty retrospectively from hospital Electronic Health Records (EHRs). The aim of this research was to explore the utility of the Pictorial Fit-Frail Scale (PFFS) in determining frailty retrospectively in older adults admitted to hospital with a hip fracture. A random sample of 200 patients who had a hip fracture was extracted from a larger sample of 682 hip fractures that occurred in older adults (65 years and older) admitted to a Level 1 Trauma Center (April 2015-March 2019). Each EHR was reviewed to determine the availability of data and the score for each of the 14 PFFS domains. The majority, 189 (94.5%) of the EHRs, had data to complete 11-14 of the domains. Patient information was often unavailable to complete the domains of daytime tiredness and pain. The average age was 83.2 (SD 8.2), and 73.0% were female. The mean Raw PFFS score prior to admission was 9.7 (SD 6.6), and 45.5% of patients were classified as moderately or severely frail. Using the Standardized PFFS score (adjusted for up to three missing domains), the mean score was 11.8 (SD 7.9), and 58.2% of patients were classified as moderately or severely frail. The hospital EHR can be used to complete the PFFS. This finding provides researchers and healthcare professionals with a way to stratify older hospitalized patients by frailty, which may be a useful tool for evaluating health outcomes.

Using Principles of Agile Leadership in a Frontier Hospital Electronic Health Record System Implementation.

The challenge of implementing a new electronic health record system in any hospital can be daunting. Doing so in a small frontier hospital with limited resources can be monumental. By incorporating fundamental leadership principles, including Agile leadership principles and committing to a set of values, Lincoln Health in Hugo, Colorado, achieved a successful implementation on an accelerated schedule.

Evaluating Effective Therapeutic Options for Inhibitor Eradication in Patients with Acquired Hemophilia a: A 10-Year Single Center Experience

Background Acquired hemophilia A (AHA) is a rare disorder characterized by emergence of neutralizing antibodies or inhibitors to factor VIII. The main treatment strategy for AHA involves control of bleeding with factor VIII bypassing agents and eradicating the autoantibodies using immunosuppressive therapy (IST) for restoration of normal hemostasis. Previous studies have demonstrated the effectiveness of both cyclophosphamide and rituximab in combination with steroids for treating AHA, however, clear guidelines for choosing between these agents for rapid inhibitor eradication are lacking. This retrospective study aimed to compare the effectiveness of cyclophosphamide and rituximab as first-line therapies for rapid antibody elimination and relapse prevention. Methods We queried our hospital electronic health record system using ICD 9/10 code to identify patients &amp;gt;18 years that had at least 2 inpatient or outpatient encounters for the diagnosis of AHA between 1 st July 2013 and 30 th June 2023. Variables collected included initial aPTT value, serial factor VIII activity &amp; Bethesda inhibitor titer and immunosuppressive therapies used. Time to remission was defined when inhibitor titer was &amp;lt;1% along with improving factor VIII activity. At our institute, all patients received 1mg/kg of steroids initially, then either six cycles of 400mg/kg IV Cyclophosphamide every 28 days on day 1 along with 100mg of oral Prednisone days 1-5 or four cycles of IV Rituximab at a weekly dose of 375mg/m2 was used as 1 stline IST for patients with inhibitor titer &amp;gt;10%. Patients that did not achieve remission or those with persistently high inhibitor titers after 3 cycles of Cyclophosphamide were switched to 2 nd line therapy. In few patients oral Cyclophosphamide or Mycophenolate mofetil was used as maintenance therapy after 1 st or 2 nd line therapy. Bleeding control was achieved with use of rpFVIII or rFVII, FEIBA or emicizumab depending on product availability. Descriptive statistics (mean, SD) &amp; openAI.ChatGPT-4 generated correlation coefficient was used for data analysis. Results A total of 11 male and 5 female patients were identified. The mean age at diagnosis was 69 years and the average length of follow up was 672 days. The mean aPTT value at diagnosis was 84.3 seconds. Inhibitor titer ranged from 1.5 to 329% with an average of 63.62%. Patients with low inhibitor titer of &amp;lt;10% received only steroids and all of them achieved remission without relapse. Rituximab as first-line therapy led to remission in 100% of cases, while only 28.5% of patients treated with cyclophosphamide achieved remission without needing second-line therapy. The time to remission was significantly shorter in patients treated with rituximab compared to cyclophosphamide (43.4vs148.7days). Additionally, none of the patients treated with rituximab experienced a relapse after 1 st remission, while 57% of patients treated with cyclophosphamide did and majority needed 2 nd line &amp; maintenance therapy (Figure-1). Initial inhibitor titer had a moderate to strong positive correlation with the time to remission, the incidence of relapse, and the need for second line and maintenance therapy (Figure- 2). Conclusions Rituximab as first line IST appeared to be more effective than cyclophosphamide in achieving rapid remission and reducing incidence of relapse. Our analysis also revealed that initial inhibitor titer may serve as a useful predictor of disease course, potentially guiding therapeutic decision-making and eliminating need for cytotoxic medication or maintenance therapy. Future large prospective studies are needed to confirm these findings and further investigate other factors influencing therapeutic outcomes in patients with AHA.

Evaluation of risk factors for surgical site infections in osteoarthritis patients undergoing total knee arthroplasty.

This research sought to delineate risk factors associated with surgical site infections (SSIs) post-total knee arthroplasty (post-TKA) in elderly osteoarthritis patients, aiming to enhance post-surgical outcomes. A retrospective examination was conducted on a cohort of 650 elderly patients who underwent unilateral TKA between January 2018 and August 2022. Data procurement was from the hospital's Electronic Health Record, and a comprehensive statistical evaluation was performed using IBM SPSS Statistics version 24.0. Both univariate and multivariate techniques assessed a spectrum of risk determinants such as age, body mass index (BMI), coexisting medical conditions and surgical variables. The univariate examination spotlighted age, BMI, diabetes prevalence, chronic corticosteroid consumption and American Society of Anesthesiologists (ASA) physical status classification as notable predictors of SSIs. The multivariate logistic regression pinpointed age, BMI, history of smoking and diabetes diagnosis as salient risk attributors for post-TKA infections. Concurrently, parameters like ASA classification, surgical duration and intraoperative haemorrhage further enriched the risk landscape. Geriatric patients undergoing TKA for knee osteoarthritis manifest a tangible infection susceptibility post-surgery. Precision interventions concentrating on amendable risk components, including meticulous preoperative evaluations and strategic postoperative care, are imperative to attenuate SSI incidence, thereby amplifying surgical efficacy and optimizing patient recuperation trajectories.

Inpatient EHR User Experience and Hospital EHR Safety Performance

Despite the broad adoption and optimization of electronic health record (EHR) systems across the continuum of care, serious usability and safety problems persist. To assess whether EHR safety performance is associated with EHR frontline user experience in a national sample of hospitals. This cross-sectional study included all US adult hospitals that used the National Quality Forum Leapfrog Health IT Safety Measure and also used the ARCH Collaborative EHR User experience survey from January 1, 2017, to January 1, 2019. Data analysis was performed from September 2020 to November 2022. The primary outcomes were hospital performance on the Leapfrog Health IT Safety measure (overall and 10 subcomponents) and the ARCH collaborative frontline user experience scores (overall and 8 subcomponents). Ordinary least squares models with survey responses clustered by hospital were used to assess associations between the overall measures and their subcomponents. There were 112 hospitals and 5689 frontline user surveys included in the study. Hospitals scored a mean of 0.673 (range, 0.297-0.973) on the Leapfrog Health IT safety measure; the mean ARCH EHR user experience score was 3.377 (range, 1 [best] to 5 [worst]). The adjusted β coefficient between the overall safety score and overall user experience score was 0.011 (95% CI, 0.006-0.016). The ARCH overall score was also significantly associated with 10 subcategory scores of the Leapfrog Health IT safety score, and the overall Leapfrog score was associated with the 8 subcategory scores of the ARCH user experience score. This cross-sectional study found a positive association between frontline user-rated EHR usability and EHR safety performance. This finding suggests that improving EHR usability, which is a current well-known pain point for EHR users, could have direct benefits in terms of improved EHR safety.

Retrospective Use of the Pictorial Fit-Frail Scale for Determination of Frailty Level in Hospitalized Older Adults with a Hip Fracture.

The Pictorial Fit-Frail Scale (PFFS) is a frailty tool consisting of visual images to comprehensively assess frailty across 14 domains that can be completed by health professionals, patients, or caregivers. The objective of this study was to explore the feasibility of using the PFFS retrospectively to determine a patient's frailty level using data from the hospital electronic health records (EHRs) of older adults admitted with an isolated hip fracture. A random sample of 200 hip fracture patients admitted to a Level 1 Trauma Center hospital in New Brunswick was selected for review using the PFFS. The majority (94.5%) of hospital EHRs contained the clinical information needed to populate most of the 14 PFFS domains, allowing for determination of a frailty score. The mean raw PFFS frailty score was 9.7 (SD 6.6), consistent with moderate frailty. For all patients, a Frailty Index (FI) score was calculated, with the mean being 0.27 (SD 0.18), again consistent with moderate frailty. Comparing the PFFS score to the FI score, the percentage categorized as not frail or very mildly frail fell from 33.3% to 20.1%, and those considered severely frail rose from 30.7% to 34.9%. The PFFS can be successfully used retrospectively with hospital EHRs to determine the frailty level of older patients. When converted to the FI score, there was an increase in the frequency and severity of frailty. This tool may provide a useful way to stratify older adults by frailty that can be helpful in evaluating health outcomes based on frailty levels.

A guide to mitigating audit log-related risk in medical professional liability cases.

Following the American Recovery and Reinvestment Act in 2009, use of electronic health records (EHRs) has become ubiquitous. Accordingly, one should expect most medical professional liability cases to involve review of patient records produced from EHRs. When questions arise regarding who was involved in care of a patient, what they knew and when, or the meaning, completeness, integrity, validity, timeliness, confidentiality, accuracy, or legitimacy of data, or ways that the EHR's user interface or automated clinical decision support tools may have contributed to the alleged events, one often turns to the EHR and its audit log. This manuscript discusses lines of defense incorporated into the design, development, implementation, and use of EHRs to ensure their integrity and the types of EHR transaction logs (e.g., audit log) that exist. Using these logs can help one answer questions that often arise in medical malpractice cases. Finally, there are "best practices" surrounding EHR audit logs that health care organizations should implement. When used appropriately, EHRs and their audit logs provide another source of information to help hospital risk managers, legal counsel, and EHR expert witnesses to investigate adverse incidents and, if needed, prosecute or defend clinicians and/or health care organizations involved in the patient's care.

Development and Internal Validation of a Prediction Model for Falls Using Electronic Health Records in a Hospital Setting.

Fall prevention is important in many hospitals. Current fall-risk-screening tools have limited predictive accuracy specifically for older inpatients. Their administration can be time-consuming. A reliable and easy-to-administer tool is desirable to identify older inpatients at higher fall risk. We aimed to develop and internally validate a prognostic prediction model for inpatient falls for older patients. Retrospective analysis of a large cohort drawn from hospital electronic health record data. Older patients (≥70years) admitted to a university medical center (2016 until 2021). The outcome was an inpatient fall (≥24hours of admission). Two prediction models were developed using regularized logistic regression in 5 imputed data sets: one model without predictors indicating missing values (Model-without) and one model with these additional predictors indicating missing values (Model-with). We internally validated our whole model development strategy using 10-fold stratified cross-validation. The models were evaluated using discrimination (area under the receiver operating characteristic curve) and calibration (plot assessment). We determined whether the areas under the receiver operating characteristic curves (AUCs) of the models were significantly different using DeLong test. Our data set included 21,286 admissions. In total, 470 (2.2%) had a fall after 24hours of admission. The Model-without had 12 predictors and Model-with 13, of which 4 were indicators of missing values. The AUCs of the Model-without and Model-with were 0.676 (95% CI 0.646-0.707) and 0.695 (95% CI 0.667-0.724). The AUCs between both models were significantly different (P= .013). Calibration was good for both models. Both the Model-with and Model-without indicators of missing values showed good calibration and fair discrimination, where the Model-with performed better. Our models showed competitive performance to well-established fall-risk-screening tools, and they have the advantage of being based on routinely collected data. This may substantially reduce the burden on nurses, compared with nonautomatic fall-risk-screening tools.

Concordance between electronic health record-recorded race/ethnicity and parental report in hospitalized children.

Electronic health records (EHRs) have become an important repository for patient race and ethnicity. Misclassification could negatively affect efforts to monitor and reduce health disparities and structural discrimination. We assessed the concordance of parental reports of race/ethnicity for their hospitalized children with EHR-documenteddemographics. We also aimed to describe parents' preferences on how race/ethnicity should be captured in the hospital's EHR. From December 2021 to May 2022, we conducted a single-center cross-sectional survey of parents of hospitalized children asking to describe their child's race/ethnicity and compared these responses to the race/ethnicity documented in the EHR. Concordance was analyzed with a kappa statistic (κ). Additionally, we queried respondents about their awareness of and preferences for race/ethnicity documentation. Of the 275 participants surveyed (79% response rate), there was 69% agreement (κ = 0.56) for race and 80% agreement (κ = 0.63) for ethnicity between parent report and EHR documentation. Sixty-eight parents (21%) felt that the designated categories poorly represent their child's race/ethnicity. Twenty-two (8%) were uncomfortable with their child's race/ethnicity being displayed on the hospital's EHR. Eighty-nine (32%) preferred a more comprehensive list of race/ethnicity categories. Nonconcordance between EHR-recorded race/ethnicity and parental report exists in the EHR for our hospitalized patients, which has implications for describing patient populations and for understanding racial and ethnic disparities. Current EHR categories may be limited in their ability to capture the complexity of these constructs. Future efforts should focus on ensuring that demographic information in the EHR is accurately collected and appropriately reflects families' preferences.

Effectiveness of non-interruptive nudge interventions in electronic health records to improve the delivery of care in hospitals: a systematic review.

To describe the application of nudges within electronic health records (EHRs) and their effects on inpatient care delivery, and identify design features that support effective decision-making without the use of interruptive alerts. We searched Medline, Embase, and PsychInfo (in January 2022) for randomized controlled trials, interrupted time-series and before-after studies reporting effects of nudge interventions embedded in hospital EHRs to improve care. Nudge interventions were identified at full-text review, using a pre-existing classification. Interventions using interruptive alerts were excluded. Risk of bias was assessed using the ROBINS-I tool (Risk of Bias in Non-randomized Studies of Interventions) for non-randomized studies or the Cochrane Effective Practice and Organization of Care Group methodology for randomized trials. Study results were summarized narratively. We included 18 studies evaluating 24 EHR nudges. An improvement in care delivery was reported for 79.2% (n = 19; 95% CI, 59.5-90.8) of nudges. Nudges applied were from 5 of 9 possible nudge categories: change choice defaults (n = 9), make information visible (n = 6), change range or composition of options (n = 5), provide reminders (n = 2), and change option-related effort (n = 2). Only one study had a low risk of bias. Nudges targeted ordering of medications, laboratory tests, imaging, and appropriateness of care. Few studies evaluated long-term effects. Nudges in EHRs can improve care delivery. Future work could explore a wider range of nudges and evaluate long-term effects. Nudges can be implemented in EHRs to improve care delivery within current system capabilities; however, as with all digital interventions, careful consideration of the sociotechnical system is crucial to enhance their effectiveness.

A data-driven approach to evaluate factors affecting resident performance in cataract surgery.

To evaluate the operative duration and clinical performance of ophthalmology residents performing standard phacoemulsification cataract surgeries using information available from electronic health records (EHR). This is a retrospective cohort study. De-identified surgical records of all standard phacoemulsifications performed in a tertiary institution between 1st January 2015 and 8th August 2018 were retrieved from the hospital EHR. The main outcome measures were improvement in operative duration with case experience, corrected distance visual acuity (CDVA) improvement, and intra-operative complication rates. Twelve ophthalmology residents performed a total of 1427 standard phacoemulsifications. The median operative duration was 27min (interquartile range, 22-34min), which improved from 31 to 24min (before the 101st case [Group 1] versus 101st case onwards [Group 2], p < 0.001). Gradient change analysis (non-linear regression) showed significant reduction until the 100th case (p = 0.043). Older patients (0.019), worse pre-operative CDVA (0.343), and surgery performed by Group 1 (1.115) were significantly associated with operative duration above 30min. LogMAR CDVA improved from a mean of 0.57 ± 0.52 pre-operatively to 0.10 ± 0.18 post-operatively (p < 0.001). Posterior capsule rupture (PCR) rate decreased from 4.0% [Group 1] to 2.1% [Group 2] (p = 0.096), while overall complication rate decreased from 8.9% to 3.1% (p < 0.001). The median operative duration reduced consistently with surgical experience for the first 100 cases. Older patients, poorer pre-operative VA, and surgical experience of less than 100 cases were significantly associated with an operative duration above 30min. There was a statistically significant decrease in complication rate between Group 1 and 2.

Comparison of Antiemetics in the Management of Pediatric Cannabinoid Hyperemesis Syndrome.

As a result of recent legislative changes allowing for increased access to marijuana products, there have been increasing rates of cannabis abuse among adolescents and subsequent diagnoses of cannabinoid hyperemesis syndrome (CHS). Most available literature on this syndrome exists within the adult population and describes benzodiazepines, haloperidol, and topical capsaicin as potentially efficacious in the management of CHS. The objectives of this study were to identify antiemetics and compare their efficacy and safety in the management of pediatric CHS. A retrospective review of Penn State Children's Hospital electronic health record was performed to identify patients 18 years or younger who had an emergency department or inpatient encounter, a cannabis hyperemesis-related diagnosis code, and met diagnostic criteria for CHS. Antiemetic efficacy was determined using subjective patient perception of nausea and objective documentation of vomiting. Benzodiazepines, haloperidol, and topical capsaicin were classified as nontraditional antiemetics, whereas all other antiemetics were classified as traditional. Nontraditional antiemetic medications appeared to be more effective in resolving patient symptoms compared with traditional antiemetics. Analysis of all ordered antiemetics demonstrated a gap in partial or full symptom resolution between nontraditional and traditional agents. Reported adverse effects were minimal. Cannabinoid hyperemesis syndrome is an underrecognized and underdiagnosed condition characterized by cyclic vomiting related to chronic cannabis use. Abstinence from cannabis remains the most effective approach to mitigating morbidity associated with CHS. Medications such as lorazepam or droperidol may have benefit in managing toxidrome symptoms. Traditional antiemetic prescribing remains a key barrier to effective management of pediatric CHS.

Discordant Race and Ethnicity Documentation in the Georgetown Multiple Sclerosis and Neuroimmunology Center (P4-9.005)

<h3>Objective:</h3> We aimed to evaluate the reliability of R/E documentation in the EHR of MedStar Georgetown University Hospital. <h3>Background:</h3> The incidence and prevalence of multiple sclerosis (MS) appears to vary by race and ethnicity (R/E), and prognosis has been reported to be worse in Black and Hispanic/Latinx MS patients compared to White MS patients. Frequently, studies rely on electronic health records (EHR), but discrepancies in R/E documentation may be a potential source of errors in health disparities assessment. <h3>Design/Methods:</h3> Self-reported data from the MS-ADVANCE study at Georgetown University was compared to demographics extracted from the MedStar Georgetown University Hospital EHR. Concordance was defined as the percent agreement between self-reported R/E and R/E demographic information found in the EHR. <h3>Results:</h3> R/E data from 197 participants in the MS-ADVANCE study were analyzed. Most participants self-reported as Non-Hispanic White (n=142), which generally matched EHR documentation (concordance 92.6%). Similarly, 86% of Non-Hispanic Black (n=43) and 100% of Asian individuals (n=2) were accurately identified in the EHR. However, only 2 of 8 self-identified Hispanic/Latinx patients were identified as such in the EHR (concordance 25%). <h3>Conclusions:</h3> This is the first study evaluating concordance of self-reported R/E information compared to EHR documentation in patients with MS. While concordance was generally good in most groups, R/E information in the EHR was often incorrect for Hispanic/Latinx patients. Because most epidemiological analyses extract data from electronic records, this considerable observed discrepancy in R/E documentation may impact our understanding of prevalence, incidence, and prognosis in Hispanic/Latinx individuals with MS. Since obtaining reliable demographic information is crucial to determine quality of care and health outcomes, improvement in data collection is necessary when exploring healthcare disparities in Hispanic/Latinx individuals living with MS. <b>Disclosure:</b> Dr. Manrique has nothing to disclose. Miss Peres Da Silva has nothing to disclose. Dr. Osborne has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Alexion. Dr. Osborne has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Biogen. Dr. Osborne has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Bristol Myer Squibb. Dr. Osborne has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Horizon. Dr. Osborne has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Peter Angelos Law Firm. Dr. Osborne has received publishing royalties from a publication relating to health care. Dr. Tornatore has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Serono. Dr. Tornatore has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Sanofi. Dr. Tornatore has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Biogen. Dr. Tornatore has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Biogen. Dr. Shin has received personal compensation in the range of $50,000-$99,999 for serving as a Consultant for Sanofi Genzyme. Dr. Shin has received personal compensation in the range of $50,000-$99,999 for serving as a Consultant for Biogen. Dr. Shin has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Novartis. Dr. Shin has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Celgene. Dr. Shin has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for EMD Serono. Dr. Shin has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Alexion. Dr. Shin has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Mallinckrodt. Dr. Shin has received personal compensation in the range of $50,000-$99,999 for serving on a Speakers Bureau for Biogen. Dr. Shin has received personal compensation in the range of $50,000-$99,999 for serving on a Speakers Bureau for Sanofi Genzyme. Dr. Shin has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Novartis. Dr. Shin has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Celgene. Dr. Shin has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for EMD Serono. Dr. Shin has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Alexion. Dr. Shin has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Mallinckrodt.