National Electronic Medical Record Research Articles

Prevention of adverse HIV treatment outcomes: machine learning to enable proactive support of people at risk of HIV care disengagement in Tanzania

ObjectivesThis study aimed to develop a machine learning (ML) model to predict disengagement from HIV care, high viral load or death among people living with HIV (PLHIV) with the goal...

Cardiovascular calcification in hemodialysis patients: A Qatar-based prevalence and risk factors study.

Patients with end-stage kidney disease on hemodialysis (HD) have an increased risk of death due to the high prevalence of cardiovascular disease. Vascular calcification (VC) is predictive of cardiovascular disease and mortality. We conducted a study to evaluate the prevalence and risk factors for VC in dialysis patients in Qatar. This is a retrospective nationwide study including all chronic ambulatory dialysis patients in Qatar from 2020 to 2022. We used our national electronic medical record to track demographics, clinical characteristics, comorbidities, laboratory values, and diagnostic data for each patient. Calcifications were assessed by echocardiography (routinely done for all our dialysis population per national protocol), computed tomography, X-ray, and ultrasound. The study protocol was approved by the local medical research ethics committee (MRC-01-20-377). 842 HD patients were included in this study. Vascular calcifications (VC) were prevalent in 52.6% of patients. The main site of VC was Mitral valve calcifications in 55.5% of patients. Patients with VC were significantly older and had more prevalence of diabetes mellitus (p = 0.001 and p = 0.006, respectively). There was no statistically significant difference between patients with calcifications and patients without calcifications regarding serum calcium, phosphorus, and PTH level. In multivariate analysis, age and diabetes significantly increased the risk factor for calcification (95% CI 1.033-1.065, p < 0.0001, and 95% CI 1.128-2.272, p < 0001, respectively). Moreover, higher vitamin D levels and higher doses of IV Alfacalcidol were significant risk factors for calcifications (95% CI 1.005-1.030, p < 0.007, and 95% CI 1.092-1.270, p < 0.0001, respectively). Our study found that vascular calcification was widespread among our dialysis population in Qatar. Implementing the practice of echocardiography in dialysis patients was extremely helpful and the most productive in detecting vascular calcification. Diabetes mellitus almost doubles the risk for vascular calcifications in dialysis patients. These results are beneficial in identifying risk factors for vascular calcification, which can help stratify dialysis patients' risk of cardiovascular disease and optimize prevention efforts.

Assessing pediatric neurosurgery capacity in La Paz, Bolivia: an illustrative institutional experience of a lower-middle-income country in South America.

The current pediatric neurosurgery capacity in lower-middle-income countries (LMICs) in South America is poorly understood. Correspondingly, the authors sought to interrogate the neurosurgical inpatient experience of the sole publicly funded pediatric hospital in one of the largest regional departments of Bolivia to better understand this capacity. A retrospective review of all neurosurgical procedures performed at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria") between 2019 and 2023 was conducted after institutional approval using a recently implemented national electronic medical record system. A total of 475 neurosurgical admissions satisfied inclusion for analysis over the 5-year span. The majority of admissions were from within the La Paz Department (87%) via the emergency department (77%), without private insurance (83%). The most common indications for neurosurgical intervention were trauma (35%), followed by hydrocephalus (28%), congenital disease (12%), infection (5%), and craniosynostosis (3%). Overall, the median age at time of surgery was 2.0 years, and the median operating time was 1.5 hours with a minority of intraoperative complications (2%). The most common inpatient complication was unplanned return to the operating room (19%), most commonly seen in congenital indications. At final discharge, the median postoperative length of stay was 10 days. Twenty-seven (6%) of the 475 patients died during hospitalization, most commonly seen in tumor indications. Of the 448 patients who were discharged, 299 (67%) returned for at least one follow-up appointment. There is restricted breadth in neurosurgical indications and outcomes achievable at the Children's Hospital of La Paz, Bolivia. As such, the capacity of pediatric neurosurgery at institutions in LMICs in South America such as this one is very limited. Identifying and prioritizing actionable interventions to improve this capacity is institution- and LMIC-dependent, and as such, future efforts will need to be tailored appropriately.

Effectiveness of mRNA Booster Vaccine Against Coronavirus Disease 2019 Infection and Severe Outcomes Among Persons With and Without Immune Dysfunction: A Retrospective Cohort Study of National Electronic Medical Record Data in the United States.

Real-world evidence of coronavirus disease 2019 (COVID-19) messenger RNA (mRNA) booster effectiveness among patients with immune dysfunction are limited. We included data from patients in the United States National COVID Cohort Collaborative (N3C) who completed ≥2 doses of mRNA vaccination between 10 December 2020 and 27 May 2022. Immune dysfunction conditions included human immunodeficiency virus infection, solid organ or bone marrow transplant, autoimmune diseases, and cancer. We defined incident COVID-19 BTI as positive results from laboratory tests or diagnostic codes 14 days after at least 2 doses of mRNA vaccination; and severe COVID-19 BTI as hospitalization, invasive cardiopulmonary support, and/or death. We used propensity scores to match boosted versus nonboosted patients and evaluated hazards of incident and severe COVID-19 BTI using Cox regression after matching. Among patients without immune dysfunction, the relative effectiveness of booster (3 doses) after 6 months from the primary (2 doses) vaccination against BTI ranged from 69% to 81% during the Delta-predominant period and from 33% to 39% during the Omicron-predominant period. Relative effectiveness against BTI was lower among patients with immune dysfunction but remained statistically significant in both periods. Boosted patients had lower risk of COVID-19-related hospitalization (hazard ratios [HR] ranged from 0.5 [95% confidence interval {CI}, .48-.53] to 0.63 [95% CI, .56-.70]), invasive cardiopulmonary support, or death (HRs ranged from 0.46 [95% CI, .41-.52] to 0.63 [95% CI, .50-.79]) during both periods. Booster vaccines remain effective against severe COVID-19 BTI throughout the Delta- and Omicron-predominant periods, regardless of patients' immune status.

Metabolic and Bariatric Surgery Utilization Trends in the United States: Evidence From 2012 to 2021 National Electronic Medical Records Network.

Bariatric surgery has evolved over the past 2 decades yet assessing trends of bariatric surgery utilization in the growing eligible population is lacking. This study aimed to update the trends in bariatric surgery utilization, changes in types of procedures performed, and the characteristics of patients who underwent bariatric surgery in the United States, using real-world data. This retrospective descriptive observational study was conducted using the TriNetX, a federated electronic medical records network from 2012 to 2021, for adult patients 18 years old or older who had bariatric surgery. Descriptive statistical analysis was conducted to assess patients' demographics and characteristics. Annual secular trend analyses were conducted for the annual rate of bariatric surgery, and the specific procedural types and proportions of laparoscopic surgeries. A steady increase in the number of procedures performed in the United States over the first 6 years of the study, a plateau for the following 2 years, and then a decline in 2020 and 2021 (during the coronavirus disease 2019 pandemic). The annual rate of bariatric surgery was lowest in 2012 at 59.2 and highest in 2018 at 79.6 surgeries per 100,000 adults. During the study period, 96.2% to 98.8% of procedures performed annually were conducted laparoscopically as opposed to the open technique. Beginning in 2012, the Roux-en-Y gastric bypass (RYGB) procedure fell to represent only 17.1% of cases in 2018, along with a sharp decline in the adjustable gastric band (AGB) procedure, replaced by a sharp increase in the sleeve gastrectomy (SG) procedure to represent over 74% of cases in 2018. Bariatric surgery utilization in the United States showed a moderate decline in the number of RYGB procedures, which was offset by a substantial increase in the number of SG procedures and a precipitous drop in the annual number of AGB procedures.

Prediction model for real-world survival in men with castration-resistant prostate cancer and bone metastases in the United States: A real-world database study.

507 Background: Bone metastases (bm) are common in men with castration-resistant prostate cancer (CRPC) and are associated with poor prognosis. Therefore, identifying prognostic factors for survival is key to aid decision-making. While several models exist for predicting survival in men with mCRPC, most were derived using randomized controlled trial (RCT) data, which may have limited application to real-world (RW) populations and utilized traditional linear methods. We aimed to develop and validate a prediction model of real-world survival (rwOS) in men with bmCRPC using a national RW electronic medical record (EMR) database with traditional and advanced machine learning (ML) methods. Methods: A retrospective cohort of men diagnosed with bmCPRC between 2010 and 2021 was identified using the Optum EMR. rwOS was identified as documented evidence of death in the EMR derived through either the Social Security Death Index or EMR-reported death date. Independent variables were demographic (age, race), clinical conditions (Charlson comorbidity index, pain, prior phases of PC), PC-related medications, and laboratory parameters during a 6-month baseline period. A dynamic model was used to predict survival at 1, 2, and 3 years after diagnosis of bmCRPC using traditional (logistic, Cox regression) and ML (light gradient boosting (LGB)) models. Training, calibration, and validation were performed by splitting the data and utilizing 5-fold cross-validation on the training sample and calibration plots. Diagnostic performances were evaluated using area-under-the-curve (AUC), precision-recall curve (PRC), and calibration curves across three models. Results: The study cohort included 4,097 men with a median age of 76 years (interquartile range: 68-82), predominantly white (81.2%), and residing in the Midwest (48.2%). Over a median follow-up period of 19.2 months, 2,220 (54.2%) men died with median rwOS of 31.0 months (95% CI: 29.6-32.9). The AUC for Cox, logistic and LGB models at 1 year were well within the acceptable range of (≥0.7.0) 0.78, 0.79, and 0.81 respectively. Similar findings were observed at 2 and 3-year landmark analyses with marginal improvement in model performance with LGB. Top predictors of rwOS were consistent across all time points in the LGB models and included laboratory parameters (prostate-specific antigen level, alkaline phosphatase, albumin, hemoglobin), age, presence of pain, transition from mHSPC to mCRPC, surgical castration, and baseline use of androgen receptor inhibitors. Conclusions: Study findings highlight consistency in the predictors of rwOS in a large cohort of men with bmCRPC using a national EMR database. ML-based models predicted rwOS with modest performance improvement compared to traditional models and could provide rwOS prediction to aid treatment decision-making.

Estimating remaining life expectancy in veterans with basal cell carcinoma using an automated electronic health record scoring system: A retrospective cohort study

Active surveillance may be considered for low-risk basal cell carcinomas (BCCs) in patients with limited life expectancy; however, estimates of life expectancy are not readily available. Veterans Health Administration's Care Assessment Need (CAN) score may address this problem. We examined the CAN score's performance in predicting 1-, 3-, and 5-year mortality in US veterans with BCC. This retrospective cohort study used national Veterans Health Administration's electronic medical record data. The CAN score's performance in the prediction of mortality in veterans with BCC was evaluated based on tests of goodness-of-fit, discrimination, and calibration. For 54,744 veterans with BCC treatment encounters between 2013 and 2018, the CAN score performed well in the prediction of mortality based on multiple tests. A threshold CAN score of 90 had a positive predictive value of 55% for 3-year mortality, clinically useful in identifying patients with intermediate-term survival. The study relied upon the combination of diagnosis codes and procedure codes to identify BCC cases. The CAN score has the potential to improve the quality of cancer care for veterans by providing clinicians with an estimate of life expectancy and facilitating conversations in cases where active surveillance can be considered.

Early Diagnosis of Pancreatic Cancer via Machine Learning Analysis of a National Electronic Medical Record Database.

Pancreatic cancer (PaC) is often diagnosed at advanced stages, resulting in one of the lowest survival rates among patients with cancer. The purpose of this study was to investigate whether machine learning (ML) models can predict with high sensitivity and specificity an increased risk for PaC ahead of clinical diagnosis. Optum deidentified electronic health record (EHR) data set was used to extract 1-year data for each patient and to sample for PaC diagnosis, the number of interactions with the health care system, and unique demographic and clinical features. Data for patients with PaC diagnosis were collected between 1 and 2 years before the diagnosis. Standard binary classification ML models were used on training and testing data sets. Data analyses were performed using the scikit-learn package version 1.0.1. The data set consisted of 18,987 patient EHRs collected between December 31, 2007, and December 31, 2017. EHRs with 10 unique features and at least three health care interactions were used for model training (N = 15,189; n = 8,438 [56%] with PaC) and testing (N = 3,798; n = 2,127 [56%] with PaC). The ensemble model achieved an AUC of 0.89, a sensitivity of 85.61%, and a specificity of 76.18% on the testing data set and produced superior results compared with other binary classifiers. Increasing unique health care interactions to nine failed to improve the AUC score. When the testing data set was enlarged to 5,696 patients, the ensemble model achieved an AUC of 0.92 and a specificity of 93.21%, but the sensitivity was compromised. The ensemble model exceeded the state-of-the-art level of performance for prediction of PaC ahead of clinical diagnosis with a minimal clinically guided input, providing a potential strategy for selection of high-risk patients for further screening.

Impact of the AACAP practice parameters on the metabolic adverse event monitoring for second-generation antipsychotics (SGAs) in children and adolescents

IntroductionThe objective of our study was to evaluate the impact of the publication of the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters for SGA metabolic monitoring in 2011 on SGA metabolic monitoring uptake among pediatric SGA recipients. MethodsThis was a retrospective study of children 1–17 years of age who initiated SGA treatment from Jan 2010 to December 2018 using a national Electronic Medical Records database. A segmented regression of interrupted time-series (ITS) analysis was conducted to analyze the change of metabolic monitoring rates for Body Mass Index (BMI), Blood Glucose (BG), and Total Cholesterol (CHL) 9 quarters pre- and 26 quarters post-the publication of the AACAP practice parameters. ResultsThe analytical cohort included 9620 children and adolescents who initiated SGA treatment during the study period. The ITS results showed that the publication of the AACAP practice parameter for SGA metabolic monitoring was associated with a 12.61 percentage points (p < 0.0002) immediate increase in BMI monitoring rate, (increased from 29.10% in Q4 2011 to 40.10% in Q3 2012). There was a positive trend of BMI monitoring rate prior to the publication of AACAP practice parameters, which continued during the post-publication period. Neither immediate nor sustained changes in the association of monitoring rates for BG and CHL were observed after the issuance of the guidelines. ConclusionThe publication of AACAP practice parameters for SGA monitoring was associated with a significant improvement in the monitoring for BMI, but not for BG and CHL in children and adolescents.

CO189 Metabolic and Bariatric Surgery Utilization Trends in the United States: Evidence from 2012–2021 National Electronic Medical Records Data

Bariatric surgery has evolved over the past two decades yet assessing trends of bariatric surgery utilization in the growing eligible population is lacking.This study aimed to update the trends in bariatric surgery utilization, changes in types of procedures performed, and the characteristics of patients who underwent bariatric surgery in the US, using real-world data.

Clinical outcomes and national information of patients with multiple myeloma (MM) covered under the largest national health insurance in a low-middle-income country.

e18561 Background: In Colombia, national health insurance is private in all the country, with coverage greater than 95% of population. However, there is few health outcomes published in specific neoplastic diseases. We analyze relevant clinical outcomes and the information known by the largest health insurer Nueva EPS (NEPS) in a major region of Colombia, in patients with MM, which could allow decision-making in public health. Methods: Pts treated under the Valle del Cauca regional NEPS insurance with a diagnosis of MM between 1996 and 2018 and who received care at comprehensive cancer centers, were retrospectively identified. We collect relevant variables from the institutional electronic medical records and the information available from the insurer. Our primary objective was to determine the overall survival (OS) in general and specific populations and what was the important clinical information that could be extracted directly by the insurer to analyze and support decisions. We performed Kaplan Meier, and cox regression analysis with relevant variables. Results: 233 pts treated in 3 comprehensive cancer care centers in the city of Cali were included. Median overall survival was 68 months, with 25% alive at 15 years. Age &gt; 75 years [HR 2.4, 95%CI 1.5-4, P = 0.0001], ISS category [HR 1.7, 95%CI 1.0-2.9, P = 0.003], and chronic kidney disease [HR 3.6, 95%CI 1.9- 6.7, P = 0.0004] were associated with a higher risk of death. Receiving an autologous transplant [HR 0.2, 95% CI 0.1-0.6, P = 0.0006] and the use of proteasome inhibitors and or immunomodulators were associated with better survival (OS 54 vs 15 months, p = 0.05). This contrasts with the scarce data available at the insurer, with information about heavy chain involved in only 63% of pts, light chain 44%, Durie-Salmon stage 54%, ISS stage 31%, FISH studies in 16%, type of 1st line of treatment in 65%, objective response 26% and overall survival in 72%. Conclusions: The survival of patients with MM treated under the largest health insurer in Colombia was good and similar to international series in highly experienced centers, however the relevant clinical information known by the insurer was poor. This supports the need to develop and have a single national electronic medical record that allows a better access to health data for decision-making in public health.

Utilization and Predictors of Adjuvant Metformin for Children and Adolescents on Mixed Receptor Antagonists (Second-Generation Antipsychotics)

To examine utilization and predictors of adjuvant metformin among pediatric recipients of second-generation antipsychotics (SGAs) (mixed receptor antagonist). This study used 2016-2021 data of a national electronic medical record database. Eligible participants were children aged 6 to 17 with a new SGA prescription for at least 90 days. Predictors of prescribing adjuvant metformin in general and to nonobese pediatric SGA recipients in particular were assessed using conditional logistic regression and logistic regression analyses, respectively. Of 30,009 pediatric SGA recipients identified, 2.3% (n= 785) received adjuvant metformin. Among 597 participants with a body mass index z score documented during the 6-month period before metformin initiation, 83% were obese, and 34% had either hyperglycemia or diabetes. Significant predictors for metformin prescribing were high baseline body mass index z score (odds ratio [OR] 3.5, 95% CI 2.8-4.5, p< .0001), having hyperglycemia or diabetes (OR 5.3, 95% CI 3.4-8.3, p< .0001), and undergoing a switch from a higher metabolic risk SGA to a lower risk one (OR 9.9, 95% CI 3.5-27.5, p= .0025) or a switch in the opposite direction (OR 4.1, 95% CI 2.1-7.9, p= .0051) compared with no switch. Nonobese metformin users were more likely to have a positive body mass index z score velocity before metformin initiation than their obese counterparts. Receiving the index SGA prescribed by a mental health specialist was associated with higher likelihood of receiving adjuvant metformin and receiving metformin before the development of obesity. Utilization of adjuvant metformin among pediatric SGA recipients is uncommon, and early introduction of the medication among nonobese children is rare.

Caregiver Satisfaction with Emergency Department Care for Pediatric Patients with Neurodevelopmental Disorders.

Children with neurodevelopmental disorders (NDDs) often encounter increased adversity when navigating the health care system. In this study, we explored the pediatric emergency department (PED) experience for patients with NDDs and their caregivers compared with that of patients without NDDs. Data for this study were obtained from National Research Corporation patient experience survey questionnaires and electronic medical record (EMR) data for patients presenting to a PED between May 2018 and September 2019. ED satisfaction was determined by the top-box approach; ED ratings of 9/10 or 10/10 were considered to reflect high ED satisfaction. Demographics, Emergency Severity Index, ED length of stay, time from arrival to triage, time to provider assessment, and diagnoses were extracted from the EMR. Patients with NDDs were identified based on International Classification of Diseases, Tenth Revision codes; patients with intellectual disabilities, pervasive and specific developmental disorders, or attention-deficit/hyperactivity disorders were included in the NDD cohort. One-to-one propensity score matching between patients with and without NDDs was performed, and a multivariable logistic regression model was built on the matched cohort. Patients with NDDs represented over 7% of survey respondents. Matching was successful for 1162 patients with NDDs (99.5%), resulting in a matched cohort sample size of 2324. Caregivers of patients with NDDs had 25% lower odds of reporting high ED satisfaction (95% confidence interval [CI], 0.62-0.91, p = 0.004). Caregivers of patients with NDDs make up a significant proportion of survey respondents and are more likely to rate the ED poorly than caregivers of patients without NDDs. This suggests an opportunity for targeted interventions in this population to improve patient care and experience.

WCN23-0285 Acute Kidney Disease in the Outpatient Setting: A Hidden Burden Detected by the Integrated National and Institutional Electronic Medical Records Exchange Platform

WCN23-0285 Acute Kidney Disease in the Outpatient Setting: A Hidden Burden Detected by the Integrated National and Institutional Electronic Medical Records Exchange Platform

An analysis of sex differences and socioeconomic deprivation among Canadian children with high blood pressure: a retrospective, cross-sectional study.

Understanding which children are at highest risk for high blood pressure (HBP) can inform surveillance and treatment. This study evaluated sex differences in childhood HBP and its associations with socioeconomic status. This retrospective cross-sectional study assessed 74,233 children with data from a national primary care electronic medical record database. Differences between sex and material and social deprivation scores for children with and without HBP were examined. Covariates included age, BMI z-score, diabetes, hyperlipidemia, and depression. HBP was defined as > 90th percentile for < 13-year-olds, and ≥ 120/80 for age ≥ 13years on 2 separate occasions between 2010 and 2017. The prevalence of HBP was 10.2% in males and 7.6% in females (p < 0.0001). Children with HBP had higher BMI z-scores (0.66 vs. 0.18, p < 0.0001), and higher rates of diabetes (1.31 vs. 0.54%, p < 0.0001), depression (9.89 vs. 7.11%, p < 0.0001), and hyperlipidemia (2.82 vs. 0.86%, p < 0.0001). In univariate regression analyses, boys in the most materially deprived quintile had increased odds of HBP (OR 1.24 (95% CI 1.08-1.43)), whereas females did not (OR 1.11 (95% CI 0.95-1.29)). In multivariate regression, male sex was associated with HBP with adjusted OR of 1.39 (95% CI 1.24-1.55). After statistical adjustment, material deprivation was no longer significant (aOR 1.05, 95% CI 0.94-1.17). Male sex is associated with HBP in Canadian children. This study also suggests a possible association between material deprivation and HBP, particularly in boys. Further study is required to better understand this relationship. A higher resolution version of the Graphical abstract is available as Supplementary information.

Preliminary considerations for electronic medical record (EMR) in the public hospitals of Gandaki province in Nepal

Electronic Medical Record (EMR) is the digital tool to keep records of valuable information on computer or computer-like equipment, regarding health systems, including patient’s records and stock management which can provide real time evidence for better patient record, clinical care and health policy making. As Nepal does not have a national EMR system, and it is a challenge to get real time data, information and evidence required for effective health policy making. With an effective national EMR system in Nepal, the health system can be improved with reliable information of patients for the continuity of clinical care.&#x0D; &#x0D; There are existing scientific evidence of EMR on the lessons of implementation in Nepal, opportunities for the use of EMR in Malaysia, perspectives of health care workers on EMR after its implementation in Canada, on the development of success measuring tools and the use of questionnaires for the EMR implementation in Canada, best practices, impact of EMR on physician practice, and barriers for EMR implementation.&#x0D; &#x0D; EMR can improve the quality, effectiveness, transparency and efficiency of healthcare services and its management. Gandaki province is one of seven provinces in Nepal and is exploring ways to implement EMR in all the hospitals operated under the province government. There can be step wise approach to have EMR in all of these hospitals. This can give more strategies for the national EMR system.

Development of automated HIV case reporting system using national electronic medical record in Thailand

BackgroundAn electronic medical record (EMR) has the potential to improve completeness and reporting of notifiable diseases. We developed and assessed the validity of an HIV case detection algorithm and deployed...

Predictors of telemedicine use during the COVID-19 pandemic in the United States-an analysis of a national electronic medical record database.

Telemedicine utilization increased significantly in the United States during the COVID-19 pandemic. However, there is concern that disadvantaged groups face barriers to access based on single-center studies. Whether there has been equitable access to telemedicine services across the US and during later parts of the pandemic is unclear. This study retrospectively analyzes outpatient medical encounters for patients 18 years of age and older using Healthjump–a national electronic medical record database–from March 1 to December 31, 2020. A mixed effects multivariable logistic regression model was used to assess the association between telemedicine utilization and patient and area-level factors and the odds of having at least one telemedicine encounter during the study period. Among 1,999,534 unique patients 21.6% had a telemedicine encounter during the study period. In the multivariable model, age [OR = 0.995 (95% CI 0.993, 0.997); p<0.001], non-Hispanic Black race [OR = 0.88 (95% CI 0.84, 0.93); p<0.001], and English as primary language [OR = 0.78 (95% CI 0.74, 0.83); p<0.001] were associated with a lower odds of telemedicine utilization. Female gender [OR = 1.24 (95% CI 1.22, 1.27); p<0.001], Hispanic ethnicity or non-Hispanic other race [OR = 1.40 (95% CI 1.33, 1.46);p<0.001 and 1.29 (95% CI 1.20, 1.38); p<0.001, respectively] were associated with a higher odds of telemedicine utilization. During the COVID-19 pandemic, therefore, utilization of telemedicine differed significantly among patient groups, with older and non-Hispanic Black patients less likely to have telemedicine encounters. These findings are relevant for ongoing efforts regarding the nature of telemedicine as the COVID-19 pandemic ends.

Factors Influencing Implementation of the Survivorship Passport: The IT Perspective.

Compared to the general population, childhood cancer survivors represent a vulnerable population as they are at increased risk of developing health problems, known as late effects, resulting in excess morbidity and mortality. The Survivorship Passport aims to capture key health data about the survivors and their treatment, as well as personalized recommendations and a care plan with the aim to support long-term survivorship care. The PanCareSurPass (PCSP) project building on the experience gained in an earlier implementation in Giannina Gaslini Institute, Italy, will implement and rigorously assess an integrated, HL7 FHIR based, implementation of the Survivorship Passport. The six implementation countries, namely Austria, Belgium, Germany, Italy, Lithuania, and Spain, are supported by different national or regional digital health infrastructures and Electronic Medical Record (EMR) systems. Semi structured interviews were carried out to explore potential factors affecting implementation, identify use cases, and coded data that can be semi-automatically transferred from the EMR to SurPass. This paper reflects on findings of these interviews and confirms the need for a multidisciplinary and multi-professional approach towards a sustainable and integrated large-scale implementation of the Survivorship Passport across Europe.

The VA Life-Sustaining Treatment Decisions Initiative: A qualitative analysis of veterans with advanced kidney disease.

Documentation of patients' goals of care is integral to promoting goal-concordant care. In 2017, the Department of Veterans Affairs (VA) launched a system-wide initiative to standardize documentation of patients' preferences for life-sustaining treatments (LST) and related goals-of-care conversations (GoCC) that included using a note template in its national electronic medical record system. We describe implementation of the LST note based on documentation in the medical records of patients with advanced kidney disease, a group that has traditionally experienced highly intensive patterns of care. We performed a qualitative analysis of documentation in the VA electronic medical record for a national random sample of 500 adults with advanced kidney disease for whom at least one LST note was completed between July 2018 and March 2019 to identify prominent themes pertaining to the content and context of LST notes. During the observation period, a total of 723 (mean 1.5, range 1-6) LST notes were completed for this cohort. Two themes emerged from the analysis: (1) Reactive approach: LST notes were largely completed in response to medical crises, in which they focused on short-term goals and preferences rather than patients' broader health and goals, or certain clinical encounters designated by the initiative as "triggering events" for LST note completion; (2) Practitioner-driven: Documentation suggested that practitioners would attempt to engage patients/surrogates in GoCC to lay out treatment options in order to move care forward, but patients/surrogates sometimes appeared reluctant to engage in GoCC and had difficulty communicating in ways that practitioners could understand. Standardized documentation of patients' treatment preferences and related GoCC was used to inform in-the-moment decision-making during acute illness and certain junctures in care. There is opportunity to expand standardized documentation practices and related GoCC to address patients'/surrogates' broader health concerns and goals and to enhance their engagement in these processes.