Nationwide Electronic Health Record Research Articles

Understanding EHR current status and challenges to a nationwide electronic health records implementation in Morocco

BackgroundElectronic health records (EHRs) are transforming and revolutionizing the healthcare industry. While developed countries have a high EHR adoption rate, developing countries like Morocco are still struggling on deploying it over the whole territory. ObjectivesGiven the lack of scientific contribution on the topic, this study aims to fill this gap by investigating the status of Electronic Health Record (EHR) systems in Morocco with a focus on usage scenarios, implementation approach, and barriers to its implementation. MethodsThis study is based on documentary analysis. The analyzed documents include the limited research papers available on the subject, data from local and international press, reports from health entities and project partners and data from the high commission of planning, which is the main administrative structure responsible for producing official statistics in Morocco. ResultsThe findings of this study unveil significant advancements in the deployment of EHR systems at the sub-national level in Morocco by adopting a “middle-out” implementation approach. Currently, EHR is utilized for clinical purposes within individual healthcare providers in a centralized manner. It is also used to some extent for epidemiological and research purposes. Although there is a growing awareness and willingness to implement a nationwide EHR to fully leverage EHR potential, several key organizational, technical, and human barriers impede its effective implementation. ConclusionsThis study investigates the status of EHR implementation in Morocco. It presents some barriers to the successful implementation of nationwide EHR. Findings along with the experiences of developing countries that already succeed in nationwide EHR implementation will help support current efforts.

Initial versus early switch to targeted therapy during first-line treatment among patients with biomarker-positive advanced or metastatic non-small cell lung cancer in the United States

ObjectivesThis study compared outcomes between patients with biomarker-positive advanced/metastatic non-small cell lung cancer (a/mNSCLC) who initiated treatment with targeted therapy versus those who initiated chemotherapy-based treatment and switched to targeted therapy during the first ∼3 cycles (defined as the first 56 days) of first-line treatment. Materials and MethodsThis was an observational study of patients with a/mNSCLC who received targeted therapy from a nationwide electronic health record (EHR)-derived de-identified database. Outcomes were compared between those who initiated targeted therapy versus those who switched from chemotherapy to a targeted agent. Time-to-event outcomes were evaluated using Kaplan-Meier method; Cox proportional hazards models (adjusted for baseline covariates) were used to compare outcomes between groups. ResultsOf the 4,244 patients in this study, 3,107 (73.2%) initiated the first line with targeted therapy and 346 (8.2%) switched to targeted therapy. Patients who received initial targeted therapy were significantly more likely to be non-smokers, treated in an academic practice setting, and of slightly older age (all p < 0.05). Patients who received initial targeted therapy also had a significantly longer time to start of first-line treatment (35.8 vs 25.3 days, p < 0.001). No significant differences were observed for clinical outcomes between groups. ConclusionIn both unadjusted and adjusted analyses, there were no differences in the clinical outcomes observed among patients with a/mNSCLC in this study. This study found that initiating chemotherapy with an early switch to targeted therapy (within 56 days) of receiving biomarker positive results may be an acceptable strategy for a patient for whom immediate care is needed.

The impact of COVID-19 and rapid policy exemptions expanding on access to medication for opioid use disorder (MOUD): A nationwide Veterans Health Administration cohort study

BackgroundIn March 2020, Veterans Health Administration (VHA) enacted policies to expand treatment for Veterans with opioid use disorder (OUD) during COVID-19. In this study, we evaluate whether COVID-19 and subsequent OUD treatment policies impacted receipt of therapy/counseling and medication for OUD (MOUD). MethodsUsing VHA’s nationwide electronic health record data, we compared outcomes between a comparison cohort derived using data from prior to COVID-19 (October 2017-December 2019) and a pandemic-exposed cohort (January 2019-March 2021). Primary outcomes included receipt of therapy/counseling or any MOUD (any/none); secondary outcomes included the number of therapy/counseling sessions attended, and the average percentage of days covered (PDC) by, and months prescribed, each MOUD in a year. ResultsVeterans were less likely to receive therapy/counseling over time, especially post-pandemic onset, and despite substantial increases in teletherapy. The likelihood of receiving buprenorphine, methadone, and naltrexone was reduced post-pandemic onset. PDC on MOUD generally decreased over time, especially methadone PDC post-pandemic onset, whereas buprenorphine PDC was less impacted during COVID-19. The number of months prescribed methadone and buprenorphine represented relative improvements compared to prior years.We observed important disparities across Veteran demographics. ConclusionReceipt of treatment was negatively impacted during the pandemic. However, there was some evidence that coverage on methadone and buprenorphine may have improved among some veterans who received them. These medication effects are consistent with expected COVID-19 treatment disruptions, while improvements regarding access to therapy/counseling via telehealth, as well as coverage on MOUD during the pandemic, are consistent with the aims of MOUD policy exemptions.

Curating a knowledge base for individuals with coinfection of HIV and SARS-CoV-2: a study protocol of EHR-based data mining and clinical implementation

IntroductionDespite a higher risk of severe COVID-19 disease in individuals with HIV, the interactions between SARS-CoV-2 and HIV infections remain unclear. To delineate these interactions, multicentre Electronic Health Records (EHR)...

An Extensive Survey on Blockchain-Based Electronic Health Record Systems

Healthcare systems around the world are beset by problems due to the lack of effective communication. Significant problems relating to patient medical records access, transition, and storage have persisted due to the lack of resources to adequately interact and track records between all main participants. To overcome this challenge, a nationwide Electronic Health Record (EHR) solution may be utilized. To further enhance EHR efficiency, Blockchain technology can be used to improve security, performance, and cost. In this survey, various literature proposing Blockchain-based EHR systems are discussed, along with their benefits and potential research gaps. Also Authors proposed a comprehensive architecture that could bridge all the gaps.

The Frequency of Infant-Feeding Presentations at English Emergency Departments During the SARS-CoV-2 Pandemic: A Nation-Wide Electronic Health Records Study.

Objectives: To examine the frequency and distribution of infant feeding-related presentations at emergency departments (EDs) before and during the SARS-CoV-2 pandemic.Setting: Attendances at 48 major EDs in England in two 50-week periods before and during the COVID-19 pandemic: period 1, April 2, 2019 to March 10, 2020 and period 2, April 1, 2020 to March 10, 2021.Methods: We estimated the change in frequency of ED presentations by age group and diagnosis before and after the start of the SARS-CoV-2 pandemic in England. We compared changes in the frequency of attendances of infant-feeding related presentations by infant age, sex, ethnicity, deprivation, rurality, arrival mode, arrival time, acuity, mother’s age, gravidity and mental health, birth length of stay, attendance duration, and disposal (i.e., admission or discharge).Results: While total ED attendances fell by 16.7% (95% CI -16.8% to -16.6%), infant attendances increased for feeding problems (+7.5% 95% CI 2.3% to 13.0%), neonatal jaundice (+12.8%, 95% CI 3.3% to 23.3%) and gastro-esophageal reflux (+9.7%, 95% CI 4.4% to 15.2%). These increases were more pronounced amongst first babies (+22.4%, 95% CI 13.1% to 32.5%), and where the stay in hospital after birth was brief (0-1 days, +20.1%, 95% CI 14.8% to 25.7%). Our analysis suggests that many of these attendances were of low acuity.Conclusions: While ED attendances reduced dramatically and systematically with the COVID-19 pandemic, presentations for infant feeding issues increased, implying growth in the unmet needs of new mothers and infants.

Going by the Book: Rule-Following in Primary Care Teams

Coordinated rule following is often important for ensuring consistent performance by execution-oriented teams in high-reliability industries. In health care, clinical practice guidelines codify best practices as rules for providers to follow. We examine primary care teams that manage new-onset type II diabetes, where diagnosis is based on an abnormally elevated hemoglobin A1c lab value. Using nationwide electronic health record data that include more than 12 million visits by over 1 million patients from 2013 to 2018, we apply a regression discontinuity design—with hemoglobin A1c as the running variable—and a difference-in-discontinuity strategy to compare providers’ rule-following responses to the diabetes diagnosis threshold across different team characteristics, including size, concentration, predominant provider type, and familiarity. We measure team performance on rule following and clinical outcomes, including diabetes diagnosis, prescribing of medications, diabetes monitoring, and guideline-concordant disease control. We find that teams that are larger and those with effort more diffusely distributed across members are more responsive to the diabetes diagnosis threshold than are solo providers. We find no meaningful differences in team performance based on whether the predominant provider is a physician or a nurse practitioner, nor do we see an impact of team familiarity. Health care managers can consider organizing large or diffuse teams—where each member contributes meaningfully but not exhaustively—to promote rule following and manage chronic diseases more effectively.

A Real-World Data Retrospective Cohort Study of Low Estrogen Receptor-Positive Early Breast Cancer: Natural History and Treatment Outcomes.

PurposeEstrogen receptor-positive (ER+) breast cancer (BC) is a heterogeneous disease, and there is an ongoing debate regarding the optimal cut point for clinically relevant ER expression. We used a real-world database to assess the prognostic and predictive values of lower ER expression levels on treatment outcomes with endocrine therapy.MethodsWe used a nationwide electronic health record database. Descriptive statistics were used to evaluate the association between ER expression, tumor characteristics, and treatment patterns among patients with early-stage BC. We used Kaplan–Meier survival curves to estimate recurrence-free survival (RFS) and overall survival (OS). We assessed associations between an alternative ER expression-level cut point and clinical outcomes.ResultsAmong 4697 patients with early-stage HER2-negative BC, 83 (2.04%) had ER+-low BC (ER expression, 1–9.99%) and 36 (0.88%) had ER+-intermediate BC (10–19.9%). ER+-low tumors were associated with higher tumor grade, larger size, and higher axillary tumor burden than ER+-high tumors (≥20% ER expression). African Americans had a higher prevalence of both triple-negative BC (TNBC) and ER+-low BC than ER+-high BC. Patients with ER+-low and ER+-intermediate tumors had survival outcomes similar to patients with TNBC and worse survival outcomes than patients with ER+-high tumors (P < 0.001). Tumors with <20% ER expression were associated with worse outcomes.ConclusionIn our cohort, patients with BCs with ER expression levels <20% had poor clinical outcomes similar to those of patients with TNBC.

Impact of Label Restriction on Checkpoint-Inhibitor Use in Bladder Cancer and Changes in Mortality.

In 2018, the US Food and Drug Administration (FDA) limited the indication for immune checkpoint inhibitors (ICI) in metastatic bladder cancer to patients with programmed cell death protein ligand-1 (PD-L1)–positive tumors. The impact of the label change on survival outcomes remains unknown. We conducted a controlled interrupted time series analysis using a nationwide electronic health record–derived oncology dataset. We used Cox regression to compare mortality in the post- vs prelabel change periods among affected (initiators of ICI or carboplatin-based chemotherapy) vs unaffected (initiators of cisplatin-based chemotherapy) patients. The use of ICI, carboplatin, and cisplatin was similar pre- and postlabel change, but PD-L1 testing increased postlabel change. In adjusted models, survival did not differ after the FDA label change policy compared with prior to the label change in any of the groups. The FDA label restriction on immunotherapy was associated with increased PD-L1 testing but not with changes in treatment patterns or mortality among patients with metastatic bladder cancer.

Predictors of Treatment Change Among Patients with Rheumatoid Arthritis Treated with TNF Inhibitors as First-Line Biologic Agent in the USA: A Cohort Study from Longitudinal Electronic Health Records.

Previous observational studies utilizing administrative claims data have largely been unable to consider clinical factors that may be related to patterns of drug use among patients with rheumatoid arthritis (RA). To understand predictors of treatment changes following initiation of a tumor necrosis factor inhibitor (TNFi) using nation-wide electronic health record (EHR) data in the USA. The Optum Immunology Condition EHR data (01/01/2011-09/30/2019) was used to identify a population of adult patients with RA initiating a TNFi as the first line biologic disease-modifying anti-rheumatic drug (DMARD). The primary outcome was any treatment change during the 1-year post-index period defined as cycling to a different TNFi or switching to non-TNFi biologic or targeted synthetic DMARDs. Secondary outcomes were the individual components of TNFi cycling and switching, examined separately. To identify predictors of DMARD treatment changes, we used a least absolute shrinkage and selection operator (LASSO) regression model. Model c-statistics and odds ratios (ORs, 95% confidence intervals (CIs)) of predictors were reported. We identified 24,871 patients with RA who initiated a TNFi. The mean age was 55.5 (±13.7) years and 77.2% were female. Among the TNFi initiators, 22.2% experienced TNFi cycling or switching during the 1-year follow-up time. Predictors that are associated with higher likelihood of TNFi cycling or switching included female gender (OR: 1.26, 95% CI: 1.16-1.36) and glucocorticoid use (OR: 1.30, 95% CI: 1.21-1.40). In contrast, inflammatory bowel disease (OR: 0.62, 95% CI: 0.48-0.78), psoriasis (OR: 0.82, 95% CI: 0.70-0.95), recent use of methotrexate (OR: 0.89, 95% CI: 0.81-0.97), and vitamin D intake (OR: 0.92, 95% CI: 0.85-0.99) were negatively associated with TNFi cycling or switch. Gender, glucocorticoid use, inflammatory bowel disease, psoriasis, and vitamin D intake were identified as significant predictors of TNFi cycling or switching for TNFi initiators in the RA population. Predicting treatment change remains challenging even with large detailed EHR data. This study aimed to identify key determinants of treatment changes among patients with rheumatoid arthritis (RA) initiating a tumor necrosis factor inhibitor (TNFi) as their first-line biologic disease-modifying antirheumatic drug (DMARD) in routine care settings using a US nation-wide longitudinal electronic health record (EHR). Among 24,871 patients with RA who initiated a TNFi, 22.2% experienced TNFi cycling or switching during the 1-year follow-up time. Female patients and those who used glucocorticoids were more likely to experience TNFi cycling or switching, whereas inflammatory bowel disease, psoriasis, recent methotrexate use, and vitamin D intake were negatively associated with the outcome. However, predicting treatment change remains challenging even with larger detailed EHR data potentially due to unmeasured factors such as prescriber's preference or patient's belief in the medication.

Association of antibiotic therapy and treatment efficacy in patients with renal cell carcinoma receiving immune checkpoint inhibitors.

4556 Background: There is growing evidence indicating that gut microbiome content is associated with the effectiveness of immune checkpoint inhibitory (ICI) therapy in various cancer types. Antibiotic therapy (ABT) induces significant changes in gut microbiota; however, the effects of ABT on oncologic outcomes with ICI therapy has only been explored in small, single-institution studies. We aimed to investigate the relationship between ABT on overall survival (OS) and real-world progression free survival (rwPFS) in subjects with advanced renal cell carcinoma (RCC) treated with ICI utilizing a national database. Methods: We queried the nationwide electronic health record (EHR)-derived de-identified FlatIron Health (FIH) database after Institutional Review Board approval was obtained and included a waiver of informed consent to select 1809 subjects who received ICI therapy. Patient characteristics were described and compared between those with known ABT use and without known ABT use (in the 3 months pre/post ICI initiation) using ANOVA and Chi-square tests. rwPFS and OS were calculated from date of initiation of ICI to date of real-world progression/date of death. Three-month landmark Kaplan Meier and log-rank tests were used to compare rwPFS and OS between groups defined by ABT use (any ABT, and ABT in 3 months pre-ICI vs 3 months post-ICI initiation). Cox proportional models were used to investigate the association between rwPFS, OS, and antibiotic use, adjusting for patient characteristics. Results: Patients receiving ABT group were younger (p = 0.007) and more likely female (p = 0.024) but similar in other measured demographic variables. rwPFS (median: 9.03 vs 11.6 months; p = 0.015) and OS (median: 23.7 vs 31.8 months; p = 0.019) were significantly shorter in the with-ABT group than in the without-ABT group. When assessing ABT use 3 months prior to initiation of ICI (vs ABT during/no known ABT use), neither rwPFS (median: 9.53 vs 11.66, p = 0.38) nor OS (median: 23.7 vs 22.6 months; p = 0.38) were significantly different. However, rwPFS (median: 23.5 vs 14.0 months vs not reached; p = 0.004) and OS (median: 36.2 vs 22.5 vs 31.8; p = 0.007) were statistically significantly different when stratifying based on exposure and timing of ABT amongst pre-ICI initiation ABT, post-ICI initiation ABT and no ABT groups, respectively. Multivariable analysis identified as a significant predictor of rwPFS (HR = 0.725, CI = 0.579-0.908; p =.005) and OS (HR = 0.722, CI = 0.573-0.911; p = 0.006). Conclusions: This study identifies a significant negative prognostic association of ABT administration on survival in advanced RCC treated by ICI in the first line setting. These results are consistent with the growing body of evidence suggesting that alterations in gut microbiome secondary to antibiotics appear to blunt efficacy of ICI treatment and emphasize the importance of antibiotic stewardship.

Real-world effectiveness of CPX-351 vs venetoclax and azacitidine in acute myeloid leukemia

AbstractCPX-351 and venetoclax and azacitidine (ven/aza) are both indicated as initial therapy for acute myeloid leukemia (AML) in older adults. In the absence of prospective randomized comparisons of these regimens, we used retrospective observational data to evaluate various outcomes for patients with newly diagnosed AML receiving either CPX-351 (n = 217) or ven/aza (n = 439). This study used both a nationwide electronic health record (EHR)-derived de-identified database and the University of Pennsylvania EHR. Our study includes 217 patients who received CPX-351 and 439 who received ven/aza. Paitents receiving ven/aza were older, more likely to be treated in the community, and more likely to have a diagnosis of de novo acute myeloid leukemia. Other baseline covariates were not statistically significantly different between the groups. Median overall survival (OS) for all patients was 12 months and did not differ based on therapy (13 months for CPX-351 vs 11 months for ven/aza; hazard ratio, 0.88; 95% confidence interval, 0.71-1.08; P = .22). OS was similar across multiple sensitivity analyses. Regarding safety outcomes, early mortality was similar (10% vs 13% at 60 days). However, documented infections were higher with CPX-351 as were rates of febrile neutropenia. Hospital length of stay, including any admission before the next cycle of therapy, was more than twice as long for CPX-351. In this large multicenter real-world dataset, there was no statistically significant difference in OS. Prospective randomized studies with careful attention to side effects, quality of life, and impact on transplant outcomes are needed in these populations.

Long-Term Benzodiazepine Use and Discontinuation Among Patients in the U.S. Veterans Health Administration.

Although long-term benzodiazepine use is not recommended, patients are often prescribed benzodiazepines for &gt;30 days (long-term use). Data from the Veterans Health Administration (VHA) may inform efforts to discontinue such use. This study sought to describe benzodiazepine use and discontinuation among VHA patients and compared patients who continued and discontinued use. The study used nationwide electronic health record data for all VHA-enrolled patients (age ≥18) from fiscal year (FY) 2019 (N=6,032,613). The primary outcome, benzodiazepine discontinuation, was defined as no prescription refill for 120 days. In FY2019, 3.5% of VHA enrollees were prescribed benzodiazepines for &gt;30 days, which was 72.0% of those prescribed benzodiazepines. One-third of veterans prescribed long-term benzodiazepines discontinued use. Continuation was more likely among patients who were older, not Black, taking benzodiazepines longer, and taking higher doses. When demographic factors were controlled, patients who continued long-term use were more likely to have a diagnosis of anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or psychosis and less likely to have depression or an alcohol or drug use disorder. Continuation was associated with a lower likelihood of sleep and cardiopulmonary disorders and of dementia. Higher discontinuation prevalence among patients with substance use disorders, dementia, or cardiopulmonary disorders is encouraging. However, the challenge remains of discontinuing long-term use among patients who are White, older, or diagnosed as having anxiety, PTSD, bipolar disorder, or psychosis. There is a need to identify provider, patient, and contextual factors driving long-term benzodiazepine use in these patient groups to effectively apply evidence-based discontinuation strategies.

Systemic Therapies Following Progression on First-line CDK4/6-inhibitor Treatment: Analysis of Real-world Data.

BackgroundMetastatic hormone receptor positive (HR+)/human epidermal growth factor receptor-2 negative (Her2−) breast cancer remains a significant cause of cancer-related mortality. First-line treatment with endocrine therapy (ET) with a cyclin-dependent kinases 4 and 6 inhibitor (CDK4/6i) has largely become the standard systemic therapy. Following progression, no prospective randomized data exist to help guide second-line treatment.Materials and MethodsThis study used a nationwide electronic health record (EHR)-derived de-identified database, specifically analyzing 1210 patients with HR+/Her2− metastatic breast cancer (MBC) who were treated in the first-line setting with a CDK4/6i from the years 2015-2020. The aim of this study was to assess what therapies were given after first-line progression on CDK4/6i and to observe treatment patterns over time. Determination of second-line treatment efficacy, specifically assessing real-world progression-free survival (rwPFS) and overall survival (OS) was performed.ResultsA total of 839 patients received a documented second-line therapy after progression on first-line CDK4/6i treatment. Chemotherapy was chosen for 29.7% of patients, and the use of chemotherapy decreased over time. Three hundred two (36.0%) of patients continued a CDK4/6i. Data were adjusted for age, race, Eastern Cooperative Oncology Group (ECOG) performance status, stage at breast cancer diagnosis, and insurance payer type. Continuation of the CDK4/6i was associated with improved rwPFS (HR 0.48, 95% CI 0.43-0.53, P < .0001) and OS (HR 0.30, 95% CI 0.26-0.35, P < .0001) compared to chemotherapy. A majority of these patients continued the same CDK4/6i in the second-line setting, as was given in the first-line setting.ConclusionWhile prospective data are needed, analysis of real-world data suggests a survival benefit for continuation of a CDK4/6i beyond frontline progression for patients with HR+/Her2− MBC.

Treatment Trends and Clinical Outcomes of Left-Sided RAS/RAF Wild-Type Metastatic Colorectal Cancer in the United States.

Post hoc analysis of the CALGB/SWOG 80405 trial suggests that anti-EGFR therapy may be superior to bevacizumab when added to first-line chemotherapy in patients with metastatic colorectal cancer (mCRC) who have left-sided primary tumors. We evaluated trends in use of anti-EGFR agents in patients with left-sided RAS/RAF wild-type (WT) mCRC and compared clinical outcomes among the most commonly used treatment strategies. A nationwide electronic health record (EHR)-derived deidentified database was reviewed for patients with left-sided RAS/RAF WT mCRC. Treatment trends over time were assessed by fitting a linear model to the percentage of patients receiving anti-EGFR therapy. A propensity score weighted Cox model was used to compare overall survival (OS) stratified by first-line targeted therapy received. A total of 1,607 patients with left-sided RAS/RAF WT mCRC received standard first-line chemotherapy. Of these, 965 (60%) received bevacizumab and 186 (12%) received an anti-EGFR agent. The percentage of patients receiving an anti-EGFR increased from 9% in 2013 to 16% in 2018. Median OS for patients treated with chemotherapy alone was 27.3 months (95% CI, 24.8-32.3), 27.5 months with bevacizumab (95% CI, 25.8-28.9; hazard ratio [HR], 0.88; P=.33), and 42.9 months with an anti-EGFR agent (95% CI, 36.0 to not reached; HR, 0.52; P=.005). This analysis suggests that chemotherapy with bevacizumab remained the most widely used first-line treatment strategy for patients with left-sided RAS/RAF WT mCRC in the United States in 2018. Despite this preference, treatment with an anti-EGFR agent was associated with improved OS.

Real-World Outcomes of Patients With BRAF-Mutated Metastatic Colorectal Cancer Treated in the United States

BRAF mutations portend a poor prognosis in metastatic colorectal cancer (mCRC). Whether these patients may benefit from more aggressive frontline chemotherapy with a triplet regimen such as FOLFOXIRI remains unclear. We used real-world data from a cohort of patients in the United States to assess the BRAF testing rate, determine the prevalence of FOLFOXIRI use, and compare survival outcomes in mCRC, stratified by BRAF mutation status and first-line therapy. A nationwide electronic health record-derived deidentified database was reviewed for patients diagnosed with mCRC between 2013 and 2018. Those with documented BRAF mutation testing who received standard first-line therapy were included. Kaplan-Meier estimates with corresponding log-rank tests and Cox proportional hazards modeling compared survival outcomes stratified by BRAF status and first-line therapy. Of 4,457 included patients, 3,991 (89.5%) had BRAF wild-type (BRAFwt) and 466 (10.5%) had BRAF-mutated (BRAFmt) mCRC. Median overall survival (OS) was 15.4 months in the BRAFmt group versus 28.1 months in the BRAFwt group (hazard ratio [HR], 0.48; 95% CI, 0.41-0.56; P<.001). Only 3% of patients with BRAF mutations received first-line FOLFOXIRI ± bevacizumab, with a median OS of 13.8 months compared with 15.5 months in those treated with doublet chemotherapy ± bevacizumab (P=.38). In patients with BRAF mutations, propensity-weighted analysis did not detect a significant improvement in OS with FOLFIRI + bevacizumab (HR, 0.90; 95% CI, 0.58-1.39; P=.63) or FOLFOX/CAPEOX + bevacizumab (HR, 0.81; 95% CI, 0.52-1.26; P=.35) versus doublet chemotherapy alone. In 2018, only 56% of patients diagnosed with mCRC had documented BRAF testing at any time. This real-world data analysis confirms the negative prognostic impact of BRAF mutations in mCRC and suggests that FOLFOXIRI has not been widely adopted in the United States. The proportion of patients with documented BRAF testing in this real-world population was low at 56%. We were unable to show any significant difference in OS of patients with BRAFmt mCRC based on the first-line therapy received.

Characterization of Symptoms and Symptom Clusters for Type 2 Diabetes Using a Large Nationwide Electronic Health Record Database.

A variety of symptoms may be associated with type 2 diabetes and its complications. Symptoms in chronic diseases may be described in terms of prevalence, severity, and trajectory and often co-occur in groups, known as symptom clusters, which may be representative of a common etiology. The purpose of this study was to characterize type 2 diabetes-related symptoms using a large nationwide electronic health record (EHR) database. We acquired the Cerner Health Facts, a nationwide EHR database. The type 2 diabetes cohort (n = 1,136,301 patients) was identified using a rule-based phenotype method. A multistep procedure was then used to identify type 2 diabetes-related symptoms based on International Classification of Diseases, 9th and 10th revisions, diagnosis codes. Type 2 diabetes-related symptoms and co-occurring symptom clusters, including their temporal patterns, were characterized based the longitudinal EHR data. Patients had a mean age of 61.4 years, 51.2% were female, and 70.0% were White. Among 1,136,301 patients, there were 8,008,276 occurrences of 59 symptoms. The most frequently reported symptoms included pain, heartburn, shortness of breath, fatigue, and swelling, which occurred in 21-60% of the patients. We also observed over-represented type 2 diabetes symptoms, including difficulty speaking, feeling confused, trouble remembering, weakness, and drowsiness/sleepiness. Some of these are rare and difficult to detect by traditional patient-reported outcomes studies. To the best of our knowledge, this is the first study to use a nationwide EHR database to characterize type 2 diabetes-related symptoms and their temporal patterns. Fifty-nine symptoms, including both over-represented and rare diabetes-related symptoms, were identified.

IMPLEMENTATION OF THE NATIONWIDE ELECTRONIC HEALTH RECORD SYSTEM IN SERBIA: CHALLENGES, LESSONS LEARNED, AND EARLY OUTCOMES.

Many countries around the world have recognized the need for using an electronic health record (EHR) system. However, there is limited literature that could serve as a guide during a lengthy and challenging process of planning, development, and implementation of the e-Health system. Since the EHR system was recently introduced in Serbia, the purpose of this communication is to describe our experience and lessons learned along the way. The key personnel involved in the implementation of the EHR system in Serbia that began in 2015 conducted in 2019 a retrospective narrative review of the process and early outcomes. An incremental approach in the planning, development, and implementation of the nationwide EHR system was taken. The process was split into phases with the gradual introduction of different regions of the country. The gradual shift from the existing to a new workflow for the prospective users was also implemented. The significant milestones were the achievement of quick legislative changes, the hiring of a professional team of experts in the field, the provision of timely and appropriate information and training to prospective users, the close collaboration between the implementation team and the Ministry of Health and mutual understanding of the aims and expectations, and the flexibility in accepting the evolving nature of the process, goals, and the system model. A successful implementation of the nationwide EHR system is feasible providing careful planning, the assembly of a multi-disciplinary team, the use of a stepwise approach, the early and continued involvement of the intended users, and the willingness to make adjustments along the way. The end-result sets the stage for the reform of the health care system itself.

The Hepatorenal Syndrome Patient Pathway: Retrospective Analysis of Electronic Health Records

BackgroundHepatorenal syndrome (HRS) is among the leading causes of hospitalization and mortality in patients with chronic liver disease.ObjectiveTo assess the HRS patient journey from preadmission to postdischarge to understand patient characteristics, disease progression, treatment patterns, and outcomes.MethodsWe conducted a retrospective study using real-world data from a nationwide electronic health record database (Cerner Health Facts, Kansas City, Missouri). We used ICD-9/10 diagnosis codes to identify patients hospitalized with HRS between January 1, 2009, and January 31, 2018. We assessed patient characteristics and history, clinical presentation, treatment, and outcomes. Regression analysis was conducted to assess the association between patient characteristics and survival while adjusting for demographic and clinical covariates.ResultsThe study included 3563 patients (62% men). Precipitants of HRS included gastrointestinal bleeding (18%), diuretics and infections (30%), and paracentesis (26%). Although 21% of patients had liver injury exclusively associated with alcohol use, 20% had hepatitis C, 8% had nonalcoholic steatohepatitis, and the etiology of the remainder (51%) was either some combination of conditions or unknown. A total of 42% of patients received vasopressors, including octreotide and midodrine (10%), other combinations of vasopressors (11%), or another single vasopressor (21%). In-hospital mortality was 34%, and 14% of patients were discharged to hospice. Regression analysis showed patients with acute-on-chronic liver failure had higher mortality in acute-on-chronic liver failure grades 1 (odds ratio = 1.59), 2 (odds ratio = 2.49), and 3 (odds ratio = 4.53) versus no acute-on-chronic liver failure. Among survivor patients, 38% were readmitted within 90 days of discharge; 23% of readmissions were HRS-related.ConclusionsThe HRS patient journey presented in this study highlights inconsistencies in, and provides insight into, associated hospital-based treatment strategies. A mortality rate of 34% along with a readmission rate of 23% associated with HRS-related complications warrant more disease awareness and effective treatment. Further research is needed to examine the interactions between the etiology of cirrhosis, precipitants, treatment, and outcomes. (Curr Ther Res Clin Exp. 2022; 82:XXX–XXX)

A Blockchain and NLP Based Electronic Health Record System: Indian Subcontinent Context

The healthcare system in the Indian subcontinent is plagued with numerous issues related to the access, transfer, and storage of patient's medical records. The lack of infrastructure to properly communicate and track records between all key participants has allowed the distribution of counterfeit drugs, dependency on unsafe methods of communication, and lack of trust between patients and providers. During the global COVID-19 pandemic, the need for a robust communication and record tracking system has been further emphasized. To facilitate efficient communication and mitigate the mentioned issues, a nationwide EHR (electronic health record) system must be introduced to bring the healthcare system into digital space. To further enhance security, efficiency, and cost, the innovation of Blockchain is introduced. Blockchain is a decentralized data structure that allows secure transactions between untrusted parties without needing a central authority. In this paper, a Hyperledger fabric-based Blockchain Electronic Healthcare Record (EHR) system is proposed. The system is integrated with technologies such as NLP (Natural Language Processing), and Machine Learning to provide users with practical features.