Note Template Research Articles

Barriers and Facilitators in Implementation of a New Postoperative Esophagectomy Care Pathway: A Qualitative Analysis

INTRODUCTION: We recently implemented a new esophagectomy pathway that included significant practice changes, including gastric ischemic preconditioning 4 weeks before definitive surgery and routine placement of feeding jejunostomy tubes. Practice pattern changes can prove challenging. We therefore sought to determine barriers and facilitators to the implementation at the provider level. METHODS: We utilized qualitative method guided by the Theoretical Domains Framework to study the adoption and implementation of a post-esophagectomy care pathway. Sixteen interviews with providers involved with the pathway were conducted and analyzed using Matrix Analysis. RESULTS: Salient Theoretical Domains Framework domains identified included: knowledge, beliefs about consequences, and environmental context and resources. Facilitators included electronic health record tools (note templates including pathway components, pathway specific order set), patient satisfaction, and preliminary data suggesting reduced anastomotic leak rate. Barriers reported included hesitance to abandon previous practices and a desire for more concrete data prior to changing practice; these were most prevalent at the faculty level. Suggestions included improving post-discharge communication between providers and access to pathway documents by the clinical team. CONCLUSION: The Theoretical Domains Framework was successfully able to identify individuals’ perceived barriers and facilitators to implementation and adoption of an esophagectomy pathway that included significant practice changes. This analysis helped inform faculty about implementation and promoted communication between providers about pathway components. The findings of this qualitative methodology may inform future surgical patient care protocol implementations.

Improving the Quality of Transurethral Resection of Bladder Tumour (TURBT) Operative Notes Following the European Association of Urology Guidelines: A Completed Audit Loop Study.

BackgroundThe European Association of Urology (EAU) recommends that the operative steps and documentation necessary for successful and appropriate management of bladder cancer include identifying factors necessary to assign disease risk stratification, clinical stage, adequacy of resection and the presence of complications and immediate intravesical chemotherapy administration.AimTo assess and improve the adequacy of current transurethral resection of bladder tumour (TURBT) documentation at a district general hospital in the UK against the EAU 2022 guidelines.MethodsOperative notes over a one-year period were assessed for the inclusion of key steps to achieve a comprehensive TURBT as outlined by EAU guidelines. Outcomes included documentation on the details of the operative findings and intervention as well as the perioperative assessment. A standardised template for TURBT procedures was created and surgical staff received training on its usage. The audit was subsequently repeated after six months to assess for improvements.ResultsTURBT documentation of 78 cases in the first cycle was compared to 37 cases from the second cycle. Significant improvements in the documentation of tumour size (46% to 89%; p<0.05), tumour description (59% to 89%; p <0.05), depth of resection (36% to 89%; p<0.05), administration of chemotherapy (21% to 46%; p<0.05) and assessment for perforation (22% to 68%; p=0.001) were demonstrated. Improvements in pre-operative and post-operative examination rates under anaesthesia also achieved statistical significance (47% & 14% respectively to 89%; p<0.05). There was an increase in the documentation of completeness of resection but this did not achieve statistical significance (59% to 68%; p=0.42).ConclusionThe operative note template led to the improvement in the documentation, improving the risk stratification of bladder cancer in patients undergoing TURBT. The use of procedure-specific operative note templates should be adopted for all commonly performed procedures to improve the completeness of documentation.

Development of an Electronic Health Record Registry to Facilitate Collection of Commission on Cancer Metrics for Patients Undergoing Surgery for Breast Cancer.

Accurate and efficient data collection is a challenge for quality improvement initiatives and clinical research. We describe the development of a custom electronic health record (EHR)-based registry to automatically extract structured Commission on Cancer axillary surgery-specific metrics from a custom synoptic note template included in the operative reports for patients with breast cancer undergoing surgery. The smart functionality of our enterprise-based EHR system was leveraged to create a custom smart phrase to capture axillary surgery-specific variables. A multidisciplinary team developed structured data elements correlating to each axillary surgery-specific variable. These data elements were then included in a note template for the operative report. Each variable could be aggregated and converted into a single flat database through the EHR's reporting workbench and serve as a live, prospective registry for all users within the EHR. The final axillary surgery-specific note template in a synoptic format allowed for efficient and easy entry and automatic collection of breast cancer-specific metrics. From initial adoption in February 2021-December 2021, there were 1,254 patients who underwent breast surgery with axillary surgery. The operative notes allowed for automatic capture of metrics from 60.5% (n = 759) of patients. Data capture improved from 37.6% in the initial adoption period of 6 months to 86.2% in the last 5 months. We were able to demonstrate successful implementation of provider-driven structured data entry into EHR systems that permits automatic data capture. The end result is a custom synoptic note template and a real-time, prospective registry of breast cancer-specific Commission on Cancer metrics that are robust enough to use for quality improvement initiatives and clinical research.

Disappearing Help Text: Implementing a Note-Based Tool for In-Line Clinical Decision Support and Note Bloat Reduction.

The authors describe a novel solution to the challenges of lengthy notes and poor note readability by creating an unobtrusive clinical decision support tool named "disappearing help text." We designed this tool in Pediatric Hospital Medicine (PHM) note templates to provide in-line decision support on best documentation practices, note bloat reduction, billing compliance, and provider workflow enhancement. After template changes that utilized disappearing help text, we reduced the percent of notes utilizing any laboratory SmartLink from 90.2 to 15.3% for admission notes (p <0.001), 92.6 to 17.8% for progress notes (p <0.001), and 14 to 7.2% for discharge summaries (p <0.001). In admission and progress notes, this correlated with a significant reduction in the median note length as a proxy of note bloat reduction, with a 18.7% character count reduction in progress notes (p <0.001) and a 6.4% reduction in admission notes (p <0.001). PHM coding queries decreased from an average of 42 per month to 36 per month, and there was no change in PHM attending billing compliance audit performance. Note template changes that utilized disappearing help text significantly reduced the length of both progress and admission notes, a proxy for note bloat reduction, without negatively impacting coding query frequency or internal billing audit performance. One factor that likely contributed to this reduction in note length is the reduced usage of laboratory SmartLinks prompted by disappearing help text. We present the use of in-line disappearing help text embedded into note templates as a clinical decision support tool to improve note readability, educate trainees on note documentation, and protect confidential teen information. Help text implementation correlated with a reduction in the automatic insertion of laboratories into notes and a decrease in note character count.

Improving performance status documentation using an electronic medical record tool.

309 Background: Performance status (PS) is used regularly in oncology care to select appropriate cancer treatment, track changes in level of functioning, and determine clinical trial eligibility. In addition, the American Society of Clinical Oncology (ASCO)/Oncology Nursing Society (ONS) Chemotherapy Administration Safety Standards requires that on each clinical encounter, staff performs and documents a patient assessment that includes 8 elements; one of which is PS. Currently, little instruction is provided on how to utilize and record a more standardized criteria, such as PS with either ECOG or Karnofsky scores, in the electronic medical record (EMR) which results in suboptimal documentation. We assessed documentation of PS before and after implementation of a tool within the EMR at our outpatient cancer center. Methods: Using the Plan-Do-Study-Act (PDSA) technique, a quality improvement project was developed to determine if our center was consistent with the ASCO/ONS guidelines. An EMR tool was developed that enabled clinicians to standardize PS documentation within an encounter via population of a flowsheet to improve compliance. Clinicians were educated on guidelines and utilization of the PS tool and data was collected pre- and post- implementation. A survey was developed and administered to assess PS tool use and to learn of any barriers to implementation. Based on survey results, we created a reminder tip sheet for clinicians to utilize the PS tool; a subsequent chart review was completed. Results: In a random pre-study 50 chart review, 0% of encounters in our lung and breast clinic had PS documented. At the time of pre-tool implementation, due to the lack of a retrievable flowsheet, we did not obtain a reliable PS documentation percentage. After education and tool implementation, 2481 random encounters were evaluated of which 315 encounters (12.6%) documented PS and used the PS tool. A total of 7 (35%) clinicians completed the survey: 4 physicians and 3 advanced practice registered nurses. Of those who responded, 57% used the PS tool, 71% used a note template with ECOG PS embedded, and 85.7% were willing to alter their note template to incorporate ECOG PS. Barriers identified included: limited time, workflow constraints and redundant documentation. After tip sheet implementation, 66% of encounters documented PS; however, only 6 out of those 33 encounters (18%) documented PS using the PS EMR tool. Conclusions: Documentation support tools help facilitate care and enable measurement of guideline concordance, but once implemented it can be challenging to maintain adherence. Although this study improved overall PS documentation (0 to 66%), we were only able to demonstrate a 6% increase in the use of our PS documentation tool. While PS tool implementation was feasible, adoption of the additional tool was not universal. We aim to gather additional clinician input to improve PS documentation completion and guideline adherence.

Applying the Tailored Implementation in Chronic Diseases framework to inform implementation of the Preferences Elicited and Respected for Seriously Ill Veterans through enhanced decision-making program in the United States Veterans Health Administration.

In 2017, the National Center for Ethics in Health Care for the United States Department of Veterans Affairs (VA) commenced national roll-out of the Life-Sustaining Treatment Decisions Initiative. This national VA initiative aimed to promote personalized, proactive, patient-driven care for seriously ill Veterans by documenting Veterans' goals and preferences for life-sustaining treatments in a durable electronic health record note template known as the life-sustaining treatment template. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) quality improvement program was created to address the high variation in life-sustaining treatment template completion in VA Home Based Primary Care (HBPC) and Community Nursing Home programs. This manuscript describes the program that focuses on improving life sustaining treatment template completion rates amongst HBPC programs. To increase life-sustaining treatment template completion for Veterans receiving care from HBPC programs, the PERSIVED team applies two implementation strategies: audit with feedback and implementation facilitation. The PERSIVED team conducts semi-structured interviews, needs assessments, and process mapping with HBPC programs in order to identify barriers and facilitators to life-sustaining treatment template completion to inform tailored facilitation. Our interview data is analyzed using the Tailored Implementation in Chronic Diseases (TICD) framework, which identifies 57 determinants that might influence practice or implementation of interventions. To quickly synthesize and use baseline data to inform the tailored implementation plan, we adapted a rapid analysis process for our purposes. This paper describes a six-step process for conducting and analyzing baseline interviews through applying the TICD that can be applied and adapted by implementation scientists to rapidly inform tailoring of implementation facilitation.

769 Introduction of Electronic Proforma Improves Compliance of Operation Notes with the Royal College of Surgeons Guidelines: Results of a Closed Loop Audit

Abstract Aim Operative notes (op notes) are vital and confidential data. They serve as a fundamental means of communicating operative findings and procedure details and provide information on post-operative patient care. Their accuracy or otherwise have clinical, academic, and medico-legal implications. This closed loop audit assessed the compliance of local general surgery operative notes with the guidance provided by the Royal College of Surgeons (RCS). Method Retrospective review of the general surgery operation notes completed locally to assess their various characteristics. 98 op notes were assessed for adherence to guidelines, followed by introduction of an Electronic Proforma (EP) and re-audit of 102 op notes 6 months after implementation of the EP. Results The overall compliance from the initial audit was below 80%. 7 parameters were identified with low compliance, their adherence ranged between 5% and 77%. The re-audit demonstrated increased adherence following implementation of the EP. There was improved compliance with the guidelines and documentation was generally found to be more accurate. Overall compliance was above 98%. Conclusions We achieved a sustainable change in the quality of op notes through the use of electronic op note template. This was made possible by collaborating with the IT department – this also underscores the importance of interdepartmental collaboration to effect changes.

661 A Closed Loop Audit Assessing Adherence to IR(ME)R 2017 Guidelines in Reporting Intra-Operative Ionising Radiation Images in Trauma and Orthopaedic Operation Notes

Abstract Aim To determine whether operation notes adhere to IR(ME)R guidelines when reporting intra-operative ionising radiation images. Method Trauma and Orthopaedic operation notes were selected using a random number generator. These were assessed for a clear record of ionising radiation usage, and a clear description of and/or diagnostic implications of the imaging. An operation note template was created to encourage mandatory reporting of images taken intra-operatively. The operation notes were assessed again, and data collected. Results In total 90 operation notes were assessed. Before implementation of the image reporting template, 87% showed clear use of ionising radiation, and 60% a clear description or diagnostic implications of images. After implementation of the template, 73% of reporters used it. Of those that used it, 100% showed clear use of ionising radiation and 100% a clear description or diagnostic implications of images. Of those not using the template, 62.5% showed clear use of ionising radiation and 50% a clear description or diagnostic implications of images. Conclusions IR(ME)R 2017 guidelines require a documented clinical evaluation recorded for each exposure to ionising radiation, and exposures not clinically evaluated are not justified. Ionising radiation carries a small but compound risk of cancer, and therefore all radiation should be clinically justifiable. This study shows that the introduction of a template to operation reporting systems increased the reporting of intra-operative images to 100%. One limitation is that the template can be easily bypassed, enabling the reporter to skip the image reporting section and not document their evaluation.

Innovative Approaches to Engaging Homeless and Marginally Housed Patients in Care: a Case Study of Hepatitis C.

Homeless and marginally housed (HAMH) individuals experience significant health disparities compared to housed counterparts, including higher hepatitis C virus (HCV) rates. New direct-acting antiviral (DAA) medications dramatically increased screening and treatment rates for HCV overall, but inequities persist for HAMH populations. This study examines the range of policies, practices, adaptations, and innovations implemented by Veteran Affairs Medical Centers (VAMCs) in response to Veterans Health Administration (VHA)'s 2016 HCV funding allocation to expand provision of HCV care. Ethnographic site visits to six US VAMCs varying in size, location, and availability of Homeless Patient-Aligned Care Teams. Semi-structured qualitative interviews informed by the HCV care continuum were conducted with providers, staff, and HAMH patients to elicit experiences providing and receiving HCV care. Semi-structured field note templates captured clinical care observations. Interview and observation data were analyzed to identify cross-cutting themes and strategies supporting tailored HCV care for HAMH patients. Fifty-six providers and staff working in HCV and/or homelessness care (e.g., infectious disease providers, primary care providers, social workers). Twenty-five patients with varying homeless experiences, including currently, formerly, or at risk of homelessness (n=20) and stably housed (n=5). All sites experienced challenges with continued engagement of HAMH individuals in HCV care, which led to the implementation of targeted care strategies to better meet their needs. Across sites, we identified 35 unique strategies used to find, engage, and retain HAMH individuals in HCV care. Despite highly effective, widely available HCV treatments, HAMH individuals continue to experience challenges accessing HCV care. VHA's 2016 HCV funding allocation resulted in rapid adoption of strategies to engage and retain vulnerable patients in HCV treatment. The strategies identified here can help healthcare institutions tailor and target approaches to provide sustainable, high-quality, equitable care to HAMH individuals living with HCV and other chronic illnesses.

Goals of care documentation by medical oncologists and oncology patient end-of-life care outcomes.

Goals of care (GOC) documentation is important but underused. We aimed to improve oncologist GOC documentation and end-of-life (EOL) care. In April 2020, our cancer center launched a GOC note template, including optional fields for documenting discussion with the patient about: cancer natural history, goals, and/or EOL (resuscitation preferences, hospice receptivity). Associations between GOC notes and EOL care were evaluated. Among 1721 patients dying between June 1, 2020 and June 30, 2021, median days from first GOC note (± with documentation of EOL discussion) to death was 92, whereas a GOC note including EOL discussion ("GOC EOL note"), specifically, was 31. Patients with a first GOC note >60 days before death spent fewer days inpatient (6.7 vs 10.6 days, p < .001). Among patients with GOC EOL notes, those with such documentation >30 days before death had fewer inpatient (5 vs 11, p < .001) and intensive care unit days (0.5 vs 1.5, p < .001), more hospice referrals (57% vs 44%, p=.003), and less chemotherapy ≤14 days before death (6% vs 11%, p=.010). Of 925 admissions of patients dying within ≤30 days, those with GOC EOL notes were shorter (7 vs 9 days, p=.013) but not associated with more hospice discharge (30% vs 25%, p=.163). Oncologist (vs nononcologist) GOC documentation and earlier documentation of EOL discussion were associated in subset analyses with less inpatient care and more hospice referrals. Documentation of GOC, including EOL discussions, is associated with favorable performance on accepted indicators of quality EOL care.

"I Wish Someone had Asked Me Earlier"-Perspectives on Advance Care Planning in Surgery.

"I Wish Someone had Asked Me Earlier"-Perspectives on Advance Care Planning in Surgery.

A Closed-Loop Audit for Orthopedic Trauma Operation Notes Comparing Typed Electronic Notes With Handwritten Notes

IntroductionOperation notes are important documents for ensuring patient safety, effective communication between clinicians, and for medicolegal purposes. It is essential that they are clear and accurate. We audited the quality of our operation notes against the Royal College of Surgeons (RCS) of England's Good Surgical Practice Guidelines.MethodsThis was a prospective audit of 99 orthopedic trauma operation notes. In the first cycle, we audited 58 operation notes for orthopedic trauma surgical procedures. We audited 17 parameters per note. We presented our findings, implemented changes including the use of a typed operation note template, and performed a re-audit using 41 operation notes.ResultsOur documentation for 3/17 parameters was up to standard in both cycles. Post-intervention, there was an improvement in documentation for 12/17 of the parameters with marked improvements in indication for surgery (45% vs 75%), tourniquet time (20% vs 45%), antibiotic prophylaxis (71% vs 89%), closure technique (62% vs 86%) and detailed postoperative instruction (40% vs 92%). Other parameters, particularly estimated blood loss (7% vs 8%) remained unchanged. In the second cycle, we noted that 25% of the typed notes had 100% compliance with the standards, whereas no handwritten note achieved this. However, there was no statistically significant difference in the mean number of correctly documented parameters between the typed and handwritten notes (p < 0.05).ConclusionThe use of operation note templates (preferably typed) can improve appropriate documentation in orthopedic trauma operation notes. These templates should be made easily accessible to all surgeons. We will recommend orthopedic trauma units to apply similar non-rigid templates that can be tailored to suit different categories of trauma surgery.

Implementation of a standardized process for outpatient COVID-19 treatments at a Veterans Affairs medical center

BackgroundThe initial availability and distribution of new therapeutic options for outpatients with mild to moderate coronavirus disease 2019 (COVID-19) was limited by insufficient supply, challenges related to administration and dispensing, and unique clinical considerations of each medication. ObjectiveThis study aimed to describe the implementation of a standardized process for prescribing, dispensing, and administering medications for outpatients with mild to moderate COVID-19 infection. MethodsPatients evaluated in outpatient clinics, the emergency department, or urgent care locations who tested positive for COVID-19 with mild to moderate symptoms were candidates for outpatient management. An interdisciplinary team involving physicians from primary care and the emergency department, pharmacists, and nursing developed a standardized note template to gather relevant information before initiating outpatient COVID-19 treatment. Pharmacists reviewed the patients’ eligibility for treatment and discussed the available options with providers to facilitate the timely provision of appropriate treatment. ResultsA total of 134 outpatients were evaluated for COVID-19 treatment from January 10, 2022, to March 10, 2022. Following a retrospective chart review, it was determined that a medication was administered or dispensed to 80 of those patients. ConclusionCollaboration as an interdisciplinary team allowed for the efficient development of a systematic process in which outpatients with COVID-19 could be evaluated, prescribed, and administered appropriate medications to reduce their risk of disease progression.

Can diagnostic and imaging recommendations from the 2011 AAP UTI guidelines be applied to infants

In 2011, the American Academy of Pediatrics (AAP) published guidelines regarding diagnosis and management of children 2-to-24-months-old with initial febrile urinary tract infection (fUTI). Available data were insufficient to determine whether evidence from studies of 2-to-24-month-olds applies to those <2-months-old, so they were excluded. This study aimed to 1) compare demographic, clinical, imaging and outcomes between patients <2-months-old and those 2-to-24-months-old hospitalizedwith fUTI, and 2) assess whether diagnostic and imaging recommendations of the AAP 2011 guidelines apply to those <2-months-old. A cohort study of patients ≤24-months-old hospitalized at a children's hospital with fUTI from 2016 to 2018 was conducted. Data were collected via a prospectively generated electronic medical record note template, supplemented with retrospective chart review. Primary outcomes included differences in demographics, clinical presentation, urine culture results, and imaging utilization/results by age group. Secondary outcomes included surgical procedures, UTI recurrence, and 90-day all-cause readmissions and emergency department (ED) revisits. Univariate and bivariate statistics were utilized to compare age groups. Overall, 137 patients were included (median age 70 days, 55.5% male [92.1% uncircumcised], 53.3% Hispanic/Latino, 89.8% 1st fUTI). There were no demographic differences between groups, except children <2-months-old were more frequently male (71.2 vs 43.6%, p=0.002). The Summary Table compares clinical factors and imaging utilization byage. There were no differences in urinalysis or urine culture results between groups. Patients <2-months-old had shorter fever duration, lower maximum temperature, and lower white blood cell counts. Voiding cystourethrograms (VCUGs) were recommended and obtained more frequently in patients <2-months-old, but there were no differences in renal and bladder ultrasound (RBUS) or VCUG results between age groups. There were no differences in UTI recurrence (13.6% of <2-months-old vs 14.1% of 2-to-24-months-old, p=1.00) or fUTI recurrence (13.6 vs 7.7%, p=0.40) within 1 year, 90-day readmission (6.8 vs 6.4%, p=1.00), or 90-day ED revisit (22.0 vs 20.5%, p=1.00). There were minimal differences between the <2-months-old and 2-to-24-months-old age groups in demographics, laboratory (including microbial) or imaging results, or clinical outcomes. Patients <2-months-old were more frequently male and less ill. These data support applying urinalysis and urine culture diagnostic criteria, and universal RBUS, from the AAP guidelines to patients <2-months-old. Given utilization differences, applicability of VCUG guideline recommendations requires further clarification for patients <2-months-old. Laboratory testing and RBUS recommendations from the AAP guidelines may be safely applied to infants <2-months-old. Further studies are needed to clarify optimal VCUG recommendations.

Development of an electronic health record registry to facilitate collection of Commission on Cancer (CoC) metrics for patients undergoing surgery for breast cancer.

1549 Background: Accurate and efficient data collection is a challenge for quality improvement initiatives and clinical research. We describe the development of a custom electronic health record (EHR) based registry to automatically extract structured Commission on Cancer (CoC) axillary surgery specific metrics from a custom synoptic note template included in the operative reports for breast cancer patients undergoing surgery. Methods: The “Smart” functionality of our enterprise-based EHR system was leveraged to create a custom Smart phrase to capture axillary surgery specific variables. A multidisciplinary team developed structured data elements correlating to each axillary surgery-specific variable. These data elements were then included in a note template for the operative report. Each variable could be aggregated and converted into a single flat database through the EHR’s reporting workbench and serve as a live, prospective registry for all users within the EHR. Results: The final axillary surgery-specific note template in a synoptic format allowed for efficient and easy entry and automatic collection of breast cancer specific metrics. From initial adoption in February 2021 through December 2021, there were 1,254 patients who underwent breast surgery with axillary surgery. The operative notes allowed for automatic capture of metrics from 60.5% (n = 759) of patients. Data capture improved from 37.6% in the initial adoption period of six months to 86.2% in the last five months. Capture rate in December 2021 was 98%. Conclusions: We were able to demonstrate successful implementation of provider driven structured data entry into EHR systems that permits automatic data capture. The end result is a custom synoptic note template and a real-time, prospective registry of breast cancer-specific CoC metrics that are robust enough to use for quality improvement initiatives and clinical research.

696-P: Increasing CGM Use through Standardized Documentation

Continuous glucose monitor (CGM) use is known to improve glycemic outcomes for patients with Type 1 Diabetes, but uptake is not universal in the pediatric population. We hypothesized that requiring standardized documentation of CGM use and identification of barriers would increase awareness and identify potential targets for future interventions, ultimately increasing CGM use in our population. We designed standard documentation within the electronic medical record for outpatient visits to assess CGM use and barriers to use. The documentation collects data on CGM possession, %time in use, prescriptions, and barriers to use in patients with Type 1 Diabetes. Our intervention involved integrating the standard CGM documentation into diabetes note template thus automating completion by providers. Data was pulled from clinic days two weeks prior to intervention (100 patients) and another days, two months after intervention (74 patients) . Before intervention 83% of patients had a CGM compared to 87% of patients after intervention (p=0.51) . While 63% used a CGM &amp;gt;70% of the time before intervention, 73% of patients had &amp;gt;70% use post intervention (p=0.19) . Provider documentation was not universal with 12% and 4% of encounters with no documentation of time in use before and after intervention respectively. After standardization 7/patients without a CGM were prescribed one during the visit compared to 5/17 of patients prior. Barriers identified included (n) : insurance coverage (4) , skin adhesion/issues (3) , self-image (2) , lack of education /distrust (1) , technological issues (1) , resistance to wearables (1) , and other (3) . Our patient population had a high rate of CGM use. Two months after the intervention, both use of CGM and new prescriptions increased. The improvement may be related to increased awareness and addressal of CGM barriers among providers. The intervention provided insight on barriers to CGM use, such as skin/adhesion issues, that will be targeted for future improvement. Disclosure S.E.Delacey: None. N.J.Sullivan: None. N.R.Fogel: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases Ruth L. Kirschstein National Research Service Award T32 DK007169 and T1D Exchange

Toward Safer Opioid Prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial

BackgroundThe 2016 U.S. Centers for Disease Control Opioid Prescribing Guideline (CDC Guideline) is currently being revised amid concern that it may be harmful to people with chronic pain on long-term opioid therapy (CP-LTOT). However, a methodology to faithfully implement the CDC guideline, measure prescriber adherence, and systematically test its effect on patient and public health outcomes is lacking. We developed and tested a CDC Guideline implementation strategy (termed TOWER), focusing on an outpatient HIV-focused primary care setting.MethodsTOWER was developed in a stakeholder-engaged, multi-step iterative process within an Information, Motivation and Behavioral Skills (IMB) framework of behavior change. TOWER consists of: 1) a patient-facing opioid management app (OM-App); 2) a progress note template (OM-Note) to guide the office visit; and 3) a primary care provider (PCP) training. TOWER was evaluated in a 9-month, randomized-controlled trial of HIV-PCPs (N = 11) and their patients with HIV and CP-LTOT (N = 40). The primary outcome was CDC Guideline adherence based on electronic health record (EHR) documentation and measured by the validated Safer Opioid Prescribing Evaluation Tool (SOPET). Qualitative data including one-on-one PCP interviews were collected. We also piloted patient-reported outcome measures (PROMs) reflective of domains identified as important by stakeholders (pain intensity and function; mood; substance use; medication use and adherence; relationship with provider; stigma and discrimination).ResultsPCPs randomized to TOWER were 48% more CDC Guideline adherent (p < 0.0001) with significant improvements in use of: non-pharmacologic treatments, functional treatment goals, opioid agreements, prescription drug monitoring programs (PDMPs), opioid benefit/harm assessment, and naloxone prescribing. Qualitative data demonstrated high levels of confidence in conducting these care processes among intervention providers, and that OM-Note supported these efforts while experience with OM-App was mixed. There were no intervention-associated safety concerns (defined as worsening of any of the PROMs).ConclusionsCDC-guideline adherence can be promoted and measured, and is not associated with worsening of outcomes for people with HIV receiving LTOT for CP. Future work would be needed to document scalability of these results and to determine whether CDC-guideline adherence results in a positive effect on public health.Trial registrationhttps://clinicaltrials.gov/ct2/show/NCT03669939. Registration date: 9/13/2018

Feasibility of establishing a multi-center research database using the electronic health record: The PURSUIT network

Although multi-center research is needed in pediatric urology, collaboration is impeded by differences in physician documentation and research resources. Electronic health record (EHR) tools offer a promising avenue to overcome these barriers. To assess the accuracy, completeness, and utilization of structured data elements across multiple practices. A standardized template was developed and implemented at five academic pediatric urology practices to document clinic visits for patients with congenital hydronephrosis and/or vesicoureteral reflux. Data from standardized elements in the template and from pre-existing EHR fields were extracted into a secure database. A 20% random sample of infants with data from structured elements from 1/1/2020 and 4/30/2021 were identified and compared to manual chart review at sites with >100 charts; all other sites reviewed at least 20 charts. Manual chart review was standardized across sites and included: clinic and operative notes, orders linked to the clinic encounter, radiology results, and active medications. Accuracy of data extraction was evaluated by computing the kappa statistic and percentage agreement. For sites that had adopted the templates prior to 6/1/2019 (early adopters), a list of eligible patients with an initial clinic visit from 1/1/2020-7/27/2020 was generated using standardized reporting techniques and confirmed by manual chart review. Physician utilization of the template was then calculated by comparing patients with data obtained from the note template to the generated list of eligible patients. 230 patient records met study criteria. Agreement between manual chart review and data extracted from the EHR was high (>85%). Race, ethnicity and insurance data were misclassified in about 10-15% of cases; this was due to site-specific differences in how these fields were coded. Renal ultrasound was misclassified 12% of the time; this was primarily due to outside images documented in radiology results but not included in the clinical note. All other data elements had >90% agreement (Figure). Template utilization for early adopters was >75% (75.5-87.5%). This is the first study in urology to demonstrate that use of structured data elements can support multi-center research. Limitations include: inclusion of only academic sites with the Epic EHR and lack of data on utilization and sustainability at sites without a prior history of structured template use. Multi-center research collaboration using EHR-based data collection tools is feasible with generally high accuracy compared to manual chart review. Additionally, sites with a long history of template adoption have high levels of provider utilization.

Improving Adherence to AAP Acute Otitis Media Guidelines in an Academic Pediatrics Practice through a Quality Improvement Project.

Introduction:Acute otitis media (AOM) is the most common reason for antibiotic use in children. The American Academy of Pediatrics (AAP) published its latest AOM guidelines in 2013. A safety-net antibiotic prescription (SNAP) is recommended for some patients based on age, severity, and duration of symptoms. At baseline, 78% of patients diagnosed with AOM in our general pediatrics practice met AAP guidelines, and 20% of eligible patients received a SNAP according to guidelines. We aimed to increase adherence to AAP AOM guidelines in an academic general pediatrics clinic from 78% to 90% by January 2020.Methods:A quality improvement team determined key drivers and developed interventions. Patients included were 6 months to 12 years old with AOM. Encounters were reviewed for adherence to AAP AOM guidelines. During the project, interventions included an ear pain note template, which generated guideline-based recommendations, note template education in clinic orientation sessions, a didactic session on AOM management, and reminders on workstations. Data were analyzed using P-charts.Results:Percent of AOM encounters (n = 1266) adhering to AAP AOM guidelines increased from 78% to 92%. We also reviewed two process measures. First, the use of the ear pain note template increased from 0% to 44%. Second, the percent of AOM encounters where an eligible patient received a SNAP increased from 21% to 78% (encounters n = 421).Conclusion:We demonstrate increased adherence to AAP AOM guidelines, including improved use of SNAPs after introducing a note template with clinical decision support and provider educational sessions.

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.