Outpatient Electronic Medical Record Research Articles

Disease spectrum of torticollis in children and diagnostic flowchart: A retrospective, single-centre study.

To describe the disease spectrum of torticollis in Chinese children and to improve its diagnostic flowchart. A retrospective analysis was conducted at the Rehabilitation Department of Beijing Children's Hospital from 2017 to 2021. Patients were diagnosed and referred based on a diagnostic flowchart of torticollis. Detailed patient data were collected from the outpatient electronic medical record system. A total of 2047 patients met the inclusion criteria. The top five conditions were congenital muscular torticollis (CMT) (76.6%), cerebral palsy (5.1%), ocular torticollis (4.7%), brachial plexus injury (1.9%) and atlantoaxial rotary subluxation (1.3%). CMT was most common in 0-2 year olds, cerebral palsy in 3-5 year olds, and atlantoaxial rotary subluxation in 7-12 year olds. The top five referral departments were orthopaedics, ophthalmology, otolaryngology, head and neck surgery, neurology and neurosurgery. The disease spectrum of torticollis in children and the diagnostic flowchart provide important references for diagnosing torticollis, which necessitates multidisciplinary collaboration.

Electronic Health Record Adoption in Oral and Dental Health Centres in Turkey

The digitalisation studies in public hospitals in Turkey started with the Health Transformation Program in 2003. The Ministry of Health has been measuring the dissemination of meaningful usage and adoption of electronic health record (EHR) using Electronic Medical Record Adoption Model (EMRAM) and Outpatient Electronic Medical Record Adoption Model (O-EMRAM). Using a comprehensive survey, our study intends to measure the stage of EHR adoption in oral and dental health centres (ODHCs) providing primary healthcare services in Turkey. The results obtained were classified by basic and comprehensive EHR functions and benchmarked against the studies addressing EHR adoption in primary healthcare institutions of other countries. In 2021, 167 ODHCs/oral and dental health hospitals (ODHHs) actively operating in Turkey completed the O-EMRAM survey. The data obtained from the survey results were analysed with QlikView Personal Edition. The availability and prevalence of medical information systems and EHR functions and their use were measured. It is observed that 59 (40.7%) of ODHCs/ODHHs have comprehensive EHR functions, while the remaining 86 (59.3%) have basic EHR functions. Under these circumstances, it can be stated that all ODHCs/ODHHs in Turkey use at least basic EHR functions. All ODHCs/ODHHs in Turkey have at least basic EHR functions. The integration of e-prescription, electronic authorisation system and e-Pulse used throughout Turkey and Health Information Management System Society (HIMSS) used in ODHCs/ODHHs can be listed as one of the decisive factors in this result. ODHCs/ODHHs still have a long way to go in adopting EHR, but the current circumstances are also promising. It is considered that this study will serve as a baseline for future measurements and produce a notable result for decision-makers.

Postmenopausal endometrial non-benign lesion risk classification through a clinical parameter-based machine learning model

ObjectiveThis study aimed to develop and evaluate a machine learning model utilizing non-invasive clinical parameters for the classification of endometrial non-benign lesions, specifically atypical hyperplasia (AH) and endometrioid carcinoma (EC), in postmenopausal women. MethodsOur study collected clinical parameters from a cohort of 999 patients with postmenopausal endometrial lesions and conducted preprocessing to identify 57 relevant characteristics from these irregular clinical data. To predict the presence of postmenopausal endometrial non-benign lesions, including atypical hyperplasia and endometrial cancer, we employed various models such as eXtreme Gradient Boosting (XGBoost), Random Forest (RF), Logistic Regression (LR), Support Vector Machine (SVM), Back Propagation Neural Network (BPNN), as well as two ensemble models. Additionally, a test set was performed on an independent dataset consisting of 152 patients. The performance evaluation of all models was based on metrics including the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, precision, and F1 score. ResultsThe RF model demonstrated superior recognition capabilities for patients with non-benign lesions compared to other models. In the test set, it attained a sensitivity of 88.1% and an AUC of 0.93, surpassing all alternative models evaluated in this study. Furthermore, we have integrated this model into our hospital's Clinical Decision Support System (CDSS) and implemented it within the outpatient electronic medical record system to continuously validate and optimize its performance. ConclusionsWe have trained a model and deployed a system with high discriminatory power that may provide a novel approach to identify patients at higher risk of postmenopausal endometrial non-benign lesions who may benefit from more tailored screening and clinical intervention.

Abstract C073: Assessing the prevalence of cardiometabolic diseases among breast cancers cases at the Howard University Cancer Center

Abstract Background: Cardiometabolic disorders encompass a spectrum of cardiovascular and metabolic system diseases including heart attack, stroke, type 2 diabetes (T2DM), insulin resistance, and metabolic syndrome. Common risk factors among these diseases include abdominal obesity, hyperlipidemia, and increased blood pressure. Cardiometabolic diseases disproportionately impact African American women, especially those with cancer. Evidence indicates that women with breast cancer are more likely to pass away from cardiometabolic diseases than cancer itself. Purpose: This study aims to investigate the prevalence of cardiometabolic diseases among female breast cancer patients diagnosed at the Howard University Cancer Center between January 2012 and December 2022. Methods: A retrospective chart review will be conducted using the cancer registry data from The Howard University Cancer Center and electronic medical records from the Howard University Faculty Practice Plan Outpatient Electronic Medical Records (Allscripts). This will be conducted in two phases. In Phase I, we will recruit women 18 to 88 years old diagnosed with breast cancer between 2012 and 2022. Howard University has approximately 70 to 100 breast cancer cases per year. It is anticipated that approximately 1,000 cases will be identified. From this sample, we will collect information regarding cancer diagnosis, treatment composite, and tumor characteristics. Assuming this generates 1,000 cases, we will randomly select 25% of this number (250 cases) to obtain the other variables of interest from the medical records. This initiates phase II, where we will use the medical record number provided by the cancer registry to identify and review records of the 250 cases. The electronic medical records will be reviewed on-site upon approval of the Director of Outpatient Medical Records. The variables assessed will include demographic data (age at diagnosis, ethnicity, geographical location, and level of education), body mass index (BMI), date of diagnosis, treatment composite (initial treatment at the time of diagnosis), menopausal status, tobacco use, cardiometabolic diseases (diabetes, heart attack, stroke, abdominal obesity), cardiometabolic risk factors (hypertension and hyperlipidemia), and tumor characteristics (number of primary sites and stages of cancer). All data will be maintained using REDCap which is a secure web-based application designed to manage online surveys and data. An electronic data abstraction form will be developed in REDCap to record all of the information listed below in Table 1. All statistical analyses will be conducted using SPSS. The quantitative data will be characterized by means, medians, modes, and frequencies in a descriptive analysis. Log-binomial regression will be used to calculate prevalence ratios. A chi-square test will be utilized to examine cardiometabolic disorders and breast cancer at diagnosis. Anticipated Deliverable: Determine the prevalence of cardiometabolic diseases among female breast cancer patients diagnosed at The Howard University Cancer Center. Citation Format: Ozioma A. Scott. Assessing the prevalence of cardiometabolic diseases among breast cancers cases at the Howard University Cancer Center [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C073.

Age-related Changes with the Trabecular Bone of Ward's Triangle and Neck-shaft Angle in the Proximal Femur: A Radiographic Study.

The Ward triangle is an important area used clinically to diagnose and assess osteoporosis and its fracture risk in the proximal femur. The main objective of this study was to investigate the rules of development and maturation of the trabeculae of Ward's triangle to provide a basis for the prevention and treatment proximal femur fracture. From January 2018 to December 2019, individuals from 4 months to 19 years old who underwent hip growth and development assessments at the Third Hospital of Hebei Medical University were selected retrospectively. The outpatient electronic medical record system was used to collect information such as age, gender, imaging images, and clinical diagnosis. The development score and maturity characteristics of the trabecular bone were analyzed using hip radiograph data. Correlation analysis was performed to identify the relationship among age, neck-shaft angle and development and maturity score of the trabecular bone. A total of 941 patients were enrolled in this study, including 539 males and 402 females. Primary compression trabeculae were all present at 1 year of age and matured at 7 years of age and older; primary tension trabeculae were all present at 4 years of age and matured at 18 years of age. Secondary compression trabeculae were present at 4 years of age and matured at 18 years of age. In addition, the neck-shaft angle progressively decreases from 4 months to 14 years of age but barely changes between 15 and 19 years of age. In short, the development and maturation of the trabeculae in the ward' triangle followed a specific temporal pattern that was related to the neck-shaft angle. Therefore, these findings can help us understand structure and mechanical characteristics of proximal femoral trabeculae, and improve our understanding of the mechanism and treatment of proximal femoral fractures.

Applying the Healthcare Failure Mode and Effect Analysis (HFMEA) Method for the Risk Management of Self-Developed Electronic Medical Records (EMRs) in Hospitals

The organization of electronic medical records (EMR) in hospitals is vital. In cases where EMRs are developed independently, failures that hamper the hospital's operations could sometimes occur. Risk management is needed to identify, reduce, and eliminate potential failures. This study aimed to analyze a risk management by using the Healthcare Failure Mode and Effects Analysis (HFMEA) method to reduce the risk of failure in the outpatient EMR development process at Baitul Hikmah General Hospital (RSBH). This observational research applied an action research design and was conducted using the HFMEA method. It analyzed the outpatient EMR development process at RSBH. Research data was obtained through a mixed method where information was collected from focus group discussions (FGD) and calculated risk priority numbers (RPN). The research subjects were determined by the purposive sampling technique (HFMEA team). The HFMEA form was used as the research instrument. At least 33 failure modes were identified. These failure modes were evenly distributed throughout the outpatient EMR development process at RSBH. The top five failure modes received treatment actions and their outcomes were measured. Four out of the five failure modes showed a significant decrease in RPN value. In short, risk management analysis using the FMEA method could significantly reduce the potential for failure in the outpatient EMR development process at RSBH

Effect of "one-stop" outpatient management on the control rate of multiple metabolic disorders patients

Objective: To explore the effect of "one-stop" outpatient management on the therapeutic schedule and control rate of patients with metabolic disorders. Methods: A total of 332 patients who met the inclusion criteria were enrolled and treated regularly in the "one-stop" outpatient department of the Department of Cardiology of the Third Hospital of Peking University from November 1, 2020 to April 30, 2022. The general information, personal history, family history, drug treatment plan, blood pressure, height, weight, waist circumference, and hip circumference of patients were collected through the outpatient electronic medical record system, and patients were followed up through conducting "one-stop" comprehensive management. The baseline clinical characteristics were analyzed, and the changes of metabolic indexes, treatment conditions and control rate of patients with different metabolic disorders before and after the "one-stop" outpatient management were compared. Results: The time interval between the first visit and the last visit was 44 (26, 60) weeks in 332 patients, whose age was (57.2±13.2) years, including 219 males (66.0%). After the "one-stop" outpatient management, fasting blood glucose (FBG) [ 6.6 (5.6, 7.9) mmol/L vs 6.3 (5.6, 6.9) mmol/L], glycosylated hemoglobin A1c (HbA1c) [ (7.2±1.5) % vs (6.6±0.8) %], low density lipoprotein cholesterol (LDL-C) [ 2.70 (1.97, 3.55) mmol/L vs 2.04 (1.66, 2.63) mmol/L] and blood uric acid (UA) [ (383.7±107.1) μmol/L vs (341.2±90.6) μmol/L] all decreased significantly (all P values<0.05). The control rates of hypertension (19.8% vs 28.2%), diabetes (45.2% vs 66.5%), hyperlipidemia (54.9% vs 87.6%) and hyperuricemia (16.7% vs 49.0%) were significantly improved after the "one-stop" outpatient management (all P values<0.05). Conclusion: The "one-stop" outpatient management of cardiovascular department can significantly improve the metabolic condition and the control rate of patients with multiple metabolic disorders.

S1470 A Quality Improvement Project to Increase Bariatric Surgery Referrals at an Urban Primary Care Clinic

Introduction: According to the American Society for Metabolic and Bariatric Surgery, bariatric surgery is recommended for all patients with a BMI of 40 or higher. Bariatric surgery is also recommended for patients with a BMI of 35 or higher and one or more obesity-related comorbidity. Incidentally, we have observed that patients who meet these BMI cutoffs are often not referred to bariatric surgery. We sought to quantify whether or not patients meeting these criteria are appropriately referred to bariatric surgery, and if not, to improve the number of bariatric surgery conversations and referrals at an urban primary care clinic. Methods: A retrospective study was performed that involved collecting data from the out-patient electronic medical record (EMR). Patients included in this study had both a BMI of 35 or higher and a formal diagnosis of diabetes mellitus, indicating that they would warrant referral to bariatric surgery for an initial evaluation based on current guidelines. Charts were reviewed for each patient to determine if they 1) had been seen by a bariatric surgeon, 2) had been referred to but not established care with a bariatric surgeon, or 3) had been counseled by their primary care provider about the potential benefits of weight-loss surgery. Additional variables collected were as follows: sex, age, BMI, and ethnicity. Results: Overall, data was collected on 70 patients total (19 males, 51 females) from an urban primary care clinic. The average age of the patients included was 55.7 years-old. The average BMI across the group was 43.3, and all patients carried a formal diagnosis of diabetes. Only 11.4% (8/70) of patients had actually established care and been seen by bariatric surgery for an initial evaluation, but 25.7% (18/70) had been formally referred to bariatric surgery. Conversations about weight-loss surgery were documented in progress notes for 27.1% (19/70) of patients. Conclusion: Of the 70 patients included in this study, only 18 patients were referred to bariatric surgery despite all of them meeting criteria to warrant referral. This study confirms our hypothesis that there is a need to improve the rate at which primary care providers refer patients with a BMI of 35 and obesity-related comorbidity or a BMI of 40 to bariatric surgery for a preliminary evaluation. To address this, we have implemented an out-patient quality improvement program to ensure both conversations about weight-loss surgery and bariatric surgery referrals occur for patients who necessitate them.

Medical data formatting to improve physician interpretation speed in the Military Healthcare System.

The purpose of this project was to improve ease and speed of physician comprehension when interpreting daily laboratory data for patients admitted within the Military Healthcare System (MHS). A JavaScript program was created to convert the laboratory data obtained via the outpatient electronic medical record (EMR) into a "fishbone diagram" format that is familiar to most physicians. Using a balanced crossover design, 35 internal medicine trainees and staff at Naval Medical Center Portsmouth were asked to complete timed comprehension tests for laboratory data sets formatted in the outpatient EMR's format and in fishbone diagram format. The number of responses per second and error rate per response were measured for each format. Participants were asked to rate relative ease of use for each format and indicate which format they preferred. Comprehension speed increased 37% (6.28 seconds per interpretation) with the fishbone diagram format with no observed increase in errors. Using a Likert scale of 1-5 (1 being hard, 5 easy), participants indicated the new format was easier to use (4.14 for fishbone vs 2.14 for table) with 89% expressing preference for the new format. The publically available web application that converts tabular lab data to fishbone diagram format is currently used 10000-12000 times per month across the MHS, delivering significant benefit to the enterprise in terms of time saved and improved physician experience. This study supports the use of fishbone diagram formatting for laboratory data for inpatients within the MHS.

Incidence of Pediatric Eosinophilic Esophagitis and Characterization of the Stricturing Phenotype in Alberta, Canada.

We retrospectively identified all new cases of EoE at our center from 2015 to 2018 using esophageal biopsy reports, EoE clinic lists, and a local OR database of esophageal dilatations. Electronic medical records (EMRs) were reviewed to confirm EoE diagnosis. Clinical data were captured from the outpatient EMR and gastroscopy/pathology reports. Scope adverse event data were captured from multiple sources. The 2016 census data were used to calculate incidence rates. One hundred eighty-five new cases of EoE were diagnosed during the study period. For patients <15 years old living in Edmonton, the incidence over the 4 years was 11.1 cases per 100,000 person years. Eight of 185 (4%) patients had endoscopically confirmed esophageal strictures, 4 of which required mechanical dilation. Eleven of 185 (5.9%) patients had more subtle signs of esophageal narrowing, but no focal strictures. No perforations or episodes of significant bleeding were reported. Pain was reported after 15% of all scopes, including 50% of the 28 scopes with focal strictures. No unexpected admissions or emergency department visits occurred within 72 hours of a gastroscope with esophageal narrowing. Edmonton zone has one of the highest incidences of pediatric EoE reported. In this cohort, 4% had focal esophageal strictures, and 6% had more subtle narrowing. Mechanical dilation of esophageal strictures was associated with no significant adverse events.

Provider and clinical setting characteristics associated with tobacco pharmacotherapy dispensed in the Veterans Health Administration.

INTRODUCTIONWhile initiation rates of tobacco cessation pharmacotherapy have improved both inside and outside the Department of Veteran Affairs (VA), prescribing rates remain low. The objective of this study was to examine correlation of the characteristics of providers, clinics, and facilities with initiation of tobacco cessation pharmacotherapy.METHODSThis retrospective, observational study used VA outpatient electronic medical record data from federal fiscal year 2011. Logistic regression models estimated the adjusted odds ratio associated with provider characteristics for pharmacotherapy initiation.RESULTSFor the 639507 veterans who used tobacco, there were 30388 providers caring for them. Younger (p<0.001) and female (p<0.001) providers were more likely to initiate tobacco cessation pharmacotherapy. Compared to physicians, pharmacists were 74% more likely to initiate pharmacotherapy, while all groups of nurses were 5–8% and physicians’ assistants were 12% less likely (p<0.001). Compared to those seen in primary care clinics, patients assessed in substance use treatment clinics were 16% more likely to have pharmacotherapy initiated (p<0.001), while those in psychiatry were 10% less likely (p<0.001), and those in outpatient surgery were 39% less likely to initiate pharmacotherapy (p<0.001). Compared to almost all other classes of VA facilities, patients seen in primary care community-based outpatient clinics (CBOCs) were 7–28% more likely to initiate pharmacotherapy (p<0.0001).CONCLUSIONSWhile the VA is at the leading edge of providing tobacco cessation pharmacotherapy, targeting quality improvement efforts towards providers, clinics, and facilities with low prescribing rates will be essential to continue the declining rates of tobacco use among VA patients.

622 Enhanced Recovery After Surgery for Fractional CO2 Laser Treatment of Burn Scars

Abstract Introduction Healthcare systems have adopted enhanced recovery after surgery (ERAS) programs as evidence-based, multimodal, and multidisciplinary perioperative approaches to mitigate complications and improve early recovery. ERAS programs modify psychological and physiological response to surgery with standardized care pathways that range from preoperative assessment and education through pharmacologic and surgical interventions. Our study demonstrates a burn scar specific ERAS protocol with pre- and post- intervention outcomes. Methods As part of a quality and performance improvement initiative, a multidisciplinary panel at an ABA-verified burn center consisting of burn nurses, burn surgeons, burn physician assistants, burn therapist, clinical pharmacist, certified medical laser safety officer, and anesthesiologist reviewed the available literature regarding pain, laser treatments, and medication histories of prior fractional CO2 laser treatments. The ERAS program was designed with preoperative, perioperative, and postoperative interventions to reduce pain and complications defined as unscheduled visits/admission to the ER or burn center, narcotic administration &amp;gt;1 hour post procedure, or wound complications secondary to laser treatment requiring dressing changes &amp;gt;1 week post-procedure. Quality and performance metrics were collected as a component of the burn registry program and reviewed twice monthly. The ERAS protocol preoperative phase included standardization of outpatient screening, assessment, and electronic medical record documentation. The perioperative phase included standardization of preprocedural medications including multimodal analgesia. The intraoperative phase included standardization of medications and dressing application. Post procedural phase included standardized instructions for wound care and follow-up. Results Pre-implementation complications over a three-month period included one patient requiring wound care &amp;gt;1 week post laser treatment and 4 patients requiring narcotic administration &amp;gt;1 hour post procedure (16% of laser cases). Post-implementation of the ERAS program no complications were identified in 62 cases over a three-month period. Conclusions At our institution a burn scar specific ERAS protocol reduced perioperative complications following fractional CO2 laser procedures. While many opportunities exist to improve scarring and pain, the multidisciplinary approach in burn care is as essential for outpatients as it is for inpatients at reducing avoidable complications.

1402. Smart Technology and Education for Smart Protection against the Flu: Impact of a Multifaceted Quality Improvement (QI) Intervention on Influenza Vaccination Rates in Children

BackgroundLow pediatric influenza vaccination rates are a public health challenge. It is imperative that innovative measures to promote influenza immunization are studied.MethodsAim: To study impact of a multifaceted QI intervention on influenza vaccination rates in children evaluated at outpatient clinics, urgent care (UC) and emergency departments (ED) at UnityPoint Health tertiary care centers (UPH) across Northwestern (NW) and Northcentral (NC) Iowa (IA). Patients aged 6 months-18 years evaluated at UPH in NW and NC IA (encompassing 5 outpatient clinics, 2 UC, 2 ED) were included. A multifaceted QI intervention was implemented on 9/1/2018 consisting of all of the following concomitantly: 1. Patient/family education: Posters about flu vaccination displayed at entrance, in waiting rooms and patient rooms throughout the clinics, UC, ED as well as patient/family handouts emphasizing importance of influenza immunization. 2. Information Technology: “Health maintenance” reminder in outpatient electronic medical record (EMR- EPIC) that appears as soon as a patient’s chart is accessed to remind nurses/providers that influenza vaccine is due. 3. Provider Education flyers at study sites about debunking flu myths. We compared pre-intervention period (P1, 09/01/2017– 05/31/2018) with intervention period (P2, 09/01/2018 – 05/31/2019) for influenza vaccination rates.ResultsA total of 10050 and 9889 patients were evaluated during P1 and P2 respectively. Influenza vaccination rate increased significantly from 56.1% (5642) in P1 to 73.3% (7252) in P2 (p< 0.0001). Patients were 1.43 times more likely to get vaccinated during P2 than P1 (95% CI= 1.32-1.46). Regionally during P2, influenza vaccination rate was higher than the national (62.6%; p< 0.0001) and Iowa state averages (65.8%; p< 0.0001) respectively. Proportion of children aged < 9 years receiving second dose of influenza vaccine increased from 43% to 69% (p< 0.001). Influenza vaccination rates among children aged 6-36 months increased significantly [40% (1078/2671) in P1 to 47.2% (1287/2723) in P2; p< 0.01].ConclusionWith the combined educational and technologic intervention, pediatric influenza vaccination rates increased significantly across NW and NC IA, including proportion of patients receiving second dose of the vaccine.DisclosuresRichard Malley, MD, Merck (Consultant)

Detecting Patients With Nonvalvular Atrial Fibrillation and Atrial Flutter in the Canadian Primary Care Sentinel Surveillance Network: First Steps

BackgroundA recent feasibility assessment of quality indicators for nonvalvular atrial fibrillation/atrial flutter (NVAF/AFL) identified the Canadian Primary Care Sentinel Surveillance Network, a national outpatient electronic medical record (EMR) system, as a data source for measurement. As a first step, we adapted and validated an existing EMR case definition. MethodsA diagnosis of NVAF/AFL was defined using International Classification of Disease, 9th Revision, Clinical Modification codes (427.3) in either the physician billing, encounter diagnosis, or health condition fields. We identified all presumed cases in a single clinical site with the algorithm and selected a random sample of those who were presumed NVAF/AFL negative with the same algorithm. A chart audit diagnosis of “definite” NVAF/AFL was confirmed by electrocardiogram and nonvalvular diagnosis confirmed after echocardiogram, attending physician, or specialist letter review. To demonstrate face validity, clinical characteristics were compared for patients with and without NVAF/AFL. ResultsThe case definition identified a possible 184 patients with and 184 without NVAF/AFL. The case validation resulted in a sensitivity of 100% (95% confidence interval [CI], 100-100), specificity of 84.3% (95% CI, 78.8-89.9), and positive and negative predictive value of 74.7% (95% CI, 66.4-83.2) and 100% (95% CI 100-100), respectively. Patients with NVAF/AFL were older (63 vs 42 years) and had a higher proportion of cardiovascular comorbidities and relevant medications. ConclusionsWe think it is possible that with further validation work, NVAF/AFL can be accurately identified using this large pan-Canadian EMR system and used as a future tool to measure quality of care in the outpatient setting.

A196 INCIDENCE OF PEDIATRIC EOSINOPHILIC ESOPHAGITIS IN EDMONTON ZONE AND RISK OF STRICTURING AT DIAGNOSIS

Abstract Background Eosinophilic esophagitis (EoE) is a common cause of esophageal dysfunction in children. A subset of children have a more severe phenotype of EoE, complicated by esophageal stricturing. Limited work has been done to characterize this phenotype. Aims To determine the incidence of EoE, and the frequency of esophageal stricturing in pediatric EoE. Methods We retrospectively identified all new cases of EoE at the Stollery Children’s Hospital from 2015–2018 using esophageal biopsy reports for the province of Alberta (CoPath database), EoE clinic lists and an OR database for esophageal dilatation at the Stollery. Electronic medical records (EMR) were reviewed to confirm EoE diagnosis. For each confirmed case, clinical data was captured from the outpatient EMR and gastroscopy/pathology reports. A review of peri-endoscopy OR/nursing charts was performed on a subset of patients (n=75) to capture scope adverse event. Statistics Canada 2016 census data was used to calculate incidence rates. Results 185 new cases of EoE were diagnosed at our center during the study period (see table). For patients &amp;lt; 15 years old living in Edmonton zone (n=73), the incidence over the 4 years was 11.1 cases per 100,000 person years {8.7 (0–4 year-old), 7.6 (5–9 year old), and 18.1 (10–14 year old)}. There was limited variation in incidence in the 4 years (9.1–12.1 per 100,000 person years). 8 of 185 (4%) patients had endoscopically confirmed esophageal strictures, 4 of which required mechanical dilation (mean 3.75 dilations per patient, range 1–6). 11/185 (5.9%) patients had more subtle signs of esophageal narrowing, but no strictures. No perforations or episodes of significant bleeding were reported in peri-endoscopy charts reviewed for 239 gastroscopes, including 16 dilations. Pain was reported after 15% of all scopes, including 50% of the 28 scopes with strictures and 63% of the 16 scopes involving dilations. Conclusions Edmonton zone has one of the highest incidences of EoE reported in children. In this cohort, 4% had esophageal stricture (half required dilatation) and 5.9% had more subtle narrowing. Patients with strictures were older, had more frequent food impaction and longer duration of symptoms (Table). This data will be included in an ongoing multicenter case-control study across Canada. Funding Agencies CAGWomen and Children’s Health Research Institute (Univ. Alberta)

Goals of care designations in advanced pancreatic cancer patients undergoing palliative chemotherapy.

683 Background: Discussion of goals of care (GoC) is a key part of quality care for patients with palliative cancer. Numerous studies have shown that documentation of GoC in this population remains low. In 2014, Alberta Health Services launched a health-system wide initiative to provide patients with physical copies of their GoC designation intended to be available at all health-system interactions. Here we describe rates of GoC documentation in the period surrounding this initiative. Methods: This is a retrospective cohort analysis of 240 patients with locally advanced or metastatic pancreatic cancer treated with palliative chemotherapy from 2012-2015 in Alberta, Canada. Data were obtained from outpatient electronic medical record documentation and the provincial cancer registry. Results: 63.8% (153/240) of patients had a documented GoC discussion, with 60.4% (145/240) receiving a specific GoC designation. 59.6% (143/240) of patients were referred to palliative care, with 32.5% (78/240) seen by palliative care physician. Of 334 individual GoC discussions documented, 38.6% (129/334) were by medical oncologists, 2.3% (10/334) were by radiation oncologists, 27.2% (91/334) were by palliative care, and 19.2% (64/334) were by other inpatient physicians during hospital admissions. At least 9.6% (32/334) referenced discussions that occurred prior to initial consultation with an oncology physician. Conclusions: The majority of pancreatic cancer patients undergoing palliative chemotherapy had a documented GoC designation during the study period. Providing patients with physical copies of their GoC designation may therefore represent a simple but effective means of increasing GoC documentation in the outpatient oncology setting.

Weighing the odds: Assessing underdiagnosis of adult obesity via electronic medical record problem list omissions.

BackgroundObesity is a continuing national epidemic, and the condition can have a physical, psychological, as well as social impact on one’s well-being. Consequently, it is critical to diagnose and document obesity accurately in the patient’s electronic medical record (EMR), so that the information can be used and shared to improve clinical decision making and health communication and, in turn, the patient’s prognosis. It is therefore worthwhile identifying the various factors that play a role in documenting obesity diagnosis and the methods to improve current documentation practices.MethodWe used a retrospective cross-sectional design to analyze outpatient EMRs of patients at an academic outpatient clinic. Obese patients were identified using the measured body mass index (BMI; ≥30 kg/m2) entry in the EMR, recorded at each visit, and checked for documentation of obesity in the EMR problem list. Patients were categorized into two groups (diagnosed or undiagnosed) based on a documented diagnosis (or omission) of obesity in the EMR problem list and compared.ResultsA total of 10,208 unique patient records of obese patients were included for analysis, of which 4119 (40%) did not have any documentation of obesity in their problem list. Chi-square analysis between the diagnosed and undiagnosed groups revealed significant associations between documentation of obesity in the EMR and patient characteristics.ConclusionEMR designers and developers must consider employing automated decision support techniques to populate and update problem lists based on the existing recorded BMI in the EMR in order to prevent omissions occurring from manual entry.

2076. Comparison of Diagnosis and Prescribing Practices between Virtual Visits and Office Visits for Sinusitis within a Primary Care Network

BackgroundThe majority of antibiotics prescribed in the outpatient setting result from upper respiratory tract infections; however, these infections are often viral. Virtual visits (VV) have emerged as a popular alternative to office visits (OV) for sinusitis complaints and are an important area for stewardship programs to target for intervention.MethodsA retrospective cohort study was conducted utilizing the outpatient electronic medical record for Mercy Health Physician Partners (MHPP) and Zipnosis database for VV to compare diagnosis and prescribing between OV and VV for sinusitis. VV consisted of an online questionnaire for patients to complete, which was then sent to a provider to evaluate electronically without face-to-face interaction. Adult patients were included with a diagnosis code for sinusitis during the 6-month study period from January to June 2018. The primary objective was to compare rates of appropriate diagnosis of viral vs. bacterial sinusitis between OV and VV, based on national guideline recommendations. Secondary objectives were to compare the appropriateness of antibiotic prescribing and supportive therapy prescribing between OV and VV, as well as 24-hour, 7-day and 30-day re-visits.ResultsA total of 350 patients were included in the study (OV n = 175, VV n = 175). Appropriate diagnosis per national guidelines was 45.7% in OV compared with 69.1% in the VV group (P < 0.001). Additionally, patients that completed VV were less likely to receive antibiotic prescriptions (OV 94.3%, VV 68.6%, P < 0.001). Guideline-concordant antibiotic prescribing was similar between groups (OV 60.6%, VV 58.3%, P = 0.70) and both visit types had a median duration of treatment of 10 days (P = 0.88). Patients that completed VV were more likely to re-visit for sinusitis within 24 hours (OV 1.7%, VV 8%, P = 0.006) and within 30-days (OV 7.4%, VV 14.9%, P = 0.027). In multivariate logistic regression the only factor independently associated with 24-hour re-visit was patient self-request for antibiotics (OR 0.20, 95% CI 0.06–0.68).ConclusionAppropriate diagnosis of sinusitis was more likely in the VV group, which shows that VV provides a good platform to target outpatient antimicrobial prescribing. These findings support opportunities for antimicrobial stewardship intervention in both OV and VV.Disclosures All authors: No reported disclosures.

Concomitant Use of Opioids and Benzodiazepines in the Outpatient Setting.

Benzodiazepines have been identified as a concurrent factor in opioid-related deaths. Although the dangers of concomitant administration of opioids and benzodiazepines are well documented, implementation of this knowledge into practice may be lagging behind. To examine the concomitant use of opioids and benzodiazepines in the outpatient setting. Retrospective study. Academic outpatient multispecialty practice. Over 2000 outpatient clinic visits from January 2018 to April 2018 among four physiatrists were analyzed. All patients were reviewed in the Prescription Drug Monitoring Program (PDMP) website to identify whether they have filled either opioid or benzodiazepine prescription(s) in the last 12 months. Number of opioid and benzodiazepine prescriptions, discrepancies in reporting of medications, providers prescribing medications, and cigarette/alcohol use. A total of 353 patients were identified to have filled either opioid or benzodiazepine prescription(s) in last 12 months. 49.4% of patients prescribed opioids were found to be taking benzodiazepines concurrently. Reporting discrepancies were noted between the outpatient electronic medical record and PDMP in 17.2% of patients. Among patients taking both opioids and benzodiazepines, 38.9% had multiple providers prescribing these medications, 41.9% were over 65 years old, and 11.9% were daily cigarette/alcohol users. Patients taking both types of drugs (opioids and benzodiazepines) were significantly more likely to use different providers (38.9%) compared to patients taking one type of drug (9.8%, P < .001). The former group was also noted to fill significantly more prescriptions than the latter group (P < .001). The study results emphasize that clinicians may not be aware that some of their patients are concurrently taking opioids and benzodiazepines. These results highlight the importance of routinely checking the PDMP and using that information to make fully informed decisions to minimize risks in use of these controlled substances. III.

Diagnosis of COPD Based on a Knowledge Graph and Integrated Model

Chronic obstructive pulmonary disease (COPD) is a chronic lung disease that causes a progressive decline in respiratory function. Diagnosing COPD in the early curable stages is very important and may even save the life of a patient. In this paper, we present an integrated model for diagnosing COPD based on a knowledge graph. First, we construct a knowledge graph of COPD to analyze the relationship between feature subsets and further discover the knowledge of implied diseases from the data. Second, we propose an algorithm for sorting features and an adaptive feature subset selection algorithm CMFS- $\eta $ , which selects an optimal subset of features from the original high-dimensional set. Finally, the DSA-SVM integrated model is suggested to build the classifier for the diagnosis and prediction of COPD. We performed extensive experiments on the dataset from the hospital outpatient electronic medical record database. The classification accuracy of our method was 95.1%. It is superior to some state-of-the-art classification methods for this problem.