Standardized Electronic Medical Record Research Articles

A Quality Improvement Project to Improve After-visit Summary Patient Instructions in a Pediatric Multidisciplinary Neuromuscular Program.

Multidisciplinary clinics aim to coordinate care between multiple specialties for children with medical complexity yet may result in information overload for caregivers. The after-visit summary (AVS) patient instruction section offers a solution by summarizing visit details and recommendations. No known studies address patient instruction optimization and integration within a multidisciplinary clinic setting. This project aimed to improve the quality of patient instructions to support better postvisit communication between caregivers and providers in a multidisciplinary pediatric neuromuscular program. A multidisciplinary stakeholder team created a key driver diagram to improve postvisit communication between caregivers and providers in the clinic. The first specific aim was to achieve an 80% completion rate of AVS patient instructions within 6 months. To do so, a standardized electronic medical record "text shortcut" was created for consistent information in each patient's instructions. Feedback on AVS from caregivers was obtained using the Family Experiences with Coordination of Care survey and open-ended interviews. This feedback informed the next specific aim: to reduce medical jargon within patient instructions by 25% over 3 months. Completion rates and jargon use were reviewed using control charts. AVS patient instruction completion rates increased from a mean of 39.4%-85.0%. Provider education reduced mean jargon usage in patient instructions, from 8.2 to 3.9 jargon terms. Provider education and caregiver feedback helped improve patient communication by enhancing AVS compliance and diminishing medical jargon. Interventions to improve AVS patient instructions may enhance patient communication strategies for complex medical visits.

Improving Inpatient Colonoscopy Bowel Preparation: A Successful Quality Improvement Project.

Inadequate inpatient bowel preparation can lead to repeat procedures, prolonged hospital stays, and increased financial burden. In this quality improvement project, the authors developed an electronic medical record (EMR)-based order set with precise instructions and anticipatory guidance for inpatient bowel preparation before colonoscopy. The current study is a nonrandomized intervention study. The authors compared 2 groups: an intervention group using a newly developed, consensus-based, standardized EMR bowel preparation order set and a control group using previously existing EMR bowel preparation orders. Bowel preparation outcomes were followed over the course of 16 months. The aim was to improve inpatient colonoscopy bowel preparation, as evaluated by the Boston Bowel Preparation Scale, procedure delays, and length of hospital stay. We additionally evaluated the groups' demographics and patient-level factors. A total of 459 inpatient colonoscopies were evaluated over a 16-month period. The intervention group consisted of 227 inpatient colonoscopies, while the control group consisted of 232. The intervention group showed superior Boston Bowel Preparation Scale score and decreased length of hospital stay. The number of adequate bowel preparations increased in the intervention group when compared to the control group from 77% to 86%. The creation of an EMR-based order set is a low-cost and sustainable action that can be easily implemented throughout a hospital system.

Readability of patient education materials for bariatric surgery.

Bariatric surgery is a successful treatment for obesity, but barriers to surgery exist, including low health literacy. National organizations recommend patient education materials (PEM) not exceed a sixth-grade reading level. Difficult to comprehend PEM can exacerbate barriers to bariatric surgery, especially in the Deep South where high obesity and low literacy rates exist. This study aimed to assess and compare the readability of webpages and electronic medical record (EMR) bariatric surgery PEM from one institution. Readability of online bariatric surgery and standardized perioperative EMR PEM were analyzed and compared. Text readability was assessed by validated instruments: Flesch Reading Ease Formula (FRE), Flesch Kincaid Grade Level (FKGL), Gunning Fog (GF), Coleman-Liau Index (CL), Simple Measure of Gobbledygook (SMOG), Automated Readability Index (ARI), and Linsear Write Formula (LWF). Mean readability scores were calculated with standard deviations and compared using unpaired t-tests. 32 webpages and seven EMR education documents were analyzed. Webpages were overall "difficult to read" compared to "standard/average" readability EMR materials (mean FRE 50.5 ± 18.3 vs. 67.4 ± 4.2, p = 0.023). All webpages were at or above high school reading level: mean FKGL 11.8 ± 4.4, GF 14.0 ± 3.9, CL 9.5 ± 3.2, SMOG 11.0 ± 3.2, ARI 11.7 ± 5.1, and LWF 14.9 ± 6.6. Webpages with highest reading levels were nutrition information and lowest were patient testimonials. EMR materials were sixth to ninth grade reading level: FKGL 6.2 ± 0.8, GF 9.3 ± 1.4, CL 9.7 ± 0.9, SMOG 7.1 ± 0.8, ARI 6.1 ± 1.0, and LWF 5.9 ± 0.8. Surgeon curated bariatric surgery webpages have advanced reading levels above recommended thresholds compared to standardized PEM from an EMR. This readability gap may unintentionally contribute to barriers to surgery and affect postoperative outcomes. Streamlined efforts are needed to create materials that are easier to read and comply with recommendations.

Outcomes Following Repair of Achilles Midsubstance Tears: Percutaneous Knotless Repair vs Open Repair.

Optimum treatment for acute Achilles tendon rupture results in high mechanical strength, low risk of complications, and return to preinjury activity level. Percutaneous knotless repair is a minimally invasive technique with promising results in biomechanical studies, but few comparison clinical studies exist. Our study purpose was to compare functional outcomes and revision rates following acute Achilles tendon rupture treated between percutaneous knotless repair and open repair techniques. Patients 18 years or older with an acute Achilles tendon rupture, treated by a single surgeon with either open repair or percutaneous knotless repair, and more than 2 years after surgery were assessed for eligibility. Prospective clinical data were obtained from the data registry and standard electronic medical record. Additionally, the patients were contacted to obtain current follow-up questionnaires. Primary outcome measure was Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL). Secondary outcome measures were FAAM sports, 12-Item Short Form Health Survey (SF-12), Tegner activity scale, patient satisfaction with outcome, complications, and revisions. Postoperative follow-up closest to 5 years was used in this study. In total, 61 patients were included in the study. Twenty-four of 29 patients (83%) in the open repair group and 28 of 32 patients (88%) in the percutaneous knotless repair group completed the questionnaires with average follow-up of 5.8 years and 4.2 years, respectively. We found no significant differences in patient-reported outcomes or patient satisfaction between groups (FAAM ADL: 99 vs 99 points, P = .99). Operative time was slightly longer in the percutaneous knotless repair group (46 vs 52 minutes, P = .02). Two patients in the open group required revision surgery compared to no patients in the percutaneous group. In our study, we did not find significant differences in patient-reported outcomes or patient satisfaction by treating Achilles tendon midsubstance ruptures with percutaneous knotless vs open repair. Level IlI, retrospective cohort study.

Surgeon input can increase the value of registry data: early experience from the American Spine Registry.

Clear diagnostic delineation is necessary for the development of a strong evidence base in lumbar spinal surgery. Experience with existing national databases suggests that International Classification of Diseases, Tenth Edition (ICD-10) coding is insufficient to support that need. The purpose of this study was to assess agreement between surgeon-specified diagnostic indication and hospital-reported ICD-10 codes for lumbar spine surgery. Data collection for the American Spine Registry (ASR) includes an option to denote the surgeon's specific diagnostic indication for each procedure. For cases treated between January 2020 and March 2022, surgeon-delineated diagnosis was compared with the ICD-10 diagnosis generated by standard ASR electronic medical record data extraction. For decompression-only cases, the primary analysis focused on the etiology of neural compression as determined by the surgeon versus that determined on the basis of the related ICD-10 codes extracted from the ASR database. For lumbar fusion cases, the primary analysis compared structural pathology, which may have required fusion, as determined by the surgeon versus that determined on the basis of the extracted ICD-10 codes. This allowed for identification of agreement between surgeon delineation and extracted ICD-10 codes. In 5926 decompression-only cases, agreement between the surgeon and ASR ICD-10 codes was 89% for spinal stenosis and 78% for lumbar disc herniation and/or radiculopathy. Both the surgeon and database indicated no structural pathology (i.e., none) suggesting the need for fusion in 88% of cases. In 5663 lumbar fusion cases, agreement was 76% for spondylolisthesis but poor for other diagnostic indications. Agreement between surgeon-specified diagnostic indication and hospital-reported ICD-10 codes was best for patients who underwent decompression only. In the fusion cases, agreement with ICD-10 codes was best in the spondylolisthesis group (76%). In cases other than spondylolisthesis, agreement was poor due to multiple diagnoses or lack of an ICD-10 code that reflected the pathology. This study suggested that standard ICD-10 codes may be inadequate to clearly define the indications for decompression or fusion in patients with lumbar degenerative disease.

Single institution experience with death by neurological criteria/brain death guideline adherence

ObjectiveTo determine the effect on adherence to an institutional death by neurological criteria/brain death (DNC/BD) policy of implementation of a standardized DNC/BD checklist in the electronic medical record (EMR). MethodsThe retrospective study cohort included all patients admitted to our institution who were declared dead by neurologic criteria determined by ICD code (G93.82) between June 2015 and October 2019. Two investigators independently reviewed each case for adherence with institutional policy, and agreement was assessed using unweighted kappa statistics. Patient data and adherence to institutional policy before and after implementation of a standardized DNC/BD checklist were compared. ResultsThere were 66 patients identified by the initial search and 38 were included in the final analysis, with 19 cases in both the pre- and post- checklist periods. There were no significant differences in age, cause of DNC/BD, time to DNC/BD determination, potential toxic, metabolic, physiologic confounders, or use of ancillary testing. The pre-checklist period adherence was 47.4% (n = 9/19) versus 94.6% (n = 18/19; p = 0.001) in the post-checklist EMR DNC/BD period. ConclusionImplementation of a standardized EMR checklist substantially improved DNC/BD policy adherence in our institution. Classification of EvidenceThis study provides Class IV evidence on the use of standardized EMR checklist to improve death by neurologic criteria/brain death policy adherence.

1036: DIGITAL HEALTH STRATEGIES TO SUPPORT CLINICIAN ICU POPULATION MANAGEMENT: A CROSSOVER STUDY

Introduction: The quantity of information generated for the intensive care unit (ICU) patient can be 10 times more than in other hospital settings. This information burden can strain cognitive reasoning, hinder medical decision making, and cause medical errors. The aim of this study was to investigate whether a novel Acute care Multi-Patient viewer (AMP), created with an understanding of clinician information and process requirements, could reduce time to clinical decision and action by clinicians caring for populations of acutely ill patients compared to a widely used commercial Electronic Medical Record (EMR). Methods: We conducted a randomized crossover study at a quaternary care academic hospital. We compared ICU clinician performance in structured clinical task completion using two electronic environments – a standard EMR versus AMP. The task scenario included assessment of one entire unit and 4 individual patients using the assigned electronic environment (AMP or EMR). We assessed the difference in time required to complete structured task, the task load of clinicians performing the task measured in the range between 0 and 100 using NASA-task load index (NASA-TLX), and the reliability of task completion by the number of errors of cognition made when using AMP versus EMR. Results: 20 subjects (10 pairs of clinicians) participated in the study. During the study session, each participant completed the task on 2 ICUs (7-10 beds each) and 8 individual patients. The time for assessment of the entire ICU and the total time to task completion were significantly lower using AMP versus standard commercial EMR (the median difference in time was -6.11 minutes (IQR -7.91, -4.30) and -5.38 minutes (IQR -7.56, -3.20) respectively, p< 0.001). The time for assessment of the individual patients was similar using both the EMR and AMP (p=0.078). AMP was associated with a significantly lower clinician task load versus EMR (NASA-TLX lower by 22.6 points (IQR 12.4, 32.7); p< 0.001). The difference in total errors per user using AMP vs EMR was not statistically significant (p=0.078). Conclusions: When compared to the standard EMR, AMP significantly reduced time to clinical task completion and clinician task load. Additional research is needed to assess the clinicians’ performance while using AMP in the “live” ICU setting.

Developing a standardized EMR workflow for medical students and preceptors

ObjectivesThe electronic medical record (EMR) is an integral component of clinical encounters. However, there is no standardized curriculum for EMR education in medical school. This study aimed to create a standardized EMR workflow model for medical students in clinic. It was hypothesized that this workflow would be effectively implemented and increase physician productivity. MethodsAn outpatient clinic workflow model was created to integrate students into clinical visits as active participants in EMR documentation. 240 third and fourth-year medical students on their Neurology clerkship at a U.S. medical institution and 34 outpatient neurologists were trained on the workflow (student EMR integration training; SEIT). A total of 733 Neurology outpatient clinic days were analyzed (473 pre-SEIT and 251 post-SEIT). Productivity metrics included average lag time, average Relative Value Units (RVUs) per day, and average invoices per day. ResultsThere was a statistically significant difference in documentation time, with a pre-SEIT lag time of 14.7 days (SD 13.1 days, 95% CI 9.4–20.0) compared to 10.3 days post-SEIT (SD 10.2 days, 95% CI 6.2–14.5; p-value = 0.001). The average RVUs per day were 18.5 pre-SEIT (SD 7.8, 95% CI 15.4–21.7) and 17.8 post-SEIT (SD 8.0, 95% CI 14.6–21.0; p-value = 0.7). The average invoices per day were 7.5 pre-SEIT (SD 2.6, 95% CI 6.5–8.6) and 7.3 post-SEIT (SD 3.0, 95% CI 6.1–8.5; p-value = 0.5). ConclusionsThe workflow model utilizes medical student EMR documentation in the clinical note and decreases physician documentation time.

Standardizing the Evaluation and Management of Necrotizing Enterocolitis in a Level IV NICU.

Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outcomes. This quality improvement project aimed to decrease variation in the evaluation and management of NEC in a Level IV NICU. A multidisciplinary team investigated institutional variation in NEC management and developed a standardized guideline and electronic medical record tools to assist in evaluation and management. Retrospective baseline data were collected for 2 years previously and prospectively for 3.5 years after interventions. Outcomes included the ratio of observed-to-expected days of antibiotics and nil per os (NPO) on the basis of the novel guidelines and the percentage of cases treated with piperacillin/tazobactam. Balancing measures were death, surgery, and antifungal use. Over 5.5 years, there were 124 evaluations for NEC. Special cause variation was noted in the observed-to-expected antibiotic and NPO days ratios, decreasing from 1.94 to 1.18 and 1.69 to 1.14, respectively. Piperacillin/tazobactam utilization increased from 30% to 91%. There were no increases in antifungal use, surgery, or death. Variation in evaluation and management of NEC decreased after initiation of a guideline and supporting electronic medical record tools, with fewer antibiotic and NPO days without an increase in morbidity or mortality. A quality improvement approach can benefit patients and decrease variability, even in diseases with limited evidence-based standards.

Comparison between Retrieval Time of Manual and Electronic Medical Records –A Case Study

Purpose: A safe and effective healthcare service provides good quality medical records whether electronic or handwritten, which is essential for the continuity of patient care. In this context, a comparative study on the retrieval time of Manual and Electronic Medical Records is made to evaluate the advantages and limitations of both systems. Methodology: The present study was conducted in two phases. In the first phase, the retrieval time taken by the Manual medical record and in the second phase the retrieval time taken for electronic medical records was collected. The study site was one of the departments in a multispecialty hospital. The study period was three months and a convenient sampling technique was used to collect the data. The sample was collected during the peak hours of the day. Hence 75 medical records which were documented manually and collected in the first phase and after the introduction of electronic method of documenting medical records, another 75 electronic medical record were collected to find the retrieval time. Finding/Result: The study result revealed that standard turnaround time (TAT) as per the policy of the hospital for the retrieval of paper records exceeds whereas in electronic medical records most of the files receives within standard time and Electronic Medical Records to be implemented in various outpatient departments in order to reduce patient waiting time for the medical records during the revisit. These changes in the procedure will definitely improve the quality of healthcare and patient satisfaction. Originality/value: The result of the study will help to know the retrieval time for manual and Electronic Medical Record, its advantages and disadvantages. Study Type: Observational case study.

Data-Sharing Gateway System Design for Large-Scale Medical Information Collection with Distributed EMR Storage.

The collection and use of large-scale medical information for developing artificial intelligence engines are actively ongoing. In Japan, collection systems have been built to collect data for medical image analysis and disease repositories. In the experimental project for the next generation medical infrastructure law, a centrally integrated basic system was developed, and standardized electronic medical record (EMR) storage data distributed to each hospital were transferred into one data center and imported to a database for secondary use. The law requires a mechanism for maintaining a list of notified or opted-out patients. To operate these systems, safe and efficient secondary use of collected information is essential not just for the law but also for large-scale data collection projects, such as multifacility clinical research. This paper considers whole-somely, requirements for providing medical care information to data collection projects and proposes additional requirements for a gateway system under development.

Measles seroprevalence in human immunodeficiency virus-infected adults born in the era of measles vaccination.

Widespread use of the measles vaccine should lead to the elimination of this disease. Here, we study the seroprevalence of measles in a cohort of adults living with HIV born after the introduction of measles vaccine in France and attempt to identify risk factors for the absence of serum measles antibody. In this multi-centre cross-sectional study, adult outpatients born after 1980 were screened for the presence of measles IgG antibody. Demographic and clinical data were obtained from the standardized electronic medical record system. Univariate and multivariate logistic regressions were performed to identify factors associated with the absence of measles antibodies. Between April 2019 and April 2020, 648 participants were enrolled. The median age was 33 years, 53.6% were born outside of France, and 74% were considered as socially deprived. Plasma HIV RNA was undetectable in 86% of patients. Among 603 evaluable patients, measles serology was positive in 87.2%. Only 81.8% of the patients with documented vaccination tested positive for measles IgG. Younger age was significantly associated with the absence of measles serum antibodies ( P = 0.004 for each 10-year lower), as was birth in France ( P < 0.001) and absence of social vulnerability ( P = 0.04). The current study revealed a low seroprevalence of measles compared with that previously reported in France 6 years earlier and to the expected rate to achieve herd immunity. Checking vaccination record should be systematically carried out in patients living with HIV to fill the immunity gaps.

Predicting unplanned medical visits among patients with diabetes: translation from machine learning to clinical implementation

BackgroundDiabetes is a medical and economic burden in the United States. In this study, a machine learning predictive model was developed to predict unplanned medical visits among patients with diabetes, and findings were used to design a clinical intervention in the sponsoring healthcare organization. This study presents a case study of how predictive analytics can inform clinical actions, and describes practical factors that must be incorporated in order to translate research into clinical practice.MethodsData were drawn from electronic medical records (EMRs) from a large healthcare organization in the Northern Plains region of the US, from adult (≥ 18 years old) patients with type 1 or type 2 diabetes who received care at least once during the 3-year period. A variety of machine-learning classification models were run using standard EMR variables as predictors (age, body mass index (BMI), systolic blood pressure (BP), diastolic BP, low-density lipoprotein, high-density lipoprotein (HDL), glycohemoglobin (A1C), smoking status, number of diagnoses and number of prescriptions). The best-performing model after cross-validation testing was analyzed to identify strongest predictors.ResultsThe best-performing model was a linear-basis support vector machine, which achieved a balanced accuracy (average of sensitivity and specificity) of 65.7%. This model outperformed a conventional logistic regression by 0.4 percentage points. A sensitivity analysis identified BP and HDL as the strongest predictors, such that disrupting these variables with random noise decreased the model’s overall balanced accuracy by 1.3 and 1.4 percentage points, respectively. These recommendations, along with stakeholder engagement, behavioral economics strategies, and implementation science principles helped to inform the design of a clinical intervention targeting behavioral changes.ConclusionOur machine-learning predictive model more accurately predicted unplanned medical visits among patients with diabetes, relative to conventional models. Post-hoc analysis of the model was used for hypothesis generation, namely that HDL and BP are the strongest contributors to unplanned medical visits among patients with diabetes. These findings were translated into a clinical intervention now being piloted at the sponsoring healthcare organization. In this way, this predictive model can be used in moving from prediction to implementation and improved diabetes care management in clinical settings.

Event Surrogate from Clinical Pathway Completion to Daily Meal for Availability Extension Using Standard Electronic Medical Records: a Retrospective Cohort Study.

This study aimed to improve generalizability of our previous study that analyzed clinical pathway (CP) completion. Although our previous study demonstrated that CP completion can reduce the length of hospital stay, it is possible for few medical organizations to extract the implementation of treatment registered on CP from typical electronic medical records. Therefore, we have defined a prospective event for event substitution, called meal completion (MC), in which patients can take their meal daily. Data were collected from April 2013 to March 2018 from the electronic medical records of the University of Miyazaki Hospital. We used propensity score matching to extract records from 8033 patients. Patients were further divided into the MC and non-MC groups; 2577 patients in each group were available for data analysis. The numbers of patients with CP completion were 646 (28.1%) in the MC group and 411 (18.2%) in the non-MC group. The P value of the chi-square test was <0.001. According to this result, there was the causation from MC to increase in CP completion. Additionally, it was possible to consider the inclusion relationship in all treatments (universal set), treatments registered on CP (subset of all treatments), and meals (subset of treatments registered on CP). In conclusion, MC can substitute for CP completion because the demonstration is appropriate for the Prentice criterion, which is often used for the evaluation of a surrogate endpoint.

625. Sustained Efforts Improve Adherence to Monitoring for Solid Tumor Patients Discharged on Outpatient Parenteral Antimicrobial Therapy (OPAT) at a Comprehensive Cancer Center

BackgroundOPAT helps reduce hospital length of stay, but 1 in 4 patients is readmitted within 30 days of discharge. Follow up < 30 days after discharge and laboratory monitoring during therapy have been shown to reduce hospital readmissions. However, few OPAT studies have included patients with malignancies, who may not experience the same benefits due to increased risks for hospital admission and infection related to antineoplastic therapy. We started an OPAT program to increase laboratory monitoring and clinic follow up among patients with solid tumors, attempting to also decrease readmissions.MethodsWe obtained demographic data and baseline frequencies of laboratory monitoring, ID clinic follow up, 30-day OPAT-related readmissions, Emergency Center (EC) visits, and deaths by retrospective chart review. We conducted multiple interventions from June 2018-January 2020: clarifying physician recommendations for laboratory monitoring and follow up by using a standardized electronic medical record template, communicating recommendations to case management, and changing the lab ordering workflow. We compared frequencies after interventions to baseline by using Fisher’s exact test.ResultsMost commonly observed malignancies in our patient cohort included genitourinary, breast, gastrointestinal, gynecologic, and head and neck. The most commonly treated infections included abscess, bacteremia, and skin and soft tissue. The percentage of patients without recommended lab monitoring decreased from 32.3% to 15.3% (p=0.03). We observed trends toward improved ID clinic follow up (54.8% to 71.8%; p=0.12) and decreased 30-day OPAT-related readmissions from 16.7% to 8.6% (p = 0.17). We observed no difference in mortality or EC visits.ConclusionOPAT-treated infections in our solid tumor patient cohort differed from those reported commonly. Through continued interventions, we improved lab monitoring rates among solid tumor patients with trends toward improved ID clinic follow up and decreased readmission rates. Our findings suggest that despite competing reasons for hospital readmission, OPAT may still benefit this population.Disclosures All Authors: No reported disclosures

Implement an International Interoperable PHR by FHIR—A Taiwan Innovative Application

Personal health records (PHRs) have lots of benefits for things such as health surveillance, epidemiological surveillance, self-control, links to various services, public health and health management, and international surveillance. The implementation of an international standard for interoperability is essential to accessing personal health records. In Taiwan, the nationwide exchange platform for electronic medical records (EMRs) has been in use for many years. The Health Level Seven International (HL7) Clinical Document Architecture (CDA) was used as the standard of the EMRs. However, the complication of implementing CDA became a barrier for many hospitals to realize the standard EMRs. In this study, we implemented a Fast Healthcare Interoperability Resources (FHIR)-based PHR transformation process including a user interface module to review the contents of PHRs. We used “My Health Bank, MHB”, a PHR data book developed and issued to all people by the Taiwan National Health Insurance, as the PHRs contents in this study. Network Time Protocol (NTP)/Simple Network Time Protocol (SNTP) was used in the security and user authentication mechanism when processing and applying personal health information. Transport Layer Security (TLS) 1.2 (such as HyperText Transfer Protocol Secure (HTTPS) was used for protection in data communication. User authentication is important in the platform. OAuth (OAuth 2.0) was used as a user authentication mechanism to confirm legitimate user access to ensure data security. The contents of MHB were analyzed and mapped to the FHIR, and then converted to FHIR format according to the mapping logic template. The function of format conversion was carried out by using ASP.NET. XPath and JSPath technologies filtered out specific information tags. The converted data structure was verified through an HL7 Application Programming Interface (HAPI) server, and a new JSON file was finally created. This platform can not only capture any PHR based on the FHIR format but also publish FHIR-based MHB records to any other platform to bridge the interoperability gap between different PHR systems. Therefore, our implementation/application with the automatic transformation from MHB to FHIR format provides an innovative method for people to access their own PHRs (MHB). No one has published a similar application like us using a nationwide PHR standard, MHB, in Taiwan. The application we developed will be very useful for a single person to use or for other system developers to implement their own standard PHR software.

Twelve-month prescribing of contraceptive pill, patch, and ring before and after a standardized electronic medical record order change

ObjectiveTo evaluate the proportion of 12-month contraceptive pill, patch, and ring prescriptions before and after an institution-wide change of default electronic medical record facility orders to dispensing 12-month supply. Study designThis retrospective pre-post study compares outpatient contraception prescriptions from August 10, 2019 through April 9, 2020 obtained from our institutional electronic medical record prescription database. On December 10, 2019, we facilitated a change in the default orders for dispensing self-administered hormonal contraceptives from one-month to 12-months. We evaluated the primary outcome of 12-month supply prescriptions during the four months before and after the change. We also compared 12-month supply prescriptions for pills, patch, and ring by prescriber specialty and location. ResultsThe dataset included 4897 distinct evaluable prescriptions for the pill, patch, or ring, with an overall increase in 12-month prescriptions from 260/2437 (10.7%) to 669/2460 (27.2%) after the order change (p < 0.001). Twelve-month pill prescriptions increased from 238/2250 (10.6%) to 607/2250 (27.0%) (p < 0.001), patch prescriptions from 6/40 (15.0%) to 21/44 (47.7%) (p = 0.002), and ring prescriptions from 16/147 (10.9%) to 41/165 (24.8%) (p = 0.001). Twelve-month prescriptions increased after the order change among all provider types at the medical center campus (194/594 [32.7%] to 329/623 [52.8%], p < 0.001). At community clinics, non-obstetrics/gynecology providers increased 12-month prescriptions after the order change (58/1616 [3.6%] to 327/1612 [20.3%], p < 0.001), but obstetrics/gynecology providers did not (8/227 [3.5%] to 13/225 [5.8%], p = 0.27). ConclusionProviders more frequently prescribed a 12-month supply of contraceptive pills, patches, and rings after a change in the default dispensing quantity in electronic medical record orders. ImplicationsInstitution-wide changes to the electronic medical record default facility order settings can increase 12-month supply contraceptive prescriptions. As a 12-month prescription order represents only one step of many in obtaining a 12-month contraception supply, additional research is required to elucidate and remove other potential barriers.

Utilizing Electronic Medical Records to Standardize Handoffs in Academic Ophthalmology

Abstract Purpose Formalized handoff procedures have been shown to increase patient safety and quality of care across multiple medical and surgical specialties,1–4 but literature regarding handoffs in ophthalmology remains sparse. We instituted a standardized handoff utilizing an electronic medical record (EMR) system to improve care for patients shared by multiple resident physicians across weekday, weeknight, and weekend duty shifts. We measured efficiency, efficacy, and resident satisfaction before and after the standardized handoff was implemented. Methods Resident physicians surveyed were primarily responsible for patient care on consult and call services at two quaternary academic medical centers in a major metropolitan area. Patient care was performed in outpatient, emergency, and inpatient settings. Annual anonymous questionnaires consisting of 6 questions were used to collect pre- and postintervention impressions of the standardized EMR handoff process from ophthalmology resident physicians (9 per year; 3 preintervention years and 1 postintervention year). An additional anonymous postintervention questionnaire consisting of 12 questions was used to further characterize resident response to the newly implemented handoff procedure. Results Prior to implementation of a standardized EMR-based handoff procedure, residents unanimously reported incomplete, infrequently updated handoff reports that did not include important clinical and/or psychosocial information. Following implementation, residents reported a statistically significant increase in completeness and timeliness of handoff reports. Additionally, resident perception of EMR handoff utility, efficiency, and usability were comprehensively favorable. Residents reported handoffs only added a mean of 6.5 minutes to a typical duty shift. Conclusion Implementation of our protocol dramatically improved resident perceptions of the handoff process at our institution. Improvements included increased quality, ease-of-use, and efficiency. Our standardized EMR-based handoff procedure may be of use to other ambulatory-based services.

Guideline Adherence and Hearing Outcomes of Sudden Sensorineural Hearing Loss in the Military Health System.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline (CPG) proposes several treatment recommendations regarding sudden sensorineural hearing loss (SSNHL). The treatments for this disorder have been controversial and remain varied. We sought to determine CPG adherence and hearing outcomes of SSNHL within the Military Health System (MHS). This was a retrospective case series with chart review of the MHS's electronic medical record. Patients with SSNHL (n=112) were treated between March 1, 2012 and September 30, 2015. Clinical improvement was defined as a 20-dB improvement in pure tone averages or a 20% increase in word recognition scores. Oral steroids were used in 63 (56%) patients, intratympanic (IT) steroids were utilized in 11 (10%) patients, and combination therapy was used in 38 (34%) patients. Average pure tone averages improvements with oral steroids, IT steroids, and combination therapy were 31.2dB (95% CI, 24.4-38.0), 13.4dB (95% CI, 0.4-29.6), and 17.3dB (95% CI, 9.32-25.3), respectively. Average word recognition scores improvements with oral steroids, IT steroids, and combination therapy were 29.64% (95% CI, 19.5-39.7), 14.43% (95% CI, -8.32 to 45.3), and 18.48% (95% CI, 5.48-31.5), respectively. Clinical improvements with oral steroids, IT steroids, and combination therapy were 65, 46, and 50%, respectively. The MHS is uniquely positioned to evaluate adherence to CPGs on a national and international level given the robust and standardized electronic medical record. Areas identified for improvement include more timely initiation of treatment, standardization of IT steroid dosing, more accurate coding for diagnosis and treatment, and standardization of audiology evaluation.

Addition of Efficiency Measures to Current Accuracy Measures in the Vascular Laboratory Can Be Used for Future Accreditation and Payment Models

The Medicare Access and CHIP Reauthorization Act (MACRA) brings with it increased regulatory requirements not traditionally addressed by standard vascular laboratory accreditation, which is based on accuracy. The new quality improvement project of the Intersocietal Accreditation Commission (IAC) may satisfy an improvement activity (IA) of the MACRA. We hypothesize that other IAs in the MACRA such as timeliness of test results or patient care quality performance requirements can be met by analyzing data already being collected by the vascular laboratory. After a process improvement strategy, we chose to review progress in our vascular laboratory related to time to interpretation (TI), patient check-in to study completion (study time), wait time for first available outpatient venous duplex scan (wait time), technologist productivity, and critical results reporting. Data from our hospital-based vascular laboratory were collected from 2010 to 2016. TI was collected through our reporting software VascuPro (Consensus Medical), and study time and wait time were obtained from electronic medical records (EMR) (Epic). Technologist productivity was calculated by commercially available productivity tools, and compliance with critical results reporting was calculated quarterly as per our quality assurance program. Appropriateness of carotid duplex scan testing was performed by expert review of International Classification of Disease codes used to request the test. TI analysis comprised 91,352 studies with a mean of 3.3hr between test completion and final interpretation. The TI improved from 5.0 to 2.1hr on weekdays and was longer on weekends (4.9 hr; P<0.001). The study time improved from 29.8 to 27.2min and was 14.9min shorter on the weekends (P<0.001). The wait time ranged from a mean of 1-2.08days. Technologist productivity improved from 90.7% to 93.6%. Critical results reporting quarterly audits showed a 100% compliance rate. On expert review, the International Classification of Disease code on carotid duplex scan requests in the EMR was deemed inaccurate in 17.4% of cases. TI and study time improved; wait time and critical results reporting remained steady. Most of the data are readily available in a vascular laboratory standard EMR. The plan-do-study-act (PDSA or Shewhart Cycle) principle is critical to process improvement and needed as we transition from traditional accreditation mostly based on test accuracy to one demanding efficiency, timeliness, patient satisfaction, productivity, accountability, and appropriateness of testing. Process improvement studies will improve patient care and satisfaction, increase efficiency and throughput, while satisfying changing IAC standards and preparing for upcoming regulatory requirements of the MACRA.