Standard EMR Research Articles

How automated insurance authorization affects transparency, provider burden, and payer policies and processes: The true impact of prior authorization.

5 Background: Insurance prior authorization (PA) is pervasive in modern oncology treatment, with both Medical and Radiation Oncology ranked among the top 5 in a survey of PA burdens across all medical specialties. The cumbersome process delays patient care and increases provider friction, with a major contributor being the perceived lack of transparency regarding PA decisions. Challenges arise because policies are often located behind portal logins, are inaccessible within the clinical workflow, or are too broad to capture patient nuances. We hypothesized that integrating automated insurance authorization software into the clinical workflow would enhance transparency to payer policies. Additionally, we investigated whether these policies could predict whether authorizations would be issued. Methods: We tracked radiation medicine treatment PA requests at a multisite academic healthcare network. Cases were tracked utilizing a standard clinical EMR. We concurrently implemented InsightRT (Siris Medical, Division of TurningPoint Healthcare), an EMR-integrated software system, to automate authorization documentation by capturing and transmitting patient and treatment characteristics. The online portal informed whether a prescribed treatment met the payer policy and tracked the approval process. A pilot subset of physicians was transitioned to using InsightRT. Results: A total of 1418 non-Medicare/Medicaid PA requests were tracked, with 1235 using the traditional clinical workflow and 183 utilizing InsightRT. The software system indicated 162 (88.5%) were “in policy” and only 2 prescriptions were eventually denied. Of the 21 (11.5%) prescriptions that were "Out of Policy" as indicated by the software, only 1 was denied. Sensitivity and specificity of Insight RT policy determination was 98.8% and 97.6% respectively. Overall, there were 43 denials across a total of 1418 cases with payer review only downgrading or changing 4 cases out of 1418, or 0.3%. The other 39 denials were overturned, with 23 (59%) by peer-to-peer (P2P), and 16 (41%) by documentation review. Conclusions: Automated insurance prior authorization provides increased transparency to the provider with high sensitivity and specificity. However, improvements to payer policies and processes are needed to decrease unnecessary burden and delays to care, as the true impact of PA is limited to 0.3% in this cohort. All cases from 12/23 - 5/24. All Cases from non Medicare/Medicaid 1418 Cases processed in InsightRT 183 Cases processed in EMR and not InsightRT 1235 Denials 43 Overturned denials that went to P2P 23 Overturned denials that only needed clinical documentation 16 Cases with confirmed P2P that were downgraded 4 The True Impact of PA - % of all cases changed due to PA 0.30%

Impact of Surgical Resident Education and EMR Standardization in Enhancing ERAS Adherence and Outcomes in Colorectal Surgery

Our study aimed at investigating the degree of adherence to ERAS pathway at our institution and to evaluate the role of providing resident education and a standardized EMR order set in improving adherence and patient surgical outcomes. The study is prospective in nature and consists of two phases with a preintervention cohort to assess adherence to ERAS protocol and a postintervention cohort to evaluate improvement in adherence and patient outcomes. Adherence with the ERAS protocol was assessed across preoperative, intraoperative, and postoperative phases. The study took place at MedStar Franklin Square Medical Center in Baltimore, Maryland, involving inpatient care at a surgical ward. During the preintervention phase, patients undergoing elective colorectal surgery were identified over 6 months (N = 77), and their adherence to the ERAS protocol was assessed. Following the intervention of surgical resident and faculty education sessions on the ERAS protocol and the implementation of a standardized order set in the Electronic Medical Record, a postintervention cohort (N = 54) was selected for comparison over another 6 months. Among 77 patients who underwent elective colorectal surgery, the adherence rate to ERAS protocol was notably below 80% for most elements of the postoperative phase. When pre- and postintervention cohorts were compared, there were no significant differences in the baseline demographics and perioperative variables. After the implementation of our intervention, adherence rates were significantly improved in 7 out of 8 ERAS protocol elements of the postintervention phase. Among primary outcome measures, readmission rate (24.7% vs.9.4%; p = 0.022) and length of stay (7.3 ± 4.5 vs. 5.5 ± 3.6; p = 0.014) were significantly lower in the postintervention cohort. Although the rate of postoperative complications did not decrease significantly (33.8% vs. 31.5%; p = 0.284), there were fewer patients with postoperative ileus and surgical site infections. Outcomes were evaluated based on an 8-point score of postoperative ERAS elements. A significant decrease in mean length of stay and readmission rates is observed when at least 5 elements are completed, emphasizing the ERAS pathway's importance as a complementary bundle. Our study highlights the impact of resident education and electronic medical record standardization on ERAS adherence in colorectal surgery. This multidisciplinary approach improves adherence, reduces hospital stay, and enhances communication among healthcare providers for better patient outcomes.

A study on the status and applicability of Korean medicine EMR for establishment of Korean medicine standard EMR certification criteria: Through surveys of Korean medical institutions and Korean medicine EMR companies

Objectives: The aim of this study is to explore and investigate the status of EMR currently used in Korean medical institutions and the suitability of the existing certification criteria for Korean medicine EMR certification.Methods: The survey was conducted using a related questionnaire from September to October 2022. The survey for current status and the suitability of the existing certification criteria was conducted separately between Korean medical institutions and Korean medicine EMR companies.Results: In a survey of Korean medical institutions on the current status of EMR, more than 80% answered that the imaging system and Korean medicine EMR could be linked. Most medical institutions did not exchange clinical information between institutions. When asked about the intention to develop standard EMR of Korean medicine in the future, 57% of institutions answered ‘yes’. In future, if Korean medicine EMR certification criteria are developed, all EMR companies are willing to develop the EMR that satisfy them. Looking at the satisfaction survey of the existing EMR certification criteria of the Korean medicine EMR system, it was found that high/low satisfaction was shown in various areas, and in particular, the overall clinical information exchange function was insufficient.Conclusion: In order to introduce the Korean medicine EMR certification criteria, it must be considered of the current status of EMR and applicability of Korean medicine EMR for establishment of Korean medicine standard EMR certification criteria. By developing Korean medicine EMR certification criteria, high-quality medical services can be provided to medical consumers who want Korean medical treatment.

Cap-assisted endoscopic mucosal resection as a salvage technique for challenging colorectal laterally spreading tumors.

Cap-assisted endoscopic mucosal resection (EMR-c) has emerged as a potential alternative to standard piecemeal wide-field EMR (WF-EMR) for the resection of laterally spreading tumors (LSTs). However, clear indications for this technique are still lacking. Our objective was to investigate the performance of salvage EMR-c after WF-EMR failure in the resection of large colorectal LSTs. The data of consecutive patients undergoing WF-EMR for large colorectal LSTs (2015-2021) were analyzed in this single-center, retrospective, observational study. In the event of a WF-EMR failure, the procedure was switched to EMR-c in the same session. The efficacy of the two techniques was evaluated in terms of complete endoscopic resection, R0 resection, and recurrence rate. Safety was also assessed. Overall,the data from 81 WF-EMRs were collected. Eighteen cases of WF-EMR failure were switched to EMR-c in the same session and complete endoscopic resection was achieved in 17/18 patients (94.4%). No statistically significant difference was observed between WF-EMR and salvage EMR-c in terms of macroscopic radicality (P = 0.40) and R0 resection (P = 0.12). However, recurrence was more common with EMR-c (44.4% vs. 23.5%; P = 0.05), as were adverse events, particularly intraprocedural bleeding (27.8% vs. 7.9%; P = 0.04). EMR-c is an effective salvage technique for challenging colorectal LSTs following WF-EMR failure. Due to the elevated risk of adverse events associated with this procedure, careful patient selection, endoscopic expertise, and close follow-up are strongly recommended.

Determinants of Point-of-Care Technology Use among Health Care Workers in Comprehensive Care Centres, A Case of Central Kenya

The Point of Care (POC) approach is the highest level of interaction between health care workers (HCW) and the information system, which generally requires interaction during clinical meetings. Although it is hard to do so, it offers the most significant benefits. The POC strategy offers the system’s benefits to healthcare workers, patients, and those who monitor and evaluate them. The study focused on identifying key determinants of point-of-care technology use among healthcare workers offering services in comprehensive care centres in Central Kenya. A Cross-sectional descriptive study was adopted, two-stage cluster sampling design method was used in determining the sample size. The study involved a sample size of 217 respondents and over a 100% was achieved. The study results revealed that social demographic factors of health care workers have no significant influence on POC technology use as a p-value of above 0.05 was observed on all the variables. Some organisational factors such as adequate workstations (p = 0.0) and EMR reducing patient time (p = 0.012) were found to have significant influence on POC technology use. Significant influence on POC use was noted on source of funding for software and hardware maintenance (p = 0.001). The utilisation of EMR to review client progress in real-time (p = 0.001) was found to have a significant influence on POC technology use as well as the use of EMR to report to the national reporting system (KHIS) (p = 0.014). 71% of respondents reported that availability of clinical decision support features in the EMR was contributing to improved use of POC. An overwhelming 72% reported that they were very motivated to use POC technology due to the ability of auto generating reports. In addition, three factors were highlighted as key contributors to the success of POC use, and these were reliable power supply (44%), adequate and trained healthcare workers (24%), standard and stable EMR Systems (17%). The study recommended for adequate training of health care workers, adequate workstations, and reliable power supply. For initial implementers of EMRs, they should consider having Standard EMRs that support both clinical decision support features and automated reporting.

Evaluation of Digital Health Strategy to Support Clinician-Led Critically Ill Patient Population Management: A Randomized Crossover Study.

Single center randomized crossover study. Quaternary care academic hospital. Attending and in-training critical care physicians, and advanced practice providers. AMP. We compared ICU clinician performance in structured clinical task completion using two electronic environments-the standard commercial EMR (Epic) versus the novel AMP in addition to Epic. Twenty subjects (10 pairs of clinicians) participated in the study. During the study session, each participant completed the tasks on two ICUs (7-10 beds each) and eight individual patients. The adjusted time for assessment of the entire ICU and the adjusted total time to task completion were significantly lower using AMP versus standard commercial EMR (-6.11; 95% CI, -7.91 to -4.30 min and -5.38; 95% CI, -7.56 to -3.20 min, respectively; p < 0.001). The adjusted time for assessment of individual patients was similar using both the EMR and AMP (0.73; 95% CI, -0.09 to 1.54 min; p = 0.078). AMP was associated with a significantly lower adjusted task load (National Aeronautics and Space Administration-Task Load Index) among clinicians performing the task versus the standard EMR (22.6; 95% CI, -32.7 to -12.4 points; p < 0.001). There was no statistically significant difference in adjusted total errors when comparing the two environments (0.68; 95% CI, 0.36-1.30; p = 0.078). When compared with the standard EMR, AMP significantly reduced time to assessment of an entire ICU, total 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.

Comparison of Modified Cap-Assisted Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection in Treating Intraluminal Gastric Gastrointestinal Stromal Tumor (≤20 mm).

A modified cap-assisted endoscopic mucosal resection (mEMR-C), introduced in this study, was a novel variation of the standard EMR. We aimed to compare the outcomes of mEMR-C and endoscopic submucosal dissection (ESD) for the treatment of small (≤20 mm) intraluminal gastric gastrointestinal stromal tumors (gGISTs). This retrospective study included 43 patients who underwent mEMR-C and 156 patients who received ESD at Nanjing Drum Tower Hospital. Baseline characteristics, adverse events, and clinical outcomes were compared between the 2 groups. Univariate and multivariable analyses were conducted to adjust for confounders. After propensity score matching using sex, year, location, and tumor size, outcomes were compared with 41 patients in each group. A total of 199 patients underwent endoscopic resection and the en bloc resection rate was 100%. The complete resection rate was comparable in both groups ( P = 1.000). Approximately 9.5% of all patients had a positive margin. There was no significant difference in positive margin for patients undergoing mEMR-C or ESD (9.3% vs 9.6%, P = 1.000). No difference in adverse events in both groups ( P = 0.724). The mEMR-C was associated with shorter operation time and lower cost than the ESD. Recurrence was reported in 2 patients at 1 and 5 years after ESD during a median follow-up of 62 months. No metastasis and disease-related death were identified in both groups. Propensity score matching analysis revealed similar results. The mEMR-C was found to be the preferable technique for small (≤20 mm) intraluminal gGISTs with shorter operation time and lower cost as compared with ESD.

Charge capture in the BICU: Increasing revenue by improving documentation behaviors

Documentation by a healthcare provider is the key to capturing appropriate reimbursement for effort, expertize, and time given to patients. However, patient encounters are known to be under-coded; often describing a level of service that does not reflect the physician’s labor. If there is deficient medical decision making (MDM) documentation, this will ultimately lead to a loss of revenue, as coders can only evaluate service levels from the documentation during the encounter. Physicians at the Timothy J. Harnar Regional Burn Center at Texas Tech University Health Sciences Center were experiencing below-average reimbursement for work performed in the burn center and theorized that deficiencies in documentation (particularly in the area of MDM) were the cause. They hypothesized that poor documentation by physicians was resulting in a substantial proportion of encounters being compulsorily coded at inadequate and imprecise levels of service. To improve the service levels of MDM in physician documentation at the Burn Center and consequently, increase the numbers and levels of billable encounters in the unit with an accompanying increase in revenue, two resources were created and employed with the purpose of providing increased documentation recall and thoroughness. These resources included a pocket card, designed to prevent missed details when documenting patient encounters, and a standardized EMR template that was mandated to be used by all BICU medical professionals rotating through the unit. After completion of the intervention period (July - October 2021), a comparison was made between the 4-month periods of July-October 2019 and 2021. Based on the encounters provided by residents and one fellow assigned to the BICU medical director, inpatient subsequent visit codes showed an average increase in billable encounters of 1500% amid the compared periods. Upon implementation of the intervention, subsequent visit codes 99231, 99232, and 99233 (higher-numbered codes indicating an increased level of service and accompanying reimbursement) raised by 142%, 2158%, and 2200%, respectively. An additional finding since the implementation of the pocket card and revised template, billable encounters have replaced the once-dominate global encounter, 99024 (associated with no reimbursement); realizing an increase in billable inpatient services due to complete and thorough documentation of non-global issues patients experienced throughout their hospital stays. Obtaining buy-in from physicians proved a significant challenge; consistent training and feedback allowed for an improved understanding of billing and coding processes within the BICU. The described findings indicate that a focused effort to improve documentation offers a promising method to yield potentially significant improvements in a unit’s profitability.

Standard Endoscopic Mucosal Resection vs Precutting Endoscopic Mucosal Resection Using Novel Disk-Tip Snare for Colorectal Lesions.

SOUTEN (KANEKA Co., Tokyo, Japan) is a unique snare with a disk tip. We analyzed the efficacy of precutting endoscopic mucosal resection with SOUTEN (PEMR-S) for colorectal lesions. We retrospectively reviewed 57 lesions of 10-30mm treated with PEMR-S at our institution from 2017 to 2022. The indications were lesions that were difficult for standard EMR due to size, morphology, and poor elevation by injection. Various therapeutic results of PEMR-S such as en bloc resection, procedure time, and perioperative hemorrhage were analyzed, and the results of 20 lesions of 20-30mm with PEMR-S were compared to those of lesions with standard EMR (2012-2014) using propensity score matching. Additionally, the stability of the SOUTEN disk tip was analyzed in a laboratory experiment. The polyp size was 16.5 ± 4.2mm and the non-polypoid morphology rate was 80.7%. Histopathological diagnosis included 10 sessile-serrated lesions, 43 low-grade and high-grade dysplasias, and 4 T1 cancers. After matching, the en bloc resection and histopathological complete resection rates of lesions of 20-30mm between PEMR-S and standard EMR (90.0% vs. 58.1%, p = 0.03 and 70.0% vs. 45.0%, p = 0.11). The procedure time (min) was 14.8 ± 9.7 and 9.7 ± 8.3 (p < 0.01). The en bloc resection (%) and procedure time of expert/non-expert were 89.7/85.7 (p = 0.96) and 6.1 ± 2.2/18.5 ± 7.2 (p < 0.01). The perioperative bleeding and hemostasis success rates with SOUTEN were 43.9% and 96.0%. In the experiment, the SOUTEN disk tip was fixed stably compared to other EMR snares. PEMR-S achieved high en bloc resection of colorectal lesions of 20-30mm though it leaded to long procedure time.

Impact of margin ablation after EMR of large nonpedunculated colonic polyps in routine clinical practice

Owing to its simplicity, effectiveness, and safety, EMR is the preferred treatment for the majority of large (≥20mm) nonpedunculated colonic polyps (LNPCPs); however, residual and recurrent adenomas (RRAs) encountered during surveillance constitute a major limitation. Thermal ablation of the post-EMR mucosal defect margin has been shown to be highly efficacious in reducing RRA in a randomized trial setting, but data on effectiveness in clinical practice are scarce. We aimed to determine the effectiveness of this technique for reducing RRAs in routine clinical practice. We analyzed data collected in 3 hospitals in Israel: Prospective data were available in 2 hospitals where margin thermal ablation with snare-tip soft coagulation (STSC) is routinely performed after EMR of LNPCP (TA-EMR). Only retrospective data were available from the third center, which exclusively did not perform STSC (standard EMR] [S-EMR]), during the study period. Surveillance was performed 4 to 6 months after resection. RRA was assessed endoscopically with high-definition white light and optical chromoendoscopy. The primary endpoint was RRA at first surveillance colonoscopy. Data from 764 patients with 824 LNPCPs were analyzed. The patient and lesion characteristics were similar between the groups. Four hundred sixty-four LNPCPs were treated by TA-EMR and 360 LNPCPs by S-EMR. RRA at first surveillance colonoscopy was detected in 14 (3.6%) of lesions in the TA-EMR group compared with 96 (31.6%) in the S-EMR group (P< .001; RR= .14; 95% CI, .07-.29). Adverse events were comparable between the 2 groups. TA-EMR leads to a significant reduction in post-EMR recurrence in routine clinical practice.

Benefits of a novel in-line decision support and ordering platform to support genomic test ordering.

431 Background: For many cancer patients, identifying the best treatment options requires timely genomic and molecular testing. However, only a small fraction of eligible patients receive timely access to evidence-based testing. Testing barriers include the clinician efforts to stay abreast of the vast number of genomic tests, rapidly evolving recommendations, and the variety of vendors offering these costly tests. We piloted a genomic test ordering solution that is integrated directly with the EMR and evaluated its benefits. Methods: We worked with experts from multiple specialties to finalize simple, context-based decision support and used standard EMR functionality to enable providers to order appropriate tests directly from the decision support webpage, seamlessly queuing orders in the EMR. We evaluated a set of metrics based on expected benefits of this new solution. We focused our analysis on lung cancer patients, and on five genomic tests: blood-based NGS, tissue-based NGS, EGFR PCR, PDL1 28-8, PDL1 22C3. Regional oncologists and nurse navigators were surveyed before and after the pilot period to ascertain ordering length of time and experience. Aggregate claims data were reviewed to assess adherence rates to recommended testing guidance and the ordering tool. The pilot launched July 2021, and six-month pre- and post-pilot data were used to evaluate its impact. Results: We received 46 and 53 pre- and post-pilot survey responses, respectively. There was an increase in the proportion of respondents who reported that ordering took ‘Less than 5 minutes’ (39% (pre) to 72% (post)), and that the ordering process was ‘Easy’ (28% (pre) to 74% (post)). In pre-pilot survey comments, ‘knowing the right test’ and ‘how to order’ comprised 30% of 40 comments. These issues were not raised in the 37 post-pilot survey comments we received. Approximately 35% of post-pilot comments revealed no issues with the new process, though 24% of comments expressed issues finding test guidance and the order button. Adherence to recommended guidance and the ordering tool grew from 0% to 44% from July to November 2021 but maintained a steady pace since then to April 2022. Conclusions: Connecting genomic test decision support to ordering capability can lead to significant benefits for providers and patients. The pilot was successful in saving ordering time, improving the ordering experience, and improving adherence to guideline concordant treatments. Success factors include elimination of a cumbersome ordering interface, development of individually orderable tests, implementation of a central ordering location, and guidance to preferred vendors. There are opportunities to improve clinician onboarding, boost adherence rates, and assess other impacts to outcomes such as cost savings and time to treatment. Additional analyses are required to understand the broader impact to these measures.

Cap-assisted EMR versus standard inject and cut EMR for treatment of large colonic laterally spreading tumors: a randomized multicenter study (with videos)

Piecemeal EMR of colorectal laterally spreading tumors (LSTs) >20mm is effective. Experience is limited in the use of cap-assisted EMR (EMR-C) for resection of colonic lesions. We compared the efficacy and the safety of EMR-C for the removal of colonic LSTs≥30mm with "inject-and-cut" standard EMR (EMR-S). In this randomized trial from 4 Italian centers, 138 patients were treated with EMR-C and 102 with EMR-S. The rates of residual lesions, percentage of recurrence after 12 months, and adverse events were evaluated. One hundred forty-three lesions were resected with EMR-C and 102 with EMR-S. Argon plasma coagulation (APC) was used as adjunctive treatment in 2.9% of EMR-Cs and in 22.5% of EMR-Ss (P< .001). The median time required was 20 minutes for EMR-C and 30 minutes for EMR-S (P< .001). Adverse events (AEs) occurred in 14 EMR-Cs (10.1%; 2 perforations, 11 bleeding events, and 1 stenosis) and in 22 EMR-Ss (21.6%; 1 perforation and 21 bleeding events) (P= .017). Intraprocedural AEs occurred in 3.6% of EMR-Cs and 16.7% of EMR-Ss (P= .001). Overall, residual lesions within 12 months were found to be significantly higher with EMR-S (32 patients, 31.4%) than with EMR-C (8 patients, 5.8%) (P< .001). Recurrence at follow-up colonoscopy in 12 months occurred in 7 EMR-Cs (5.1%) and 17 EMR-Ss (16.7%; P< .001). The study demonstrated the feasibility and safety of EMR-C for removing large colorectal LSTs, with higher eradication rates, shorter resection time, and less use of APC when compared with EMR-S. (Clinical trial registration number: NCT03498664.).

Endoscopic Resection of Gastrointestinal Neuroendocrine Tumors: Long-Term Outcomes and Comparison of Endoscopic Techniques

Introduction: Gastrointestinal neuroendocrine tumors (GI-NETs) are being more frequently diagnosed and treated by endoscopic resection (ER) techniques. However, comparison studies of the different ER techniques or long-term outcomes are rarely reported. Methods: This was a single-center retrospective study analyzing short and long-term outcomes after ER of gastric, duodenum, and rectal GI-NETs. Comparison between standard EMR (sEMR), EMR with a cap (EMRc), and endoscopic submucosal dissection (ESD) was made. Results: Fifty-three patients with GI-NET (25 gastric, 15 duodenal, and 13 rectal; sEMR = 21; EMRc = 19; ESD = 13) were included in the analysis. Median tumor size was 11 mm (range 4–20), significantly larger in the ESD and EMRc groups compared to the sEMR group (p < 0.05). Complete ER was possible in all cases with 68% histological complete resection (no difference between the groups). Complication rate was significantly higher in the EMRc group (EMRc 32%, ESD 8%, and EMRs 0%, p = 0.01). Local recurrence occurred in only one patient, and systemic recurrence in 6%, with size ≥ 12 mm being a risk factor for systemic recurrence (p = 0.05). Specific disease-free survival after ER was 98%. Conclusion: ER is a safe and highly effective treatment particularly for less than 12 mm luminal GI-NETs. EMRc is associated with a high complication rate and should be avoided. sEMR is an easy and safe technique that is associated with long-term curability, and it is probably the best therapeutic option for most luminal GI-NETs. ESD appears to be the best option for lesions that cannot be resected en bloc with sEMR. Multicenter, prospective randomized trials should confirm these results.

Improving Compliance and Quality of Documentation of Cerebral Function Monitoring in a Neonatal Neurocritical Care Unit.

Neonates admitted to neurocritical care units frequently undergo continuous bedside cerebral function monitoring (CFM). Documentation of CFM findings that are complete and accurate can augment the quality of care through improved communication. We aimed to increase the compliance with and quality of CFM documentation in the electronic medical records by 50% in our neonatal intensive care unit over 6 months. We used the Plan-Do-Study-Act methodology, process mapping, and fishbone analysis. We implemented interventions, including the development of standardized EMR templates, face-to-face reminders at staff meetings and clinical handover sessions, and teaching on CFM interpretation. We evaluated 50 and 161 charts pre (August-October 2018) and postintervention (December 2018-July 2019), respectively. We improved compliance with documentation from 72% to 89% (P = 0.004); and the quality of documentation from 10% to 61% (P < 0.001). Multimodal reminders to document and educational sessions to increase familiarity with CFM interpretation effectively improved the quality of documentation. We improved the compliance with and the quality of CFM documentation using targeted quality improvement interventions with case-focused educational sessions, reference tools, and standardized templates. Barriers to compliance with documentation were adverse effects on the workflow that changes in the EMR system may address. A significant challenge to sustainability was the high frequency of rotating trainees. We addressed this challenge by developing mandatory electronic teaching modules that include reminders to document and a case-focused teaching curriculum; to increase awareness of the importance of CFM documentation and increase confidence in CFM interpretation.

Hybrid APC Colon EMR, A Novel Approach to Reduce Local Recurrence

Background and AimsEndoscopic mucosal resection (EMR) has become the standard for removing large colon polyps but has a 10%-30% recurrence rate using standard techniques. Data shows improved recurrence rates with focal therapy of the edge of the resection base using cautery. We examine a novel technique, hybrid APC assisted EMR, which treats both the edge and the base with cautery to assess its effect on local recurrence. MethodsWe reviewed all EMRs of polyps >2 cm by a single endoscopist with 6-month follow-up from May 2018 to November 2019 using both standard EMR as well as hybrid APC assisted EMR to assess local recurrence as well adverse events. ResultsForty-eight patients with 59 polyps removed by EMR had full 6 month follow up with a mean age of 66.1 years of age, 45% were female. Thirty polyps were removed by hybrid APC assisted EMR and 29 removed with standard EMR. Overall, 0 (0%) polyps in the h-APC arm had local recurrence while 6 (20.7%) in the standard group had histological proven local recurrence (P = 0.01). Postresection bleeding occurred in 6 patients, 2 in the hAPC arm and 4 in the standard arm (P = 0.41). ConclusionIn this retrospective pilot study, hybrid APC assisted EMR was superior to conventional EMR for local recurrence after removal of large colon polyps and trended towards a less post-EMR bleeds.

Checklists in Femur Fractures: High Adherence After Implementation of Computer-based Pediatric Femur Guidelines.

Introduction:The American Academy of Orthopaedic Surgeons (AAOS) created an evidence-based clinical practice guideline for the care of pediatric diaphyseal femur fractures in 2010. Our institution implemented checklists based off these guidelines embedded in a standardized EMR order. The purpose of this study was to describe compliance with checklist completion and to assess safety improvement in a large urban pediatric hospital.Methods:Retrospective and prospective data were collected from 2 years before and 5 years after checklist implementation. This included the patient safety checklists from August 2011 through August 2016. Patients aged 0 to 18 years with a diaphyseal femur fracture were queried from the EMR and included in this study. Patient charts were reviewed for complications, including nerve injury, pressure sore, leg length discrepancy, loss of reduction, failure of fixation, nonunion, delayed union, and infection. Compliance rates were reported based on the AAOS clinical practice guidelines.Results:A total of 313 patients for the postchecklist period were reviewed in this study. Of 219 patients eligible for inclusion, 198 had checklists completed (group B). This group was compared with 100 patients with diaphyseal femur fractures from the period before implementation of the checklist (group A). We found no statistical difference in the number of patients with complications between groups (12% in both groups, P = 0.988). Postoperative checklists demonstrated that 89.9% of patients (178/198) received age-appropriate treatment consistent with the AAOS guideline recommendations after implementation of the checklist. Before the checklist implementation (group A), 94% (94/100) adhered to the guidelines.Conclusion:This study reveals high compliance rates with the AAOS evidence-based clinical practice guideline for the management of pediatric femur fractures. Implementing standardized checklists is possible by embedding them into the EMR. Implementation of checklists did not improve compliance or patient outcomes.

Tu1102 EFFICACY AND SAFETY OF COLD ENDOSCOPIC MUCOSAL RESECTION OF LARGE COLONIC ADENOMAS

Cold snare polypectomy is safe, and recent studies have shown a high level of efficacy for large sessile serrated lesions. In contrast, data on cold resection of large adenomas are limited, with previous studies utilizing high rates of adjuvant therapy (biopsy forceps or argon plasma coagulation). The aim of this study was to evaluate the safety and efficacy of a standardised cold EMR technique for large (≥20mm) colonic adenomas. We retrospectively analysed all consecutive large adenomas removed by cold EMR by the study endoscopists at a single academic endoscopy centre between June 2015-May 2019. High definition cap-fitted colonoscopy was performed with a standardized cold EMR technique1: a) submucosal injection of succinylated gelatin with methylene blue or indigo carmine; b) piecemeal cold snare resection with at least 3mm margin of normal mucosa; and c) targeted clip placement for persistent or focal ooze when early post-procedural anticoagulation was planned. Adjuvant therapy was never applied. All specimens were reviewed by a specialist GI pathologist. First surveillance colonoscopy (SC1) was performed at 3-6 months and SC2 at subsequent 6-12 months. Structured scar assessment involved white light and narrow band imaging examination. Flat bland scars were assessed endoscopically; non-bland scars were biopsied; suspected residual adenoma was treated by cold snare or cold biopsy avulsion followed by snare tip soft coagulation. 100 adenomas were removed in 93 patients over 51 months (mean age 68 years, 53 % female). Mean polyp size was 26mm (median 23mm, 20-70mm), 90% were located in the proximal colon and were predominantly Paris 0-IIa morphology (87%). Final histology was tubular/tubulovillous adenoma in 93 (58 low grade and 35 high grade dysplasia) and traditional serrated adenoma in 7. Unanticipated unifocal low risk submucosal invasive adenocarcinoma was present in a single case. A median of 2 clips were placed in 21 defects (23%). Adverse events occurred in 4 (4%); delayed bleeding 2 (2%) and hospitalisation for mild abdominal symptoms in 2 (2%). SC1 is complete for 95 (95%) lesions with surveillance of 3 lesions pending. No residual was detected in 88/95 (endoscopic 38, biopsy 50) at SC1. Residual neoplasia was identified in 7/95 (7.36%) and was treated endoscopically. All residual cases have completed SC2; 5 (71%) had no residual and 2 had further residual treated and are awaiting SC3. Overall SC2 is complete in 52 (52%) and residual was not detected in any additional cases. Selected large colonic adenomas can be safely removed by cold EMR with a low rate of residual neoplasia. Further study is required comparing cold and conventional EMR to further define which lesions and patients are best served by cold resection.

Can automating surgical processes reduce operating room supply costs? A pilot study of a novel OR based technology.

Introduction In the struggling economic post covid era, there will be greater cost containment, efficiency, and quality pressures. How does novel technology to dynamically digitize and automate surgical processes, as an adjunct to existing static workflows, impact surgical supply costs in knee replacement surgeries compared to traditional non automated knee replacement surgeries? Materials/Methods A novel innovative patented technology (SIGHT Medical, Alexandria LA) was created to digitize surgical processes and interface with hospital data systems (EMR- EPIC and ERP- Lawson) within Ochsner health system. Medical Surgical supplies and billable medical supplies were captured by the OR staff using standard hospital EMR and materials management workflows. Outcome measures included costs of surgical supplies, length of stay and number of cases captured using the Ochsner Health system data analytics platform (Tableau, Seattle, WA). Results 1023 knee replacement surgeries were reviewed over 3 years by 3 surgeons at 3 different hospitals within the Ochsner Health system. There was an average of $479/surgery in medical surgical supply costs for automated surgeries and $557/surgery for traditional surgeries. There was an average of $2,444/surgery in billable medical supply costs for automated surgeries and $4,660/surgery for traditional surgeries. Discussion Deploying innovative technology to create a real time dynamic communication and transparency platform can create significant supply cost savings. An average of $78 in medical surgical supply cost savings and $2216 in billable medical supply cost savings can be achieved by automating many of the surgical workflows and processes.

Care coordination for oral oncolytics through pharmacy integration and cycle 1-day 1 documentation.

260 Background: The growing number of oral oncolytic therapies (OOTs) necessitates a standardized EMR workflow that integrates pharmacy activities for dispense and patient management and standardizes cycle-1/day-1 (C1D1) documentation. Our practice’s treatment plans contain appropriately timed OOT follow-up activities including labs, physician follow-up visits, and pharmacy calls for toxicity and adherence checks, however complications in prescription fulfillment such as prior authorization, co-pay assistance, or inability of in-practice pharmacy to dispense limit the predictability of C1D1 dates of OOTs. Methods: An EMR query identified patients at a single clinic location of 5-medical oncologists (MDs) for whom oral oncolytic treatment plans were entered from January 1 to June 30, 2018. C1D1 date entered by the MD in the EMR was compared to the pharmacy processing system dispense date. Ten patients were identified, and 10% (1/10) had an accurate C1D1 documented within the EMR. As part of the ASCO Quality Training Program, to improve the accuracy of C1D1 documentation, a new workflow was implemented whereby: (1) a “hold” activity was added to new EMR treatment plans so that C1D1 remained pending until patients had received medication; (2) clinic checkout staff provided patients with information on the in-practice pharmacy and expectations for next steps; (3) pharmacists utilized existing reporting tools to identify newly entered treatment plans and transcribed orders into e-prescriptions sent to our practice pharmacy; (4) the pharmacy workflow ensued with pharmacy staff leading patient engagement, drug counseling; (5) pharmacists confirm C1D1, document within EMR (6) subsequent treatment plan activities were scheduled. Results: Following education and process changes within the clinic and pharmacy, accurate C1D1 documentation occurred in 90% (9/10) of patients initiating OOTs. Conclusions: Including pharmacy fulfillment time in EMR workflow can improve C1D1 documentation accuracy and associated management of OOTs. Education regarding roles and processes of prescribing MDs, pharmacy staff and clinic staff will be required to scale this process improvement throughout the organization.

1310. Improving Infectious Disease Electronic Medical Records Documentation: A Quality Improvement Study in an Academic Teaching Hospital

BackgroundImproving efficiency of documentation and sign outs during transitions of care were identified as areas of interest by the University of South Florida Infectious Disease (ID) Division. Our aim is by May 2018, we will achieve >50% improvement in our ID EMR note efficiency score for any adult patient at Tampa General Hospital. Note efficiency score involves listing all of the following key elements with 1 point awarded for each: active problem in the subjective section, updated hospital course under assessment, active problem prioritized first under assessment and non-relevant problems removed from assessment.MethodsInstitute of Healthcare Improvement’s model with Plan-Do-Study-Act (PDSA) cycles was used for project implementation from March 2018 to May 2018 (Figure 1). Cycle 1: Conducting a needs assessment survey and education. Cycle 2: Changing the existing template and implementing a new standardized template that includes the key elements, along with removal of auto populated non relevant information. Audits of notes with a 4-point system scoring was done. A pre and post implementation physician survey was conducted.ResultsID fellow and faculty completed the baseline survey (N = 25). Less than half (46%) felt that they could interpret patient assessments with ease and even fewer respondents (36%) felt there was adequate weekend sign out. More than one-third (36%) reported writing majority of notes after 5 pm (Figure 1). Pilot project involved nine ID faculty and fellows. We had 95% compliance with use of the standardized EMR template. Notes were evaluated at baseline (n = 190), cycle 1 (n = 85), and cycle 2 (n = 56). An increase in average note efficiency score from baseline, cycle 1 and cycle 2 occurred as follows (Mean ± SD): 2.0 ± 0.84 vs. 2.8 ± 0.95 vs. 3.6 ± 0.5 (Figure 2). Compared with baseline, cycle 2 achieved 42% improvement in the ease of interpretation of patient assessments and 41% improvement in adequate sign out. No increase in note writing after 5pm (36% vs. 30% baseline and cycle 2, respectively) reported.ConclusionTargeted education and changing the EMR note template can achieve improved efficiency of ID note. These efforts to improve documentation enhance physician’s ease of interpretation of patient assessments and sign out during transition of care. Disclosures All authors: No reported disclosures.