System-wide Electronic Medical Record Research Articles

Guidance Directed Care of Spontaneous Coronary Artery Dissection: A Healthcare System-Based Experience

IntroductionData on treatment of spontaneous coronary artery dissection (SCAD) has evolved with guidance from national societies beginning around 2018. Given emerging guidance and relatively uncommon presentation of SCAD, we hypothesized that a specialized SCAD clinic would improve guidance-based care. MethodsWe utilized a system-wide electronic medical record search to identify individuals with SCAD diagnosis from 2018 to 2023. All diagnostic angiograms were reviewed to verify diagnosis. We analyzed frequency of guidance-based care since 2018 system-wide. We also compared guidance-based care for individuals with index visits to the SCAD outpatient clinic as compared to non-SCAD clinic providers from initiation of specialty clinic in 2021. ResultsDifferences were observed in pregnancy and contraception discussions (88 % vs 0 %, p < 0.001) among pre-menopausal individuals in SCAD clinic compared to non-SCAD clinics. Safety of hormone replacement therapy (HRT) in menopausal women was addressed more by SCAD clinic providers (85 % vs 7 %, p < 0.001). There was more fibromuscular dysplasia (FMD) screening in SCAD clinic (100 % vs 30 %, p < 0.001). Among individuals with migraines, there was more discussion of triggering medications (triptans) in SCAD clinic (80 % vs 14 %, p = 0.008). In individuals prescribed statins not by primary prevention guidelines and without atherosclerosis, there was a trend toward more discussion of statin use in SCAD clinic follow up vs non-SCAD clinic providers (63 % vs 17 %, p = 0.06). ConclusionsIndividuals with follow up in SCAD clinic compared to non-SCAD clinics were more likely to have future pregnancy and contraception counseling, discussion of HRT safety, and FMD screening following index outpatient visit. Future quality improvement initiatives will target these aspects of guidance-based care among non-SCAD clinic providers with integration into cardiology fellow training.

Protocol paper for an implementation science approach to promoting colorectal cancer screening in Federally Qualified Health Center clinics: A stepped-wedge, multilevel intervention trial.

Colorectal cancer is the third leading cause of cancer-related deaths in the United States. Despite the Healthy People 2030 goal of 70.5%, colorectal cancer (CRC) screening rates in Federally Qualified Health Centers (FQHCs) are suboptimal at about 40%. The Colorectal Cancer Awareness, Research, Education and Screening-Rural Expansion, Access, and Capacity for Health (CARES-REACH) study seeks to address this disparity and accelerate the adoption and utilization of effective, evidence-based CRC screening practices. This paper describes the CARES-REACH study design and implementation methods. Informed by a community-based participatory research (CBPR) framework and enriched by implementation science approaches, CARES-REACH features a stepped wedge design with extension for maintenance to support an implementation strategy focused on multiple levels: organizational, provider, and patient levels that entail processes to boost initial and repeat screening among average risk and age-eligible adults. This multilevel study entails the implementation of a core set of evidence-based interventions (EBIs) that include low literacy patient education (English, Spanish, and Haitian Creole language); provider education, system-wide electronic medical record (EMR) tools including provider prompts and patient reminders, FIT (fecal immunochemical test) kit distribution, plus an organization-wide cancer control champion who motivates providers, coaches and navigates patients, and monitors system-wide CRC screening activities. NCT04464668.

PD45-10 OUTCOMES AFTER HOLMIUM LASER ENUCLEATION OF THE PROSTATE, OPEN SIMPLE PROSTATECTOMY, AND ROBOTIC SIMPLE PROSTATECTOMY: EXPERIENCE FROM A LARGE ACADEMIC MEDICAL CENTER

You have accessJournal of UrologyCME1 May 2022PD45-10 OUTCOMES AFTER HOLMIUM LASER ENUCLEATION OF THE PROSTATE, OPEN SIMPLE PROSTATECTOMY, AND ROBOTIC SIMPLE PROSTATECTOMY: EXPERIENCE FROM A LARGE ACADEMIC MEDICAL CENTER Matthew Lee, Meera Ganesh, Joshua Han, Quan Mai, Mark Assmus, Jessica Helon, Briana Kaplunov, and Amy Krambeck Matthew LeeMatthew Lee More articles by this author , Meera GaneshMeera Ganesh More articles by this author , Joshua HanJoshua Han More articles by this author , Quan MaiQuan Mai More articles by this author , Mark AssmusMark Assmus More articles by this author , Jessica HelonJessica Helon More articles by this author , Briana KaplunovBriana Kaplunov More articles by this author , and Amy KrambeckAmy Krambeck More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002613.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Per AUA guidelines, large prostates (defined as ≥80g in size) can be managed with Holmium Laser Enucleation of the Prostate (HoLEP), Open simple prostatectomy (OSP) or robotic simple prostatectomy (RSP). While these modalities have been previously compared to one another, one study only compared 32 RSPs to 600 HoLEPs. To our knowledge, the three modalities have never been compared against each other in the same cohort. Furthermore, in any published studies, the authors were not performing same-day catheter removal and discharge after HoLEP, indicating the studies must be updated. Herein, we present our experience performing HoLEP, OSP, and RSP for large prostates at a large academic medical center. METHODS: The Northwestern Enterprise Data Warehouse (EDW) is a system-wide electronic medical record based data platform. We queried the EDW for all patients undergoing HoLEP, OSP, and RSP from Jan 2011 to Oct 2021 for prostates ≥80g. Patients were identified by CPT code (52649, 55831/ 55821, 55899, respectively). Variables were abstracted from the EDW and medical record. Statistical analysis was performed using SAS studio (2021). Multiple comparisons for continuous variables were performed using ANOVA with Tukey’s corrections. Chi-square tests were used for categorical variables. P-value <0.05 was determined to be statistically significant. RESULTS: The three cohorts were similar in age, BMI, and Carlson comorbidity index. There was no difference in preoperative Hgb, Cr or prostate volume. PSA was higher in the OSP group (p=0.0077). Surgery duration, estimated blood loss (EBL), length of stay (LOS) and catheter duration were all shortest in the HoLEP group (p<0.0001). OSP had the highest EBL and HoLEP had the lowest EBL (P<0.0001) which also translated into less RBC transfusions for HoLEP and RSP compared to OSP (p<0.0001). There were no differences in ED visits, but RSP had the highest readmission rate (p<0.0001). CONCLUSIONS: In this cohort where HoLEP patients underwent same-day catheter removal and discharge, despite similar preoperative characteristics, HoLEP was associated with shorter surgery duration, LOS and catheter duration. HoLEP also had the lowest EBL and RBCs transfused with an increase in ED visits or readmissions. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e786 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Lee More articles by this author Meera Ganesh More articles by this author Joshua Han More articles by this author Quan Mai More articles by this author Mark Assmus More articles by this author Jessica Helon More articles by this author Briana Kaplunov More articles by this author Amy Krambeck More articles by this author Expand All Advertisement PDF DownloadLoading ...

Comparing race and ethnicity across safety-net and non-safety net practices pre- and post-an HIV screening alert.

CONTEXT: Societal and economic burdens of human immunodeficiency virus (HIV) continue to grow, even as treatments and prevention for this disease becomes more readily available and efficacious. HIV screening is more likely to be performed in minority (including Black) patient populations compared to whites. The likelihood of getting screened also depends on primary care practice attributes. OBJECTIVE: Evaluate HIV screening demographics by safety-net and non-safety net practices. STUDY DESIGN and ANALYSIS: Pre-post analysis. SETTING: Atrium Health is a non-profit, vertically integrated healthcare system with approximately 16 million patient encounters per year across the Southeast US. POPULATION STUDIED: Twelve primary care practices, including four safety-net practices serving predominantly Medicaid and uninsured patients, with over 115,00 patients between the ages of 18 and 64 were selected for the educational intervention. INTERVENTION/INSTRUMENT: A system-wide electronic medical record alert prompting HIV screening was implemented in October 2017 targeting adults between 18-64 years old. In addition to the system alert, a provider peer-to-peer educational program detailing HIV disease epidemiology, screening recommendations, and algorithms to guide screening efforts was developed. OUTCOME MEASURES: HIV screenings. RESULTS: From October 2016- April 2017, 3,413 patients were screened for HIV at the twelve participating primary care practices. Immediately after the HIV alert activation, from October 2017 - April 2018, 6,256 patients were screened, resulting in an 83% increase in screening. However, increases were different based on practice type, race and ethnicity. Black patients in safety net clinics had higher screening rates prior to the alert and showed less of an increase in screening (37%) compared to whites (102%) after the alert was activated. Hispanic/Latino patients showed similar increases at both safety net (99%) and non-safety net (108%) practices. Both Black and white patients showed larger increases of 99% and 139% in non-safety net clinics. Chi-squared analysis comparing the percentage of patients screened during these time periods was significantly different (p=0.001). CONCLUSION: While race and practice characteristics influence the likelihood of HIV screening, EMR modifications and provider education can significantly enhance screening and care for patients with HIV regardless of race and practice type.

Building on lessons learned: A US Midwest healthcare system’s COVID-19 response

While noting that the COVID-19 pandemic remains ongoing, this paper reviews the incident response at one Midwestern healthcare system in order to identify lessons learned and key modifications to strengthen the response. The paper describes how a strong modified incident command structure provided the framework for the response. These modifications were based on successes during a system-wide electronic medical record implementation and included workgroups specific to a subject or discipline. These workgroups reported up through the traditional hospital incident command structure, allowing for situational awareness at all levels. A solid meeting cadence ensured proper visibility into the work being completed, while a data analyst group provided the much-needed data to make good decisions. Ensuring cross-pollination in the workgroups assisted with communication throughout, while establishing a regular cadence for all staff e-mails and executive updates supported frequent communication and information sharing to all 42,000 employees.

The Utility of Clinical Notes for Sexual Minority Health Research

Despite improvements in electronic medical record capability to collect data on sexual orientation, not all healthcare systems have adopted this practice. This can limit the usability of systemwide electronic medical record data for sexual minority research. One viable resource might be the documentation of sexual orientation within clinical notes. The authors developed an approach to identify sexual orientation documentation and subsequently derived a cohort of sexual minority patients using clinical notes from the Veterans Health Administration electronic medical record. A hybrid natural language processing approach was developed and used to identify and categorize instances of terms and phrases related to sexual orientation in Veterans Health Administration clinical notes from 2000 to 2019. System performance was assessed with positive predictive value and sensitivity. Data were analyzed in 2019. A total of 2,413,584 sexual minority terms/phrases were found within clinical notes, of which 439,039 (18%) were found to be related to patient sexual orientation with a positive predictive value of 85.9%. Documentation of sexual orientation was found for 115,312 patients. When compared with 2,262 patients with a record of administrative coding for homosexuality, the system found mentions of sexual orientation for 1,808 patients (79.9% sensitivity). When systemwide structured data are unavailable or inconsistent, deriving a cohort of sexual minority patients in electronic medical records for research is possible and permits longitudinal analysis across multiple clinical domains. Although limitations and challenges to the approach were identified, this study makes an important step forward for the Veterans Health Administration sexual minority research, and the methodology can be applied in other healthcare organizations.

Occult Uterine Malignancy at the Time of Sacrocolpopexy in the Context of the Safety Communication on Power Morcellation by the FDA

The objective of this study was to determine the incidence of occult uterine malignancy at the time of sacrocolpopexy with concurrent hysterectomy, in the context of practice pattern changes as a result of the 2014 Food and Drug Administration (FDA) power morcellation safety communication. Retrospective chart review. Tertiary care referral center in the United States. A total of 839 patients who underwent sacrocolpopexy from January 2004 to December 2018. All patients received a concurrent hysterectomy without a diagnosis of suspected or confirmed gynecologic malignancy before surgery. Trends of surgeries were compared before and after the 2014 FDA power morcellation safety communication. Demographic and perioperative data were collected from the system-wide electronic medical record. Operative and pathology reports were reviewed to determine the method of specimen retrieval and specimen pathology results. A total of 238 patients (28.4%) had a hysterectomy at the time of sacrocolpopexy. There were no cases of occult uterine malignancy (0%, 95% CI 0%-1.6%). There was 1 case of borderline tumor of the ovary. The most common mode of hysterectomy over the 15-year period was laparoscopic hysterectomy (n = 84, 35.3%), followed by vaginal hysterectomy (n = 63, 26.5%). After the FDA communication, the most common form of hysterectomy changed significantly to vaginal hysterectomy (n = 35, 55.6%; p <.001). When comparing the first 2 years after the announcement (2014-2016) to the subsequent 2 years (2017-2018), there was again a significant increase in the use of laparoscopic hysterectomy in the latter time period (7.3% vs 40.9%; p <.001). In this cohort of patients undergoing sacrocolpopexy with concurrent hysterectomy, the incidence of occult uterine malignancy was low. After the FDA safety communication, practice patterns with regard to the mode of hysterectomy changed, but the magnitude of these changes were transient.

Impact of EMR Automated Results Routing Tool Implementation on Notification of Inpatient Endoscopy Biopsy Results

Mucosal biopsies are often obtained during inpatient endoscopies to aid diagnosis. Up to 75% of patients are reported to have pending test results at discharge. Incomplete result communication to patients can lead to patient anxiety and poor outcomes. This study aimed to evaluate the impact of a systemwide electronic medical record (EMR) update on result communication. The researchers retrospectively reviewed 100 inpatient endoscopies pending histopathology results at discharge to see if finalized results were communicated to the patients within 30 days. The same metric was studied after implementation of an EMR update that automatically routed results to the supervising endoscopist, by reviewing another 100 inpatient endoscopies during which biopsies were obtained. Follow-up rate pre- and post-EMR update was compared. Prior to the update, 47/77 (61.0%) histopathology results were communicated to the patients. Of the 30 nonreported cases, 17 showed nonspecific/chronic inflammation, 8 had no abnormal findings, 3 showed hyperplastic colon polyps, and 2 had colonic tubular adenomas. Following the EMR update, 65/71 (91.5%) of pathology results were communicated, demonstrating an increase of 30.5 percentage points in the rate of follow-up (95% confidence interval [CI] = 17.7-43.0, p < 0.0001). This study observed that 39.0% of inpatient endoscopic mucosal biopsy results in one health care system were not communicated to the patients. Implementation of a systemwide EMR intervention reduced this to 8.5% by shifting the responsibility of result communication to the endoscopy team. Similar EMR enhancements can be applied to other pending test results in health care systems with similar issues.

A Real-Time Early Warning System for Monitoring Inpatient Mortality Risk: Prospective Study Using Electronic Medical Record Data.

BackgroundThe rapid deterioration observed in the condition of some hospitalized patients can be attributed to either disease progression or imperfect triage and level of care assignment after their admission. An early warning system (EWS) to identify patients at high risk of subsequent intrahospital death can be an effective tool for ensuring patient safety and quality of care and reducing avoidable harm and costs.ObjectiveThe aim of this study was to prospectively validate a real-time EWS designed to predict patients at high risk of inpatient mortality during their hospital episodes.MethodsData were collected from the system-wide electronic medical record (EMR) of two acute Berkshire Health System hospitals, comprising 54,246 inpatient admissions from January 1, 2015, to September 30, 2017, of which 2.30% (1248/54,246) resulted in intrahospital deaths. Multiple machine learning methods (linear and nonlinear) were explored and compared. The tree-based random forest method was selected to develop the predictive application for the intrahospital mortality assessment. After constructing the model, we prospectively validated the algorithms as a real-time inpatient EWS for mortality.ResultsThe EWS algorithm scored patients’ daily and long-term risk of inpatient mortality probability after admission and stratified them into distinct risk groups. In the prospective validation, the EWS prospectively attained a c-statistic of 0.884, where 99 encounters were captured in the highest risk group, 69% (68/99) of whom died during the episodes. It accurately predicted the possibility of death for the top 13.3% (34/255) of the patients at least 40.8 hours before death. Important clinical utilization features, together with coded diagnoses, vital signs, and laboratory test results were recognized as impactful predictors in the final EWS.ConclusionsIn this study, we prospectively demonstrated the capability of the newly-designed EWS to monitor and alert clinicians about patients at high risk of in-hospital death in real time, thereby providing opportunities for timely interventions. This real-time EWS is able to assist clinical decision making and enable more actionable and effective individualized care for patients’ better health outcomes in target medical facilities.

The impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for the large uterus

There are currently sparse data on the relationship between surgeon- and patient-related factors and perioperative morbidity in the setting of elective hysterectomy for the larger uterus. We sought to evaluate the impact of surgeon case volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for uteri >250 g. This is a retrospective cohort study of all women who underwent total vaginal, total laparoscopic, laparoscopic-assisted vaginal, or robotic-assisted total laparoscopic hysterectomy from January 2014 through July 2016. Hysterectomy was performed for: fibroids, pelvic pain, abnormal uterine bleeding, or prolapse. Patients were identified by Current Procedural Terminology codes and the systemwide electronic medical record was queried for demographic and perioperative data. Perioperative adverse events were defined a priori and classified using the Clavien-Dindo scale. Surgeon case volume was defined as the mean number of minimally invasive hysterectomy cases performed per month by each surgeon during the study period. In all, 763 patients met inclusion criteria: 416 (54.5%) total laparoscopic hysterectomy, 196 (25.7%) robotic-assisted total laparoscopic hysterectomy, 90 (11.8%) total vaginal hysterectomy, and 61 (8%) laparoscopic-assisted vaginal hysterectomy. Mean (±SD) age was 47.3 ± 6.1 years, and body mass index was 31.1 ± 7.4 kg/m2. In all, 66 surgeons performed minimally invasive hysterectomy for uteri >250 g during the study period, and the median rate of minimally invasive hysterectomy cases for large uteri per month was 3.4 (0.4-3.7) cases/month. The median (IQR) uterine weight was 409 (308-606.5) g. The rate of postoperative adverse events Dindo grade >2 was 17.8% (95% confidence interval, 15.2-20.7). The overall rate of intraoperative adverse events was 4.2% (95% confidence interval, 2.9-5.9). The rate of conversion to laparotomy was 5.5% (95% confidence interval, 4.0-7.4). There was no significant difference in adverse event rates between the routes of minimally invasive hysterectomy cases (25.6% vs 17.5% vs 18.0% vs 14.8% for total laparoscopic hysterectomy, robotic-assisted laparoscopic hysterectomy, total vaginal hysterectomy, and laparoscopic-assisted vaginal hysterectomy, respectively, P= .2). In a logistic regression model controlling for age, body mass index, uterine weight, operating time, and history of laparotomy, higher monthly minimally invasive hysterectomy volume was significantly associated with the likelihood that a patient would experience a postoperative adverse event (adjusted odds ratio, 1.1 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.0-1.3). When controlling for the same variables, a higher incidence of intraoperative complications was significantly associated with monthly minimally invasive hysterectomy case volume (adjusted odds ratio, 1.5 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.20-2.08). Increasing age was associated with a lower incidence of complications (adjusted odds ratio, 0.9 for each additional year; 95% confidence interval, 0.8-0.9). Higher monthly minimally invasive hysterectomy volume was associated with a lower rate of conversion from a minimally invasive approach to laparotomy (adjusted odds ratio, 0.4 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 0.2-0.5). The overall rate of serious adverse events associated with minimally invasive hysterectomy for uteri >250 g was low. Higher monthly minimally invasive hysterectomy case volume was associated with a higher rate of intraoperative and postoperative adverse events but was associated with a lower rate of conversion to laparotomy.

12: The impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for large uteri

To evaluate the impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy (MIH) for uteri >250 grams. This is a retrospective cohort study of all women who underwent vaginal (VH), laparoscopic (TLH), laparoscopic-assisted vaginal (LAVH), or robotic-assisted laparoscopic hysterectomy (RH) between January 2014 and July 2016 at a tertiary care referral center. Hysterectomy was performed for the following indications: fibroids, pelvic pain, abnormal uterine bleeding, and prolapse. Women were excluded if there was a preoperative diagnosis of malignancy. Patients were identified by Current Procedural Terminology codes and the system-wide electronic medical record was queried for demographic and perioperative data. Perioperative adverse events were defined a priori and classified using the Clavien-Dindo scale. Surgeon volume was defined as the mean number of MIH cases performed per month by each surgeon during the study period. Seven hundred sixty-three patients met inclusion criteria: 416 (54.5%) TLH, 196 (25.7%) RH, 90 (11.8%) TVH, and 61 (8%) LAVH. Mean (±SD) age was 47 ± 6 years, and body mass index (BMI) was 31.1 ± 7.4 kg/m2. Sixty-six surgeons performed MIH for uteri >250 grams during the study period. The mean monthly case volume was 16.4 ± 7.2 cases, and the median MIH volume was 23 cases (range: 1–147 cases). The mean uterine weight was 522.8 ± 322.7 grams. The rate of postoperative adverse events >Dindo grade 2 was 17.8% (95% CI = 15.2-20.7); 2.2% (95% CI = 1.4-3.6) were grade 3 and 0.5% (95% CI = 0.7-1.4) grade 4; there were no grade 5 adverse events. The overall rate of intraoperative adverse events was 4.2% (95% CI = 2.9-5.9). The rate of conversion to laparotomy was 5.5% (95% CI = 4.0-7.4). There was no difference in adverse event rates between the routes of MIH cases (25.6% vs. 17.5% vs. 18.0% vs. 14.8%, p = 0.2). Women who experienced any adverse event compared to those who did not were more likely to be of Hispanic, Asian or “other” ethnicity, had higher intraoperative blood loss (EBL) and longer operating case time. In a logistic regression model controlling for age, BMI, uterine weight, operating time, history of laparotomy and parity, higher monthly MIH volume remained significantly associated with adverse events (adjOR = 1.14, 95% CI = 1.0-1.3, p = 0.01), as did higher EBL (adjOR = 1.4, 95% CI = 1.1-1.8, p = 0.006). When controlling for the same variables, higher monthly MIH case volume remained significantly associated with intraoperative complications (adjOR = 1.30, 95% CI = 1.0-1.6, p = 0.02) as well as higher EBL (adjOR = 3.1, 95% CI = 2.0-4.9, p < 0.001). Conversion from a minimally invasive approach to laparotomy was not associated with monthly MIH case volume; however, conversion was associated with higher EBL (adjOR = 2.9, 95% CI = 1.8-4.9) and heavier uteri (adjOR = 9.7, 95% CI = 3.9-23). The overall rate of serious adverse events associated with MIH for uteri >250 grams was low. Higher EBL and longer operative times were associated with higher perioperative adverse event rates. Higher monthly MIH case volume was associated with a higher rate of intra- and postoperative adverse events but was not associated with conversion to laparotomy.

Incorporating medical marijuana in clinical practice.

117 Background: Medical marijuana (MM) is legal in the state of Connecticut. Regulatory issues, appropriate patient selection, and outcomes assessment have made it difficult for oncology centers to incorporate MM into clinical practice. At Smilow Cancer Hospital at Yale New Haven, a tertiary academic comprehensive cancer hospital, a multidisciplinary team was convened to propose guidelines. Based on the recommendations, the Smilow Cancer Hospital implemented a policy that outlines the use of MM in selected patients with nausea, anorexia and refractory pain. Here we describe the Smilow Experience with MM in clinical practice. Methods: Using health system-wide electronic medical record, a review of patients initiated on MM from 9/2015 to 10/2016 was conducted. Demographics, malignancy type/stage, MM indication, and preliminary data on formulation used and treatment outcomes were collected. Results: 108 cancer patients, majority evaluated by a Palliative Care physician, were initiated on MM (55.6% males/44.4% females). MM was prescribed more to patients with solid tumors compared to hematologic malignancies (91% versus 9%). The most common malignancy was gastrointestinal (34.3%), followed by lung (26.9%). Among patients with available definitive tumor staging, more had stage III or IV tumors (73.4%) compared to stage I or II tumors (26.6%). The most common indications are pain (81.8%) followed by cachexia (49.4%), and 40% of patients had more than one documented indication. Inhalation was the most common route of administration. Outcome data is limited at this juncture, though documentation indicates that more patients have reported “positive effects” from MM than “negative effects”. Conclusions: Despite legalization, the prescription of MM in cancer patients has been limited to individual practices, often outside of the context of a comprehensive cancer program. In these cases, follow up and outcomes assessment is minimal. Our review reveals that a health system-wide protocol allows patients to gain access to MM without having to leave the system. Our findings demonstrate interest among providers and patients in the potential therapeutic benefits of marijuana. Detailed data on efficacy and outcomes will be available at the time of the meeting.

Hepatitis C and HIV Primary Care Screening Intervention Increases Identification and Linkage to Care within a Large Healthcare system

BackgroundSocietal and economic burdens of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) continue to grow. The CDC recommends a one-time HCV screen for individuals in the Baby Boomer population (those born between 1945 and 1965) and a one-time HIV screen for all individuals between ages 13–64, with more frequent screening for both conditions based on individual risk factors.MethodsA system-wide electronic medical record alert prompting HCV screening was implemented in May 2016 targeting the Baby Boomer population. In addition to the system alert, an educational program detailing disease epidemiology, screening recommendations, and algorithms to guide screening efforts was developed by a quality improvement team to increase HCV and HIV screening and linkage to care for positive patients. Carolinas HealthCare System (CHS) is a nonprofit, vertically integrated healthcare system with approximately 12 million patient encounters per year. Twelve primary care practices, including 5 safety-net practices serving predominantly Medicaid and uninsured patients, with total of 43,000 patients born between 1945 and 1965 were selected for the educational intervention.ResultsPrior to the system-wide HCV alert, from May-December 2015, 2430 patients were screened for Hepatitis C; one year later post-HCV alert, from May-December 2016, 8872 patients were screened, resulting in a 350% increase in screening. Chi-squared analysis comparing the percentage of patients tested between the two- time periods was significantly different (P = 0.001). For the educational intervention initiated in November 2016: average patient HCV testing over the 12 sites was 1480 per month before the intervention, and rose to 1713 per month post-education implementation (P < 0.001). Similarly, for HIV testing: average patient HIV testing was on average 493 per month increasing to 621 average per month after the educational program (P < 0.001)ConclusionEMR modifications and provider education along with availability of connect to care partners within a large, integrated, healthcare system can significantly enhance screening and care for patients with HCV and HIV. Innovative interventions are needed to improve screening rates and link positive patients into care.Disclosures All authors: No reported disclosures.

Is neuromyelitis optica with advanced age of onset a paraneoplastic disorder?

Background: Neuromyelitis optica (NMO) antibodies are commonly found in patients with NMO, a relapsing CNS inflammatory disorder. Recent evidence suggests that the NMO antibody may be a paraneoplastic marker. We evaluated this possibility using a health system-wide electronic medical record (EMR), allowing assessment of neoplasm both before and after the assessment of NMO seropositivity. Design/Methods: An automated search of the Cleveland Clinic EMR was performed to identify patients with NMO serology testing (since 2006). Demographic, clinical, and imaging data were collected, including malignancy history. Results: A total of 41 patients NMO seropositive subjects were found. Average age at first clinical symptom was 38.7 years (SD 15.1), and 33 (80.5%) patients met formal criteria for NMO. Six malignancies were identified in five NMO seropositive patients (12.2%; age 48.7 years [SD 12.4] at presentation of NMO). Cancers included breast carcinoma (three cases), lymphoma, cervical carcinoma and leiomyosarcoma. The timing of malignancy diagnosis varied from 15 years prior to 14 years after the onset of neurologic symptoms. Among seropositive patients over age 50 years at the time of this review, malignancy was seen in 5/25 patients (20%). All five subjects fulfilled NMO clinical criteria. Conclusions: A high prevalence of malignancy was found in NMO seropositive patients, although the sample size was small. These observations support the possibility of NMO as a paraneoplastic marker. If further studies confirm this relationship, clinicians may consider malignancy screening in individuals seropositive for NMO, particularly those over the age of 48.

Prevalence of chronic medical conditions among inmates in the Texas prison system.

Given the rapid growth and aging of the US prison population in recent years, the disease profile and health care needs of inmates portend to have far-reaching public health implications. Although numerous studies have examined infectious disease prevalence and treatment in incarcerated populations, little is known about the prevalence of non-infectious chronic medical conditions in US prison populations. The purpose of this study was to estimate the prevalence of selected non-infectious chronic medical conditions among inmates in the Texas prison system. The study population consisted of the total census of inmates who were incarcerated in the Texas Department of Criminal Justice for any duration from September 1, 2006 through August 31, 2007 (N=234,031). Information on medical diagnoses was obtained from a system-wide electronic medical record system. Overall crude prevalence estimates for the selected conditions were as follows: hypertension, 18.8%; asthma, 5.4%; diabetes, 4.2%; ischemic heart disease, 1.7%; chronic obstructive pulmonary disease, 0.96%; and cerebrovascular disease, 0.23%. Nearly one quarter (24.5%) of the study population had at least one of the selected conditions. Except for asthma, crude prevalence estimates of the selected conditions increased monotonically with age. Nearly two thirds (64.6%) of inmates who were >or=55 years of age had at least one of the selected conditions. Except for diabetes, crude prevalence estimates for the selected conditions were lower among Hispanic inmates than among non-Hispanic White inmates and African American inmates. Although age-standardized prevalence estimates for the selected conditions did not appear to exceed age-standardized estimates from the US general population, a large number of inmates were affected by one or more of these conditions. As the prison population continues to grow and to age, the burden of these conditions on correctional and community health care systems can be expected to increase.

Managing the Complexity of a Systemwide Electronic Medical Record Design and Implementation

Nurse executives are critical to the successful planning, implementation, and adoption of technology to support the workflow and documentation needs of nurses and other end users. Informed by key principles of complexity theory, the enormous task of broad-based implementation of a standardized electronic medical record can be accomplished through the thoughtful development of flexible structures and change management principles that promote intelligent decision making and adoption by key stakeholders.

Hospitals honored for innovations in patient safety efforts.

New technologies for monitoring and recordkeeping systems were among the innovations highlighted in the American Hospital Association’s (AHA) annual prize program for U.S. hospitals. Top honors in the American Hospital Quest for Quality Prize and a $75,000 cash award went to Sentara Norfolk General Hospital in Norfolk, VA. In announcing the award, AHA recognized Norfolk General and three other hospitals for their leadership and innovation in quality, safety, and commitment to patient care. Technology lauded by judges included Norfolk General’s realtime, behavior-based monitor program, the first of its kind to be implemented in a health care environment. The program provides data to reveal symptoms of organizational and programmatic issues before they become adverse events. “This prize culminates two years of hard work by leadership and staff to create a culture of safety,” said Sentara Administrator Rodney Hochman, MD, in a news release. Gary Yates, MD, Sentara vice president for clinical effectiveness, added that the safety program piloted at Norfolk General, will soon be employed in all of Sentara’s six hospitals and other sites of care. “It’s about every employee learning our systems to prevent errors, patient injuries, and workplace accidents—and actively applying that knowledge in their work,” Yates explained. Finalists for the prize—The Johns Hopkins Hospital, Baltimore, MD, and Mary Lanning Memorial Hospital, Hastings, NE—received a $12,500 award. In addition, Advocate Health System in Oakbrook, IL, was awarded a Citation of Merit. Judges pointed to a three-year-old bar coding system at Mary Lanning Memorial as part of an institutionwide financial commitment to technology designed to improve safety. Advocate Health System was also recognized for implementing patient safety technologies, including an integrated system-wide electronic medical record with computerized physician order entry. “Each hospital recognized...has taken a slightly different path to achieving a culture of safety,” said AHA President Dick Davidson in a statement. “But each has a strong commitment to a new culture based on trust, understanding, and openness. That culture goes a long way to improving the care patients receive.” Hospitals Honored for Innovations in Patient Safety Efforts