Completeness and quality of text paging for subspecialty consult requests.

It is unclear whether previously developed frameworks for effective consultation apply to requests initiated by alphanumeric text page. We assessed a random sample of 210 text paged consult requests for communication of previously described 'essential elements' for effective consultation: reason for consult, level of urgency and requester contact information. Overall page quality was evaluated on a 5-point Likert scale. Over 90% of text paged consult requests included contact information and reason for consult; 14% indicated level of urgency. In ordinal logistic regression, reason for consult was most strongly associated with quality (OR 22.4; 95% CI 8.1 to 61.7), followed by callback number (OR 6.2; 95% CI 0.8 to 49.5), caller's name (OR 5.0; 95% CI 1.9 to 13.1) and level of urgency (OR 3.3; 95% CI 1.6 to 6.7). Results suggest that text paged consult requests often include most informational elements, and that urgency, often missing, may not be as 'essential' for text pages as it was once thought to be.

Letting a Good Crisis Go to Waste.

The widespread implementation of electronic health records (EHRs) was predicated on hopes that they would rapidly improve care, but initial experiences have been disappointing and thought to be a key part of physician dissatisfaction and burnout. The crisis created by EHR implementation is only in part due to EHRs themselves, and might also be viewed as a crisis that has served to surface longstanding problems in healthcare-ones that if grappled with, will lead to more rapidly effective digital transformation.

Differences in Narrative Language in Evaluations of Medical Students by Gender and Under-represented Minority Status.

BACKGROUND: In varied educational settings, narrative evaluations have revealed systematic and deleterious differences in language describing women and those underrepresented in their fields. In medicine, limited qualitative studies show differences in narrative language by gender and under-represented minority (URM) status. OBJECTIVE: To identify and enumerate text descriptors in a database of medical student evaluations using natural language processing, and identify differences by gender and URM status in descriptions. DESIGN: An observational study of core clerkship evaluations of third-year medical students, including data on student gender, URM status, clerkship grade, and specialty. PARTICIPANTS: A total of 87,922 clerkship evaluations from core clinical rotations at two medical schools in different geographic areas. MAIN MEASURES: We employed natural language processing to identify differences in the text of evaluations for women compared to men and for URM compared to non-URM students. KEY RESULTS: We found that of the ten most common words, such as "energetic" and "dependable," none differed by gender or URM status. Of the 37 words that differed by gender, 62% represented personal attributes, such as "lovely" appearing more frequently in evaluations of women (p < 0.001), while 19% represented competency-related behaviors, such as "scientific" appearing more frequently in evaluations of men (p < 0.001). Of the 53 words that differed by URM status, 30% represented personal attributes, such as "pleasant" appearing more frequently in evaluations of URM students (p < 0.001), and 28% represented competency-related behaviors, such as "knowledgeable" appearing more frequently in evaluations of non-URM students (p < 0.001). CONCLUSIONS: Many words and phrases reflected students' personal attributes rather than competency-related behaviors, suggesting a gap in implementing competency-based evaluation of students. We observed a significant difference in narrative evaluations associated with gender and URM status, even among students receiving the same grade. This finding raises concern for implicit bias in narrative evaluation, consistent with prior studies, and suggests opportunities for improvement.

Predictive value of the present-on-admission indicator for hospital-acquired venous thromboembolism.

BACKGROUND: Hospital-acquired venous thromboembolic (HA-VTE) events are an important, preventable cause of morbidity and death, but accurately identifying HA-VTE events requires labor-intensive chart review. Administrative diagnosis codes and their associated "present-on-admission" (POA) indicator might allow automated identification of HA-VTE events, but only if VTE codes are accurately flagged "not present-on-admission" (POA=N). New codes were introduced in 2009 to improve accuracy. METHODS: We identified all medical patients with at least 1 VTE "other" discharge diagnosis code from 5 academic medical centers over a 24-month period. We then sampled, within each center, patients with VTE codes flagged POA=N or POA=U (insufficient documentation) and POA=Y or POA=W (timing clinically uncertain) and abstracted each chart to clarify VTE timing. All events that were not clearly POA were classified as HA-VTE. We then calculated predictive values of the POA=N/U flags for HA-VTE and the POA=Y/W flags for non-HA-VTE. RESULTS: Among 2070 cases with at least 1 "other" VTE code, we found 339 codes flagged POA=N/U and 1941 flagged POA=Y/W. Among 275 POA=N/U abstracted codes, 75.6% (95% CI, 70.1%-80.6%) were HA-VTE; among 291 POA=Y/W abstracted events, 73.5% (95% CI, 68.0%-78.5%) were non-HA-VTE. Extrapolating from this sample, we estimated that 59% of actual HA-VTE codes were incorrectly flagged POA=Y/W. POA indicator predictive values did not improve after new codes were introduced in 2009. CONCLUSIONS: The predictive value of VTE events flagged POA=N/U for HA-VTE was 75%. However, sole reliance on this flag may substantially underestimate the incidence of HA-VTE.

Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model.

BACKGROUND: Only half of hypertensive adults achieve blood pressure (BP) control in the United States, and it is unclear how BP control rates may be improved most effectively and efficiently at the population level. OBJECTIVE: We sought to compare the potential effects of system-wide isolated improvements in medication adherence, visit frequency, and higher physician prescription rate on achieving BP control at 52 weeks. DESIGN: We developed a Markov microsimulation model of patient-level, physician-level, and system-level processes involved in controlling hypertension with medications. The model is informed by data from national surveys, cohort studies and trials, and was validated against two multicenter clinical trials (ALLHAT and VALUE). SUBJECTS: We studied a simulated, nationally representative cohort of patients with diagnosed but uncontrolled hypertension with a usual source of care. INTERVENTIONS: We simulated a base case and improvements of 10 and 50%, and an ideal scenario for three modifiable parameters: visit frequency, treatment intensification, and medication adherence. Ideal scenarios were defined as 100% for treatment intensification and adherence, and return visits occurring within 4 weeks of an elevated office systolic BP. MAIN OUTCOME: BP control at 52 weeks of follow-up was examined. RESULTS: Among 25,000 hypothetical adult patients with uncontrolled hypertension (systolic BP ≥ 140 mmHg), only 18% achieved BP control after 52 weeks using base-case assumptions. With 10/50%/idealized enhancements in each isolated parameter, enhanced treatment intensification achieved the greatest BP control (19/23/71%), compared with enhanced visit frequency (19/21/35%) and medication adherence (19/23/26%). When all three processes were idealized, the model predicted a BP control rate of 95% at 52 weeks. CONCLUSION: Substantial improvements in BP control can only be achieved through major improvements in processes of care. Healthcare systems may achieve greater success by increasing the frequency of clinical encounters and improving physicians' prescribing behavior than by attempting to improve patient adherence to medications.

Physician underutilization of effective medications for resistant hypertension at office visits in the United States: NAMCS 2006-2010.

BACKGROUND: The American Heart Association (AHA) published guidelines for treatment of resistant hypertension in 2008 recommending use of thiazide diuretics (particularly chlorthalidone), aldosterone antagonists, and fixed-dose combination medications, but it is unclear the extent to which these guidelines are being followed. OBJECTIVE: To describe trends in physician use of recommended medications for resistant hypertension and assess variations in medication use based on geography, physician specialty and patient characteristics. DESIGN: Cross-sectional analysis using the National Ambulatory Medical Care Survey from 2006 to 2010. STUDY SAMPLE: We analyzed visits of hypertension patients to family physicians, general internists, and cardiologists. Resistant hypertension was defined as concurrent use of ≥ 4 classes of blood pressure (BP) medications or elevated BP despite the use of ≥ 3 medications. Pregnant patients and visits with diagnosed heart failure or end-stage renal disease were excluded. MAIN OUTCOME: Use of AHA-recommended medications for management of resistant hypertension. RESULTS: Of 19,500 patient visits with hypertension, 1,567 or 7.1 % CI (6.6-7.7 %) met criteria for resistant hypertension. Thiazide diuretic use was reported in 58.9 % of visits pre-guidelines vs. 54.8 % post-guidelines (p = 0.37). Use of aldosterone antagonists was low and also did not change significantly after guideline publication (3.1 % vs. 4.5 %, p = 0.27). Fixed-dose combinations use was 42.0 % before and 37 % after guideline publication (p = 0.29). Each 10-year increase in patient age was associated with lower thiazide use (OR 0.87, CI 0.77-0.97), as was presence of comorbid ischemic heart disease (OR 0.62, CI 0.41-0.94). Medication use did not vary by geography or physician specialty. CONCLUSION: Use of AHA-recommended medications for resistant hypertension remains low after publication of guidelines. Healthcare systems should encourage more frequent prescribing of these medications to improve care in this high-risk population.

Improvements to emergency department length of stay and user satisfaction after implementation of an integrated consult order.

Objective: Subspecialty consultation in the emergency department (ED) is a vital, albeit time consuming, part of modern medicine. Traditional consultation requires manual paging to initiate communication. Although consult orders through the electronic health record (EHR) may help, they do not facilitate 2-way communication. However, the impact of combining these systems within the EHR is unknown. We estimated the effect of implementing an integrated paging system on ED workflow efficiency and user attitudes. Methods: We integrated a messaging system into order entry at our tertiary care academic ED, such that placing a consult order simultaneously paged the consultant. We measured ED workflow efficiency metrics (length of stay [LOS], consult initiation time) and MD/nurse practitioner (NP)/physician assistant (PA) attitudes (perceived mis-pages, efficiency, and workflow preference) 3 months before and 6 months after the implementation. Results: Six months after implementation, there was 25% use of the new workflow. During the pre-implementation phase, the median time to consult initiation and ED LOS were 150 and 621 minutes, respectively. Implementation of the order was associated with a 15-minute reduction in median time to consult initiation (P < 0.001), and a 52-minute reduction in median ED LOS (P < 0.001). ED MDs/NPs/PAs perceived a reduction in the rate of mis-pages, improved efficiency, and overall preferred the new workflow. Conclusions: We consolidated steps in the ED consult workflow using an integrated consult order, which improved user satisfaction, and reduced consult initiation time and ED LOS for patients requiring a consult at an urban tertiary care ED.

Governance of Electronic Health Record Modification at U.S. Academic Medical Centers.

OBJECTIVES: A key aspect of electronic health record (EHR) governance involves the approach to EHR modification. We report a descriptive study to characterize EHR governance at academic medical centers (AMCs) across the United States. METHODS: We conducted interviews with the Chief Medical Information Officers of 18 AMCs about the process of EHR modification for standard requests. Recordings of the interviews were analyzed to identify categories within prespecified domains. Responses were then assigned to categories for each domain. RESULTS: At our AMCs, EHR requests were governed variably, with a similar number of sites using quantitative scoring systems (7, 38.9%), qualitative systems (5, 27.8%), or no scoring system (6, 33.3%). Two (11%) organizations formally review all requests for their impact on health equity. Although 14 (78%) organizations have trained physician builders/architects, their primary role was not for EHR build. Most commonly reported governance challenges included request volume (11, 61%), integrating diverse clinician input (3, 17%), and stakeholder buy-in (3, 17%). The slowest step in the process was clarifying end user requests (14, 78%). Few leaders had identified metrics for the success of EHR governance. CONCLUSION: Governance approaches for managing EHR modification at AMCs are highly variable, which suggests ongoing efforts to balance EHR standardization and maintenance burden, while dealing with a high volume of requests. Developing metrics to capture the performance of governance and quantify problems may be a key step in identifying best practices.

Impact of standardized, language-concordant hospital discharge instructions on postdischarge medication questions.

Written instructions improve patient comprehension of discharge instructions but are often provided only in English even for patients with a non-English language preference (NELP). We implemented standardized written discharge instructions in English, Spanish, and Chinese for hospital medicine patients at an urban academic medical center. Using an interrupted time series analysis, we assessed the impact on medication-related postdischarge questions for patients with English, Spanish, or Chinese language preferences. Of 4013 patients, ∼15% had NELP. Preintervention, Chinese-preferring patients had a 5.6 percentage point higher probability of questions (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI]: 1.08, 2.21) compared to English-preferring patients; Spanish-preferring and English-preferring patients had similar rates of questions. Postintervention, English-preferring and Spanish-preferring patients had no significant change; Chinese-preferring patients had a significant 10.9 percentage point decrease in the probability of questions (aOR = 0.38, 95% CI: 0.21, 0.69) thereby closing the disparity. Language-concordant written discharge instructions may reduce disparities in medication-related postdischarge questions for patients with NELP.

Behavioral "nudges" in the electronic health record to reduce waste and misuse: 3 interventions.

Electronic health records (EHRs) offer decision support in the form of alerts, which are often though not always interruptive. These alerts, though sometimes effective, can come at the cost of high cognitive burden and workflow disruption. Less well studied is the design of the EHR itself-the ordering provider's "choice architecture"-which "nudges" users toward alternatives, sometimes unintentionally toward waste and misuse, but ideally intentionally toward better practice. We studied 3 different workflows at our institution where the existing choice architecture was potentially nudging providers toward erroneous decisions, waste, and misuse in the form of inappropriate laboratory work, incorrectly specified computerized tomographic imaging, and excessive benzodiazepine dosing for imaging-related sedation. We changed the architecture to nudge providers toward better practice and found that the 3 nudges were successful to varying degrees in reducing erroneous decision-making and mitigating waste and misuse.

A Systematic Approach to the Design and Implementation of Clinical Informatics Fellowship Programs.

Clinical Informatics (CI), a medical subspecialty since 2011, has grown from the initial four fellowship programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) in 2014 to more than 50 and counting in the present day. In parallel, the literature guiding Clinical Informatics Fellowship training and the curriculum evolved from the original core content published in 2009 to the more recent CI Subspecialty Delineation of Practice and the updated ACGME Milestones 2.0 for CI. In this paper, we outline this evolution and its impact on CIF Curricula. We then propose a framework, specific processes, and tools to standardize the design and optimize the implementation of CIF programs.

Unintended consequences of a standard admission order set on venous thromboembolism prophylaxis and patient outcomes.

BACKGROUND: Standard order sets often increase the use of desirable interventions for patients likely to benefit from them. Whether such order sets also increase misuse of these interventions in patients potentially harmed by them is unknown. We measured the association between a paper-based standard admission order set with a venous thromboembolism pharmacoprophylaxis (VTEP) module and use of VTEP for patients likely to benefit from it as well as patients with unclear benefit or potential harm from it. METHODS: We conducted a retrospective cohort study using administrative and pharmacy charge data of patients admitted between 1 July 2005 and 31 December 2008 to two medical and three surgical services that implemented a standard admission order set in August 2006. The primary outcome was use of VTEP in patients with likely benefit, unclear benefit, and potential harm from VTEP prior to and following order set implementation. KEY RESULTS: A total of 8,429 patients (32%) were admitted prior to and 17,635 (68%) following order set implementation. There was a small unadjusted rise in overall VTEP use after implementation (51% to 58%, p < 0.001). In multivariable models with interrupted time series analysis, patients with potential harm from VTEP had the largest increase in VTEP use at the time of implementation [adjusted odds ratio = 1.58; 95% confidence interval (CI), 1.12-2.22]. The increased likelihood of receiving VTEP in this subgroup gradually returned to baseline (adjusted odds ratio per month = 0.98; 95% CI, 0.96-0.99). CONCLUSIONS: Implementation of a standard admission order set transiently increased VTEP in patients with potential harm from it. Order set and guideline success should be judged based on the degree to which they successfully target patients likely to benefit from the intervention without inadvertently targeting patients potentially harmed.

Using Technology to Enhance Communication.

Digital communication, facilitated by the rise of the electronic health record and telehealth, has transformed clinical workflow. The communication tools, and the purposes they are being used for, need to account for the benefits, risks, and fault tolerance for each tool. In this article, the authors offer several suggestions on how to approach these important issues. These new digital communication tools open the door to novel care models for connecting patients and providers. Most importantly, the way a message is delivered, not the medium through which it is transmitted, is the key to successful communication.

Protecting reproductive health information in the post-Roe era: interoperability strategies for healthcare institutions.

On June 24, 2022, the US Supreme Court ended constitutional protections for abortion, resulting in wide variability in access from severe restrictions in many states and fewer restrictions in others. Healthcare institutions capture information about patients' pregnancy and abortion care and, due to interoperability, may share it in ways that expose their providers and patients to social stigma and potential legal jeopardy in states with severe restrictions. In this article, we describe sources of risk to patients and providers that arise from interoperability and specify actions that institutions can take to reduce that risk. Institutions have significant power to define their practices for how and where care is documented, how patients are identified, where data are sent or hosted, and how patients are counseled, and thus should protect patients' privacy and ability to receive medical care that is safe and legal where it is performed.

The Launch of the iCoDE Standard Project.

INTRODUCTION: The first meeting of the Integration of Continuous Glucose Monitor Data into the Electronic Health Record (iCoDE) project, organized by Diabetes Technology Society, took place virtually on January 27, 2022. METHODS: Clinicians, government officials, data aggregators, attorneys, and standards experts spoke in panels and breakout groups. Three themes were covered: 1) why digital health data integration into the electronic health record (EHR) is needed, 2) what integrated continuously monitored glucose data will look like, and 3) how this process can be achieved in a way that will satisfy clinicians, healthcare organizations, and regulatory experts. RESULTS: The meeting themes were addressed within eight sessions: 1) What Do Inpatient Clinicians Want to See With Integration of CGM Data into the EHR?, 2) What Do Outpatient Clinicians Want to See With Integration of CGM Data into the EHR?, 3) Why Are Data Standards and Guidances Useful?, 4) What Value Can Data Integration Services Add?, 5) What Are Examples of Successful Integration?, 6) Which Privacy, Security, and Regulatory Issues Must Be Addressed to Integrate CGM Data into the EHR?, 7) Breakout Group Discussions, and 8) Presentation of Breakout Group Ideas. CONCLUSIONS: Creation of data standards and workflow guidance are necessary components of the Integration of Continuous Glucose Monitor Data into the Electronic Health Record (iCoDE) standard project. This meeting, which launched iCoDE, will be followed by a set of working group meetings intended to create the needed standard.

Designing and Implementing a Novel Virtual Rounds Curriculum for Medical Students' Internal Medicine Clerkship During the COVID-19 Pandemic.

Introduction: During the COVID-19 pandemic, third-year medical students were temporarily unable to participate in onsite clinical activities. We identified the curricular components of an internal medicine (IM) clerkship that would be compromised if students learned solely from online didactics, case studies, and simulations (i.e., prerounding, oral presentations, diagnostic reasoning, and medical management discussions). Using these guiding principles, we created a virtual rounds (VR) curriculum to provide IM clerkship students with clinical exposure during a virtual learning period. Methods: Held three times a week for 2 weeks, VR consisted of three curricular components. First, clerkship students prerounded on an assigned hospitalized patient by remotely accessing the electronic health record and calling into hospital rounds. Second, each student prepared an oral presentation on their assigned patient. Third, using videoconferencing, students delivered these oral presentations to telemedicine VR small groups consisting of three to four students and three tele-instructors. Tele-instructors then provided feedback on oral presentations and taught clinical concepts. We assessed the effectiveness of VR by anonymously surveying students and tele-instructors. Results: Twenty-nine students and 34 volunteer tele-instructors participated in VR over four blocks. A majority of students felt VR improved their prerounding abilities (86%), oral presentation abilities (93%), and clinical reasoning skills (62%). All students found small group to be useful. Discussion: VR allowed students to practice rounding skills in a supportive team-based setting. The lessons learned from its implementation could facilitate education during future pandemics and could also supplement in-person clerkship education.