Beyond Getting Rid of Stupid Stuff in the Electronic Health Record (Beyond-GROSS): Protocol for a User-Centered, Mixed-Method Intervention to Improve the Electronic Health Record System.

BACKGROUND: Up to 60% of health care providers experience one or more symptoms of burnout. Perceived clinician burden resulting in burnout arises from factors such as electronic health record (EHR) usability or lack thereof, perceived loss of autonomy, and documentation burden leading to less clinical time with patients. Burnout can have detrimental effects on health care quality and contributes to increased medical errors, decreased patient satisfaction, substance use, workforce attrition, and suicide. OBJECTIVE: This project aims to improve the user-centered design of the EHR by obtaining direct input from clinicians about deficiencies. Fixing identified deficiencies via user-centered design has the potential to improve usability, thereby increasing satisfaction by reducing EHR-induced burnout. METHODS: Quantitative and qualitative data will be obtained from clinician EHR users. The input will be received through a form built in a REDCap database via a link embedded in the home page of the EHR. The REDCap data will be analyzed in 2 main dimensions, based on nature of the input, what section of the EHR is affected, and what is required to fix the issue(s). Identified issues will be escalated to relevant stakeholders responsible for rectifying the problems identified. Data analysis, project evaluation, and lessons learned from the evaluation will be incorporated in a Plan-Do-Study-Act (PDSA) manner every 4-6 weeks. RESULTS: The pilot phase of the study began in October 2020 in the Gastroenterology Division at Mount Sinai Hospital, New York City, NY, which includes 39 physicians and 15 nurses. The pilot is expected to run over a 4-6-month period. The results of the REDCap data analysis will be reported within 1 month of completing the pilot phase. We will analyze the nature of requests received and the impact of rectified issues on the clinician EHR user. We expect that the results will reveal which sections of the EHR have the highest deficiencies while also highlighting issues about workflow difficulties. Perceived impact of the project on provider engagement, patient safety, and workflow efficiency will also be captured by evaluation survey and other qualitative methods where possible. CONCLUSIONS: The project aims to improve user-centered design of the EHR by soliciting direct input from clinician EHR users. The ultimate goal is to improve efficiency, reduce EHR inefficiencies with the possibility of improving staff engagement, and lessen EHR-induced clinician burnout. Our project implementation includes using informatics expertise to achieve the desired state of a learning health system as recommended by the National Academy of Medicine as we facilitate feedback loops and rapid cycles of improvement. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25148.

Improving transitions of care for patients on warfarin: The safe transitions anticoagulation report.

Adverse drug events are common during the transition period after hospitalization, and anticoagulants are among the medication classes for which the incidence is highest. We aimed to develop a concise report to improve the timeliness of international normalized ratio (INR) testing and quality of warfarin management posthospitalization. We developed the Safe Transitions Anticoagulation Report (STAR), which contains essential information on anticoagulation and is embedded in the discharge summary, and implemented the report and associated workflow in a tertiary care hospital within an integrated healthcare system. We performed a retrospective administrative database review of 505 patients in the preintervention period and 292 patients in the intervention period who were discharged on warfarin and were established patients at an affiliated ambulatory practice. There was no change in the frequency of obtaining an INR value within 10 days of discharge (41.4% and 47.6%, respectively, P = 0.09), and no increase in attaining a therapeutic INR level within 10 days of discharge (17.0% and 21.2%, respectively, P = 0.14). Ambulatory clinicians reported that the STAR improved "workflow and efficiency" (58%) and "patient safety" (77%), and led to an altered warfarin dose for 34% of survey respondents. Our study found that a concise anticoagulation report embedded in the discharge summary was perceived by ambulatory physicians as improving patient safety, but had no impact on clinical outcomes, suggesting that this electronic medical record tool would need to be a component of a broader multifaceted intervention to be effective.

Afferent-induced changes in rhythmic motor programs in the feeding circuitry of aplysia.

A manipulation often used to determine whether a neuron plays a role in the generation of a motor program involves injecting current into the cell during rhythmic activity to determine whether activity is modified. We perform this type of manipulation to study the impact of afferent activity on feeding-like motor programs in Aplysia. We trigger biting-like programs and manipulate sensory neurons that have been implicated in producing the changes in activity that occur when food is ingested, i.e., when bites are converted to bite-swallows. Sensory neurons that are manipulated are the radula mechanoafferent B21 and the retraction proprioceptor B51. Data suggest that both cells are peripherally activated during radula closing/retraction when food is ingested. We found that phasic subthreshold depolarization of a single sensory neuron can significantly prolong radula closing/retraction, as determined by recording both from interneurons (e.g., B64), and motor neurons (e.g., B15 and B8). Additionally, afferent activity produces a delay in the onset of the subsequent radula opening/protraction, and increases the firing frequency of motor neurons. These are the changes in activity that are seen when food is ingested. These results add to the growing data that implicate B21 and B51 in bite to bite-swallow conversions and indicate that afferent activity is important during feeding in Aplysia.