Implementation of a Real-Time Documentation Assistance Tool: Automated Diagnosis (AutoDx).

BACKGROUND: Clinical documentation improvement programs are utilized by most health care systems to enhance provider documentation. Suggestions are sent to providers in a variety of ways, and are commonly referred to as coding queries. Responding to these coding queries can require significant provider time and do not often align with workflows. To enhance provider documentation in a more consistent manner without creating undue burden, alternative strategies are required. OBJECTIVES: The aim of this study is to evaluate the impact of a real-time documentation assistance tool, named AutoDx, on the volume of coding queries and encounter-level outcome metrics, including case-mix index (CMI). METHODS: The AutoDx tool was developed utilizing tools existing within the electronic health record, and is based on the generation of messages when clinical conditions are met. These messages appear within provider notes and required little to no interaction. Initial diagnoses included in the tool were electrolyte deficiencies, obesity, and malnutrition. The tool was piloted in a cohort of Hospital Medicine providers, then expanded to the Neuro Intensive Care Unit (NICU), with addition diagnoses being added. RESULTS: The initial Hospital Medicine implementation evaluation included 590 encounters pre- and 531 post-implementation. The volume of coding queries decreased 57% (p < 0.0001) for the targeted diagnoses compared with 6% (p = 0.77) in other high-volume diagnoses. In the NICU cohort, 829 encounters pre-implementation were compared with 680 post. The proportion of AutoDx coding queries compared with all other coding queries decreased from 54.9 to 37.1% (p < 0.0001). During the same period, CMI demonstrated a significant increase post-implementation (4.00 vs. 4.55, p = 0.02). CONCLUSION: The real-time documentation assistance tool led to a significant decrease in coding queries for targeted diagnoses in two unique provider cohorts. This improvement was also associated with a significant increase in CMI during the implementation time period.

Use of clinical pathways integrated into the electronic health record to address the coronavirus disease 2019 (COVID-19) pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has required healthcare systems to meet new demands for rapid information dissemination, resource allocation, and data reporting. To help address these challenges, our institution leveraged electronic health record (EHR)-integrated clinical pathways (E-ICPs), which are easily understood care algorithms accessible at the point of care. OBJECTIVE: To describe our institution's creation of E-ICPs to address the COVID-19 pandemic, and to assess the use and impact of these tools. SETTING: Urban academic medical center with adult and pediatric hospitals, emergency departments, and ambulatory practices. METHODS: Using the E-ICP processes and infrastructure established at our institution as a foundation, we developed a suite of COVID-19-specific E-ICPs along with a process for frequent reassessment and updating. We examined the development and use of our COVID-19-specific pathways for a 6-month period (March 1-September 1, 2020), and we have described their impact using case studies. RESULTS: In total, 45 COVID-19-specific pathways were developed, pertaining to triage, diagnosis, and management of COVID-19 in diverse patient settings. Orders available in E-ICPs included those for isolation precautions, testing, treatments, admissions, and transfers. Pathways were accessed 86,400 times, with 99,081 individual orders were placed. Case studies demonstrate the impact of COVID-19 E-ICPs on stewardship of resources, testing optimization, and data reporting. CONCLUSIONS: E-ICPs provide a flexible and unified mechanism to meet the evolving demands of the COVID-19 pandemic, and they continue to be a critical tool leveraged by clinicians and hospital administrators alike for the management of COVID-19. Lessons learned may be generalizable to other urgent and nonurgent clinical conditions.

Reducing Inpatient Hypoglycemic Events: A Focus on Mealtime Insulin.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an effort to reduce iatrogenic insulin-associated hypoglycemia at the University of Chicago Medical Center in Chicago, IL.

Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients: An NATF Anticoagulation Action Initiative.

Hospitalized patients with acute medical illnesses are at risk for venous thromboembolism (VTE) during and after a hospital stay. Risk factors include physical immobilization and underlying pathophysiologic processes that activate the coagulation pathway and are still present after discharge. Strategies for optimal pharmacologic VTE thromboprophylaxis are evolving, and recommendations for VTE prophylaxis can be further refined to protect high-risk patients after hospital discharge. An early study of extended VTE prophylaxis with a parenteral agent in medically ill patients yielded inconclusive results with regard to efficacy and bleeding. In the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial, extended use of betrixaban halved symptomatic VTE, decreased hospital readmission, and reduced stroke and major adverse cardiovascular events compared with standard enoxaparin prophylaxis. Based on findings from APEX, the Food and Drug Administration approved betrixaban in 2017 for extended VTE prophylaxis in acute medically ill patients. In the Reducing Post-Discharge Venous Thrombo-Embolism Risk (MARINER) study, extended use of rivaroxaban halved symptomatic VTE in high-risk medical patients compared with placebo. In 2019, rivaroxaban was approved for extended thromboprophylaxis in high-risk medical patients, thus making available a new strategy for in-hospital and post-discharge VTE prevention. To address the critical unmet need for VTE prophylaxis in medically ill patients at the time of hospital discharge, the North American Thrombosis Forum (NATF) is launching the Anticoagulation Action Initiative, a comprehensive consensus document that provides practical guidance and straightforward, patient-centered recommendations for VTE prevention during hospitalization and after discharge.

Consumer Mobile Health Apps: Current State, Barriers, and Future Directions.

This paper discusses the current state, barriers, and future directions of consumer-facing applications (apps). There are currently more than 165,000 mobile health apps publicly available in major app stores, the vast majority of which are designed for patients. The top 2 categories are wellness management and disease management apps, whereas other categories include self-diagnosis, medication reminder, and electronic patient portal apps. Apps specific to physical medicine and rehabilitation also are reviewed. These apps have the potential to provide low-cost, around-the-clock access to high-quality, evidence-based health information to end users on a global scale. However, they have not yet lived up to their potential due to multiple barriers, including lack of regulatory oversight, limited evidence-based literature, and concerns of privacy and security. The future directions may consist of improving data integration into the health care system, an interoperable app platform allowing access to electronic health record data, cloud-based personal health record across health care networks, and increasing app prescription by health care providers. For consumer mobile health apps to fully contribute value to health care delivery and chronic disease management, all stakeholders within the ecosystem must collaborate to overcome the significant barriers.

Neurologic complication after a roller coaster ride.

Neurologic complications after roller coaster rides are uncommon but potentially catastrophic. Physicians should have a high index of suspicion and prompt appropriate investigation. A 22-year-old healthy African American man presented with a 2-day history of constant occipital headache associated with vertigo, nausea, vomiting, and ambulatory dysfunction. Physical examination showed gait ataxia, slight dysmetria, and vertical nystagmus. Magnetic resonance imaging (MRI) of the brain showed early subacute ischemic infarct in the right cerebellum in the distribution of the right posterior inferior cerebellar artery. Magnetic resonance angiography of the neck showed focal dissection of the right vertebral artery at C1 through C2 level. On subsequent questioning, the patient recollected riding a roller coaster 2 weeks before the onset of symptoms. Anticoagulation with heparin was started, and the patient was bridged to oral warfarin. After a 5-day uneventful hospital course, symptoms improved and patient was discharged on oral anticoagulation. Cervicocephalic arterial dissections after roller coaster rides are rarely described in literature. The acceleration and abrupt changes of direction might lead to indirect trauma that is applied to mobile portions of the cervicocephalic arteries leading to intimal tears. Magnetic resonance angiography combined with axial T1-weighted cervical MRI is preferred because it is a high-sensitive, noninvasive test. The rationale for the use of anticoagulants or antiplatelets in patients with cervicocephalic arterial dissection is to prevent early recurrence and infarction. However, a meta-analysis failed to show significant difference in the rates of disability or death between both groups. Therefore, the decision for medical treatment should be made in a case-by-case basis.

The association between transforming growth factor-beta gene promoter C-509T polymorphism and Chinese children with Henoch-Schönlein purpura.

Many cytokines, including transforming growth factor-beta (TGF-beta) and tumor necrosis factor-alpha (TNF-alpha), are involved in the inflammatory process of Henoch-Schönlein purpura (HSP). The objective of this study was to investigate whether TGF-beta C-509T and TNF-alpha G-308A polymorphisms are associated with childhood HSP. The loci of interest were amplified from genomic DNA using specific primers and polymerase chain reaction, and these two polymorphisms were compared between Chinese children with HSP and healthy controls. The disease severities evaluated and expressed as symptom score of patients with different genotypes were also compared. The TGF-beta -509 TT genotype was more common in children with HSP than controls (31% vs. 8%, P =0.03, odds ratio=4.95). The allelic frequencies of TGF-beta -509, genotypic and allelic frequencies of TNF-alpha -308 were not significantly different. Patients with the TT genotype had more severe clinical presentations than non-TT (TC+CC) patients (4.1+/-0.42 vs. 2.7+/-0.31, P =0.018). These results suggest that the TT genotype of the C-509T polymorphism of the TGF-beta gene might be related to the susceptibility of Chinese children to HSP and to the severity of this disease.