AI-Generated Draft Replies Integrated Into Health Records and Physicians' Electronic Communication.

Importance: Timely tests are warranted to assess the association between generative artificial intelligence (GenAI) use and physicians' work efforts. Objective: To investigate the association between GenAI-drafted replies for patient messages and physician time spent on answering messages and the length of replies. Design, Setting, and Participants: Randomized waiting list quality improvement (QI) study from June to August 2023 in an academic health system. Primary care physicians were randomized to an immediate activation group and a delayed activation group. Data were analyzed from August to November 2023. Exposure: Access to GenAI-drafted replies for patient messages. Main Outcomes and Measures: Time spent (1) reading messages, (2) replying to messages, (3) length of replies, and (4) physician likelihood to recommend GenAI drafts. The a priori hypothesis was that GenAI drafts would be associated with less physician time spent reading and replying to messages. A mixed-effects model was used. Results: Fifty-two physicians participated in this QI study, with 25 randomized to the immediate activation group and 27 randomized to the delayed activation group. A contemporary control group included 70 physicians. There were 18 female participants (72.0%) in the immediate group and 17 female participants (63.0%) in the delayed group; the median age range was 35-44 years in the immediate group and 45-54 years in the delayed group. The median (IQR) time spent reading messages in the immediate group was 26 (11-69) seconds at baseline, 31 (15-70) seconds 3 weeks after entry to the intervention, and 31 (14-70) seconds 6 weeks after entry. The delayed group's median (IQR) read time was 25 (10-67) seconds at baseline, 29 (11-77) seconds during the 3-week waiting period, and 32 (15-72) seconds 3 weeks after entry to the intervention. The contemporary control group's median (IQR) read times were 21 (9-54), 22 (9-63), and 23 (9-60) seconds in corresponding periods. The estimated association of GenAI was a 21.8% increase in read time (95% CI, 5.2% to 41.0%; P = .008), a -5.9% change in reply time (95% CI, -16.6% to 6.2%; P = .33), and a 17.9% increase in reply length (95% CI, 10.1% to 26.2%; P < .001). Participants recognized GenAI's value and suggested areas for improvement. Conclusions and Relevance: In this QI study, GenAI-drafted replies were associated with significantly increased read time, no change in reply time, significantly increased reply length, and some perceived benefits. Rigorous empirical tests are necessary to further examine GenAI's performance. Future studies should examine patient experience and compare multiple GenAIs, including those with medical training.

Association of physician burnout with perceived EHR work stress and potentially actionable factors.

OBJECTIVE: Physicians of all specialties experienced unprecedented stressors during the COVID-19 pandemic, exacerbating preexisting burnout. We examine burnout's association with perceived and actionable electronic health record (EHR) workload factors and personal, professional, and organizational characteristics with the goal of identifying levers that can be targeted to address burnout. MATERIALS AND METHODS: Survey of physicians of all specialties in an academic health center, using a standard measure of burnout, self-reported EHR work stress, and EHR-based work assessed by the number of messages regarding prescription reauthorization and use of a staff pool to triage messages. Descriptive and multivariable regression analyses examined the relationship among burnout, perceived EHR work stress, and actionable EHR work factors. RESULTS: Of 1038 eligible physicians, 627 responded (60% response rate), 49.8% reported burnout symptoms. Logistic regression analysis suggests that higher odds of burnout are associated with physicians feeling higher level of EHR stress (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07-1.25), having more prescription reauthorization messages (OR, 1.23; 95% CI, 1.04-1.47), not feeling valued (OR, 3.38; 95% CI, 1.69-7.22) or aligned in values with clinic leaders (OR, 2.81; 95% CI, 1.87-4.27), in medical practice for ≤15 years (OR, 2.57; 95% CI, 1.63-4.12), and sleeping for <6 h/night (OR, 1.73; 95% CI, 1.12-2.67). DISCUSSION: Perceived EHR stress and prescription reauthorization messages are significantly associated with burnout, as are non-EHR factors such as not feeling valued or aligned in values with clinic leaders. Younger physicians need more support. CONCLUSION: A multipronged approach targeting actionable levers and supporting young physicians is needed to implement sustainable improvements in physician well-being.

Improving the design of California's prescription drug monitoring program.

OBJECTIVE: The US CDC identified prescription drug monitoring programs (PDMPs) as a tool to address the contemporary opioid crisis, but few studies have investigated PDMP usability and effectiveness from the users' perspective. Even fewer have considered how practices differ across medical domains. In this study, we aimed to address these gaps, soliciting perspectives on PDMPs from providers contending with the opioid crisis: physicians working in emergency departments (EDs) and pain management clinics. We aimed to provide practical design recommendations to improve PDMP workflow integration, as well as controlled substance history retrieval, interpretation, and decision support. METHODS: We conducted 16 in-depth semi-structured interviews with practicing emergency and pain physicians regarding their procedures, problems, and proposed solutions surrounding their use of CURES, California's PDMP. We investigated design problems in CURES by combining users' feedback with our usability inspection, drawing upon an extensive body of design literature. Then, we generated alternatives using design methods. RESULTS: We found CURES's design did not accommodate the unique information needs of different medical domains. Further, clinicians had trouble accessing CURES and retrieving patients' controlled substance histories, mainly due to usability problems that could be addressed with little technical adjustment. Additionally, CURES rendered patient histories in large, cluttered tables, devoid of overview or context, making interpretation difficult and precarious. Lastly, our interviewees had rarely noticed or used advanced features, such as decision support. DISCUSSION AND CONCLUSION: Usability barriers inhibited adoption and effective use. We provide practical recommendations for improving opioid control by way of improving PDMP design, based on interviewees' suggestions and research-based design principles. Our findings have implications for other disciplines, including surgery and primary care.

Implementing an overdose education and naloxone distribution program in a health system.

OBJECTIVE: To design and implement a health system-wide program increasing provision of take-home naloxone in patients at risk for opioid overdose, with the downstream aim of reducing fatalities. The program includes health care professional education and guidelines, development, and dissemination of patient education materials, electronic health record changes to promote naloxone prescriptions, and availability of naloxone in pharmacies. SETTING: Academic health system, San Diego, California. PRACTICE DESCRIPTION: University of California, San Diego Health (UCSDH), offers both inpatient and outpatient primary care and specialty services with 563 beds spanning 2 hospitals and 6 pharmacies. UCSDH is part of the University of California health system, and it serves as the county's safety net hospital. PRACTICE INNOVATION: In January 2016, a multisite academic health system initiated a system-wide overdose education and naloxone distribution program to prevent opioid overdose and opioid overdose-related deaths. An interdisciplinary, interdepartmental team came together to develop and implement the program. To strengthen institutional support, naloxone prescribing guidelines were developed and approved for the health system. Education on naloxone for physicians, pharmacists, and nurses was provided through departmental trainings, bulletins, and e-mail notifications. Alerts in the electronic health record and preset naloxone orders facilitated co-prescribing of naloxone with opioid prescriptions. EVALUATION: Electronic health record reports captured naloxone prescriptions ordered. Summary reports on the electronic health record measured naloxone reminder alerts and response rates. RESULTS: Since the start of the program, the health system has trained 252 physicians, pharmacists, and nurses in overdose education and take-home naloxone. There has been an increase in the number of prescriptions for naloxone from a baseline of 4.5 per month to an average of 46 per month during the 3 months following full implementation of the program including implementation of electronic health record alerts. CONCLUSION: Initiating and implementing an overdose education and naloxone distribution program is feasible in an academic health system.

rTMS in Alleviating Mild TBI Related Headaches--A Case Series.

BACKGROUND: Headache is one of the most common debilitating chronic pain conditions in patients with mild traumatic brain injury. Conventional pharmacological treatments have not been shown to be effective in alleviating debilitating mild traumatic brain injury related headaches (MTBI-HA). Therefore, the development of an innovative non-invasive therapy in managing MTBI-HA is needed in the field of pain management. Repetitive transcranial magnetic stimulation (rTMS) utilizes a basic electromagnetic coupling principle in which a rapid discharge of electrical current is converted into dynamic magnetic flux, allowing the induction of a localized current in the brain for neuromodulation. The treatment is currently FDA approved for treating depression in the United States. Recent meta-analysis studies have implicated its usage in chronic pain management. OBJECTIVE: The objective of the prospective case series is to assess the potential application of rTMS in alleviating MTBI-HA. STUDY DESIGN: A prospective evaluation was conducted in patients with established diagnoses of MTBI-HA and treated with neuronavigational guided rTMS. SETTING: The study was conducted at the Veteran Administration San Diego Healthcare System where over 400 patients with MTBI were being evaluated annually by the Rehabilitation Medicine Service. A fraction of this patient population was referred and evaluated in the Anesthesia Pain Clinic for the consideration of rTMS for their headaches. METHODS: A prospective case series was conducted with human subject protection committee approval. Patients with established diagnoses of MTBI and constant headaches rated at = 4 on a 0 - 10 Numerical Rating Pain Scale (NRPS), and on stable headache medication regimens were selected to receive the treatment. Four sessions of rTMS were delivered to specific areas of cortices over a 2-month period. Patients' average intensities of lingering constant headaches (defined as duration of headache lasting more than 48 hours), and the average frequency (number of severe headache episodes per day), intensity (NRPS), and duration (hours) of headache exacerbations were assessed before and after the rTMS treatment protocol. RESULTS: Six men (average age of 50) with MTBI-HA received the rTMS treatment protocol. Average pre and post-rTMS constant headache scores (± SD) on the NRPS were 5.50 (± 1.38) and 2.67 (± 1.75), respectively, with an average post-rTMS headache intensity reduction of 53.05% (± 19.90). The average headache exacerbation frequency (episodes per week) was reduced by 78.97% (±19.88) with 2 patients reporting complete cessation of severe headache episodes. For those (N = 4) with persistent headache exacerbations, the average duration and intensity of these exacerbations were reduced by 50.0% and 31.7%, respectively. LIMITATIONS: This prospective evaluation provides the initial insight that rTMS may be beneficial in alleviating a debilitating chronic pain condition in patients with MTBI-HA. More controlled randomized studies should be conducted to validate its efficacy. Other co-existing cognitive and mood dysfunction should be assessed as well. CONCLUSIONS: rTMS offers a non-invasive treatment option for MTBI-HA. The tested treatment protocol was well tolerated by the patients and can be adopted for future randomized controlled studies in further validating the treatment efficacy.

Integration of acupuncture into the oncology clinic.

PURPOSE/OBJECTIVE: Patients with cancer or symptoms referable to cancer therapy were offered acupuncture as potential palliation of their symptoms. This paper describes the physical integration of the discipline into the Oncology Clinic, and patient perspectives on its availability and efficacy. PATIENTS AND METHODS: Between August 1999 and May 2000, 123 patients with varying symptoms received acupuncture in our Center's Radiation and Medical Oncology Clinics and Breast Health Center. These patients had 823 visits during this time period. A practice outcome analysis was performed on patients receiving therapy between 1 January 2000 and 30 April 2000. The 89 patients treated during this interval had 444 total visits. In June and July 2000, a questionnaire was administered by phone to 79 of these patients (89%). Standard allopathic care continued while patients were receiving acupuncture. RESULTS: Major reasons for referral included pain (53%), xerostomia (32%), hot flashes (6%) and nausea/loss of appetite (6%). Patients had a mean of five acupuncture visits (range 1-9). Most patients (60%) showed at least 30% improvement in their symptoms. About one-third of patients had no change in severity of symptoms. There were no untoward effects reported related to the acupuncture. When analysed by diagnosis, these values persist. Irrespective of response to therapy, 86% of respondents considered it 'very important' that we continue to provide acupuncture services. CONCLUSION: Acupuncture may contribute to control of symptoms for cancer patients. Expansion of providers, continued patient follow-up, optimization of techniques and prospective objective measurement of response continue in our clinic.