Recycled melanoma-secreted melanosomes regulate tumor-associated macrophage diversification.

Extracellular vesicles (EVs) are important mediators of communication between cells. Here, we reveal a new mode of intercellular communication by melanosomes, large EVs secreted by melanocytes for melanin transport. Unlike small EVs, which are disintegrated within the receiver cell, melanosomes stay intact within them, gain a unique protein signature, and can then be further transferred to another cell as "second-hand" EVs. We show that melanoma-secreted melanosomes passaged through epidermal keratinocytes or dermal fibroblasts can be further engulfed by resident macrophages. This process leads to macrophage polarization into pro-tumor or pro-immune cell infiltration phenotypes. Melanosomes that are transferred through fibroblasts can carry AKT1, which induces VEGF secretion from macrophages in an mTOR-dependent manner, promoting angiogenesis and metastasis in vivo. In melanoma patients, macrophages that are co-localized with AKT1 are correlated with disease aggressiveness, and immunotherapy non-responders are enriched in macrophages containing melanosome markers. Our findings suggest that interactions mediated by second-hand extracellular vesicles contribute to the formation of the metastatic niche, and that blocking the melanosome cues of macrophage diversification could be helpful in halting melanoma progression.

Variable Impact of Medical Scribes on Physician Electronic Health Record Documentation Practices: A Quantitative Analysis Across a Large, Integrated Health-System.

BACKGROUND: Medical scribes have been utilized to reduce electronic health record (EHR) associated documentation burden. Although evidence suggests benefits to scribes, no large-scale studies have quantitatively evaluated scribe impact on physician documentation across clinical settings. This study aimed to evaluate the effect of scribes on physician EHR documentation behaviors and performance. METHODS: This retrospective cohort study used EHR audit log data from a large academic health system to evaluate clinical documentation for all ambulatory encounters between January 2014 and December 2019 to evaluate the effect of scribes on physician documentation behaviors. Scribe services were provided on a first-come, first-served basis on physician request. Based on a physician's scribe use, encounters were grouped into 3 categories: never using a scribe, prescribe (before scribe use), or using a scribe. Outcomes included chart closure time, the proportion of delinquent charts, and charts closed after-hours. RESULTS: Three hundred ninety-five physicians (23% scribe users) across 29 medical subspecialties, encompassing 1,132,487 encounters, were included in the analysis. At baseline, scribe users had higher chart closure time, delinquent charts, and after-hours documentation than physicians who never used scribes. Among scribe users, the difference in outcome measures postscribe compared with baseline varied, and using a scribe rarely resulted in outcome measures approaching a range similar to the performance levels of nonusing physicians. In addition, there was variability in outcome measures across medical specialties and within similar subspecialties. CONCLUSION: Although scribes may improve documentation efficiency among some physicians, not all will improve EHR-related documentation practices. Different strategies may help to optimize documentation behaviors of physician-scribe dyads and maximize outcomes of scribe implementation.

Using ChatGPT-4 to Create Structured Medical Notes From Audio Recordings of Physician-Patient Encounters: Comparative Study.

BACKGROUND: Medical documentation plays a crucial role in clinical practice, facilitating accurate patient management and communication among health care professionals. However, inaccuracies in medical notes can lead to miscommunication and diagnostic errors. Additionally, the demands of documentation contribute to physician burnout. Although intermediaries like medical scribes and speech recognition software have been used to ease this burden, they have limitations in terms of accuracy and addressing provider-specific metrics. The integration of ambient artificial intelligence (AI)-powered solutions offers a promising way to improve documentation while fitting seamlessly into existing workflows. OBJECTIVE: This study aims to assess the accuracy and quality of Subjective, Objective, Assessment, and Plan (SOAP) notes generated by ChatGPT-4, an AI model, using established transcripts of History and Physical Examination as the gold standard. We seek to identify potential errors and evaluate the model's performance across different categories. METHODS: We conducted simulated patient-provider encounters representing various ambulatory specialties and transcribed the audio files. Key reportable elements were identified, and ChatGPT-4 was used to generate SOAP notes based on these transcripts. Three versions of each note were created and compared to the gold standard via chart review; errors generated from the comparison were categorized as omissions, incorrect information, or additions. We compared the accuracy of data elements across versions, transcript length, and data categories. Additionally, we assessed note quality using the Physician Documentation Quality Instrument (PDQI) scoring system. RESULTS: Although ChatGPT-4 consistently generated SOAP-style notes, there were, on average, 23.6 errors per clinical case, with errors of omission (86%) being the most common, followed by addition errors (10.5%) and inclusion of incorrect facts (3.2%). There was significant variance between replicates of the same case, with only 52.9% of data elements reported correctly across all 3 replicates. The accuracy of data elements varied across cases, with the highest accuracy observed in the "Objective" section. Consequently, the measure of note quality, assessed by PDQI, demonstrated intra- and intercase variance. Finally, the accuracy of ChatGPT-4 was inversely correlated to both the transcript length (P=.05) and the number of scorable data elements (P=.05). CONCLUSIONS: Our study reveals substantial variability in errors, accuracy, and note quality generated by ChatGPT-4. Errors were not limited to specific sections, and the inconsistency in error types across replicates complicated predictability. Transcript length and data complexity were inversely correlated with note accuracy, raising concerns about the model's effectiveness in handling complex medical cases. The quality and reliability of clinical notes produced by ChatGPT-4 do not meet the standards required for clinical use. Although AI holds promise in health care, caution should be exercised before widespread adoption. Further research is needed to address accuracy, variability, and potential errors. ChatGPT-4, while valuable in various applications, should not be considered a safe alternative to human-generated clinical documentation at this time.

Clinical comparison of HMPV and RSV infections in hospitalised Malaysian children: A propensity score matched study.

INTRODUCTION: Human metapneumovirus (hMPV) and respiratory syncytial virus (RSV) are significant contributors to the burden of acute respiratory infections in children, but data on hMPV from Southeast Asia are limited despite its potential for serious disease. This study aimed to compare the clinical presentation, resource utilisation and outcomes between hMPV and RSV infections in hospitalised Malaysian children. METHODS: This retrospective, observational study included children aged ≤12 years old hospitalised with hMPV or RSV, confirmed via direct fluorescent antibody (DFA) methods, between 1 July to 30 October 2022 at Hospital Tuanku Ja'afar Seremban, Malaysia. Demographic, clinical presentation, resource utilisation and outcome data were analysed. Propensity score matching was used to balance cohorts based on key demographic and clinical characteristics. RESULTS: This study included 192 patients, comprising 112 with hMPV and 80 with RSV. hMPV patients were older (median age 20.5 vs. 9.4 months, p < 0.001) and had a higher incidence of comorbidities (24.1% vs. 7.5%, p = 0.003). Fever was more common in the hMPV group (97.3% vs. 73.8%, p < 0.001), but the other clinical manifestations were similar. Postmatching analysis showed higher corticosteroid use in the hMPV group (p = 0.01). No significant differences were observed in the use of other resources, PICU admissions, duration of hospitalisation or mortality rates between both groups. CONCLUSION: hMPV and RSV infections in children share similar clinical manifestations and outcomes, with hMPV affecting older children and showing higher corticosteroid usage. These findings emphasise the need for equal clinical vigilance for both hMPV and RSV in paediatric respiratory infections.

Structure and Funding of Clinical Informatics Fellowships: A National Survey of Program Directors.

BACKGROUND: In 2011, the American Board of Medical Specialties established clinical informatics (CI) as a subspecialty in medicine, jointly administered by the American Board of Pathology and the American Board of Preventive Medicine. Subsequently, many institutions created CI fellowship training programs to meet the growing need for informaticists. Although many programs share similar features, there is considerable variation in program funding and administrative structures. OBJECTIVES: The aim of our study was to characterize CI fellowship program features, including governance structures, funding sources, and expenses. METHODS: We created a cross-sectional online REDCap survey with 44 items requesting information on program administration, fellows, administrative support, funding sources, and expenses. We surveyed program directors of programs accredited by the Accreditation Council for Graduate Medical Education between 2014 and 2021. RESULTS: We invited 54 program directors, of which 41 (76%) completed the survey. The average administrative support received was $27,732/year. Most programs (85.4%) were accredited to have two or more fellows per year. Programs were administratively housed under six departments: Internal Medicine (17; 41.5%), Pediatrics (7; 17.1%), Pathology (6; 14.6%), Family Medicine (6; 14.6%), Emergency Medicine (4; 9.8%), and Anesthesiology (1; 2.4%). Funding sources for CI fellowship program directors included: hospital or health systems (28.3%), clinical departments (28.3%), graduate medical education office (13.2%), biomedical informatics department (9.4%), hospital information technology (9.4%), research and grants (7.5%), and other sources (3.8%) that included philanthropy and external entities. CONCLUSION: CI fellowships have been established in leading academic and community health care systems across the country. Due to their unique training requirements, these programs require significant resources for education, administration, and recruitment. There continues to be considerable heterogeneity in funding models between programs. Our survey findings reinforce the need for reformed federal funding models for informatics practice and training.

Epidemiology, clinical characteristics and outcomes of multisystem inflammatory syndrome in children.

BACKGROUND: We describe the epidemiology, clinical characteristics, and outcomes of multisystem inflammatory syndrome in children (MIS-C) among children from Negeri Sembilan, Malaysia. METHODS: A retrospective, multicentre, observational study was performed among children ≤15 years old who were hospitalized for MIS-C between January 18, 2021 and June 30, 2023. The incidence of MIS-C was estimated using reported SARS-CoV-2 cases and census population data. Descriptive analyses were used to summarize the clinical presentation and outcomes. RESULTS: The study included 53 patients with a median age of 5.7 years (IQR 1.8-8.7 years); 75.5% were males. The overall incidence of MIS-C was approximately 5.9 cases per 1,000,000 person-months. Pediatric intensive care unit (PICU) admission was required for 22 (41.5%) patients. No mortalities were recorded. Children aged 6-12 years were more likely to present with cardiac dysfunction/shock (odds ratio [OR] 5.43, 95% confidence interval [CI] 1.67-17.66), whereas children below 6 years were more likely to present with a Kawasaki disease phenotype (OR 5.50, 95% CI 1.33-22.75). Twenty patients (37.7%) presented with involvement of at least four organ systems, but four patients (7.5%) demonstrated single-organ system involvement. CONCLUSION: An age-based variation in the clinical presentation of MIS-C was demonstrated. Our findings suggest MIS-C could manifest in a spectrum, including single-organ involvement. Despite the high requirement for PICU admission, the prognosis of MIS-C was favorable, with no recorded mortalities.

Instability of mixing layers: Momentum and thermal transport in the continuum breakdown regime.

We examine the momentum and thermal transport in the continuum breakdown regime of a mixing layer flow, which exhibits Kelvin-Helmholtz instability under ideal continuum conditions. The Grad 13 moment model is used as it provides an adequate description of the flow physics (second-order accurate in Knudsen number) in the transition regime. Analytical solutions are developed under breakdown conditions for two-dimensional, compressible, parallel shear flows. It is shown that the deviation of viscous stress and heat flux from the Navier-Stokes-Fourier system follows two different scaling regimes depending upon the Mach number. At low Mach numbers, the departure of all stress and heat-flux components depends only upon the Knudsen number. At high Mach number, the scaling of shear stress and transverse heat flux depends on the product of the Knudsen and Mach numbers. The normal stresses depend individually on the Knudsen and Mach number. The scaling results are verified against numerical simulations of compressible mixing layers performed using the unified gas kinetic scheme for various degrees of rarefaction.

A Case Study Through an Audiological Perspective on a Pediatric Patient Diagnosed with Zellweger Syndrome.

Zellweger Syndrome (ZS) is a genetic mutation disorders with associated craniofacial and developmental anomalies in new-born babies. It also manifest with hearing and vision disorders. This case report discuss on a 2 year old male child diagnosed as ZS with hypotonia and the important milestones in the audiological diagnostic evaluation.

Identifying Electronic Health Record Contributions to Diagnostic Error in Ambulatory Settings Through Legal Claims Analysis.

This qualitative study analyzes closed legal claims data to determine whether problems with electronic health records are associated with diagnostic errors, in which part of the diagnostic process errors occur, and the specific types of errors that occur.

Clinical profile and risk factors for mortality in children admitted with diphtheria: an observational study.

BACKGROUND: There is an ongoing resurgence of diphtheria infection worldwide despite a vaccine being available to prevent it for more than four decades. OBJECTIVES: To study the clinical characteristics and risk factors for mortality of diphtheria cases among children 1-12 years of age treated in our hospital from 1 April 2014 to 31 March 2021. METHODOLOGY: The data of hospitalised cases of childhood diphtheria from 1 April 2014 to 31 March 2019 were retrospectively analysed from the medical records department of our hospital. All hospitalised children with diphtheria from 1 April 2019 to 31 March 2021, were prospectively studied. All categorical variables were expressed as proportion/percentage and all continuous variables were expressed as median with interquartile range (IQR). Risk factors for morbidity and mortality were analysed and tested for significance. Unadjusted odds ratio (OR) was calculated and significant variables were subjected to multivariate logistic regression. RESULTS: Of the 58 children with diphtheria, 62% were lab-confirmed, most cases (45%) were between 5 and 9 years of age. Majority (57%) were completely immunised as per the national immunisation schedule. Fever (97%) was the most predominant clinical symptom. The classical diphtheria pseudo membrane was identified in all. Respiratory failure was the most predominant complication, followed by myocarditis and acute kidney injury. The case fatality rate was 8.6%. CONCLUSION: Diphtheria cases were seen among children 5-9 years of age more commonly. Infection requiring hospitalisation was seen in vaccinated children too. No atypical manifestations were observed. Complications of the disease adversely affected the overall survival.

Blood Neutrophil Count and Neutrophil-to-Lymphocyte Ratio for Prediction of Disease Progression and Mortality in Two Independent Systemic Sclerosis Cohorts.

OBJECTIVE: To assess the predictive significance of blood neutrophil count and the ratio between neutrophil and lymphocyte count (neutrophil-to-lymphocyte ratio [NLR]) for disease severity and mortality in systemic sclerosis (SSc). METHODS: Neutrophil and lymphocyte counts were prospectively measured in the Genetics versus Environment in Scleroderma Outcome Study (GENISOS) and the Scleroderma Lung Study II (SLS II). Forced vital capacity percent predicted (FVC%) and modified Rodnan skin thickness score (MRSS) were used as surrogate measures for disease severity. Longitudinal analyses were performed using generalized linear mixed models. Cox proportional hazards models evaluated the predictive significance of these cell counts for mortality. RESULTS: Of the 447 SSc patients in the GENISOS cohort at the time of analysis, 377 (84.3%) had available baseline blood neutrophil and lymphocyte counts. Higher baseline neutrophil count and NLR predicted lower serially obtained FVC% (b = -4.74, P = 0.009 and b = -2.68, P = 0.028, respectively) and higher serially obtained MRSS (b = 4.07, P < 0.001 and b = 2.32, P < 0.001, respectively). Longitudinal neutrophil and NLR measurements also significantly correlated with lower concurrently obtained FVC% measurements and higher concurrently obtained MRSS. Baseline neutrophil count and NLR predicted increased risk of long-term mortality, even after adjustment for baseline demographic and clinical factors (hazard ratio [HR] 1.42, P = 0.02 and HR 1.48, P < 0.001, respectively). The predictive significance of higher baseline neutrophil count and NLR for declining FVC% and increased long-term mortality was confirmed in the SLS II. CONCLUSION: Higher blood neutrophil count and NLR are predictive of more severe disease course and increased mortality, indicating that these easily obtainable laboratory studies might be a reflection of pathologic immune processes in SSc.

Electronic Health Record Use Issues and Diagnostic Error: A Scoping Review and Framework.

BACKGROUND: Diagnostic errors are a major source of patient harm, most of which are caused by cognitive errors and biases. Despite research showing the relationship between software systems and cognitive processes, the impact of the electronic health record (EHR) on diagnostic error remains unknown. METHODS: We conducted a scoping review of the scientific literature to (1) survey the association between aspects of the EHR and diagnostic error, and (2) through a human-systems integration lens, identify the types of EHR issues and their impact on the stages of the diagnostic process. RESULTS: We analyzed 11 research articles for the relationship between EHR use and diagnostic error. These articles highlight specific technical, usability, and workflow issues with the EHR that pose risks for diagnostic error at every stage of the diagnostic process. DISCUSSION: Although technical problems such as EHR interoperability and data integrity pose critical issues for the diagnostic process, usability and workflow issues such as poor display design, and inability to track test results also hamper clinicians' ability to track, process, and act in the diagnostic process. Current research methods have limited coverage over clinical settings, are not standardized, and rarely include measures of patient harm. CONCLUSIONS: The available evidence shows that EHRs pose risks for diagnostic error throughout the diagnostic process, with most issues involving their incompatibility with providers' cognitive processing. A structured and systematic model of collecting and reporting on these errors is needed to understand how the EHR shapes the diagnostic process and improve diagnostic accuracy.

How Providers Can Optimize Effective and Safe Scribe Use: a Qualitative Study.

BACKGROUND: The use of electronic health records has generated an increase in after-hours and weekend work for providers. To alleviate this situation, the hiring of medical scribes has rapidly increased. Given the lack of scribe industry standards and the wide variance in how providers and scribes work together, it could potentially create new patient safety-related risks. OBJECTIVE: The purpose of this paper was to identify how providers can optimize the effective and safe use of scribes. DESIGN: The research team conducted a secondary analysis of qualitative data where we reanalyzed data from interview transcripts, field notes, and transcribed group discussions generated by four previous projects related to medical scribes. PARTICIPANTS: Purposively selected participants included subject matter experts, providers, informaticians, medical scribes, medical assistants, administrators, social scientists, medical students, and qualitative researchers. APPROACH: The team used NVivo12 to assist with the qualitative analysis. We used a template method followed by word queries to identify an optimum level of scribe utilization. We then used an inductive interpretive theme-generation process. KEY RESULTS: We identified three themes: (1) communication aspects, (2) teamwork efforts, and (3) provider characteristics. Each theme contained specific practices so providers can use scribes safely and in a standardized way. CONCLUSION: We utilized a secondary qualitative data analysis methodology to develop themes describing how providers can optimize their use of scribes. This new knowledge could increase provider efficiency and safety and be incorporated into further and future training tools for them.

Medical Record Closure Practices of Physicians Before and After the Use of Medical Scribes.

This study uses electronic health record data to evaluate medical record closure outcomes before and after the use of medical scribes at a large academic medical center.

Just-in-Time Electronic Health Record Retraining to Support Clinician Redeployment during the COVID-19 Surge.

BACKGROUND: In response to surges in demand for intensive care unit (ICU) care related to the COVID-19 pandemic, health care systems have had to increase hospital capacity. One institution redeployed certified registered nurse anesthetists (CRNAs) as ICU clinicians, which necessitated training in ICU-specific electronic health record (EHR) workflows prior to redeployment. Under time- and resource-constrained settings, clinical informatics (CI) fellows could effectively be lead instructors for such training. OBJECTIVE: This study aimed to deploy CI fellows as lead EHR instructional trainers for clinician redeployment as part of an organization's response to disaster management. METHODS: CI fellows led a multidisciplinary team alongside subject matter experts to develop and deploy a tailored EHR curriculum comprising in-person classes and online video modules, leveraging high-fidelity simulated patient cases. The participants completed surveys immediately after the in-person training session and after deployment. RESULTS: Eighteen CRNAs participated, with 15 completing the postactivity survey (83%). All felt the training was useful and improved their EHR skills with a Net Promoter score of +87. Most (93%) respondents indicated the pace of the session was "just right," and 100% felt the clarity of instruction was "just right" or "extremely easy" to understand. Twelve participants (67%) completed the postdeployment survey. The training increased comfort in the ICU for all respondents, and 91% felt the training prepared them to work in the ICU with minimal guidance. All stated that the concepts learned would be useful in their anesthesia role. Fifty-eight percent viewed the online video library. CONCLUSION: This case report demonstrates that CI fellows with dual domain expertise in their clinical specialty and informatics are uniquely poised to deliver clinician redeployment EHR training in response to operational crises. Such opportunities can achieve fellowship educational goals while conserving physician resources which can be a strategic option as organizations plan for disaster management.

Continuum breakdown in compressible mixing layers.

Gas-kinetic simulations of rarefied and compressible mixing layers are performed to characterize continuum breakdown and the effect on the Kelvin-Helmholtz instability. The unified gas-kinetic scheme (UGKS) is used to perform the simulations at different Mach and Knudsen numbers. The UGKS stress tensor and heat-flux vector fields are compared against those given by the Navier-Stokes-Fourier constitutive equations. The most significant difference is seen in the shear stress and transverse heat flux. The study demonstrates the existence of two distinct continuum breakdown regimes, one at low and the other at high convective Mach numbers. Overall, at low convective Mach numbers, the deviation from continuum stress and heat flux appears to scale exclusively with the micro-macro length scale ratio given by the Knudsen number. On the other hand, at high convective Mach numbers, the deviation depends on the global micro-macro timescale ratio given by the product of Mach and Knudsen numbers. We further demonstrate that, unlike shear stresses and transverse heat flux, the deviations in normal stresses and the streamwise heat flux depend separately on Knudsen and Mach numbers. A local parameter called the gradient Knudsen number is proposed to characterize the rarefaction effects on the local momentum and thermal transport. Noncontinuum aspects of gas-kinetic stress-tensor and heat-flux behavior that Grad's 13-moment equation model reasonably captures are identified.

Translating ethnographic data into knowledge, skills, and attitude statements for medical scribes: a modified Delphi approach.

OBJECTIVE: While the use of medical scribes is rapidly increasing, there are not widely accepted standards for their training and duties. Because they use electronic health record systems to support providers, inadequately trained scribes can increase patient safety related risks. This paper describes the development of desired core knowledge, skills, and attitudes (KSAs) for scribes that provide the curricular framework for standardized scribe training. MATERIALS AND METHODS: A research team used a sequential mixed qualitative methods approach. First, a rapid ethnographic study of scribe activities was performed at 5 varied health care organizations in the United States to gather qualitative data about knowledge, skills, and attitudes. The team's analysis generated preliminary KSA related themes, which were further refined during a consensus conference of subject-matter experts. This was followed by a modified Delphi study to finalize the KSA lists. RESULTS: The team identified 90 descriptions of scribe-related KSAs and subsequently refined, categorized, and prioritized them for training development purposes. Three lists were ultimately defined as: (1) Hands-On Learning KSA list with 47 items amenable to simulation training, (2) Didactic KSA list consisting of 32 items appropriate for didactic lecture teaching, and (3) Prerequisite KSA list consisting of 11 items centered around items scribes should learn prior to being hired or soon after being hired. CONCLUSION: We utilized a sequential mixed qualitative methodology to successfully develop lists of core medical scribe KSAs, which can be incorporated into scribe training programs.

Utilizing eye tracking to assess electronic health record use by pharmacists in the intensive care unit.

PURPOSE: A study was conducted using high-fidelity electronic health record (EHR)-based simulations with incorporated eye tracking to understand the workflow of critical care pharmacists within the EHR, with specific attention to the data elements most frequently viewed. METHODS: Eight critical care pharmacists were given 25 minutes to review 3 simulated intensive care unit (ICU) charts deployed in the simulation instance of the EHR. Using monitor-based eye trackers, time spent reviewing screens, clinical information accessed, and screens used to access specific information were reviewed and quantified to look for trends. RESULTS: Overall, pharmacists viewed 25.5 total and 15.1 unique EHR screens per case. The majority of time was spent looking at screens focused on medications, followed by screens displaying notes, laboratory values, and vital signs. With regard to medication data, the vast majority of screen visitations were to view information on opioids/sedatives and antibiotics. With regard to laboratory values, the majority of views were focused on basic chemistry and hematology data. While there was significant variance between pharmacists, individual navigation patterns remained constant across cases. CONCLUSION: The study results suggest that in addition to medication information, laboratory data and clinical notes are key focuses of ICU pharmacist review of patient records and that navigation to multiple screens is required in order to view these data with the EHR. New pharmacy-specific EHR interfaces should consolidate these elements within a primary interface.

Comparison of Ordering Tools on Adherence to Treatment Protocols in the Emergency Department.

OBJECTIVE: To assess adherence to clinical protocols in the emergency department after the implementation of embedded order panels in the electronic health record. MATERIALS AND METHODS: Due to infrequent use, a subset of order sets were redesigned as embedded order panels in a menu-style quick list. Usage was measured before and after implementation at seven departments. RESULTS: There were 2,247 applicable encounters during the pre-intervention period and 1,723 post-intervention. The use of order sets increased significantly after implementation (14% vs. 33% or encounters, p < 0.001). Traditional order sets required at least seven keystrokes or mouse clicks, while embedded order panels required only two. DISCUSSION AND CONCLUSION: Use of order sets increased after implementation of embedded order panels; however, they were still only used for about one-third of applicable encounters suggesting that more work is needed to increase treatment protocol adherence and electronic health record efficiency.