Optimization of Electronic Health Record Usability Through a Department-Led Quality Improvement Process.

BACKGROUND: Electronic health records (EHR) have become commonplace in medicine. A disconnect between developers and users while creating the interface often fails to create a product that captures clinical workflow, and issues become apparent with implementation. Optimization allows collaboration of clinicians and informaticists after implementation, but documentation of success has only been at the institutional level. METHODS: A 4-month, department-wide EHR optimization was conducted with information technology (IT). Optimizations were developed from an intensive quality improvement process involving all levels of clinicians and clinical staff. The optimizations were then categorized as accommodations (department adjusted workflow to EHR), creations (IT developed new workflows within EHR), discoveries (department found workflows within EHR), and modifications (IT changed workflows within EHR). Departmental productivity, defined as number of visits, charges, and payments, was standardized to ratios prior to the COVID-19 pandemic and evaluated by Taylor's change point analysis. Significant improvements were defined as shifts (change points), trends (5 or more consecutive values above/below the mean), and values outside 95% CIs. RESULTS: The 124 optimizations were categorized as 43 accommodations, 13 creations, 54 discoveries, and 14 modifications. Productivity ratios of monthly charges (0.74 to 1.28) and payments (0.83 to 1.58) significantly improved with the optimization efforts. Monthly visit ratios increased (0.65 to 0.98) but did not change significantly. CONCLUSION: Departmental collaboration with organizational IT for EHR optimization focused on detailed analysis of how workflows can impact productivity. Discovery optimization predominance indicates many solutions to EHR usability problems were already in the system. A large proportion of accommodation optimizations reinforced the need for better developer-user collaboration before implementation.Annals Early Access.

Nutrition and Isolation in a Rural US Population over 80 Years Old: A Descriptive Analysis of a Vulnerable Population.

Factors allowing rural, community-dwelling 80+ year-olds to thrive remain unexplored. Isolation can impact this vulnerable population. In this study, patients were prospectively surveyed for age, gender, cohabitation (self, spouse, family) and location (suburban, rural, and isolated). Mini-nutritional assessment short form (MNA-SF) and BMI were obtained. A p < 0.05 represented statistical significance. Patients (n = 167) were mostly female (120; 71.9%) with an average overweight BMI (26.5) and low-normal MNA-SF scores (11.8). Most live alone (49.7%), followed by spousal (31.7%) and family (18.6%) cohabitation. Over 80% are rural (71) or rural-isolated (67), and of these, 83% had normal nutrition. Self-habitation correlated with lower MNA-SF scores (p = 0.02). Normal BMIs correlated with family cohabitation (OR = 0.90 [CI: 0.82-0.99]) and nourished MNA-SF scores with spousal cohabitation (OR = 1.69; CI: 1.15-2.47) rather than living alone. Self-habitation increases vulnerability to obesity and malnutrition. Interventions should aim to maintain independence while improving the effects of habitation on nutrition.

Analysis of a Division I Sports Medicine Program's COVID-19 Protocol: Identifying Factors that Predict Testing Demands and Positive Rates During a Pandemic.

OBJECTIVE: To determine factors indicating testing frequency and positive test results in a Division I sports department intrapandemic. DESIGN: Retrospective analysis. SETTING: A single Division I collegiate sports department. PATIENTS: All student-athlete (n = 437), student staff (n = 89), and adult staff (n = 202) members of the sports department. Total cohort (n = 728). INTERVENTIONS: The authors analyzed the independent variables of local positive rates, sport characteristics, and campus events for impact on the volume of the departmental testing and positive rates. MAIN OUTCOME MEASURES: Measured dependent variables of the volume of departmental testing and positive rates were analyzed. RESULTS: Positive predictive rates (PPRs) largely differed from local, off-campus rates in timing and duration (59.52%: P < 0.05). Overall, 20633 tests were administered with 201 positive results (0.97% PPR). Student-athlete numbers were highest in all categories, followed by adult then student staff. Greater proportions of contact sports became positive (53.03%: P < 0.001) and all-male sports (47.69%: P < 0.001). No comparative difference was seen for teams using fomites (19.15%: P = 0.403). Spring sports teams had the lowest percentage of the team positive (22.22%: P < 0.001). Winter sports had the highest PPR (1.15%), all occurring during team-controlled activities. Playing sports indoors did not increase inside team-controlled activity positive rates ( P = 0.066). CONCLUSIONS: Longitudinal changes in local, off-campus infection rates partially affected sports departmental positive results while testing rates were more influenced by sport and university schedule. Testing resources should be directed toward high-risk sports, which included contact sports (football, basketball, and soccer), all-male teams, both Winter and indoor sports inside team-controlled activities, and sports with long periods of time outside team-controlled activities.

Targeted care coordination towards patients with a history of multiple readmissions effectively reduces readmissions.

BACKGROUND: To decrease hospital readmission rates, clinical practices create a transition of care (TOC) process to assess patients and coordinate care postdischarge. As current evidence suggests lack of universal benefit, this study's objectives are to determine what patient and process factors associate with hospital readmissions, as well as construct a model to decrease 30-day readmissions. METHODS: Three months of retrospective discharged patient data (n = 123) were analysed for readmission influences including: patient-specific comorbidities, admission-specific diagnoses, and TOC components. A structured intervention of weekly contact, the Care Coordination Cocoon (CCC), was created for multiply readmitted patients (MRPs), defined as ≥2 readmissions. Three months of postintervention data (n = 141) were analysed. Overall readmission rates and patient- and process-specific characteristics were analysed for associations with hospital readmission. RESULTS: Standard TOC lacked significance. Patient-specific comorbidities of cancer (odds ratio [OR] 6.27; 95% confidence interval [CI] 1.73-22.75) and coronary artery disease (OR 6.71; 95% CI 1.84-24.46), and admission-specific diagnoses within pulmonary system admissions (OR 7.20; 95% CI 1.96-26.41) were associated with readmissions. Post-CCC data demonstrated a 48-h call (OR 0.21; 95% CI 0.09-0.50), answered calls (OR 0.16; CI 0.07-0.38), 14-day scheduled visit (OR 0.20; 95% CI 0.07-0.54), and visit arrival (OR 0.39; 95% CI 0.17-0.91) independently associated with decreased readmission rate. Patient-specific (hypertension-OR 3.65; CI 1.03-12.87) and admission-specific (nephrologic system-OR 3.22; CI 1.02-10.14) factors associated with readmissions which differed from the initial analysis. CONCLUSIONS: Targeting a practice's MRPs with CCC resources improves the association of TOC components with readmissions and rates decreased. This is a more efficient use of TOC resources.

Parental Reading to Infants Improves Language Score: A Rural Family Medicine Intervention.

INTRODUCTION: Both expressive and receptive language development begins early in life. While the benefits of reading to toddlers (over 12 months old) is well-established, benefits of reading to infants (birth to 12 months old) is less established. This study's objective is to determine if consistent reading to infants improves expressive and receptive language development during the first year of life. METHODS: We prospectively randomized infants at a family medicine clinic during their 2-week-old visits and gave them a collection of books. Group A (n = 16) received no instructions, while patients in Group B (n = 18) committed to read 1 book a day. Parents in Group C (n = 18) enrolled after 34 weeks gestation, committed to read 1 book a day, and watch an infant brain development video. We obtained average book counts and both expressive and receptive language testing at standard preventative visits through 12 months. RESULTS: Language scores did not differ between randomized groups. Always reading 7 books per week led to higher expressive, receptive and combined language scores at 9 months than sometimes reading fewer than 7 books per week (P = .025, 0.009 and 0.011 respectively). These differences increased by 12 months (P = .004, 0.002, and 0.003, respectively). Instructing parents to read daily encouraged parents to read more books per week at 4 months (P = .031) and 6 months (P = .049). DISCUSSION: Early, consistent reading demonstrates improved language scores as early as 9 months of age. Setting expectations of minimal daily reading impacted daily reading compliance early in life.

Rank and Tenure Amongst Faculty at Academic Medical Centers: A Study of More Than 50 Years of Gender Disparities.

PURPOSE: To investigate progress toward gender equality in academic medicine through a longitudinal analysis of gender parity among faculty at medical schools. METHOD: The authors conducted a retrospective analysis of Association of American Medical Colleges Faculty Roster data on gender, tenure status, and academic rank of faculty in basic science (BSc) and clinical science (CSc) departments from 1966 to 2019. They expressed data as whole numbers and percent female. A trend analysis projected time to gender parity across rank and tenure categories, and cross-tabulation analysis revealed the relative odds of females being in a rank and tenure position relative to males. RESULTS: A 12-fold increase in the number of faculty occurred from 1966 to 2019, driven largely by increases in non-tenure track faculty. Female tenured and tenure track numbers increased at consistent rates (121 and 174 per year; P < .001). Female non-tenure track rates mirrored those for males, both changing in 2000. Odds ratios in 2019 for BSc and CSc females to be in tenure track versus non-tenure track positions compared with males were 0.83/0.98 and to be tenured were 0.63/0.44. Odds ratios in 2019 for BSc and CSc females to be full professors versus assistant or associate professors compared with males were 0.55/0.42. BSc assistant and associate professor percent female rates increased linearly from 1966 to 2019, while full professor rates increased in 1986. Transition points between periods of linear change were seen later in CSc departments (1977, 1980, 1985, 1994). Best fit line models indicated gender parity will be reached for BSc/CSc faculty in 2034/2023, 2047/2033, and 2065/2053 for assistant, associate, and full professors, respectively. CONCLUSIONS: These findings suggest large historical changes in medical school expansion, medical education, and economics have shifted gender curves at all academic ranks. To achieve gender parity, additional national changes are needed.

Building a Culture of Scholarship Within a Family Medicine Department: a Successful Eight-Year Journey of Incremental Interventions Following a Historical Perspective of Family Medicine Research.

BACKGROUND AND OBJECTIVES: Family medicine (FM), a discipline that eschewed worshiping the ivory tower of research in favor of patient care, has struggled with its role in the world of scholarly activity. FM residencies mirror this conflict despite the Accreditation Council for Graduate Medical Education's requirements for creating an environment of inquiry and scholarship. Because of this, the faculty within the Department of Family and Community Health (dFCH) at Marshall University changed its culture of scholarship. METHODS: A faculty-driven needs-based assessment of the department's strengths and deficiencies for enhancing scholarship was conducted. A three-pronged approach of creating motivation, developing an infrastructure, and consolidating resources was created. This process was periodically re-evaluated and augmented. Departmental scholarly activity, defined as both publications and presentations, was tracked for an eight year period. RESULTS: Scholarly output increased by 483% (6 to 29) in year 1 and 10-fold by year 8 (6 to 60) from the pre-culture change baseline. This represents one- and eight-year increases for both publications (4 to 6 and 4 to 18 respectively) and presentations (2 to 23 and 2 to 42 respectively). Scholarly involvement became more widespread among faculty (n = 30) and increased linearly for residents (n = 19) and students (n = 13). CONCLUSION: Through a series of needs-based interventions with consistent reanalysis, the dFCH changed its culture of scholarship. Understanding that other departments have similar competing interests to negotiate, the principles of creating motivation, developing research infrastructure, and consolidating resources could be successfully applied elsewhere.

Finding Greater Value in the Fourth Year of Medical School: Accelerating the Transition to Residency.

The recent focus on competency-based medical education has heralded a true change in U.S. medical education. Accelerating the transition from medical school to residency may reduce student debt, encourage competency-based educational advancement, and produce residency graduates better prepared for the independent and unsupervised practice of medicine. With some purposeful design considerations, innovative time-variable programs or fixed-time accelerated tracks can be implemented within current regulatory parameters and without major alteration of existing institutional regulatory guidelines, state licensing requirements, or specialty certification requirements. Conferring an MD degree in less than 4 full academic years provides opportunities to customize and find greater value in the fourth year of medical school as well as to redeploy time from undergraduate medical education to graduate medical education; this could shorten the overall time to completion of training and/or provide for customization of training in the final years of residency. In this article, the authors discuss the regulatory requirements for successful implementation; consider issues related to "off-cycle" graduates advancing to residency training outside of the Match; and share examples of 3 innovative accelerated programs in pediatrics, family medicine, and orthopaedics that have yielded advantages to individual learners, including reduced educational debt, as well as to the health care system.

Progressive Supranuclear Palsy - A Case Study from the Perspective of a Primary Care Physician Son.

Progressive Supranuclear Palsy (PSP) is a rare geriatric pathology, from the abnormal deposition of the tau protein, combining the motor tremor and bradykinesia of Parkinson's disease with the cognitive defects of Alzheimer's disease. As physical and mental debilities progressively manifest in PSP, the physician, family, and patient face decisions on how to manage this terminal neurodegenerative disease. Physicians note the outcomes of decisions and often express, either to peers or internally to oneself, how they would handle a similar situation affecting their own family. In this case, we will explore PSP and examine a physician's perspective as his father navigates his journey through it.