Resident Perceptions of Continuity Clinic Patient Metrics Differ From EHR Data: Pilot Use of Population Health Dashboards.

BACKGROUND AND OBJECTIVES: Population health management (PHM) dashboards using electronic health record (EHR) data can teach trainees about the population they serve while also delivering data on their clinical practice. Yet, few studies have demonstrated their use. In this pilot study, we assessed baseline resident perceptions of population health metrics for continuity clinic panels by comparing resident estimates with EHR-reported values delivered by individualized PHM dashboards. METHODS: A descriptive, comparative study was conducted at a primary continuity clinic site for pediatric residents in January 2018. Residents were surveyed about population health metrics for their patient panels, including demographics, utilization, and medical diagnoses. We compared resident estimates to corresponding EHR-reported values using 2-tailed paired t tests. RESULTS: A total of 42 out of 55 eligible residents (76%) completed the survey. Compared with EHR-reported values, residents estimated higher percentages of emergency department utilization (22.1% vs 10.3%, P < .01) and morbidity, including medical complexity (15.6% vs 5.9%, P < .01), overweight (38.1% vs 11.7%, P < .01), obesity (20.5% vs 15.8%, P = .02), and asthma (34.6% vs 21.4%, P < .01). CONCLUSIONS: In this pilot study of PHM dashboards, resident perceptions of continuity clinic population health metrics did not align with EHR data. Estimates were higher for measures of utilization and morbidity. PHM dashboards may help trainees better understand their patient populations and serve as a consistent source of objective practice data. However, further research and investment is needed to evaluate dashboard implementation and impact on trainee and patient outcomes.

Evaluating a handheld decision support device in pediatric intensive care settings.

OBJECTIVE: To evaluate end-user acceptance and the effect of a commercial handheld decision support device in pediatric intensive care settings. The technology, pac2, was designed to assist nurses in calculating medication dose volumes and infusion rates at the bedside. MATERIALS AND METHODS: The devices, manufactured by InformMed Inc., were deployed in the pediatric and neonatal intensive care units in 2 health systems. This mixed methods study assessed end-user acceptance, as well as pac2's effect on the cognitive load associated with bedside dose calculations and the rate of administration errors. Towards this end, data were collected in both pre- and postimplementation phases, including through ethnographic observations, semistructured interviews, and surveys. RESULTS: Although participants desired a handheld decision support tool such as pac2, their use of pac2 was limited. The nature of the critical care environment, nurses' risk perceptions, and the usability of the technology emerged as major barriers to use. Data did not reveal significant differences in cognitive load or administration errors after pac2 was deployed. DISCUSSION AND CONCLUSION: Despite its potential for reducing adverse medication events, the commercial standalone device evaluated in the study was not used by the nursing participants and thus had very limited effect. Our results have implications for the development and deployment of similar mobile decision support technologies. For example, they suggest that integrating the technology into hospitals' existing IT infrastructure and employing targeted implementation strategies may facilitate nurse acceptance. Ultimately, the usability of the design will be essential to reaping any potential benefits.

A System-Level Approach to Improve HIV Screening in an Urban Pediatric Primary Care Setting.

BACKGROUND AND OBJECTIVES: Less than 50% of youth living with HIV know their status. The Centers for Disease Control and Prevention and the United States Preventive Services Task Force recommend universal HIV screening in adolescence. Pediatric primary care settings are still lacking in testing youth who are at risk for HIV. Our objective was to determine whether implementing rapid HIV screening improved HIV screening rates and result receipt in 13- to 25-year-old pediatric primary patients. METHODS: From March 2014 to June 2015, a 4-cycle plan-do-study-act quality improvement model was used. A total of 4433 patients aged 13 to 25 years were eligible for HIV screening on the basis of Centers for Disease Control and Prevention criteria. Logistic regression with random effects was used to estimate the odds of HIV screening and screening with a rapid test compared with each previous cycle. Statistical process control charts using standard interpretation rules assessed the effect of patients receiving rapid HIV screening. RESULTS: Baseline HIV screening rate was 29.6%; it increased to 82.7% in cycle 4. The odds of HIV screening increased 31% between cycle 1 and baseline (odds ratio 1.31 [95% confidence interval: 1.01-1.69]) to a 1272% increase between cycle 4 and baseline (odds ratio 12.72 [95% confidence interval: 10.45-15.48]), with most (90.4%) via rapid screening. Rapid screening yielded higher same-day result receipt . Five patients were identified with HIV and immediately linked to on-site care. CONCLUSIONS: Rapid HIV screening and system-level modifications significantly increased screening rates and result receipt, revealing this to be an effective method to deliver HIV services to youth.

Missed Opportunities to Address Pregnancy Prevention With Young Men in Primary Care.

Young men (aged 15-24 years) have pregnancy prevention needs, yet little is known about whether they perceive they learn about pregnancy prevention in primary care. A sample of 190 young men seen in primary care in one city from April 2014 to September 2016 were assessed on perceived learning about pregnancy prevention, background and visit characteristics, pregnancy prevention care receipt, and contraception needs at last sex. The majority of participants were non-Hispanic black (92%), aged 15 to 19 years (54%), seen for a physical examination (52%), and established patients (87%). Few participants perceived they learned about pregnancy prevention (32%), regardless of sexual activity (33% among sexually active participants, 26% among never sexually active). Poisson regression models determined that perceived learning about pregnancy prevention was independently associated with young men's pregnancy prevention care receipt and contraception needs at last sex. Findings highlight the need to improve providers' delivery of pregnancy prevention services to young men.

Integrating Pregnancy Prevention Into an HIV Counseling and Testing Program in Pediatric Primary Care.

PURPOSE: Certified health educator (CHE)-based HIV counseling and testing typically focus on HIV and sexually transmitted infection (STI) prevention only. A quality improvement initiative examined integrating assessment of reproductive life plans, counseling about pregnancy prevention, and contraception referral into a CHE-based HIV testing program. METHODS: Between February 2014 and January 2017, in one urban pediatric primary care clinic serving patients aged 0-25, CHEs assessed sexual history, HIV risk, short-term (i.e., the next 6-12 months) pregnancy desire, and current contraception method and satisfaction among patients aged 13-25 who had ever had vaginal sex, using a standardized questionnaire. Data were analyzed using a de-identified administrative dataset that also tracked referrals to initiate contraception and actual method initiation. RESULTS: Of 1,211 patients, most (96%) reported no short-term pregnancy or partner pregnancy desire. Use of less effective or no contraception, as well as method dissatisfaction, was common. A high proportion of female patients referred to new methods opted for more effective methods (62%) and initiated these methods (76%); a high proportion of male patients opted for receipt of condoms (67%). Patients reporting short-term pregnancy desire reported higher rates of previous pregnancy and STIs. CONCLUSIONS: Program findings highlight the potential benefit of integrating assessment for and counseling about pregnancy prevention in a CHE-based HIV testing program. This can more effectively address the needs of patients with concomitant risks of STI/HIV and unintended pregnancy, and link patients who do not desire pregnancy to more effective methods.

Sideways camera rotations of 90° and 135° result in poorer performance of laparoscopic tasks for novices.

OBJECTIVE: The aim of this study was to determine the impact of sideways visuomotor rotations between 0° and 180° on novice performance in a laparoscopic simulator. BACKGROUND: The laparoscopic surgical environment often involves visuomotor rotations because the laparoscope may be placed to the surgeon's side. Basic research by Cunningham indicated that visuomotor rotations between 90° and 135° result in peak performance decrements. Research by Ames and colleagues failed to replicate Cunningham's results in the laparoscopic environment, possibly due to (a) confounds from carryover effects or (b) use of an alternative laparoscopic training task rather than the straight-line pointing task used by Cunningham. Two experiments were conducted to determine if Cunningham's results generalize to the laparoscopic environment when controlling for carryover effects for a three-dimensional "straight-line" pointing task (Experiment 1) and a laparoscopic training task (Experiment 2). METHOD: In Experiments 1 and 2, participants were assigned to one of five visuomotor rotations: 0°, 45°, 90°, 135°, or 180°. Utilizing a laparoscopic simulator, participants performed either a three-dimensional pointing task (Experiment 1) or a peg transfer task (Experiment 2). RESULTS: In both experiments, visuomotor rotations of 90° or 135° resulted in the poorest performance. CONCLUSION: When controlling for carryover effects, Cunningham's results generalize to novices' performance of a pointing and a peg transfer task in the laparoscopic environment. APPLICATIONS: The results indicate that 90° and 135° sideways laparoscope placements may result in worse performance for novices in the laparoscopic environment, indicating potentially longer learning curves for these conditions in the laparoscopic as well as other teleoperation environments.