Early Adopters of Apple Health Records at a Large Academic Medical Center: Cross-sectional Survey of Users.

BACKGROUND: Mobile applications offer a new approach to personal health records, which are internet-based tools for patients to consolidate and manage their health information. The University of Pennsylvania Health System (UPHS) was one of the first health systems to participate in Apple Health Records (AHR), a prominent example of this new generation of personal health records. OBJECTIVE: This study aimed to characterize early adoption of AHR among UPHS patients and understand user perspectives. METHODS: An email-based survey with fixed answer, Likert scale, and open-ended questions was administered to all UPHS patients using AHR in the first 10 months of enrollment. Survey data linked to the UPHS electronic health record system were used to analyze responses. Multivariable logistic regression modeled the association of patient characteristics with user ratings. Content analysis was used to analyze open-ended questions. RESULTS: At the time of the survey, a total of 1458 patients had used AHR at least once. Mean age of AHR users was 47.5 years, 66.3% (967/1458) were male, 70.9% (1033/1458) were white, and 80.8% (1178/1458) had private insurance. Response rate was 26.8% (391/1458); 46.3% (180/389) were very satisfied with AHR, and 67.7% (264/390) described it as very easy to use. The most commonly utilized features were lab results (324/391, 82.9%), clinical vitals (264/391, 67.5%), and medications (253/391, 64.7%). No patient characteristics were associated with reporting high satisfaction or ease of use. The most common reason for using AHR was convenience/ease of use, and 58.2% (160/275) of users reported allowing no other apps to access their health information, citing privacy as one consideration. CONCLUSIONS: Early adopters of AHR were demographically white, male, and privately insured. Convenience was an important facilitator, and users were selective in which apps they allowed to access their health information.

The Association Between Hospital End-of-Life Care Quality and the Care Received Among Patients With Heart Failure.

CONTEXT: Improving end-of-life care (EOLC) quality among heart failure patients is imperative. Data are limited as to the hospital processes of care that facilitate this goal. OBJECTIVES: To determine associations between hospital-level EOLC quality ratings and the EOLC delivered to heart failure patients. METHODS: Retrospective analysis of the Veterans Health Administration (VA) and the Bereaved Family Survey data of heart failure patients from 2013 to 2015 who died in 107 VA hospitals. We calculated hospital-level observed-to-expected casemix-adjusted ratios of family reported excellent EOLC, dividing hospitals into quintiles. Using logistic regression, we examined associations between quintiles and palliative care consultation, receipt of chaplain and bereavement services, inpatient hospice, and intensive care unit death. RESULTS: Of 6256 patients, mean age was 77.4 (SD = 11.1), 98.3% were male, 75.7% were white, and 18.2% were black. Median hospital scores of "excellent" EOLC ranged from 41.3% (interquartile range 37.0%-44.8%) in the lowest quintile to 76.4% (interquartile range 72.9%-80.3%) in the highest quintile. Patients who died in hospitals in the highest quintile, relative to the lowest, were slightly although not significantly more likely to receive a palliative care consultation (adjusted proportions 57.6% vs. 51.2%; P = 0.32) but were more likely to receive chaplaincy (92.6% vs. 81.2%), bereavement (86.0% vs. 72.2%), and hospice (59.7% vs. 35.9%) and were less likely to die in the intensive care unit (15.9% vs. 31.0%; P < 0.05 for all). CONCLUSION: Patients with heart failure who die in VA hospitals with higher overall EOLC quality receive more supportive EOLC. Research is needed that integrates care processes and develops scalable best practices in EOLC across health care systems.

Comparison of Web-Based and Paper Advance Directives: A Pilot Randomized Clinical Trial.

BACKGROUND: Digital tools to document care preferences in serious illnesses are increasingly common, but their impact is unknown. We developed a web-based advance directive (AD) featuring (1) modular content eliciting detailed care preferences, (2) the ability to electronically transmit ADs to the electronic health record (EHR), and (3) use of nudges to promote document transmission and sharing. OBJECTIVE: To compare a web-based, EHR-transmissible AD to a paper AD. METHODS: Patients with gastrointestinal and lung malignancies were randomized to the web or paper AD. The primary outcome was the proportion of patients with newly documented advance care plans in the EHR at 8 weeks. Secondary outcomes assessed through an e-mail survey included the change in satisfaction with end-of-life plans, AD acceptability, and self-reported sharing with a surrogate. RESULTS: Ninety-one participants were enrolled: 46 randomly allocated to the web AD and 45 to paper. Thirteen patients assigned to web AD (28%) had new documentation versus 7 (16%) assigned to paper (P = .14). Adjusted for demographic factors and primary diagnosis, the odds ratio of new documentation with web AD was 3.7 (95% CI: 0.8-17.0, P = .10). Satisfaction with advance care planning and AD acceptability were high in both groups and not significantly different. Among patients completing web ADs, 79% reported sharing plans with their caregivers, compared with 65% of those completing paper ADs (P = .40). CONCLUSION: Web-based ADs hold promise for promoting documentation and sharing of preferences, but larger studies are needed to quantify effects on these intermediate end points and on patient-centered outcomes.

Spending and quality after three years of Medicare's bundled payments for medical conditions: quasi-experimental difference-in-differences study.

OBJECTIVE: To evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or health service use. DESIGN: Quasi-experimental difference-in-differences analysis. SETTING: US hospitals participating in bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and propensity score matched to non-participating hospitals. PARTICIPANTS: 238 hospitals participating in the Bundled Payments for Care Improvement initiative (BPCI) and 1415 non-BPCI hospitals. 226 BPCI hospitals were matched to 700 non-BPCI hospitals. MAIN OUTCOME MEASURES: Primary outcomes were total spending on episodes and death 90 days after discharge. Secondary outcomes included spending and use by type of post-acute care. BPCI and non-BPCI hospitals were compared by patient, hospital, and hospital market characteristics. Market characteristics included population size, competitiveness, and post-acute bed supply. RESULTS: In the 226 BPCI hospitals, episodes of care totaled 261 163 in the baseline period and 93 562 in the treatment period compared with 211 208 and 78 643 in the 700 matched non-BPCI hospitals, respectively, with small differences in hospital and market characteristics after matching. Differing trends were seen for some patient characteristics (eg, mean age change -0.3 years at BPCI hospitals v non- BPCI hospitals, P<0.001). In the adjusted analysis, participation in BPCI was associated with a decrease in total episode spending (-1.2%, 95% confidence interval -2.3% to -0.2%). Spending on care at skilled nursing facilities decreased (-6.3%, -10.0% to -2.5%) owing to a reduced number of facility days (-6.2%, -9.8% to -2.6%), and home health spending increased (4.4%, 1.4% to 7.5%). Mortality at 90 days did not change (-0.1 percentage points, 95% confidence interval -0.5 to 0.2 percentage points). CONCLUSIONS: In this longer term evaluation of a large national programme on medical bundled payments in the US, participation in bundles for four common medical conditions was associated with savings at three years. The savings were generated by practice changes that decreased use of high intensity care after hospital discharge without affecting quality, which also suggests that bundles for medical conditions could require multiple years before changes in savings and practice emerge.

The Quality of End-of-Life Care among ICU versus Ward Decedents.

Rationale: Admissions to ICUs are common during terminal hospitalizations, but little is known about how ICU care affects the end-of-life experience for patients dying in hospitals and their families.Objectives: We measured the association between ICU care during terminal hospitalization and family ratings of end-of-life care for patients who died in 106 Veterans Affairs hospitals from 2010 to 2016.Methods: Patients were divided into four categories: no-ICU care, ICU-only care, mixed care (died outside ICU), and mixed care (died in ICU). Multivariable linear probability models were adjusted for patient and hospital characteristics. Patients receiving mixed care were also analyzed based on percentage of time in ICU.Measurements and Main Results: Of 57,550 decedents, 28,062 (48.8%) had a survey completed by a family member or close contact. In adjusted models, ICU-only care was associated with more frequent optimal ratings than no-ICU care, including overall excellent care (56.6% vs. 48.1%; P < 0.001), care consistent with preferences (78.7% vs. 72.4%; P < 0.001), and having pain controlled (51.3% vs. 46.7%; P < 0.001). Among patients with mixed care, increasing ICU time was associated with higher ratings on these same measures (all P < 0.001 for comparisons of those spending >75% time in ICU vs. ≤25% time).Conclusions: Among hospital decedents, ICU care was associated with higher family ratings of quality of end-of-life care than ward care. Reducing ICU use among hospital decedents may not improve end-of-life quality, and efforts to understand how ICU care improves end-of-life quality could help provide better care outside ICUs.

Learning Health Systems and the Revised Common Rule.

Quality improvement (QI) is an important function of learning health systems, and public policy should promote QI activities. Use of systematic methodologies in QI has prompted substantial confusion regarding when QI is human subjects research under the Common Rule, and this confusion persists with the revised Rule. Difficulty distinguishing research from QI imposes costs on the quality improvement process. I offer guidance to IRBs to mitigate these costs and suggest a new regulatory exclusion for minimal risk quality improvement activities.

The States as Laboratories: Regulation of Decisions for Incapacitated Patients.

In the United States, patients who lose the ability to make their own medical decisions are subject to the laws of their respective states. Laws governing advance directives and physician orders for life-sustaining therapies (POLST), and establishing a surrogate in the absence of an advance directive, vary substantially by jurisdiction. This article traces those laws from their origins, describes current practices and challenges with their application to patient care, and considers future avenues for ethics research and legislative reform.

Electronic health record-based clinical decision support alert for severe sepsis: a randomised evaluation.

BACKGROUND: Sepsis remains the top cause of morbidity and mortality of hospitalised patients despite concerted efforts. Clinical decision support for sepsis has shown mixed results reflecting heterogeneous populations, methodologies and interventions. OBJECTIVES: To determine whether the addition of a real-time electronic health record (EHR)-based clinical decision support alert improves adherence to treatment guidelines and clinical outcomes in hospitalised patients with suspected severe sepsis. DESIGN: Patient-level randomisation, single blinded. SETTING: Medical and surgical inpatient units of an academic, tertiary care medical centre. PATIENTS: 1123 adults over the age of 18 admitted to inpatient wards (intensive care units (ICU) excluded) at an academic teaching hospital between November 2014 and March 2015. INTERVENTIONS: Patients were randomised to either usual care or the addition of an EHR-generated alert in response to a set of modified severe sepsis criteria that included vital signs, laboratory values and physician orders. MEASUREMENTS AND MAIN RESULTS: There was no significant difference between the intervention and control groups in primary outcome of the percentage of patients with new antibiotic orders at 3 hours after the alert (35% vs 37%, p=0.53). There was no difference in secondary outcomes of in-hospital mortality at 30 days, length of stay greater than 72 hours, rate of transfer to ICU within 48 hours of alert, or proportion of patients receiving at least 30 mL/kg of intravenous fluids. CONCLUSIONS: An EHR-based severe sepsis alert did not result in a statistically significant improvement in several sepsis treatment performance measures.

Patients' Perspectives on Approaches to Facilitate Completion of Advance Directives.

BACKGROUND: Little is understood about the different ways patients complete advance directives (ADs), which is most commonly through lawyers and increasingly using websites. OBJECTIVE: To understand patients' perspectives on different approaches to facilitating AD completion, the value of legal regulation of ADs, and the use of a web-based platform to create an AD. DESIGN: Semi-structured interviews with patients. SETTING/PARTICIPANTS: We purposively sampled 25 patients at least 70 years of age or with a chronic disease from 2 internal medicine clinics. MEASUREMENTS: Interviews focused on experiences and perspectives creating ADs, including facilitation by lawyers, health-care professionals, and websites. Feedback on a website prototype was also obtained. Responses were analyzed with modified grounded theory until thematic saturation was achieved. RESULTS: Although a majority of participants with ADs had used lawyers, participants were ambivalent about the benefits of lawyer facilitation. Most valued both the medical perspective of a health-care professional and a lawyer's attention to legal requirements for AD validity. Participants had positive impressions of the web platform, but some were concerned about privacy with online storage. Trust emerged as an overarching theme, and participants valued legal regulation of ADs to ensure document authenticity and delivery of preference-concordant care. CONCLUSION: Efforts to improve documentation of care planning need to address the disparate methods by which participants complete ADs. Creating options that combine the perceived benefits of a legal approach with greater health professional involvement could appeal to participants. Privacy concerns may limit web use by some patients.

A systematic study of stereotypy in epileptic seizures versus psychogenic seizure-like events.

OBJECTIVE: The objective of this study was to quantify the features of stereotypy in epileptic seizures and compare it with that of stereotypy in psychogenic nonepileptic seizure-like events (PNES) confirmed by video-electroencephalography (VEEG) monitoring. METHODS: Video-electroencephalography monitoring records of 20 patients with temporal lobe seizures (TLS) and 20 with PNES were retrospectively reviewed (n = 138 seizures, 48 TLS and 90 PNES). We analyzed the semiology of 59 behaviors of interest for their presence, duration, sequence, and continuity using quantified measures that were entered into statistical analysis. RESULTS: We identified discontinuity as the parameter that was clearly distinct between PNES and epileptic TLS events: there were significantly more frequent pauses of behavior (i.e., "on-off" pattern) in PNES compared with TLS (P = 0.012). The frequency of pauses during an event was diagnostic of PNES events. For instance, the presence of 2 "pauses" during an episode determines a 69% probability of the seizure being nonepileptic. Moreover, PNES events had significantly greater duration (143 s) than TLS events (68 s) (excluding outliers, P = 0.002) and greater duration variability from one event to another in the same subject (P = 0.005). SIGNIFICANCE: Our work provides the first quantified measure of behavioral semiology during epileptic and nonepileptic seizures and offers novel behavioral measures to differentiate them from each other.

The Use of Individual Provider Performance Reports by US Hospitals.

Medicare reimbursement for hospitals is increasingly tied to performance. The use of individual provider performance reports offers the potential to improve clinical outcomes through social comparison, and isolated cases of clinical dashboard uses at specific institutions have been previously reported. However, little is known about overall trends in how hospitals use the electronic health record to track and provide feedback on provider performance. We used data from 2013 to 2015 from the American Hospital Association (AHA) Annual Survey Information Technology Supplement, which asked hospitals if they have used electronic data to create performance profiles. We linked these data to AHA Annual Survey responses for all general adult and pediatric hospitals. Multivariable logistic regression was used to model the odds of use as a function of hospital characteristics. In 2015, 65.8% of the 2334 respondents used performance profiles, whereas 59.3% of the 2077 respondents used them in 2013. Report use was associated with non-profit status (odds ratio [OR], 2.77; 95% confidence interval [CI], 1.94-3.95) compared to for-profit, large hospital size (OR, 2.37; 95% CI, 1.56-3.60) compared to small size, highest quartile of bed-adjusted expenditures compared to bottom quartile (OR, 2.09; 95% CI, 1.55-2.82; P < .01), and participation in a health maintenance organization (OR, 1.50; 95% CI, 1.17-1.90; P < .01) or bundled payment program (OR, 1.61; 95% CI, 1.18- 2.19; P < .01). While a majority of hospitals now use such profiles, more than a third do not. The hospitals that do not use performance profiles may be less well positioned to adapt to value-based payment reforms.

Validation of Test Performance and Clinical Time Zero for an Electronic Health Record Embedded Severe Sepsis Alert.

BACHGROUND: Increasing use of EHRs has generated interest in the potential of computerized clinical decision support to improve treatment of sepsis. Electronic sepsis alerts have had mixed results due to poor test characteristics, the inability to detect sepsis in a timely fashion and the use of outside software limiting widespread adoption. We describe the development, evaluation and validation of an accurate and timely severe sepsis alert with the potential to impact sepsis management. OBJECTIVE: To develop, evaluate, and validate an accurate and timely severe sepsis alert embedded in a commercial EHR. METHODS: The sepsis alert was developed by identifying the most common severe sepsis criteria among a cohort of patients with ICD 9 codes indicating a diagnosis of sepsis. This alert requires criteria in three categories: indicators of a systemic inflammatory response, evidence of suspected infection from physician orders, and markers of organ dysfunction. Chart review was used to evaluate test performance and the ability to detect clinical time zero, the point in time when a patient develops severe sepsis. RESULTS: Two physicians reviewed 100 positive cases and 75 negative cases. Based on this review, sensitivity was 74.5%, specificity was 86.0%, the positive predictive value was 50.3%, and the negative predictive value was 94.7%. The most common source of end-organ dysfunction was MAP less than 70 mm/Hg (59%). The alert was triggered at clinical time zero in 41% of cases and within three hours in 53.6% of cases. 96% of alerts triggered before a manual nurse screen. CONCLUSION: We are the first to report the time between a sepsis alert and physician chart-review clinical time zero. Incorporating physician orders in the alert criteria improves specificity while maintaining sensitivity, which is important to reduce alert fatigue. By leveraging standard EHR functionality, this alert could be implemented by other healthcare systems.

Aggregate health data in the United States: steps toward a public good.

The rise of electronic medical records promotes the collection and aggregation of medical data. These data have tremendous potential utility for health policy and public health; yet there are gaps in the scholarly literature. No articles in the medical or legal literature have mapped the "information flows" from patient to database, and commentary has focused more on privacy than on data's social value and incentives for production. Utilizing short case studies of data flows, I show that ample data exist, much of them are available online through government websites or hospital trade associations. However, available information comes from billing records rather than medical records. Turning to legal and policy recommendations for better provision, I note that weak intellectual property law has ironically led to stronger control over health data through private contracts and technological barriers, as these methods of protection lack any exceptions for noncommercial use. I conclude with a series of policy proposals to make data more available.

Legal restrictions and complications of abortion: insights from data on complication rates in the United States.

Although US federal law requires all American states to permit abortion within their borders, states retain authority to impose restrictions.We used hospital discharge data to study the rates of major abortion complications in 23 states from 2001 to 2008 and their relationship to two laws: (i) restrictions on Medicaid ­ the state insurance programs for the poor ­ funding, and (ii) mandatory delays before abortion. Of 131 000 000 discharges in the data set, 10 980 involved an abortion complication. The national rate for complications was 1.90 per 1000 abortions (95 per cent CI: 1.57­2.23). Eleven states required mandatory delays and 12 restricted funding for Medicaid participants. After controlling for socioeconomic characteristics and the pregnancy complication rate, legal restrictions were associated with lower complication rates: mandatory delays (OR 0.79(0.65­0.95)) and restricted Medicaid funding (OR 0.74 (0.61­0.90)). This result may reflect the fact that states without restrictions perform a higher percentage of second-trimester abortions. This study is the first to assess the association between legal restrictions on abortion and complication rates.

Automatisms: bridging clinical neurology with criminal law.

The law, like neurology, grapples with the relationship between disease states and behavior. Sometimes, the two disciplines share the same terminology, such as automatism. In law, the "automatism defense" is a claim that action was involuntary or performed while unconscious. Someone charged with a serious crime can acknowledge committing the act and yet may go free if, relying on the expert testimony of clinicians, the court determines that the act of crime was committed in a state of automatism. In this review, we explore the relationship between the use of automatism in the legal and clinical literature. We close by addressing several issues raised by the automatism defense: semantic ambiguity surrounding the term automatism, the presence or absence of consciousness during automatisms, and the methodological obstacles that have hindered the study of cognition during automatisms.

Multislice CT angiography.

The introduction of multislice CT into clinical radiology constitutes a quantum leap that significantly widens the scope of vascular CT imaging. The advances over conventional spiral CT have been quantitative, mainly in terms of increased image acquisition speed which provides unprecedented volume coverage and spatial resolution. Moreover, significant technical innovations, such as cardiac scanning capabilities, have brought about a qualitative shift towards applications that were thought to be beyond the scope of CT imaging. This way multislice CT offers a wealth of new opportunities for quickly and accurately diagnosing suspected vascular disease in all organ systems; however, as we move towards faster and faster image acquisition techniques, we are also facing new challenges that require development of novel strategies in order to take full advantage of the increased capabilities of multislice CT in its current form and future generations of CT scanners.

Multislice CT colonography: current status and limitations.

CT colonography (CTC) is a promising method for colorectal screening providing a full structural evaluation of the entire colon and gaining in popularity due to a superior safety profile, a low rate of complications, and high patient acceptance. Multislice CT (MSCT) has further improved the diagnostic potential of CTC by generating high-resolution CT images of the abdomen and pelvis in shorter acquisition times than was previously possible. Over the past year, multiple studies have been published on every aspect of CTC including techniques, image display, image reconstruction, and clinical trial results assessing the feasibility of CTC as a screening tool. Yet despite increasing clinical use, the appropriate role of CTC in colorectal cancer screening remains undefined and barriers to widespread adoption remain. In particular, though the test is generally regarded as easy to perform, accurate interpretation requires a steep learning curve. While several large studies have found high sensitivity and specificity, the accuracy of CTC in a screening population has yet to be verified and almost no health insurance plans reimburse for its use in colorectal screening. Ongoing research in computer-aided detection and new software tools, however, have the potential to increase accuracy and ease of interpretation significantly, accelerating its acceptance as a colorectal screening tool.