Sharing Clinical Notes while Protecting Adolescent Confidentiality and Maintaining Parental Insight.

BACKGROUND: The 21st Century Cures Act mandates sharing electronic health records (EHRs) with patients. Health care providers must ensure confidential sharing of medical information with adolescents while maintaining parental insight into adolescent health. Given variability in state laws, provider opinions, EHR systems, and technological limitations, consensus on best practices to achieve adolescent clinical note sharing at scale is needed. OBJECTIVES: This study aimed to identify an effective intervention process to implement adolescent clinical note sharing, including ensuring adolescent portal account registration accuracy, across a large multihospital health care system comprising inpatient, emergency, and ambulatory settings. METHODS: A query was built to assess portal account registration accuracy. At a large multihospital health care system, 80.0% of 12- to 17-year-old patient portal accounts were classified as inaccurately registered (IR) under a parent or registration accuracy unknown (RAU). To increase accurately registered (AR) accounts, the following interventions were pursued: (1) distribution of standardized portal enrollment training; (2) patient outreach email campaign to reregister 29,599 portal accounts; (3) restriction of access to remaining IR and RAU accounts. Proxy portal configurations were also optimized. Subsequently, adolescent clinical note sharing was implemented. RESULTS: Distribution of standardized training materials decreased IR and increased AR accounts (p = 0.0492 and 0.0058, respectively). Our email campaign (response rate: 26.8%) was most effective in decreasing IR and RAU accounts and increasing AR accounts (p < 0.002 for all categories). Remaining IR and RAU accounts, 54.6% of adolescent portal accounts, were subsequently restricted. Postrestriction, IR accounts continued declining significantly (p = 0.0056). Proxy portal enhancements with interventions deployed increased proxy portal account adoption. CONCLUSION: A multistep intervention process can be utilized to effectively implement adolescent clinical note sharing at a large scale across care settings. Improvements to EHR technology, portal enrollment training, adolescent/proxy portal settings, detection, and automation in reenrollment of inaccurate portal accounts are needed to maintain integrity of adolescent portal access.

Assessing Usability and Ambulatory Clinical Staff Satisfaction with Two Electronic Health Records.

BACKGROUND: A growing body of literature has linked usability limitations within electronic health records (EHRs) to adverse outcomes which may in turn affect EHR system transitions. NewYork-Presbyterian Hospital, Columbia University College of Physicians and Surgeons (CU), and Weill Cornell Medical College (WC) are a tripartite organization with large academic medical centers that initiated a phased transition of their EHRs to one system, EpicCare. OBJECTIVES: This article characterizes usability perceptions stratified by provider roles by surveying WC ambulatory clinical staff already utilizing EpicCare and CU ambulatory clinical staff utilizing iterations of Allscripts before the implementation of EpicCare campus-wide. METHODS: A customized 19-question electronic survey utilizing usability constructs based on the Health Information Technology Usability Evaluation Scale was anonymously administered prior to EHR transition. Responses were recorded with self-reported demographics. RESULTS: A total of 1,666 CU and 1,065 WC staff with ambulatory self-identified work setting were chosen. Select demographic statistics between campus staff were generally similar with small differences in patterns of clinical and EHR experience. Results demonstrated significant differences in EHR usability perceptions among ambulatory staff based on role and EHR system. WC staff utilizing EpicCare accounted for more favorable usability metrics than CU across all constructs. Ordering providers (OPs) denoted less usability than non-OPs. The Perceived Usefulness and User Control constructs accounted for the largest differences in usability perceptions. The Cognitive Support and Situational Awareness construct was similarly low for both campuses. Prior EHR experience demonstrated limited associations. CONCLUSION: Usability perceptions can be affected by role and EHR system. OPs consistently denoted less usability overall and were more affected by EHR system than non-OPs. While there was greater perceived usability for EpicCare to perform tasks related to care coordination, documentation, and error prevention, there were persistent shortcomings regarding tab navigation and cognitive burden reduction, which have implications on provider efficiency and wellness.

Advancing the Agenda in Pediatric Mental Health Education.

BACKGROUND AND OBJECTIVES: There is an urgent need to advance mental health (MH) education and/or training in pediatric residency programs, yet no consensus on how to achieve this. We created an operational framework from ideas provided by a diverse group of stakeholders on how to advance MH education. METHODS: Concept-mapping methodology was used, which involves brainstorming ideas by completing a focus prompt, sorting ideas into groups, and rating them for importance and feasibility. Multidimensional scaling and hierarchical cluster analysis grouped ideas into clusters. Average importance and feasibility were calculated for each statement and cluster and compared statistically in each cluster and between subgroups. RESULTS: Ninety-nine ideas were generated. Sorted ideas yielded a 7-cluster concept map: (1) modalities for MH training, (2) prioritization of MH, (3) systems-based practice, (4) self-awareness and/or relationship building, (5) training in clinical assessment of patients, (6) training in treatment, and (7) diagnosis-specific skills. Two hundred and sixteen participants rated ideas for importance and 209 for feasibility. Four clusters had a statistically significant difference between their importance and feasibility ratings (P < .001). Suburban and rural area respondents (versus urban) rated clusters higher in importance and feasibility (P < .004), trainees rated all clusters higher in feasibility than practicing clinicians, and MH professionals rated prioritization of MH higher in feasibility (3.42 vs 2.98; P < .001). CONCLUSIONS: This comprehensive set of ideas, especially those rated highly in both importance and feasibility, should inform curricular and policy initiatives. Differences between importance and feasibility may explain why there has been little progress in this field.

Implementing Emotional Debriefing in Pediatric Clinical Education.

Challenging situations and intense emotions are inherent to clinical practice. Failure to address these emotions has been associated with health care provider burnout. One way to combat this burnout and increase resilience is participation in emotional debriefing. Although there are many models of emotional debriefings, these are not commonly performed in clinical practice. We provide a guide for implementing emotional debriefing training utilizing the American Academy of Pediatrics Resilience Curriculum into clinical training programs, with a focus on preparing senior residents and fellows to act as debriefing facilitators. Senior residents and fellows can provide in-the-moment emotional debriefing which allows for greater health care provider participation, including medical students and other pediatric trainees. Training of senior residents and fellows may allow more frequent emotional debriefing and in turn may help to improve the resilience of pediatricians when they face challenging situations in clinical practice.

The AAP Resilience in the Face of Grief and Loss Curriculum.

A career in pediatrics can bring great joy and satisfaction. It can also be challenging and lead some providers to manifest burnout and depression. A curriculum designed to help pediatric health providers acquire resilience and adaptive skills may be a key element in transforming times of anxiety and grief into rewarding professional experiences. The need for this curriculum was identified by the American Academy of Pediatrics Section on Medical Students, Residents and Fellowship Trainees. A working group of educators developed this curriculum to address the professional attitudes, knowledge, and skills essential to thrive despite the many stressors inevitable in clinical care. Fourteen modules incorporating adult learning theory were developed. The first 2 sections of the curriculum address the knowledge and skills to approach disclosure of life-altering diagnoses, and the second 2 sections focus on the provider's responses to difficult patient care experiences and their needs to develop strategies to maintain their own well-being. This curriculum addresses the intellectual and emotional characteristics patient care medical professionals need to provide high-quality, compassionate care while also addressing active and intentional ways to maintain personal wellness and resilience.

The current and ideal state of mental health training: pediatric resident perspectives.

UNLABELLED: PHENOMENON: Mental health (MH) problems are prevalent in the pediatric population, and in a setting of limited resources, pediatricians need to provide MH care in the primary medical home yet are uncomfortable doing so citing a lack of training during residency as one barrier. APPROACH: The purpose of this study is to describe pediatric residents' experiences and perspectives on the current and ideal states of MH training and ideas for curriculum development to bridge this gap. A qualitative study using focus groups of pediatric residents from an urban academic medical center was performed. Audio recordings were transcribed and analyzed using a grounded theory approach. FINDINGS: Twenty-six residents participated in three focus groups, which is when thematic saturation was achieved. The team generated five major themes: capabilities, comfort, organizational capacity, coping, and education. Residents expressed uncertainty at every step of an MH visit. Internal barriers identified included low levels of comfort and negative emotional responses. External barriers included a lack of MH resources and mentorship in MH care, or an inadequate organizational capacity. These internal and external barriers resulted in a lack of perceived capability in handling MH issues. In response, residents reported inadequate coping strategies, such as ignoring MH concerns. To build knowledge and skills, residents prefer educational modalities including didactics, experiential learning through collaborations with MH specialists, and tools built into patient care flow. Insights: Pediatric residency programs need to evolve in order to improve resident training in MH care. The skills and knowledge requested by residents parallel the American Academy of Pediatrics statement on MH competencies. Models of collaborative care provide similar modalities of learning requested by residents. These national efforts have not been operationalized in training programs yet may be useful for curriculum development and dissemination to enhance trainees' MH knowledge and skills to provide optimal MH care for children.

Intercepting wrong-patient orders in a computerized provider order entry system.

STUDY OBJECTIVE: We evaluate the short- and long-term effect of a computerized provider order entry-based patient verification intervention to reduce wrong-patient orders in 5 emergency departments. METHODS: A patient verification dialog appeared at the beginning of each ordering session, requiring providers to confirm the patient's identity after a mandatory 2.5-second delay. Using the retract-and-reorder technique, we estimated the rate of wrong-patient orders before and after the implementation of the intervention to intercept these errors. We conducted a short- and long-term quasi-experimental study with both historical and parallel controls. We also measured the amount of time providers spent addressing the verification system, and reasons for discontinuing ordering sessions as a result of the intervention. RESULTS: Wrong-patient orders were reduced by 30% immediately after implementation of the intervention. This reduction persisted when inpatients were used as a parallel control. After 2 years, the rate of wrong-patient orders remained 24.8% less than before intervention. The mean viewing time of the patient verification dialog was 4.2 seconds (SD=4.0 seconds) and was longer when providers indicated they placed the order for the wrong patient (4.9 versus 4.1 seconds). Although the display of each dialog took only seconds, the large number of display episodes triggered meant that the physician time to prevent each retract-and-reorder event was 1.5 hours. CONCLUSION: A computerized provider order entry-based patient verification system led to a moderate reduction in wrong-patient orders that was sustained over time. Interception of wrong-patient orders at data entry is an important step in reducing these errors.

The current and ideal state of mental health training: pediatric program director perspectives.

OBJECTIVE: To assess pediatric residency program director (PD) perceptions of the current state of mental health (MH) training, their receptivity to curricular changes, and perceptions of their residents' knowledge and skills in MH care. METHODS: We performed a cross-sectional study utilizing a Web-based survey of pediatric residency PDs to assess program characteristics, learning modalities PDs currently had or would implement, and their knowledge of the new American Academy of Pediatrics' MH competencies. PDs then ranked their residents' knowledge and skills for 29 MH competencies. Analyses included descriptive statistics and bivariate and multivariate analyses to assess for associations between variables, particularly MH model of care and perceived competence. RESULTS: Ninety-nine PDs (51%) responded. A total of 87% of PDs reported that MH care was taught as part of another rotation, yet PDs were receptive to curricular changes. Only 45% of PDs were aware of the 2009 American Academy of Pediatrics competencies, and PDs infrequently rated their residents' MH skills and knowledge to be above average. Attention-deficit/hyperactivity disorder (ADHD) was an exception: 64% reported above-average ADHD knowledge in diagnoses and 57% in treatment. There was an association between enhanced MH services in continuity clinics and perceived resident systems-based practice (P < .01) and medical knowledge (P = .04). CONCLUSIONS: PDs acknowledged that MH training is not emphasized, leading to deficiencies in their residents' knowledge and skills in MH care. The receptivity of PDs suggests the need for targeted dissemination of national guidelines or curriculum. Integrated models of care may be one way to improve resident competencies, but this deserves further study.

Implementation of a computerized patient handoff application.

For hospitalized patients, handoffs between providers affect continuity of care and increase the risk of medical errors. Most commercial electronic health record (EHR) systems lack dedicated tools to support patient handoff activities. We developed a collaborative application supporting patient handoff that is fully integrated with our commercial EHR. The application creates user-customizable printed reports with automatic inclusion of a variety of EHR data, including: allergies, medications, 24-hour vital signs, recent common laboratory test results, isolation requirements, and code status. It has achieved widespread voluntary use at our institution (6,100 monthly users; 700 daily reports generated), and we have distributed the application to several other institutions using the same EHR. Though originally designed for resident physicians, today about 50% of the application users are nurses, 40% are physicians/physician assistants/nurse practitioners, and 10% are pharmacists, social workers, and other allied health providers.

A ballroom dance classroom program promotes moderate to vigorous physical activity in elementary school children.

PURPOSE: To determine if an existing ballroom dance classroom program meets national recommendations to engage children in moderate to vigorous physical activity (MVPA) for ≥50% of class time and to determine class effects on body mass index (BMI). DESIGN: Prospective descriptive study. Setting . Two New York City public schools. PARTICIPANTS: Seventy-nine fourth and fifth grade students. MEASUREMENTS: The System for Observing Fitness Instruction Time (SOFIT) and direct heart rate monitoring were used to determine participants' MVPA levels during class time. Weight and height were measured to calculate BMI. ANALYSIS: Means were calculated for continuous variables; frequency counts and percentages were calculated for categorical variables. Change in BMI percentiles was assessed by using Bhapkar's χ(2) test of overall marginal homogeneity. RESULTS: Data from SOFIT observations showed that a mean of 50.0% and 67.0% of class time in the first and second halves of the program, respectively, were spent in MVPA. Data from the heart rate monitoring revealed that 71.1% of students were at ≥25% heart rate reserve, which indicated MVPA for ≥50% of class time. Improvement was seen in BMI percentile (p= .051). CONCLUSION: Ballroom dance provides MVPA in elementary school children for ≥50% of class time and has a positive impact on BMI percentiles.

Use of electronic clinical documentation: time spent and team interactions.

OBJECTIVE: To measure the time spent authoring and viewing documentation and to study patterns of usage in healthcare practice. DESIGN: Audit logs for an electronic health record were used to calculate rates, and social network analysis was applied to ascertain usage patterns. Subjects comprised all care providers at an urban academic medical center who authored or viewed electronic documentation. MEASUREMENT: Rate and time of authoring and viewing clinical documentation, and associations among users were measured. RESULTS: Users spent 20-103 min per day authoring notes and 7-56 min per day viewing notes, with physicians spending less than 90 min per day total. About 16% of attendings' notes, 8% of residents' notes, and 38% of nurses' notes went unread by other users, and, overall, 16% of notes were never read by anyone. Viewing of notes dropped quickly with the age of the note, but notes were read at a low but measurable rate, even after 2 years. Most healthcare teams (77%) included a nurse, an attending, and a resident, and those three users' groups were the first to write notes during an admission. Limitations The limitations were restriction to a single academic medical center and use of log files without direct observation. CONCLUSIONS: Care providers spend a significant amount of time viewing and authoring notes. Many notes are never read, and rates of usage vary significantly by author and viewer. While the rate of viewing a note drops quickly with its age, even after 2 years inpatient notes are still viewed.

The role of housestaff in implementing medication reconciliation on admission at an academic medical center.

Since 2006, the Joint Commission has required all hospitals to have a process in place for medication reconciliation (MR). Although it has been shown that MR decreases medical errors, achieving compliance has proven difficult for many health care institutions. This article describes a housestaff-championed intervention of a "hard stop" for on-admission MR orders that led to a statistically significant increase in compliance that was sustained at 6 months after intervention. Academic medical centers, which comprise large numbers of housestaff, can improve compliance with on-admission MR by engaging housestaff in the development of solutions and in communication to their peers, leading to sustained results.

Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients.

OBJECTIVES: This study was conducted to determine the impact of a computerized physician order entry system with substantial decision support on the incidence and types of adverse drug events in hospitalized children. METHODS: A prospective methodology was used for the collection of adverse drug events and potential adverse drug events from all patients admitted to the pediatric intensive care and general pediatric units over a 6-month period. Data from a previous adverse drug event study of the same patient care units before computerized physician order entry implementation were used for comparison purposes. RESULTS: Data for 1197 admissions before the introduction of computerized physician order entry were compared with 1210 admissions collected after computerized physician order entry implementation. After computerized physician order entry implementation, it was observed that the number of preventable adverse drug events (46 vs 26) and potential adverse drug events (94 vs 35) was reduced. Reductions in overall errors, dispensing errors, and drug-choice errors were associated with computerized physician order entry. There were reductions in significant events, as well as those events rated as serious or life threatening, after the implementation of computerized physician order entry. Some types of adverse drug events continued to persist, specifically underdosing of analgesics. There were no differences in length of stay or patient disposition between preventable adverse drug events and potential adverse drug events in either study period. CONCLUSIONS: This study demonstrated that a computerized physician order entry system with substantive decision support was associated with a reduction in both adverse drug events and potential adverse drug events in the inpatient pediatric population. Additional system refinements will be necessary to affect remaining adverse drug events. Preventable events did not predict excess length of stay and instead may represent a sign, rather than a cause, of more complicated illness.

Incidence and impact of adverse drug events in pediatric inpatients.

OBJECTIVES: To determine the incidence and causes of adverse drug events (ADEs) and potential ADEs in hospitalized children, and to examine the consequences of these events. DESIGN: Prospective review of medical records and staff interviews were performed. The ADEs were defined as injuries from medications or lack of an intended medication, and potential ADEs, as errors with the potential to result in injury. SETTING: A general pediatric unit and a pediatric intensive care unit in a metropolitan medical center. PATIENTS: A total of 1197 consecutive patient admissions were studied from September 15, 2000, to May 10, 2001. The admissions represented a total of 922 patients and 10,164 patient-days. RESULTS: The ADEs (6/100 admissions, 7.5/1000 patient-days) and potential ADEs (8/100 admissions, 9.3/1000 patient-days) were common in hospitalized children. Demographic variables associated with the occurrence of these events were the length of hospital stay, case-mix index, and amount of medication exposure. After adjusting for length of stay, medication exposure continued to have a significant influence on ADEs and potential ADEs. For ADEs, 18 (24%) were judged to be serious or life threatening. Most ADEs were not associated with major or permanent disability. Patients with both ADEs and potential ADEs were less likely to be routinely discharged and more likely to be discharged with home health care or to another institution, suggesting that patient disposition was not related to the adverse event. CONCLUSIONS: Both ADEs and potential ADEs are common among hospitalized children with greater disease burden and medication exposure. These findings suggest that these events were a consequence, rather than a cause, of more severe illness.