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.

Intake assessments of salivary cortisol, survey responses, and adverse childhood experiences are associated with recovery success in an abstinence-based treatment program for substance use disorders.

BACKGROUND: Connecting patients to treatment for a substance use disorder (SUD) that satisfies their needs is often complicated by confounding factors. A reliable measurement of patients' underlying stress level may be helpful because it often reflects many of the same confounders as their SUD. Whereas cortisol levels reflect physiological responses to stress, patients' cortisol levels during recovery from an SUD may serve as biomarkers for stressors that result in poor treatment outcomes, including early discontinuation of treatment. However, further exploration of the relationship between patients' cortisol levels and their treatment outcomes is needed for this approach to be clinically useful. METHODS: We enrolled participants from an abstinence-based, male-only, residential alcohol and drug recovery program to examine the relationship between salivary cortisol, stress exposure, ACEs, and treatment retention. RESULTS: Participants who remained in the program <90 days had significantly higher initial cortisol levels than those who remained ≥90 days (0.62 ± 0.074 µg/dl vs. 0.36 ± 0.037 µg/dl). Kaplan-Meier curves differed significantly when we grouped participants according to whether their cortisol level was below or above the overall average of 0.49 ± 0.044 µg/dl, with the median numbers of days before discontinuing being 110 and 60, respectively. A Cox proportional hazards model indicated that elevated salivary cortisol (with increases in µg/dl), marital/relationship status, and adverse childhood experiences (ACEs) score correlated significantly with hazards of discontinuing the program (hazard ratios for the three factors were 3.49, 2.39, and 1.50, respectively). DISCUSSION: Cortisol level may predict, at least partially, SUD treatment program retention regardless of individuals' numerous confounding factors or the substance used. If this approach is validated, it could enable providers to consider patients' cortisol levels at the time of admission to treatment to facilitate their retention in treatment and thereby enhance their recovery.

Dose calculation for permanent prostate implants incorporating spatially anisotropic linearly time-resolving edema.

PURPOSE: The objectives of this study were (i) to develop a dose calculation method for permanent prostate implants that incorporates a clinically motivated model for edema and (ii) to illustrate the use of the method by calculating the preimplant dosimetry error for a reference configuration of 125I, 103Pd, and 137Cs seeds subject to edema-induced motions corresponding to a variety of model parameters. METHODS: A model for spatially anisotropic edema that resolves linearly with time was developed based on serial magnetic resonance imaging measurements made previously at our center to characterize the edema for a group of n = 40 prostate implant patients [R. S. Sloboda et al., "Time course of prostatic edema post permanent seed implant determined by magnetic resonance imaging," Brachytherapy 9, 354-361 (2010)]. Model parameters consisted of edema magnitude, delta, and period, T. The TG-43 dose calculation formalism for a point source was extended to incorporate the edema model, thus enabling calculation via numerical integration of the cumulative dose around an individual seed in the presence of edema. Using an even power piecewise-continuous polynomial representation for the radial dose function, the cumulative dose was also expressed in closed analytical form. Application of the method was illustrated by calculating the preimplant dosimetry error, RE(preplan), in a 5 x 5 x 5 cm3 volume for 125I (Oncura 6711), 103Pd (Theragenics 200), and 131Cs (IsoRay CS-1) seeds arranged in the Radiological Physics Center test case 2 configuration for a range of edema relative magnitudes (delta = [0.1, 0.2, 0.4, 0.6, 1.0]) and periods (T = [28, 56, 84] d). Results were compared to preimplant dosimetry errors calculated using a variation of the isotropic edema model developed by Chen et al. ["Dosimetric effects of edema in permanent prostate seed implants: A rigorous solution," Int. J. Radiat. Oncol., Biol., Phys. 47, 1405-1419 (2000)]. RESULTS: As expected, RE(preplan) for our edema model indicated underdosage in the calculation volume with a clear dependence on seed and calculation point positions, and increased with increasing values of delta and T. Values of RE(preplan) were generally larger near the ends of the virtual prostate in the RPC phantom compared with more central locations. For edema characteristics similar to the population average values previously measured at our center, i.e., delta = 0.2 and T = 28 d, mean values of RE(preplan) in an axial plane located 1.5 cm from the center of the seed distribution were 8.3% for 131Cs seeds, 7.5% for 103Pd seeds, and 2.2% for 125I seeds. Maximum values of RE(preplan) in the same plane were about 1.5 times greater. Note that detailed results strictly apply only for loose seed implants where the seeds are fixed in tissue and move in synchrony with that tissue. CONCLUSIONS: A dose calculation method for permanent prostate implants incorporating spatially anisotropic linearly time-resolving edema was developed for which cumulative dose can be written in closed form. The method yields values for RE(preplan) that differ from those for spatially isotropic edema. The method is suitable for calculating pre- and postimplant dosimetry correction factors for clinical seed configurations when edema characteristics can be measured or estimated.

Are current insulin pumps accessible to blind and visually impaired people?

BACKGROUND: In 2004, Uslan and colleagues determined that insulin pumps (IPs) on the market were largely inaccessible to blind and visually impaired persons. The objective of this study is to determine if accessibility status changed in the ensuing 4 years. METHODS: Five IPs on the market in 2008 were acquired and analyzed for key accessibility traits such as speech and other audio output, tactual nature of control buttons, and the quality of visual displays. It was also determined whether or not a blind or visually impaired person could independently complete tasks such as programming the IP for insulin delivery, replacing batteries, and reading manuals and other documentation. RESULTS: It was found that IPs have not improved in accessibility since 2004. None have speech output, and with the exception of the Animas IR 2020, no significantly improved visual display characteristics were found. Documentation is still not completely accessible. CONCLUSION: Insulin pumps are relatively complex devices, with serious health consequences resulting from improper use. For IPs to be used safely and independently by blind and visually impaired patients, they must include voice output to communicate all the information presented on their display screens. Enhancing display contrast and the size of the displayed information would also improve accessibility for visually impaired users. The IPs must also come with accessible user documentation in alternate formats.

Blood glucose meters that are accessible to blind and visually impaired persons.

Blood glucose meters (BGMs) that can be used nonvisually or with a visual limitation were introduced in the mid-1990s, but it was not until 2006 and 2007 that a new set of meters with accessibility features were introduced: Prodigy, Prodigy Autocode, and Prodigy Voice (Diagnostic Devices, Charlotte, NC), and Advocate and Advocate Redi-Code (TaiDoc, Taiwan). Accessibility attributes of the newly introduced BGMs were tabulated, and product design features were examined and documented. The Prodigy Voice was found to be the only one of these new BGMs that is fully usable by blind and visually impaired persons.