The relationship between perceptions of electronic health record usability and clinical importance of social and environmental determinants of health on provider documentation.

Social and environmental determinants of health (SEDH) data in the electronic health record (EHR) can be inaccurate and incomplete. Providers are in a unique position to impact this issue as they both obtain and enter this data, however, the variability in screening and documentation practices currently limits the ability to mobilize SEDH data for secondary uses. This study explores whether providers' perceptions of clinical importance of SEDH or EHR usability influenced data entry by analyzing two relationships: (1) provider charting behavior and clinical consideration of SEDH and (2) provider charting behavior and ease of EHR use in charting. We performed a cross-sectional study using an 11-question electronic survey to assess self-reported practices related to clinical consideration of SEDH elements, EHR usability and SEDH documentation of all staff physicians, identified using administrative listserves, at Penn State Health Hershey Medical Center during September to October 2021. A total of 201 physicians responded to and completed the survey out of a possible 2,478 identified staff physicians (8.1% response rate). A five-point Likert scale from "never" to "always" assessed charting behavior and clinical consideration. Responses were dichotomized as consistent/inconsistent and vital/not vital respectively. EHR usability was assessed as "yes" or "no" responses. Fisher's exact tests assessed the relationship between charting behavior and clinical consideration and to compare charting practices between different SEDHs. Cumulative measures were constructed for consistent charting and ease of charting. A generalized linear mixed model (GLMM) compared SDH and EDH with respect to each cumulative measure and was quantified using odds ratios (OR) and 95% confidence intervals (CI). Our results show that provider documentation frequency of an SEDH is associated with perceived clinical utility as well as ease of charting and that providers were more likely to consistently chart on SDH versus EDH. Nuances in these relationships did exist with one notable example comparing the results of smoking (SDH) to infectious disease outbreaks (EDH). Despite similar percentages of physicians reporting that both smoking and infectious disease outbreaks are vital to care, differences in charting consistency and ease of charting between these two were seen. Taken as a whole, our results suggest that SEDH quality optimization efforts cannot consider physician perceptions and EHR usability as siloed entities and that EHR design should not be the only target for intervention. The associations found in this study provide a starting point to understand the complexity in how clinical utility and EHR usability influence charting consistency of each SEDH element, however, further research is needed to understand how these relationships intersect at various levels in the SEDH data optimization process.

A retrospective analysis of complications associated with postpartum hemorrhage up to 1 year postpartum in mothers with and without a pre-existing mental health diagnosis.

BACKGROUND/OBJECTIVES: There is limited research on the associated immediate and long-term outcomes of postpartum hemorrhage. Mothers with a pre-existing psychiatric disease prior to delivery may be especially vulnerable to postpartum hemorrhage outcomes but little is known on this topic. Barriers to studying this population exist and add to knowledge gaps. The goal of this study is to determine the clinical characteristics and frequency of complications within 1 year of a postpartum hemorrhage diagnosis and the psychiatric sequelae within 7 days of a postpartum hemorrhage diagnosis in mothers with a pre-existing mental health diagnosis prior to delivery versus those without. METHODS/DESIGN: This is a multicenter retrospective observational cohort study using TriNetX, a de-identified electronic health record database. The following electronic health record data were collected and evaluated in postpartum females who were billed for either a vaginal or cesarean delivery: age, race, ethnicity, diagnostic codes, medication codes, and number of deaths. RESULTS: We included 10,649 subjects (6994 (65.7%) no mental health diagnosis and 3655 (34.3%) pre-existing mental health diagnosis). Haloperidol administration (118 (3.2%) versus 129 (1.8%), p < 0.001) was more prevalent in subjects with a pre-existing mental health diagnosis. Adjusting for demographics, pre-existing mental health diagnoses were associated with complications within 1 year after postpartum hemorrhage diagnosis (OR = 1.39, 95% CI: 1.26-1.52, p < 0.001). CONCLUSION: Having a mental health disorder history is associated with a higher odds of developing subsequent complications within 1 year of postpartum hemorrhage diagnosis. Mothers with a pre-existing mental health disorder have a significantly higher frequency of certain severe postpartum hemorrhage sequelae, including acute respiratory distress syndrome, retained placenta, sickle cell crisis, and need for mechanical ventilation/tracheostomy up to 1 year after delivery. Medications such as haloperidol were ordered more frequently within 7 days of a postpartum hemorrhage diagnosis in these mothers as well. Further research is needed to understand and manage the unique consequences of postpartum hemorrhage in this vulnerable maternal population.

Social determinants of perinatal mental health during the COVID-19 pandemic.

OBJECTIVE: We sought to clarify relevant social-structural determinants of perinatal mental health-material and social resources, as well as pandemic employment-related stressors, in White and BIPOC child-bearers-toward building comprehensive risk screening and prevention/intervention models that can alleviate health disparities. Each of these determinants was hypothesized to contribute to perinatal symptoms in ways that disproportionately benefit White child-bearers. METHOD: A community sample of Illinois child-bearers (n = 409 pregnant, 122 new parents) completed online questionnaires from May 2020-June 2021. Relations between composite measures of child-bearers' material resources, social resources, and pandemic employment-related stressors and mental health symptoms were tested in multiple regression models. Main effects of social determinant composites and moderated effects by race/ethnic identification were tested. RESULTS: All social determinants displayed significant unique associations with mental health in the sample, with social resources carrying the greatest weight. Although no moderated effects of composite resource measures were found, the relation between pandemic employment-related reduced resources and symptoms proved stronger in BIPOC compared to White child-bearers. CONCLUSIONS: Both stable social-structural determinants and acute crisis-related shifts contribute to perinatal mental health, with higher levels and/or impacts of resources helping to explain racial/ethnic disparities. These findings can inform more comprehensive screening and prevention protocols and policy recommendations that improve perinatal health outcomes.

Idiopathic spontaneous haemoperitoneum at 4 weeks gestation.

A 20-year-old nulliparous patient with acute-onset abdominal pain and imaging suggestive of haemoperitoneum was admitted for observation. Though, initially, haemodynamically stable, her clinical picture worsened throughout her hospitalisation and warranted two separate laparoscopies that revealed 1200 mL and 50 mL of haemoperitoneum, respectively, without an identifiable bleeding source. After serial ß-human chorionic gonadotropin levels and ultrasound confirmation of a viable pregnancy 23 days later, the patient underwent a normal antenatal course and delivered a healthy infant at 37 weeks gestation. This unusual case highlights the need to consider spontaneous haemoperitoneum in pregnancy as a diagnosis, particularly in the setting of pregnancy of unknown location, even at an early stage of pregnancy.

Using a one health approach can foster collaboration through transdisciplinary teaching.

Transdisciplinary education is an effective strategy to foster important skills, such as collaboration, needed in the health professions. One Health recognizes the interconnected nature of human health to ecological and animal systems providing a framework for medical educators to create transdisciplinary programs. Medical educators should emphasize One Health as a problem solving strategy and create actionable classroom objectives via distilling One Health into comprehensible concepts. This will foster a collaborative learning atmosphere between human and non-human disciplines leading to positive outcomes for both the student and teacher. Transdisciplinary education is vital to health education and will allow students and teachers to use these concepts in every day practice to become innovators of health care.

Utilizing visual art to enhance the clinical observation skills of medical students.

BACKGROUND: Clinical observation is fundamental in practicing medicine, but these skills are rarely taught. Currently no evidence-based exercises/courses exist for medical student training in observation skills. AIM: The goal was to develop and teach a visual arts-based exercise for medical students, and to evaluate its usefulness in enhancing observation skills in clinical diagnosis. METHODS: A pre- and posttest and evaluation survey were developed for a three-hour exercise presented to medical students just before starting clerkships. Students were provided with questions to guide discussion of both representational and non-representational works of art. RESULTS: Quantitative analysis revealed that the mean number of observations between pre- and posttests was not significantly different (n=70: 8.63 vs. 9.13, p=0.22). Qualitative analysis of written responses identified four themes: (1) use of subjective terminology, (2) scope of interpretations, (3) speculative thinking, and (4) use of visual analogies. Evaluative comments indicated that students felt the exercise enhanced both mindfulness and skills. CONCLUSION: Using visual art images with guided questions can train medical students in observation skills. This exercise can be replicated without specially trained personnel or art museum partnerships.

Candidate biomarkers for acute rejection of pregnancy after in-utero cell-based therapy in pre-immune embryos via ultrasound-guided celocentesis.

PROBLEM: A maternal serum biomarker profile analysis was performed to determine potential indicators of acute rejection of pregnancy following in-utero cell-based treatments in pre-immune embryos. METHOD OF STUDY: We used an established non-human primate model for in-utero stem cell therapy at 38-42 days from fertilization. The maternal serum concentrations of nine candidate biomarkers for acute rejection of pregnancy were determined before and after the injection of different cocktails of human umbilical cord blood stem cells into the gestational sac. All animals were then followed until delivery. RESULTS: Twenty-four hours after celocentesis, two of the animals aborted. These two animals received a cocktail of haemopoietic stem cells with the highest concentration of human CD3(+) cells and showed a twofold increase in maternal serum IL-6 and a threefold increase in prolactin after the procedure. The remaining six animals delivered at term live and normal newborns and only demonstrated an increase in prolactin after the celocentesis procedure. CONCLUSION: IL-6 and prolactin are master immunoregulators with pleiotropic biological functions that have different maternal serum concentrations depending on pregnancy outcome. These findings suggest that increases in maternal serum prolactin and IL-6 concentration may be associated with acute rejection of pregnancy after in-utero stem cell therapy.