HerediGene Population Study IT infrastructure: A model to support genomic research recruitment and precision public health.

The HerediGene Population Study is a large research study focused on identifying new genetic biomarkers for disease prevention, diagnosis, prognosis, and development of new therapeutics. A substantial IT infrastructure evolved to reach enrollment targets and return results to participants. More than 170,000 participants have been enrolled in the study to date, with 5.87% of those whole genome sequenced and 0.46% of those genotyped harboring pathogenic variants. Among other purposes, this infrastructure supports: (1) identifying candidates from clinical criteria, (2) monitoring for qualifying clinical events (e.g., blood draw), (3) contacting candidates, (4) obtaining consent electronically, (5) initiating lab orders, (6) integrating consent and lab orders into clinical workflow, (7) de-identifying samples and clinical data, (8) shipping/transmitting samples and clinical data, (9) genotyping/sequencing samples, (10) and re-identifying and returning results for participants where applicable. This study may serve as a model for similar genomic research and precision public health initiatives.

Evaluating the accuracy of existing EMR data as predictors of follow-up providers.

In order to evaluate the accuracy of existing EMR data in predicting follow-up providers, a retrospective analysis was performed on six months of data for inpatient and ED encounters occurring at two hospitals, and on related outpatient data. Sensitivity and Positive Predictive Value (PPV) were calculated for each of eight predictors, to determine their effectiveness in predicting follow-up providers. Our findings indicate that access to longitudinal patient care records can improve prediction of which providers a patient is likely to see post-discharge compared to simply using Primary Care Provider data from admissions records. Of the predictors evaluated, a patient's past appointment history was the best predictor of which providers they would see in the future (PPV = 48% following inpatient visits, 35% following emergency department visits). However, even the best performing predictors failed to predict more than half of the follow-up providers and might generate many "false" alerts.

Completing Death Certificates from an EMR: Analysis of a Novel Public-Private Partnership.

With the objective of increasing electronic death registration, Intermountain Healthcare and the Utah Office of Vital Records and Statistics have developed a system enabling death certification from within Intermountain's electronic medical record (EMR), consisting of an EMR module and an HL7 interface. Comparison of post-intervention death certification at Intermountain Healthcare against a baseline study found a slight increase in the percentage of deaths certified electronically (73% pre vs. 77% post). Analysis of deaths certified using the EMR-module found that they were completed significantly sooner than those certified on paper or using the state's web-based electronic death registration system (EDRS) (Mean time: Paper = 114.72 hours, EDRS = 81.84 hours, EMR = 43.92 hours; p < 0.0001). EMR-certified deaths also contained significantly more causes of deaths than either alternative method (Mean number of causes: Paper = 3.9 causes, EDRS = 4.0 causes, EMR = 5.5 causes; p < 0.0001).

Use of a Proven Framework for Computer Decision Support within the Intermountain Healthcare Network.

Hospitalized patients in the U.S. do not always receive optimal care. In light of this, Computerized Decision Support (CDS) has been recommended to for the improvement of patient care. A number of methodologies, standards, and frameworks have been developed to facilitate the development and interoperability of computerized clinical guidelines and CDS logic. In addition, Health Information Exchange using Service-Oriented Architecture holds some promise to help realize that goal. We have used a framework at Intermountain Healthcare that employs familiar programming languages and technology to develop over 40 CDS applications during the past 13 years, which clinicians are dependent on each day. This paper describes the framework, technology, and CDS application development methods, while providing three distinct examples of applications that illustrate the need and use of the framework for patient care improvement. The main limitation of this framework is its dependence on point-to-point interfaces to access patient data. We look forward to the use of validated and accessible Service-Oriented Architecture to facilitate patient data access across diverse databases.

Reduction of peripherally inserted central catheter-associated DVT.

BACKGROUND: As peripherally inserted central catheter (PICC) use has increased, so has the upper extremity DVT rate. PICC diameter may pose the most modifiable risk for PICC-associated DVT. METHODS: A 3-year, prospective, observational study of all PICC insertions by a specially trained and certified team using a consistent and replicable approach was conducted at a 456-bed, level I trauma and tertiary referral hospital during January 1, 2008, through December 31, 2010. An intensified effort by the PICC team in 2010 was introduced to discuss and reach interdisciplinary consensus on the need for each lumen of the PICC and a change to smaller diameter 5F triple-lumen PICC. RESULTS: Significantly more 4F single-lumen PICCs were used during 2010 (n = 470) compared with 2008 and 2009 (n = 338, 382; P < .0001). DVT rates were similar with the use of 5F triple-lumen PICCs in 2010 as 5F double-lumen PICCs and lower rates than 6F triple-lumen catheters used in 2008 and 2009. The PICC-associated DVT rate was significantly lower (1.9% vs 3.0%, P < .04) in 2010 compared with 2008 and 2009. The cost and length of stay attributable to PICC-associated DVT were $15,973 and 4.6 days. CONCLUSIONS: A significant increase in the use of single-lumen PICCs in addition to the institutional adoption of smaller 5F triple-lumen PICCs was associated with a significant decrease in the rate of PICC-associated DVT.

Computer surveillance of patients at high risk for and with venous thromboembolism.

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), may be the number one preventable cause of death associated with hospitalization. Numerous evidence-based guidelines for effective VTE prophylaxis therapy exist. However, underuse is common due to the difficulty in integrating VTE risk assessment into routine patient care. Previous studies utilizing computer decision support to identify high-risk patients report improved use of prophylaxis therapy and reduced VTE. However, those studies did not report the sensitivity, specificity or positive predictive value of their methods to identify patients at high risk. We report an evaluation of a computerized tool to identify patients at high risk for VTE that found a sensitivity of 98% and positive predictive value of 99%. Another computer program used to detect VTE had a sensitivity of 92%, specificity of 99% and a positive predictive value of 97% to identify DVT and a sensitivity of 100%, specificity of 98% and positive predictive value of 89% to identify PE. These tools were found to provide a dependable method to identify patients at high risk for and with VTE.

Risk of symptomatic DVT associated with peripherally inserted central catheters.

BACKGROUND: Previous studies undertaken to identify risk factors for peripherally inserted central catheter (PICC)-associated DVT have yielded conflicting results. PICC insertion teams and other health-care providers need to understand the risk factors so that they can develop methods to prevent DVT. METHODS: A 1-year prospective observational study of PICC insertions was conducted at a 456-bed, level I trauma center and tertiary referral hospital affiliated with a medical school. All patients with one or more PICC insertions were included to identify the incidence and risk factors for symptomatic DVT associated with catheters inserted by a facility-certified PICC team using a consistent and replicated approach for vein selection and insertion. RESULTS: A total of 2,014 PICCs were inserted during 1,879 distinct hospitalizations in 1,728 distinct patients for a total of 15,115 days of PICC placement. Most PICCs were placed in the right arm (76.9%) and basilic vein (74%) and were double-lumen 5F (75.3%). Of the 2,014 PICC insertions, 60 (3.0%) in 57 distinct patients developed DVT in the cannulated or adjacent veins. The best-performing predictive model for DVT (area under the curve, 0.83) was prior DVT (odds ratio [OR], 9.92; P < .001), use of double-lumen 5F (OR, 7.54; P < .05) or triple-lumen 6F (OR, 19.50; P < .01) PICCs, and prior surgery duration of > 1 h (OR, 1.66; P = .10). CONCLUSIONS: Prior DVT and surgery lasting > 1 h identify patients at increased risk for PICC-associated DVT. More importantly, increasing catheter size also is significantly associated with increased risk. Rates of PICC-associated DVT may be reduced by improved selection of patients and catheter size.

Academic podcasting: quality media delivery.

A video podcast of the CME-approved University of Utah Department of Biomedical Informatics seminar was created in order to address issues with streaming video quality, take advantage of popular web-based syndication methods, and make the files available for convenient, subscription-based download. An RSS feed, which is automatically generated, contains links to the media files and allows viewers to easily subscribe to the weekly seminars in a format that guarantees consistent video quality.