scholarly journals Giving Your EHR a Checkup after COVID-19: A Practical Framework for Reviewing Clinical Decision Support in Light of the Telemedicine Expansion (Preprint)

2020 ◽  
Author(s):  
Jonah Feldman ◽  
Adam Szerencsy ◽  
Devin Mann ◽  
Jonathan Austrian ◽  
Ulka Kothari ◽  
...  
Keyword(s):  
Decision Support ◽  
Clinical Decision Support ◽  
Clinical Data ◽  
Chronic Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Clinical Decision ◽  
Rapid Expansion ◽  
Office Visits ◽  
Academic Medical

BACKGROUND The transformation of healthcare during COVID-19 with the rapid expansion of telemedicine visits presents new challenges to chronic care and preventive health providers. Clinical decision support (CDS) is critically important to chronic care providers, and CDS malfunction is common during times of change. It is essential to regularly re-assess an organization's ambulatory CDS program to maintain care quality. This is especially true after an immense change, like the COVID-19 telemedicine expansion. OBJECTIVE Our objective is to re-assess the ambulatory CDS program at a large academic medical center in light of telemedicine's expansion in response to COVID-19. METHODS Our clinical informatics team devised a practical framework for an intra-pandemic ambulatory CDS assessment focused on the impact of the telemedicine expansion. This assessment began with a quantitative analysis comparing CDS alert performance in the context of in-person and telemedicine visits. Board-certified physician informaticists then completed a formal workflow review of alerts with inferior performance in telemedicine visits. Informaticists then reported on themes and optimization opportunities through the existing CDS governance structure. RESULTS Our assessment revealed that 10 of our top 40 alerts by volume were not firing as expected in telemedicine visits. In 3 out of the top 5 alerts, providers were significantly less likely to take action in telemedicine when compared to office visits. Cumulatively, alerts in telemedicine encounters had an action taken rate of 5.3% (3,257/64,938) compared to 8.3% (19,427/233,636) for office visits. Observations from a clinical informaticist workflow review included: (1) Telemedicine visits have different workflows than office visits. Some alerts developed for the office were not appearing at the optimal time in the telemedicine workflow. (2) Missing clinical data is a common reason for decreased alert firing seen in telemedicine visits. (3) Remote patient monitoring and patient-reported clinical data entered through the portal could replace data collection usually completed in the office by an MA or RN. CONCLUSIONS Conclusions: In a large academic medical center at the pandemic epicenter, an intra-pandemic ambulatory CDS assessment revealed clinically significant CDS malfunctions that highlight the importance of re-assessing ambulatory CDS performance after the telemedicine expansion. CLINICALTRIAL

scholarly journals Impact of clinical decision support therapeutic interchanges on hospital discharge medication omissions and duplications

2021 ◽  
Author(s):  
Erin Maxwell ◽  
James Amerine ◽  
Glenda Carlton ◽  
Jennifer L Cruz ◽  
Ashley L Pappas ◽  
...  
Keyword(s):  
Decision Support ◽  
Clinical Decision Support ◽  
Medication Reconciliation ◽  
Medical Center ◽  
Academic Medical Center ◽  
Clinical Decision ◽  
Discharge Medication ◽  
Academic Medical ◽  
Before And After ◽  
The Impact

Abstract Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Automatic therapeutic substitution (ATS) protocols are formulary tools that allow for provider-selected interchange from a nonformulary preadmission medication to a formulary equivalent. Previous studies have demonstrated that the application of clinical decision support (CDS) tools to ATS can decrease ATS errors at admission, but there are limited data describing the impact of CDS on discharge errors. The objective of this study was to describe the impact of CDS-supported interchanges on discharge prescription duplications or omissions. Methods This was a single-center, retrospective cohort study conducted at an academic medical center. Patients admitted between June 2017 and August 2019 were included if they were 18 years or older at admission, underwent an ATS protocol–approved interchange for 1 of the 9 included medication classes, and had a completed discharge medication reconciliation. The primary outcome was difference in incidence of therapeutic duplication or omission at discharge between the periods before and after CDS implementation. Results A total of 737 preimplementation encounters and 733 postimplementation encounters were included. CDS did not significantly decrease the incidence of discharge duplications or omissions (12.1% vs 11.2%; 95% confidence interval [CI], –2.3% to 4.2%) nor the incidence of admission duplication or inappropriate reconciliation (21.4% vs 20.7%; 95% CI, –3.4% to 4.8%) when comparing the pre- and postimplementation periods. Inappropriate reconciliation was the primary cause of discharge medication errors for both groups. Conclusion CDS implementation was not associated with a decrease in discharge omissions, duplications, or inappropriate reconciliation. Findings highlight the need for thoughtful medication reconciliation at the point of discharge.

scholarly journals Integrating A Clinical Decision Support Reminder To Improve Blood Pressure Reassessment For Patients With Uncontrolled Hypertension

2019 ◽  
Vol 2 (1) ◽  
pp. 01-03
Author(s):  
K. Souffront ◽  
L. Rivera ◽  
G. Loo ◽  
N. Genes ◽  
P. L. Richardson ◽  
...  
Keyword(s):  
Blood Pressure ◽  
New York ◽  
Decision Support ◽  
Clinical Decision Support ◽  
Best Practice ◽  
Medical Center ◽  
Academic Medical Center ◽  
Clinical Decision ◽  
Uncontrolled Hypertension ◽  
Control Group

Background: Emergency department clinicians often overlook asymptomatic hypertension (HTN). Clinical decision support can help improve adherence to the emergency nursing and emergency medicine clinical policy for asymptomatic HTN. While the policy indicates referral for all adults with two or more elevated blood pressures, less than 10% of patients are referred. We sought to determine the efficacy of an electronic health record clinical reminder on nursing (RN) reassessment of blood pressure (BP) for hypertensive patients. Methods: We conducted a 2-arm, pilot RCT, at an academic medical center in New York City. 107 RNs were randomized to the control group or to the intervention of a 'Best Practice Alert' (BPA) reminding him/her to recheck the BP in adult patients with an initial BP reading ≥140/90 mmHg. Descriptive statistics that included univariate and bivariate analyses were used to obtain adjusted measures of association between the intervention and control group. Results: RNs were more likely to repeat BP after receiving a BPA alert (56%) compared to RNs who did not receive an alert (44%) (OR=2.3, CI 2.1-2.5; p<.001). Patients who received BP reassessment were more likely to be triaged category 4 (OR 2.88, CI 1.81-4.59, p=.0001); age>75 years (OR 1.47; CI 1.07-2.03; p=.02); had Stage II HTN (OR 3.48; CI 2.63-4.59, p=.0001) and an ED length of stay of 3-4 hours (OR 5.85; CI 4.43-7.73; p=.0001). Conclusion: The BPA alert was effective in increasing BP reassessment by ED nurses. The findings of this study will help us translate this evidence ED practices.

scholarly journals Integrated clinical decision support : assessing opportunities and outcomes

2019 ◽  
Author(s):  
◽  
Timothy A. Green
Keyword(s):  
Decision Support ◽  
Clinical Decision Support ◽  
Medical Center ◽  
Academic Medical Center ◽  
Decision Support Tool ◽  
Clinical Decision ◽  
Perceived Usefulness ◽  
Inpatient Setting ◽  
Support Tool ◽  
Novel Approach

Medical calculators play an important role as a component of specific clinical decision support (CDS) systems that synthesize measurable evidence and can introduce new medical guidelines and standards. Understanding the features of calculators is important for calculator adoption and clinical acceptance. Some medical calculators can fulfill the role of CDS for Meaningful Use purposes. However, there are barriers for clinicians to use medical calculators in practice. This research presents a novel classification system for medical calculators and explores clinician use and perceived usefulness of medical calculators. Additionally, we examine the effects of an EHR integrated decision support tool on management of pain in an inpatient setting. Metadata on 766 medical calculators implemented online were collected, analyzed, and categorized by their input types, method of presenting results, and advisory nature of those results. Reference rate, publication year, and availability of references were collected. We surveyed a population of resident and attending physicians at a medium-sized academic medical center to discover the prevalence of medical calculator use, how they were accessed, and what factors might influence their use, for example, EMR integration. We also conducted a retrospective evaluation of an EHR integrated CDS module focused on pain management, leveraging a novel approach to digital workflow evaluation within the EHR, focusing on patient-centric outcome measurements.

scholarly journals Feasibility of computerized clinical decision support for pediatric to adult care transitions for patients with special healthcare needs

JAMIA Open ◽  
2021 ◽  
Vol 4 (4) ◽  
Author(s):  
Nikolas J Koscielniak ◽  
Ajay Dharod ◽  
Adam Moses ◽  
Richa Bundy ◽  
Kirsten B Feiereisel ◽  
...  
Keyword(s):  
Decision Support ◽  
Clinical Decision Support ◽  
Medical Center ◽  
Academic Medical Center ◽  
Tertiary Care ◽  
Care Transitions ◽  
Clinical Decision ◽  
Adult Care ◽  
Healthcare Needs ◽  
Transition Clinic

Abstract The objective of this study was to determine the feasibility of a computerized clinical decision support (cCDS) tool to facilitate referral to adult healthcare services for children with special healthcare needs. A transition-specific cCDS was implemented as part of standard care in a general pediatrics clinic at a tertiary care academic medical center. The cCDS alerts providers to patients 17–26 years old with 1 or more of 15 diagnoses that may be candidates for referral to an internal medicine adult transition clinic (ATC). Provider responses to the cCDS and referral outcomes (e.g. scheduled and completed visits) were retrospectively analyzed using descriptive statistics. One hundred and fifty-two patients were seen during the 20-month observation period. Providers referred 87 patients to the ATC using cCDS and 77% of patients ≥18 years old scheduled a visit in the ATC. Transition-specific cCDS tools are feasible options to facilitate adult care transitions for children with special healthcare needs.

scholarly journals 164. Avoiding Complacency: Assessing the Perceived Impact and Value of Antimicrobial Stewardship at a Academic Medical Center

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S90-S91
Author(s):  
Matthew S Lee ◽  
Christopher McCoy
Keyword(s):  
Antimicrobial Stewardship ◽  
Medical Center ◽  
Academic Medical Center ◽  
Clinical Decision ◽  
Team Members ◽  
Academic Medical ◽  
Support Tools ◽  
Educational Engagement ◽  
Similar Survey ◽  
Perceived Impact

Abstract Background Multi-disciplinary engagement and education remain key measures for Antimicrobial Stewardship Programs (ASPs). Over 3 years, our ASP has undergone key changes to pre-authorization review, post-prescriptive activities, and core team members, coinciding with a 30% increase in stewardship interventions. The objectives of this study were to evaluate the familiarity of Nursing, Pharmacy and Prescribers at our academic medical center regarding ASP activities and services, as well as perceived impact on patient care and value. Secondary objectives were to determine what resources are currently utilized and areas for improvement. Methods Distinct surveys were distributed to three participant groups: Nurses, Pharmacists, and Prescribers (Housestaff, Advanced Practice Providers, and staff physicians). Questions were developed to assess familiarity, perceived value, and overall satisfaction with the ASP. Additional items included questions on the current use of ASP resources and educational engagement. Survey results were compared to a similar survey conducted 3 years amongst the same participant groups. Results The survey was delivered electronically to 3367 Prescribers, Nurses and Pharmacists. 403 responders completed the survey (208 Nurses, 181 Prescribers, and 18 Pharmacists). Familiarity was lowest amongst Nurses, but almost doubled compared to 2016 (Figure). Prescribers cited “restricted antibiotic approval”, “de-escalation”, and “alternative therapies relative to allergies” as the three most common interaction types, similar to 2016. ASP interactions continued to be rated “moderate” or “high” value (88.4% vs 89.15% in 2016), however, face-to-face interactions were preferred by only 4% of responders (unchanged compared to 2016). Prescribers also responded uncommon use of ASP online resources (20%) and clinical decision support tools (34%). 78% of responders expressed desire for increased ASP-related education. Conclusion As ASPs evolve, it is important to constantly evaluate impact and value, and identify areas for growth. Despite ASP familiarity being high and interactions valued, we need to further optimize ASP provided resources, clinical support tools, and educational offerings. Disclosures All Authors: No reported disclosures

scholarly journals Qualitative exploration of the medical learner’s journey into correctional health care at an academic medical center and its implications for medical education

2020 ◽  
Author(s):  
Ahmar H. Hashmi ◽  
Alina M. Bennett ◽  
Nadeem N. Tajuddin ◽  
Rebecca J. Hester ◽  
Jason E. Glenn
Keyword(s):  
Learning Environment ◽  
Clinical Decision Making ◽  
Ethical Issues ◽  
Medical Center ◽  
Academic Medical Center ◽  
Clinical Decision ◽  
Diagnostic Laboratory ◽  
Lower Priority ◽  
Academic Medical ◽  
Qualitative Exploration

Abstract Correctional systems in several U.S. states have entered into partnerships with academic medical centers (AMCs) to provide healthcare for persons who are incarcerated. One AMC specializing in the care of incarcerated patients is the University of Texas Medical Branch at Galveston (UTMB), which hosts the only dedicated prison hospital in the U.S. and supplies 80% of the medical care for the entire Texas Department of Criminal Justice (TDCJ). Nearly all medical students and residents at UTMB take part in the care of the incarcerated. This research, through qualitative exploration using focus group discussions, sets out to characterize the correctional care learning environment medical trainees enter. Participants outlined an institutional culture of low prioritization and neglect that dominated the learning environment in the prison hospital, resulting in treatment of the incarcerated as second-class patients. Medical learners pointed to delays in care, both within the prison hospital and within the TDCJ system, where diagnostic, laboratory, and medical procedures were delivered to incarcerated patients at a lower priority compared to free-world patients. Medical learners elaborated further on ethical issues that included the moral judgment of those who are incarcerated, bias in clinical decision making, and concerns for patient autonomy. Medical learners were left to grapple with complex challenges like the problem of dual loyalties without opportunities to critically reflect upon what they experienced. This study finds that, without specific vulnerable populations training for both trainees and correctional care faculty to address these institutional dynamics, AMCs risk replicating a system of exploitation and neglect of incarcerated patients and thereby exacerbating health inequities.

scholarly journals 1074. Evaluation of a Pharmacist-led Antimicrobial and Anticoagulant Monitoring Initiative

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S380-S381
Author(s):  
Wei Hsiang Lin ◽  
Amanda Binkley ◽  
Christo L Cimino ◽  
Naasha J Talati ◽  
Jimish M Mehta ◽  
...  
Keyword(s):  
Renal Function ◽  
Decision Support ◽  
Decision Support System ◽  
Clinical Decision Support ◽  
Support System ◽  
Clinical Decision Support System ◽  
Dose Adjustment ◽  
Adverse Drug Events ◽  
Medical Center ◽  
Clinical Decision

Abstract Background Adverse drug events are associated with an increase in hospital stay and cost. Risks from these events are minimized by adjusting a medication’s dose or frequency, and changes in renal function may necessitate adjustments. Currently, there is no formal procedure for a prospective audit of renal function over the weekend at our institution. This pharmacist-driven initiative will evaluate if a prospective review identified by real-time clinical decision support alerts over the weekend will reduce the time from change in renal function to dose adjustment of select antimicrobials and/or anticoagulants. Methods This monitoring initiative is comprised of a pre- and post-cohort population. The pre-cohort population included patients admitted to Penn Presbyterian Medical Center (PPMC) from January to March of 2018 on select antimicrobials and/or anticoagulants, who were identified to have a change in renal function (serum creatinine change of 0.3 mg/dL or greater) over the weekend. The post-cohort population was identified with a clinical decision support system (ILÚM Health Solutions, Kenilworth, NJ) and included patients admitted to PPMC from January to March of 2019. A pharmacy resident reviewed alerts in the clinical decision support system over the weekend and contacted providers with dose adjustment recommendations. The Mann–Whitney U test was used to analyze the primary endpoint while descriptive statistics were used for the secondary endpoints Results Eighteen interventions were completed within the 3-month post-cohort intervention period, with a time to dose adjustment between the pre/post-cohort being reduced by 50 hours (P = 0.0001) resulting in a median time to change of 11 hours in the post-cohort. All pharmacy recommendations were accepted by the provider, and 94% of medication adjustments were antimicrobials. Conclusion The application of this prospective weekend initiative utilizing a clinical decision support system demonstrated a clinically and statistically significant reduction in the time to dose adjustments for antimicrobials and/or anticoagulants. Implementation of this initiative will further establish a role for pharmacist-led evaluations and could potentially be expanded to other clinical areas. Disclosures All authors: No reported disclosures.

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