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Patient Experience With Notification of Radiology Results: A Comparison of Direct Communication and Patient Portal Use

Garry, Kira; Blecker, Saul; Saag, Harry; Szerencsy, Adam; Jones, Simon A; Testa, Paul; Kang, Stella
OBJECTIVE:Patients increasingly access radiology results through digital portals. We compared patient satisfaction and understanding of radiology results when received through an electronic patient portal versus direct communication from providers. METHODS:tests and logistic regression. RESULTS:Of 1,005 survey respondents, 87.8% (882 of 1,005) reported having received their imaging test results, with 486 (48.4%) first being notified through the patient portal and 396 (39.4%) via direct provider communication. Patients reported high levels of satisfaction with timing regardless of whether they first received the results through the patient portal or through direct provider communication (88.8%-89.9%). Patients who first received their results through the patient portal reported a lesser degree of perceived understanding than those who first received their results through direct provider communication (26.7% versus 47.8%; P < .001). Patients were less likely to report clear understanding for advanced imaging (CT or MRI) than ultrasound or x-rays (29.3% versus 40.3% versus 38.2%, respectively; P = .02). Patient characteristics showed no association with understanding in multivariable analysis. CONCLUSION/CONCLUSIONS:As online portal release of radiology results to patients becomes commonplace, efforts may be warranted to improve patient experience when first receiving their radiology results online.
PMID: 32289281
ISSN: 1558-349x
CID: 4401322

Pajama Time: Working After Work in the Electronic Health Record [Letter]

Saag, Harry S; Shah, Kanan; Jones, Simon A; Testa, Paul A; Horwitz, Leora I
PMID: 31073856
ISSN: 1525-1497
CID: 3914432

Pajama time: Working after work in the electronic health record [Meeting Abstract]

Shah, K; Saag, H S; Horwitz, L I; Testa, P
Background: Electronic health record (EHR) documentation may contribute to burnout, especially for those with substantial clinical effort. We assessed whether clinical effort is associated with working in the EHR after work hours.
Method(s): We included all ambulatory physicians in a medicine specialty continuously practicing at any NYU Langone Health Faculty Group Practice site between May 1 and October 31, 2018. We quantified minutes logged into the EHR on days without scheduled appointments, and minutes logged into the EHR 30 minutes before and after appointments on days with scheduled appointments. We termed this time " work after work." We categorized physicians by their average number of days with appointments per week. Data were analyzed using SAS 9.4 (SAS Institute, Cary, NC). We calculated least squares means of fixed effects to account for heterogeneous variances, and compared means using Tukey's multiple comparison test. This study met institutional review board criteria for quality improvement work.
Result(s): We included 300 physicians, of whom 28.6% were general internists. The average physician had 3 days/week with scheduled appointments, spent 114.9 min in the EHR on days without appointments, and spent 21.7 min in the EHR after work hours on days with appointments. Time spent in the EHR on days without appointments increased with the number of appointment days per week (14.7 min/unscheduled day for 1 day/week vs. 193.8 min/unscheduled day for > 4 days/week, p< 0.001). Time spent in the EHR after hours on days with scheduled appointments did not significantly differ (Table 1).
Conclusion(s): All ambulatory physicians spend a substantial amount of time working in the EHR after hours and on unscheduled days (including weekends), but physicians with more clinical time were disproportionately burdened. The most clinically active spent an average of 2.8 hours in the EHR each unscheduled day. These findings add to concerns about EHR usability and documentation burden, particularly for busier clinicians. Our institution is now building dashboards to track work after work, offloading tasks to ancillary team members to reduce physician work burden, and exploring whether outliers would benefit from personalized technical assistance and training. Work after work analyses could be employed elsewhere to motivate similar improvements
EMBASE:629004270
ISSN: 1525-1497
CID: 4052632

Promoting High-Value Practice by Reducing Unnecessary Transfusions With a Patient Blood Management Program

Sadana, Divyajot; Pratzer, Ariella; Scher, Lauren J; Saag, Harry S; Adler, Nicole; Volpicelli, Frank M; Auron, Moises; Frank, Steven M
Although blood transfusion is a lifesaving therapy for some patients, transfusion has been named 1 of the top 5 overused procedures in US hospitals. As unnecessary transfusions only increase risk and cost without providing benefit, improving transfusion practice is an effective way of promoting high-value care. Most high-quality clinical trials supporting a restrictive transfusion strategy have been published in the past 5 to 10 years, so the value of a successful patient blood management program has only recently been recognized. We review the most recent transfusion practice guidelines and the evidence supporting these guidelines. We also discuss several medical societies' Choosing Wisely campaigns to reduce or eliminate overuse of transfusions. A blueprint is presented for developing a patient blood management program, which includes discussion of specific methods for optimizing transfusion practice.
PMID: 29159367
ISSN: 2168-6114
CID: 2898742

Warm Handoffs: a Novel Strategy to Improve End-of-Rotation Care Transitions

Saag, Harry S; Chen, Jingjing; Denson, Joshua L; Jones, Simon; Horwitz, Leora; Cocks, Patrick M
BACKGROUND: Hospitalized medical patients undergoing transition of care by house staff teams at the end of a ward rotation are associated with an increased risk of mortality, yet best practices surrounding this transition are lacking. AIM: To assess the impact of a warm handoff protocol for end-of-rotation care transitions. SETTING: A large, university-based internal medicine residency using three different training sites. PARTICIPANTS: PGY-2 and PGY-3 internal medicine residents. PROGRAM DESCRIPTION: Implementation of a warm handoff protocol whereby the incoming and outgoing residents meet at the hospital to sign out in-person and jointly round at the bedside on sicker patients using a checklist. PROGRAM EVALUATION: An eight-question survey completed by 60 of 99 eligible residents demonstrated that 85% of residents perceived warm handoffs to be safer for patients (p < 0.001), while 98% felt warm handoffs improved their knowledge and comfort level of patients on day 1 of an inpatient rotation (p < 0.001) as compared to prior handoff techniques. Finally, 88% felt warm handoffs were worthwhile despite requiring additional time (p < 0.001). DISCUSSION: A warm handoff protocol represents a novel strategy to potentially mitigate the known risks associated with end-of-rotation care transitions. Additional studies analyzing patient outcomes will be needed to assess the impact of this strategy.
PMCID:5756153
PMID: 28808863
ISSN: 1525-1497
CID: 2670802

Companion: A mobile app bringing evidence-based medicine to the bedside and platform technology to education [Meeting Abstract]

Saag, H S; Sippel, J
Needs and Objectives: Given the rise in mobile devices, it is critical that academic medical centers create new ways to support the educational, research, and patient care missions through mobile technology. Companion isa mobile app with a primary objective of promoting the use of evidence-based medicine at the point-of-care and enhancing the educational experience for medical students and residents through the rapid dissemination of knowledge. Setting and Participants:Companion launched in July 2017 across NYU Langone Health (NYULH), a tertiary-care academic medical center, and NYU School of Medicine. The Companion app was made available to all faculty, housestaff, and medical students for download on any Apple iPhone or iPad through NYULH's internal app catalog. Though available throughout the institution, special attention was given to the internal medicine residency program and medical students including dedicated training sessions on how to maximize the app's features for rounds and conferences. Description: Companion's core feature is a search function, similar to Google, where a user types in a keyword they are interested in looking up. For example, if a resident were admitting a patient with Congestive Heart Failure (CHF), and types "CHF" into the search box, the app will return NYULH institutional clinical guidelines related to CHF. From the results page, users can also use their finger to "swipe" into additional medical databases such as UpToDate and PubMed if they do not find what they are looking for in the institutional guidelines all from within the app. Once users find the document they are looking for they can "Favorite" the document for future reference, "Mark Up" the document with a virtual pen or highlighter, or "share" the document via QR code technology. Companion also utilizes location-aware technology for virtual "check-in" at conferences and pushing relevant clinical guidelines based on a user's physical location. Evaluation: Since launching in July 2017 our evaluation data is limited, but thus far, we have 747 active "60-day users" and over 5, 000 downloads of institutional clinical guidelines through the app. Further, there have been 5, 200 total "searches" performed within the app and over 10, 000 unique location check-ins at conference by medical students and residents. Discussion/Reflection/Lessons Learned: While still in the early stages of rolling out Companion, initial signs indicate that the app has potential to accomplish its goal of bringing evidence-based medicine to the bedside and enhancing the academic environment at our AMC. User feedback from front-line users has been instrumental in helping to refine the app and idenitfy new features that would improve the app. Since launching, we've pushed out 6 new version updates and recognize the importance of constantly iterating and adding new features to make the app as useful as possible. Next steps include integrating Companion with our electronic medical record and focusing on publicizing the app to other departments outside of internal medicine
EMBASE:622329317
ISSN: 1525-1497
CID: 3139032

Reducing liberal red blood cell transfusions at an academic medical center

Saag, Harry S; Lajam, Claudette M; Jones, Simon; Lakomkin, Nikita; Bosco, Joseph A 3rd; Wallack, Rebecca; Frangos, Spiros G; Sinha, Prashant; Adler, Nicole; Ursomanno, Patti; Horwitz, Leora I; Volpicelli, Frank M
BACKGROUND: Educational and computerized interventions have been shown to reduce red blood cell (RBC) transfusion rates, yet controversy remains surrounding the optimal strategy needed to achieve sustained reductions in liberal transfusions. STUDY DESIGN AND METHODS: The purpose of this study was to assess the impact of clinician decision support (CDS) along with targeted education on liberal RBC utilization to four high-utilizing service lines compared with no education to control service lines across an academic medical center. Clinical data along with associated hemoglobin levels at the time of all transfusion orders between April 2014 and December 2015 were obtained via retrospective chart review. The primary outcome was the change in the rate of liberal RBC transfusion orders (defined as any RBC transfusion when the hemoglobin level is >7.0 g/dL). Secondary outcomes included the annual projected reduction in the number of transfusions and the associated decrease in cost due to these changes as well as length of stay (LOS) and death index. These measures were compared between the 12 months prior to the initiative and the 9-month postintervention period. RESULTS: Liberal RBC utilization decreased from 13.4 to 10.0 units per 100 patient discharges (p = 0.002) across the institution, resulting in a projected 12-month savings of $720,360. The mean LOS and the death index did not differ significantly in the postintervention period. CONCLUSION: Targeted education combined with the incorporation of CDS at the time of order entry resulted in significant reductions in the incidence of liberal RBC utilization without adversely impacting inpatient care, whereas control service lines exposed only to CDS had no change in transfusion habits.
PMID: 28035775
ISSN: 1537-2995
CID: 2383762

Association Between End-of-Rotation Resident Transition in Care and Mortality Among Hospitalized Patients

Denson, Joshua L; Jensen, Ashley; Saag, Harry S; Wang, Binhuan; Fang, Yixin; Horwitz, Leora I; Evans, Laura; Sherman, Scott E
Importance: Shift-to-shift transitions in care among house staff are associated with adverse events. However, the association between end-of-rotation transition (in which care of the patient is transferred) and adverse events is uncertain. Objective: To examine the association of end-of-rotation house staff transitions with mortality among hospitalized patients. Design, Setting, and Participants: Retrospective multicenter cohort study of patients admitted to internal medicine services (N = 230701) at 10 university-affiliated US Veterans Health Administration hospitals (2008-2014). Exposures: Transition patients (defined as those admitted prior to an end-of-rotation transition who died or were discharged within 7 days following transition) were stratified by type of transition (intern only, resident only, or intern + resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted. Main Outcomes and Measures: The primary outcome was in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and readmission rates. A difference-in-difference analysis assessed whether outcomes changed after the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations. Adjustments included age, sex, race/ethnicity, month, year, length of stay, comorbidities, and hospital. Results: Among 230701 patient discharges (mean age, 65.6 years; men, 95.8%; median length of stay, 3.0 days), 25938 intern-only, 26456 resident-only, and 11517 intern + resident end-of-rotation transitions occurred. Overall mortality was 2.18% in-hospital, 9.45% at 30 days, and 14.43% at 90 days. Adjusted hospital mortality was significantly greater in transition vs control patients for the intern-only group (3.5% vs 2.0%; odds ratio [OR], 1.12 [95% CI, 1.03-1.21]) and the intern + resident group (4.0% vs 2.1%; OR, 1.18 [95% CI, 1.06-1.33]), but not for the resident-only group (3.3% vs 2.0%; OR, 1.07 [95% CI, 0.99-1.16]). Adjusted 30-day and 90-day mortality rates were greater in all transition vs control comparisons (30-day mortality: intern-only group, 14.5% vs 8.8%, OR, 1.17 [95% CI, 1.13-1.22]; resident-only group, 13.8% vs 8.9%, OR, 1.11 [95% CI, 1.04-1.18]; intern + resident group, 15.5% vs 9.1%, OR, 1.21 [95% CI, 1.12-1.31]; 90-day mortality: intern-only group, 21.5% vs 13.5%, OR, 1.14 [95% CI, 1.10-1.19]; resident-only group, 20.9% vs 13.6%, OR, 1.10 [95% CI, 1.05-1.16]; intern + resident group, 22.8% vs 14.0%, OR, 1.17 [95% CI, 1.11-1.23]). Duty hour changes were associated with greater adjusted hospital mortality for transition patients in the intern-only group and intern + resident group than for controls (intern-only: OR, 1.11 [95% CI, 1.02-1.21]; intern + resident: OR, 1.17 [95% CI, 1.02-1.34]). The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups. Conclusions and Relevance: Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis. The association was stronger following institution of ACGME duty hour regulations.
PMID: 27923090
ISSN: 1538-3598
CID: 2353482

Modeling the impact of healthcare reform on internal medicine service lines within an academic medical center

Saag, Harry S; Hammonds, Lee; Taylor, Benjamin B
The Patient Protection and Affordable Care Act will have a dramatic impact on Academic Medical Centers (AMC) across many fronts. The expansion of Medicaid and creation of healthcare exchanges to compete with existing commercial payers will alter the current payer-mix seen at AMC's. While prior studies have analyzed this impact at a hospital level, we evaluated these changes in payer-mix on three distinct internal medicine service lines by modeling out their effect on overall contribution margin (CM) for each service line using actual hospital data collected from a tertiary-care, urban AMC. We performed a sensitivity analysis to account for varying rates of participation in the newly created exchanges using 33, 50, and 100% take-up rates to simulate the unknown migration of current commercial patients to exchanges in addition to a threshold analysis. We found that despite an increase in CM from Medicaid expansion, the negative impact on CM from commercial patients migrating to exchange plans at all three take-up rates caused an overall loss in CM across all three service lines ranging from $215 020 to $1 482 597. Threshold points ranged from 19 to 37% across service lines. Our results reveal that the key drivers to determining the impact on CM is ultimately driven by what exchange rates will be set at as well as how many current commercial patients transition to the newly created exchanges
ORIGINAL:0011789
ISSN: 2047-9700
CID: 2482202

Increased Mortality Associated With Resident Handoff In A Multi-Center Cohort [Meeting Abstract]

Denson, JL; Jensen, A; Saag, H; Wang, B; Fang, Y; Horwitz, L; Evans, L; Sherman, S
ISI:000390749607503
ISSN: 1535-4970
CID: 2414992