Faculty Bibliography

There is limited data on which hospitalist switch day is optimal for hospital operations and throughput. A quality improvement intervention was implemented, changing the hospitalist switch day from Monday to Tuesday. Retrospective observational analysis revealed an increase in Monday discharges (1.3%, p = .01), a decrease in Tuesday discharges (-1.6%, p < .005), and a significant reduction in 30-day unplanned readmission rates (-1.5%, p = .003), with no significant changes in the average length of stay. Additional studies are needed to further verify these findings in different hospital settings and to consider other switch day patterns.

IMPORTANCE/UNASSIGNED:Hospital course (HC) summarization represents an increasingly onerous discharge summary component for physicians. Literature supports large language models (LLMs) for HC summarization, but whether physicians can effectively partner with electronic health record-embedded LLMs to draft HCs is unknown. OBJECTIVES/UNASSIGNED:To compare the editing effort required by time-constrained resident physicians to improve LLM- vs physician-generated HCs toward a novel 4Cs (complete, concise, cohesive, and confabulation-free) HC. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Quality improvement study using a convenience sample of 10 internal medicine resident editors, 8 hospitalist evaluators, and randomly selected general medicine admissions in December 2023 lasting 4 to 8 days at New York University Langone Health. EXPOSURES/UNASSIGNED:Residents and hospitalists reviewed randomly assigned patient medical records for 10 minutes. Residents blinded to author type who edited each HC pair (physician and LLM) for quality in 3 minutes, followed by comparative ratings by attending hospitalists. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Editing effort was quantified by analyzing the edits that occurred on the HC pairs after controlling for length (percentage edited) and the degree to which the original HCs' meaning was altered (semantic change). Hospitalists compared edited HC pairs with A/B testing on the 4Cs (5-point Likert scales converted to 10-point bidirectional scales). RESULTS/UNASSIGNED:Among 100 admissions, compared with physician HCs, residents edited a smaller percentage of LLM HCs (LLM mean [SD], 31.5% [16.6%] vs physicians, 44.8% [20.0%]; P < .001). Additionally, LLM HCs required less semantic change (LLM mean [SD], 2.4% [1.6%] vs physicians, 4.9% [3.5%]; P < .001). Attending physicians deemed LLM HCs to be more complete (mean [SD] difference LLM vs physicians on 10-point bidirectional scale, 3.00 [5.28]; P < .001), similarly concise (mean [SD], -1.02 [6.08]; P = .20), and cohesive (mean [SD], 0.70 [6.14]; P = .60), but with more confabulations (mean [SD], -0.98 [3.53]; P = .002). The composite scores were similar (mean [SD] difference LLM vs physician on 40-point bidirectional scale, 1.70 [14.24]; P = .46). CONCLUSIONS AND RELEVANCE/UNASSIGNED:Electronic health record-embedded LLM HCs required less editing than physician-generated HCs to approach a quality standard, resulting in HCs that were comparably or more complete, concise, and cohesive, but contained more confabulations. Despite the potential influence of artificial time constraints, this study supports the feasibility of a physician-LLM partnership for writing HCs and provides a basis for monitoring LLM HCs in clinical practice.

Electronic health records have become an integral part of modern health care, but their implementation has led to unintended consequences, such as poor note quality. This case study explores how NYU Langone Health leveraged artificial intelligence (AI) to address the challenge to improve the content and quality of medical documentation. By quickly and accurately analyzing large volumes of clinical documentation and providing feedback to organizational leadership and individually to providers, AI can help support a culture of continuous note quality improvement, allowing organizations to enhance a critical component of patient care.

BACKGROUND:Discharging clinically ready patients before noon on their discharge day may influence overall discharge process quality, emergency department (ED) boarding times, and length of stay (LOS). This study evaluated the effectiveness of a discharge before noon (DBN) initiative. METHODS:Many DBN components were refined or added during a pilot, including incorporating the DBN process into daily rounds, an electronic tracking system, and other elements for possible DBN patients such as a car service when appropriate and expedited lab results and physical therapy consults. DBN was evaluated through a retrospective pre-post study (12-month periods). Study patients were from Maimonides Medical Center's medicine units. Kaplan-Meier estimates and a log-rank test characterized and compared the discharge time probabilities in pre-DBN and post-DBN groups. Log-logistic accelerated failure time (AFT) analysis assessed the influence of DBN on discharge time. Secondary analyses examined the relationship between LOS and readmission within 30 days for any cause and DBN. RESULTS:The percentage of patients discharged before noon increased from 5.0% to 11.4% pre/post-DBN (p < 0.001). The AFT analysis estimated that post-DBN patients had discharge times 41.5% earlier (p < 0.001). DBN as an independent factor was not associated with LOS or subsequent readmissions within 30 days for any cause. Despite an increase in the percentage of patients admitted during the daytime (8:00 a.m. to 5:00 p.m.), the median ED boarding time increased by 41 minutes in post-DBN patients (p < 0.001). CONCLUSION:The DBN initiative was associated with an increased percentage of patients discharged before noon. Further research is needed to identify strategies that reliably improve discharge timeliness while reducing ED boarding.

BACKGROUND:Hospital acquired anemia is common during admission and can result in increased transfusion and length of stay. Recumbent posture is known to lead to lower hemoglobin measurements. We tested to see if an initiative promoting evening lab draws would lead to higher hemoglobin measurements due to more time in upright posture during the day and evening. METHODS:We included patients hospitalized on 2 medical units, beginning March 26, 2020 and discharged prior to January 25, 2021. On one of the units, we implemented an initiative to have routine laboratory draws in the evening rather than the morning starting on August 26, 2020. There were 1217 patients on the control unit and 1265 on the intervention unit during the entire study period. First we used a linear mixed-effects model to see if timing of blood draw was associated with hemoglobin level in the pre-intervention period. We then compared levels of hemoglobin before and after the intervention using a difference-in-difference analysis. RESULTS:In the pre-intervention period, evening blood draws were associated with higher hemoglobin compared to morning (0.28; 95% CI, 0.22-0.35). Evening blood draws increased with the intervention (10.3% vs 47.9%, P > 0.001). However, the intervention floor was not associated with hemoglobin levels in difference-in-difference analysis (coefficient of -0.15; 95% CI, -0.51-0.21). CONCLUSIONS:While evening blood draws were associated with higher hemoglobin levels, an intervention that successfully changed timing of routine labs to the evening did not lead to an increase in hemoglobin levels.

Background: The introduction of electronic workflows has allowed for the flow of raw uncontextualized clinical data into medical documentation. As a result, many electronic notes have become replete of "noise" and deplete clinically significant "signals." There is an urgent need to develop and implement innovative approaches in electronic clinical documentation that improve note quality and reduce unnecessary bloating. Objective: This study aims to describe the development and impact of a novel set of templates designed to change the flow of information in medical documentation. Methods: This is a multihospital nonrandomized prospective improvement study conducted on the inpatient general internal medicine service across 3 hospital campuses at the New York University Langone Health System. A group of physician leaders representing each campus met biweekly for 6 months. The output of these meetings included (1) a conceptualization of the note bloat problem as a dysfunction in information flow, (2) a set of guiding principles for organizational documentation improvement, (3) the design and build of novel electronic templates that reduced the flow of extraneous information into provider notes by providing link outs to best practice data visualizations, and (4) a documentation improvement curriculum for inpatient medicine providers. Prior to go-live, pragmatic usability testing was performed with the new progress note template, and the overall user experience was measured using the System Usability Scale (SUS). Primary outcome measures after go-live include template utilization rate and note length in characters. Results: In usability testing among 22 medicine providers, the new progress note template averaged a usability score of 90.6 out of 100 on the SUS. A total of 77% (17/22) of providers strongly agreed that the new template was easy to use, and 64% (14/22) strongly agreed that they would like to use the template frequently. In the 3 months after template implementation, general internal medicine providers wrote 67% (51,431/76,647) of all inpatient notes with the new templates. During this period, the organization saw a 46% (2768/6191), 47% (3505/7819), and 32% (3427/11,226) reduction in note length for general medicine progress notes, consults, and history and physical notes, respectively, when compared to a baseline measurement period prior to interventions. Conclusions: A bundled intervention that included the deployment of novel templates for inpatient general medicine providers significantly reduced average note length on the clinical service. Templates designed to reduce the flow of extraneous information into provider notes performed well during usability testing, and these templates were rapidly adopted across all hospital campuses. Further research is needed to assess the impact of novel templates on note quality, provider efficiency, and patient outcomes.

• Discoid lupus may be associated with SLE. In this study, most children with discoid lupus did not have systemic disease. Concurrent SLE was highest in female adolescents (>10 years of age) with generalized discoid lupus, who had clinically aggressive disease. • Discoid lupus in adolescence should prompt thorough evaluation for SLE.

Despite benefits of safety event reporting, few are trainee initiated. A comprehensive intervention was created to increase trainee reporting, partnering a trainee safety council with high-level faculty. Data were collected for 12 months pre intervention and 30 months post intervention, including short-term (1-12 mo) and long-term (13-30 mo) follow-up. A total of 2337 trainee events were submitted over the study period, primarily communication-related (40%) and on the medicine service (39%). Monthly submissions increased from 29.3 pre intervention to 66.2, 77.7, and 58.6 events/mo at post intervention, short-term follow-up, and long-term follow-up, respectively (P < 0.001). Proportion of hospital events submitted by trainees increased from 2.3% pre intervention to 4.1%, 4.9%, and 3.6% at post intervention, short-term, and long-term follow-up, respectively (P < 0.001). Trainee monthly submissions (P = 0.015) and proportion of hospital events (P < 0.001) declined from short- to long-term follow-up. Low- and intermediate-level harm events significantly increased post intervention (P < 0.001) while high-level events did not (P = 0.15-1.0). Our comprehensive intervention increased trainee event submissions at long-term follow-up.