Faculty Bibliography

Changing physician behaviors is difficult. Electronic health record (EHR) clinical decision support (CDS) offers an opportunity to promote guideline adherence. Behavioral economics (BE) has shown success as an approach to supporting evidence-based decision-making with little additional cognitive burden. We applied a user-centered approach to incorporate BE "nudges" into a CDS module in two "vanguard" sites utilizing: (1) semi-structured interviews with key informants (n = 8); (2) a design thinking workshop; and (3) semi-structured group interviews with clinicians. In the 133 day development phase at two clinics, the navigator section fired 299 times for 27 unique clinicians. The inbasket refill alert fired 124 times for 22 clinicians. Fifteen prescriptions for metformin were written by 11 clinicians. Our user-centered approach yielded a BE-driven CDS module with relatively high utilization by clinicians. Next steps include the addition of two modules and continued tracking of utilization, and assessment of clinical impact of the module.

BACKGROUND:Mineralocorticoid receptor antagonists (MRA) are an underutilized therapy for heart failure with a reduced ejection fraction (HFrEF), but the current impact of hospitalization on MRA use is not well characterized. The objective of this study was to describe contemporary MRA prescription for heart failure patients before and after the full scope of hospitalizations and the association between MRA discharge prescription and post-hospitalization outcomes. METHODS:We conducted a retrospective cohort study at an academic hospital system in 2013-2016. Among 1500 included hospitalizations of 1009 unique patients with HFrEF and without MRA contraindication, the mean age was 71.9 ± 13.6 years and 443 (29.5%) were female. We compared MRA prescription before and after hospitalizations with McNemar's test and between patients with principal and secondary diagnoses of HFrEF with the chi-square test, and association of MRA discharge prescription with 30-day and 180-day mortality and readmissions using generalized estimating equations. RESULTS:MRA prescriptions increased from 303 (20.2%) to 375 (25.0%) at discharge (+4.8%, p < 0.0001). More patients with principal diagnosis of HFrEF compared to those hospitalized for other reasons received MRA (34.9% versus 21.3%, p < 0.0001) and had them initiated (21.8% versus 9.7%, p < 0.0001). MRA prescription at discharge was not associated with mortality or readmission at 30 and 180 days, and there was no interaction with principal/secondary diagnosis. CONCLUSIONS:Among hospitalized HFrEF patients, 75% did not receive MRA before or after hospitalization, and nearly 90% of eligible patients did not have MRA initiated. As we found no signal for short-term harm after discharge, hospitalization may represent an opportunity to initiate guideline-directed heart failure therapy.

PURPOSE/OBJECTIVE:To develop natural language processing (NLP) to identify incidental lung nodules (ILNs) in radiology reports for assessment of management recommendations. METHOD AND MATERIALS/METHODS:We searched the electronic health records for patients who underwent chest CT during 2014 and 2017, before and after implementation of a department-wide dictation macro of the Fleischner Society recommendations. We randomly selected 950 unstructured chest CT reports and reviewed manually for ILNs. An NLP tool was trained and validated against the manually reviewed set, for the task of automated detection of ILNs with exclusion of previously known or definitively benign nodules. For ILNs found in the training and validation sets, we assessed whether reported management recommendations agreed with Fleischner Society guidelines. The guideline concordance of management recommendations was compared between 2014 and 2017. RESULTS:The NLP tool identified ILNs with sensitivity and specificity of 91.1% and 82.2%, respectively, in the validation set. Positive and negative predictive values were 59.7% and 97.0%. In reports of ILNs in the training and validation sets before versus after introduction of a Fleischner reporting macro, there was no difference in the proportion of reports with ILNs (108 of 500 [21.6%] versus 101 of 450 [22.4%]; P = .8), or in the proportion of reports with ILNs containing follow-up recommendations (75 of 108 [69.4%] versus 80 of 101 [79.2%]; P = .2]. Rates of recommendation guideline concordance were not significantly different before and after implementation of the standardized macro (52 of 75 [69.3%] versus 60 of 80 [75.0%]; P = .43). CONCLUSION/CONCLUSIONS:NLP reliably automates identification of ILNs in unstructured reports, pertinent to quality improvement efforts for ILN management.

BACKGROUND:Clinical decision support (CDS) has been shown to improve compliance with evidence-based care, but its impact is often diminished because of issues such as poor usability, insufficient integration into workflow, and alert fatigue. Noninterruptive CDS may be less subject to alert fatigue, but there has been little assessment of its usability. OBJECTIVE:This study aimed to study the usability of interruptive and noninterruptive versions of a CDS. METHODS:We conducted a usability study of a CDS tool that recommended prescribing an angiotensin-converting enzyme inhibitor for inpatients with heart failure. We developed 2 versions of the CDS: an interruptive alert triggered at order entry and a noninterruptive alert listed in the sidebar of the electronic health record screen. Inpatient providers were recruited and randomly assigned to use the interruptive alert followed by the noninterruptive alert or vice versa in a laboratory setting. We asked providers to "think aloud" while using the CDS and then conducted a brief semistructured interview about usability. We used a constant comparative analysis informed by the CDS Five Rights framework to analyze usability testing. RESULTS:A total of 12 providers participated in usability testing. Providers noted that the interruptive alert was readily noticed but generally impeded workflow. The noninterruptive alert was felt to be less annoying but had lower visibility, which might reduce engagement. Provider role seemed to influence preferences; for instance, some providers who had more global responsibility for patients seemed to prefer the noninterruptive alert, whereas more task-oriented providers generally preferred the interruptive alert. CONCLUSIONS:Providers expressed trade-offs between impeding workflow and improving visibility with interruptive and noninterruptive versions of a CDS. In addition, 2 potential approaches to effective CDS may include targeting alerts by provider role or supplementing a noninterruptive alert with an occasional, well-timed interruptive alert.

BACKGROUND:The Medicare Hospital Readmissions Reduction Program has led to fewer readmissions following hospitalizations with a principal diagnosis of heart failure (HF). Patients with HF are frequently hospitalized for other causes. OBJECTIVES/OBJECTIVE:This study sought to compare trends in Medicare risk-adjusted, 30-day readmissions following principal HF hospitalizations and other hospitalizations with HF. METHODS:This was a retrospective study of 12,973,853 Medicare hospitalizations with a principal or secondary diagnosis of HF between January 2008 and June 2015. Hospitalizations were categorized as follows: principal HF hospitalizations; principal acute myocardial infarction or pneumonia hospitalizations with secondary HF; and other hospitalizations with secondary HF. The study examined trends in risk-adjusted, 30-day, all-cause readmission rates for each cohort and trends in differences in readmission rates among cohorts by using linear spline regression models. RESULTS:Before passage of the Affordable Care Act in March 2010, risk-adjusted, 30-day readmission rates were stable for all 3 cohorts, with mean monthly rates of 26.1%, 24.9%, and 24.4%, respectively. Risk-adjusted readmission rates started declining after passage of the Affordable Care Act by 1.09% (95% confidence interval [CI]: 0.51% to 1.68%), 1.24% (95% CI: 0.92% to 1.57%), and 1.05% (95% CI: 0.52% to 1.58%) per year, respectively, until implementation of the Hospital Readmissions Reduction Program in October 2012 and then stabilized for all 3 cohorts. CONCLUSIONS:Patients with HF are often hospitalized for other causes, and these hospitalizations have high readmission rates. Policy changes led to decreases in readmission rates for both principal and secondary HF hospitalizations. Readmission rates in both groups remain high, suggesting that initiatives targeting all hospitalized patients with HF continue to be warranted.

Background/UNASSIGNED:Current guidelines recommend less aggressive target hemoglobin A1c (HbA1c) levels based on older age and lower life expectancy for older adults with diabetes. The effectiveness of electronic health record (EHR) clinical decision support (CDS) in promoting guideline adherence is undermined by alert fatigue and poor workflow integration. Integrating behavioral economics (BE) and CDS tools is a novel approach to improving adherence to guidelines while minimizing clinician burden. Methods/UNASSIGNED: = 8), (2) a 2-h, design-thinking workshop to derive and refine initial module ideas, and (3) semi-structured group interviews at each site with clinic leaders and clinicians to elicit feedback on three proposed nudge module components (navigator section, inbasket refill protocol, medication preference list). Detailed field notes will be summarized by module idea and usability theme for rapid iteration. Frequency of firing and user action taken will be assessed in the first month of implementation via EHR reporting to confirm that module components and related reporting are working as expected as well as assess utilization. To assess the utilization and feasibility of the new tools and generate estimates of clinician compliance with the Choosing Wisely guideline for diabetes management in older adults, a 6-month, single-arm pilot study of the BE-EHR module will be conducted in six outpatient primary care clinics. Discussion/UNASSIGNED:We hypothesize that a low burden, user-centered approach to design will yield a BE-driven, CDS module with relatively high utilization by clinicians. The resulting module will establish a platform for exploring the ability of BE concepts embedded within the EHR to affect guideline adherence for other use cases.

Background: Paper-based Early Recovery after Surgery (ERAS) path-ways have been shown to reduce length of stay, but there have been limited evaluations of electronic health record (EHR) based pathways. The objective of this study was to evaluate whether ERAS processes implemented with a novel pathway activity integrated with the EHR (E-Pathway) can reduce costs without resulting in increased 30 day readmissions. Methods: We performed a retrospective cohort study of surgical patients age>= 18 years hospitalized at an academic medical center from March 1, 2013 to August 31, 2016. The primary cohort consisted of patients admitted for elective colon surgery. We also studied a control group of patients undergoing elective procedures with similar length of stay as colon surgery (3-5 days). The E-Pathway was based on a pathway template developed by a common EHR vendor (Epic Systems, Verona, WI) with content developed by a multidisciplinary team based on ERAS principles. The E-Pathway was implemented on March 2, 2015. The primary outcome was variable costs per case. Secondary outcomes were observed to expected length of stay (O:E LOS) and 30 day readmissions to our hospital. For both groups, we performed an interrupted time series with segmented regression analysis with month being the unit of time. We used gamma regression for cost models and logistic models for the secondary outcomes. Results: We included 823 (470 and 353 in the pre-and post-intervention, respectively) colon surgery patients and 3415 (1,819 and 1,596 in the pre-and post-intervention) surgical control patients. Among the colon surgery cohort, we observed no changesin cost eitheratbaseline [-0.1% (95% CI-0.8%, 0.5%) per month] or with immediate introduction of the pathway. However, there was statistically significant (p = 0.040) decrease in costs of 1.3% (0.6% to 2.5%) per surgical encounter per month over the 18 month post intervention period. The surgical comparator group had no change in cost either at baseline or at the time of intervention and had a nonsignificant decrease in monthly costs of 0.6% (p = 0.231) post-intervention. There was statistically significant (p = 0.039) decrease in the O:E slope after the intervention of 1.49% per surgical encounter per month. The surgical comparator group had a nonsignificant (p = 0.761) increase in slope of 1.87%. For the 30 day readmission rates, there were no statistically significant changes in either the colon surgery or control groups. Conclusions: Our study is the first, to our knowledge, to report on the outcomes of a novel sophisticated E pathway integrated into an EHR. Following implementation of the E-pathway for colon surgery patients, we observed decreasing direct variable costs and O:E LOS over time. These improvements were not observed among comparable surgical patients. Consequently, as institutions continue to place increased emphasis on standardization of best practice care, E-pathways can be powerful vehicles to support those changes in the new EHR-centric care model

Background: Clinical decision support (CDS) has been shown to im-prove compliance with evidence-based care but its impact is often diminished due to issues such as poor usability, insufficient integration into workflow, and alert fatigue. Non-interruptive CDS may be less subject to alert fatigue but there has been little assessment of its usability. The purpose of this study was to perform usability testing on interruptive and non-interruptive versions of a CDS. Methods: We conducted a usability study ofa CDS tool that recommended prescribing an angiotensin converting enzyme (ACE) inhibitor for inpatients with heart failure. We developed two versions of the CDS that varied in its format: an interruptive alert, in which the CDS popped-up at the time of order entry, and a non-interruptive alert, which was displayed in a checklist section of the Electronic Health Record (EHR). We recruited inpatient providers to use both versions in a laboratory setting. We randomly assigned providers to first trigger the interruptive or non-interruptive alert. Providers were given a clinical scenario and asked to " think aloud" as they worked through the CDS; we then conducted a brief semi-structured interview about usability. We used a constant comparative analysis informed by the Five Rights of CDS framework to analyze the interviews. Inpatient providers from different disciplines were recruited until thematic saturation was reached. Results: Of 12 providers who participated in usability testing, seven used the interruptive followed by the non-interruptive CDS and five used the non-interruptive CDS initially. We categorized codes into four themes related to the Five Rights of CDS and determined some codes to be general to the CDS while others were specific to the interruptive or non-interruptive version (Table). Providers noted that the interruptive alert was readily noticed but generally impeded workflow. Providers found the non-interruptive CDS to be less annoying but had lower visibility; although they liked the ability to address the non-interruptive CDS at any time, some providers questioned whether it would ultimately be used. Conclusions: Providers expressed annoyance in working with an inter-ruptive CDS. Although the non-interruptive CDS was more appealing, providers admitted that it may not be used unless integrated with workflow. One potential solution was a combination of the two formats: supplementing a non-interruptive alert with an occasional, well-timed interruptive alert if uptake was insufficient