Faculty Bibliography

This study provides data on the feasibility and impact of video-enabled telemedicine use among patients and providers and its impact on urgent and non-urgent health care delivery from one large health system (NYU Langone Health) at the epicenter of the COVID-19 outbreak in the United States. Between March 2nd and April 14th 2020, telemedicine visits increased from 369.1 daily to 866.8 daily (135% increase) in urgent care after the system-wide expansion of virtual health visits in response to COVID-19, and from 94.7 daily to 4209.3 (4345% increase) in non-urgent care post expansion. Of all virtual visits post expansion, 56.2% and 17.6% urgent and non-urgent visits, respectively, were COVID-19-related. Telemedicine usage was highest by patients aged 20-44, particularly for urgent care. The COVID-19 pandemic has driven rapid expansion of telemedicine use for urgent care and non-urgent care visits beyond baseline periods. This reflects an important change in telemedicine that other institutions facing the COVID-19 pandemic should anticipate.

BACKGROUND: Virtual Urgent Care (VUC) is a now a common modality for providing real-time assessment and treatment of common medical problems. However, most providers have not had formal telemedicine training or clinical experience. Faculty have little experience with this new modality of healthcare delivery. We created an experiential onboarding program in which standardized patients (SPs) are deployed into a VUC platform to assess and deliver feedback to physicians in an effort to provide individual- level quality assurance and identify programlevel areas for improvement.
METHOD(S): We simulated a synchronous urgent care evaluation of a 25- year-old man with lingering upper respiratory tract symptoms refractory to over-the-counter medications. The SP was trained to strongly request an antibiotic prescription. A mock entry in the electronic medical record, available to providers during the visit, provided demographic, prior medical, pharmacy and allergy information. The encounter was scheduled into a regular 30-minute appointment slot during a routine 8-hour shift. We developed a behaviorally- anchored assessment tool to evaluate core communication, case-specific, and telemedicine-specific skills. Response options comprised 'not done,' 'partly done,' and 'well done.' SPs provided post-encounter verbal feedback to urgent care providers (UCPs), who received a summary report and had an opportunity provide structured feedback regarding the case. A single SP performed 20 / 21 visits.
RESULT(S): Twenty-one UCPs, with 2 to 23 years of clinical experience, participated in an announced scheduled visit. UCPs performed 'well done' in Information Gathering (93%) and Relationship Development (99%) domains. All UCPs provided appropriate management plans and did not give antibiotics. In contrast, Education and Counseling skills were less strong (32% 'well done'). Within this domain, few received 'well done' for checking understanding (14%); conveying small bits of information and summarizing to ensure clarity (9%). Most (71% well done) collaborated with the SP in discussing next steps. Specific telemedicine skills were infrequently used: only 19% performed a virtual physical exam, 24% utilized the audio/video interface to augment information gathering, 14% optimized technical aspects by assessing sound, video or ensuring a backup plan should video fail. A subset of UCPs (n=9) provided structured feedback regarding the case. 100% 'somewhat or strongly agreed' that the encounter improved their confidence communicating via the video interface and helped improved telehealth skills.
CONCLUSION(S): This experiential virtual urgent care onboarding program utilizing standardized announced encounters uncovers several areas for improvement within telemedicine-specific and patient education domains. These findings form the basis for dedicated training for virtual urgent care providers to assure quality across the program

Introduction: Oral cancer remains prevalent, despite being largely preventable. The widespread use of technology at chairside, combined with advances in electronic health record (EHR) capabilities, present opportunities to improve oral cancer screening by dentists, especially for disadvantaged patients with severe health needs. Design and methods: Using a mixed-methods approach, we will evaluate the feasibility and acceptability of integrating a telementoring component into the identification of oral lesions using the following 3 methods: 1) administering provider surveys that consist of a checklist of 10 key components of the intervention based on process, and asking the dental provider subjects if each one was covered; 2) conducting semi-structured interviews informed by the Consolidated Framework for Implementation Research and the Implementation Outcomes Framework with dental resident subjects to assess specific barriers to sustaining the intervention and strategies for addressing these barriers to facilitate integration of the intervention into the routine workflow of the dental clinics; and 3) administering brief exit interviews with patient subjects regarding the acceptability of the intervention to assess satisfaction with the use of intra-oral cameras at chairside to screen for and refer patients with oral lesions and identification of these oral lesions via EHR and secure e-mail tele-mentoring with an oral pathology expert. Expected impact of the study for public health: If successful, then later clinical trials will maximize the external validity of the intervention and facilitate the widespread implementation and dissemination of the model for the teaching of dentists and residents, with the ultimate goal of improving patient care.

Intro/Background: Virtual Urgent Care (VUC) is now a common modality for providing real-time assessment and treatment of common low acuity medical problems. However, most physicians have not had formal telemedicine training or clinical experience and therefore lack proficiency with this new modality of healthcare delivery. We created an experiential onboarding program deploying standardized patients (SPs) into a VUC platform to assess and deliver feedback to physicians, providing individual-level quality assurance and identifying program-level areas for improvement. Purpose/Objective: The objective of this program was to create an experiential training module for physicians as part of their VUC onboarding process with the goal of quality assurance and patient safety. The onboarding experience incorporated common standards for doctor-patient communication as well as the unique skills necessary for the practice of telemedicine. The encounters were unobserved by other faculty, providing participants with a safe and confidential environment to receive feedback on their communication and telemedicine skills.
Method(s): We simulated a synchronous urgent care evaluation of a 25-year-old man with lingering viral upper respiratory tract symptoms refractory to over-thecounter medications. SP training included strongly requesting an antibiotic prescription. A mock electronic medical record encounter provided physicians with demographic and prior medical history. The announced SP appointment occurred during a routine VUC shift. Our behaviorally-anchored assessment tool evaluated communication, case-specific, and telemedicine-specific skills. Response options comprised 'not done,' 'partly done,' and 'well done.' Outcomes (if available): Twenty-one physicians provided appropriate management without prescribing antibiotics. Physicians performed 'well done' in Information Gathering (93%) and Relationship Development (99%) domains. In contrast, Education and Counseling skills were less strong (32% 'well done'); few received 'well done' for checking understanding (14%); conveying and summarizing information (9%). Telemedicine skills were infrequently used: 19% performed virtual physical exam, 24% utilized audio/video interface to augment information gathering, 14% assessed sound, video or ensured backup plan should video fail.
Summary: This experiential virtual urgent care onboarding program utilizing standardized patient announced encounters uncovers several areas for improvement within telemedicine-specific and patient education domains. Participating VUC physicians had 2 to 23 years of clinical experience. Results illustrate that irrespective of experience, telemedicine visits create a unique set of challenges to the traditional way physicians are taught to engage with their patients. Overall, the onboarding exercise was well received by participating physicians. At the conclusion of the visit, SPs provided immediate verbal feedback to urgent care physicians, who received a summary report and had an opportunity provide structured feedback regarding the case. A subset of urgent care physicians (n=9) provided feedback regarding the case; 100% 'somewhat or strongly agreed' that the encounter improved their confidence communicating via the video interface and helped improve telehealth skills. Our innovative onboarding program utilizing highly trained standardized patients can uncover potential gaps in telemedicinespecific skills and form the basis for dedicated training for virtual urgent care physicians to assure quality and patient safety

BACKGROUND:The emergency department is a critical juncture in the trajectory of care of patients with serious, life-limiting illness. Implementation of a clinical decision support (CDS) tool automates identification of older adults who may benefit from palliative care instead of relying upon providers to identify such patients, thus improving quality of care by assisting providers with adhering to guidelines. The Primary Palliative Care for Emergency Medicine (PRIM-ER) study aims to optimize the use of the electronic health record by creating a CDS tool to identify high risk patients most likely to benefit from primary palliative care and provide point-of-care clinical recommendations. METHODS:A clinical decision support tool entitled Emergency Department Supportive Care Clinical Decision Support (Support-ED) was developed as part of an institutionally-sponsored value based medicine initiative at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health. A multidisciplinary approach was used to develop Support-ED including: a scoping review of ED palliative care screening tools; launch of a workgroup to identify patient screening criteria and appropriate referral services; initial design and usability testing via the standard System Usability Scale questionnaire, education of the ED workforce on the Support-ED background, purpose and use, and; creation of a dashboard for monitoring and feedback. RESULTS:The scoping review identified the Palliative Care and Rapid Emergency Screening (P-CaRES) survey as a validated instrument in which to adapt and apply for the creation of the CDS tool. The multidisciplinary workshops identified two primary objectives of the CDS: to identify patients with indicators of serious life limiting illness, and to assist with referrals to services such as palliative care or social work. Additionally, the iterative design process yielded three specific patient scenarios that trigger a clinical alert to fire, including: 1) when an advance care planning document was present, 2) when a patient had a previous disposition to hospice, and 3) when historical and/or current clinical data points identify a serious life-limiting illness without an advance care planning document present. Monitoring and feedback indicated a need for several modifications to improve CDS functionality. CONCLUSIONS:CDS can be an effective tool in the implementation of primary palliative care quality improvement best practices. Health systems should thoughtfully consider tailoring their CDSs in order to adapt to their unique workflows and environments. The findings of this research can assist health systems in effectively integrating a primary palliative care CDS system seamlessly into their processes of care. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov Identifier: NCT03424109. Registered 6 February 2018, Grant Number: AT009844-01.

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.

Introduction/UNASSIGNED:Emergency department (ED) patient care often hinges on the result of a diagnostic test. Frequently there is a lag time between a test result becoming available for review and physician decision-making or disposition based on that result. We implemented a system that electronically alerts ED providers when test results are available for review via a smartphone- and smartwatch-push notification. We hypothesized this would reduce the time from result to clinical decision-making. Methods/UNASSIGNED:We retrospectively assessed the impact of the implementation of a push notification system at three EDs on time-to-disposition or time-to-follow-up order in six clinical scenarios of interest: chest radiograph (CXR) to disposition, basic metabolic panel (BMP) to disposition, urinalysis (UA) to disposition, respiratory pathogen panel (RPP) to disposition, hemoglobin (Hb) to blood transfusion order, and abnormal D-dimer to computed tomography pulmonary angiography (CTPA) order. All ED patients during a one-year period of push-notification availability were included in the study. The primary outcome was median time in each scenario from result availability to either disposition order or defined follow-up order. The secondary outcome was the overall usage rate of the opt-in push notification system by providers. Results/UNASSIGNED:During the study period there were 6115 push notifications from 4183 ED encounters (2.7% of all encounters). Of the six clinical scenarios examined in this study, five were associated with a decrease in median time from test result availability to patient disposition or follow-up order when push notifications were employed: CXR to disposition, 80 minutes (interquartile range [IQR] 32-162 minutes) vs 56 minutes (IQR 18-141 minutes), difference 24 minutes (p<0.01); BMP to disposition, 128 minutes (IQR 62-225 minutes) vs 116 minutes (IQR 33-226 minutes), difference 12 minutes (p<0.01); UA to disposition, 105 minutes (IQR 43-200 minutes) vs 55 minutes (IQR 16-144 minutes), difference 50 minutes (p<0.01); RPP to disposition, 80 minutes (IQR 28-181 minutes) vs 37 minutes (IQR 10-116 minutes), difference 43 minutes (p<0.01); and D-dimer to CTPA, 14 minutes (IQR 6-30 minutes) vs 6 minutes (IQR 2.5-17.5 minutes), difference 8 minutes (p<0.01). The sixth scenario, Hb to blood transfusion (difference 19 minutes, p=0.73), did not meet statistical significance. Conclusion/UNASSIGNED:Implementation of a push notification system for test result availability in the ED was associated with a decrease in lag time between test result and physician decision-making in the examined clinical scenarios. Push notifications were used in only a minority of ED patient encounters.

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

Background: Emergency department (ED) care decisions often hinge on the result of a diagnostic test. Frequently there is a lag time between a test result becoming available for review, and physician decision-making based on that result. Push notifications to physician smartphones have demonstrated improvement in this lag time in chest pain patients, but have not been studied in other ED patients. We implemented a system by which ED providers can subscribe to electronic alerts when test results are available for review via a smartphone or smartwatch push notification, and hypothesized that this would reduce the time to make clinical decisions. Method(s): This was a retrospective, multicenter, observational study in three emergency departments of an urban health system. We assessed push notification impact on time to disposition or time to follow-up order in six clinical scenarios of interest: chest x-ray (CXR) to disposition, basic metabolic panel (BMP) to disposition, urinalysis (UA) to disposition, respiratory pathogen panel (RPP) to disposition, hemoglobin (Hb) to blood transfusion order, and D-dimer to computed tomography pulmonary angiography (CTPA) order. All adult ED patients during a one-year period of push notification availability were included in the study. The primary outcome was median time from result availability to disposition order or defined follow-up order. Median times with interquartile ranges were determined in each scenario and the Mann Whitney (Wilcoxon) test for unpaired data was used to determine statistical significance. Result(s): During the study period there were 6,115 push notifications from 4,183 eligible ED encounters (2.7% of all ED encounters). All six scenarios studied were associated with a decrease in median time from test result availability to patient disposition, or from test result availability to follow-up order, when push notifications were employed: CXR to disposition (24 minutes, p<0.01), BMP to disposition (12 minutes, p<0.01), UA to disposition (50 minutes, p<0.01), RPP to disposition (43 minutes, p<0.01), D-dimer to CTPA (8 minutes, p<0.01), Hb to blood transfusion (19 minutes, p=0.73). Conclusion(s): Implementation of a push notification system for test result availability in the ED was associated with a decrease in lag time between test result availability and physician decision-making