Faculty Bibliography

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.

Emergency departments (EDs) are often called the "˜safety net"™ of the U.S. health care system. Little is known, however, about the social determinants of health (SDOH)"“including rates and types of homelessness"“of ED patients. This study sought to quantify the presence of housing instability, homelessness, and other selected SDOH in ED patients. We conducted a cross-sectional survey of a random sample of 625 patients presenting to an urban ED. 13.8% of patients were currently living in a homeless shelter or on the streets. Further, 25.4% of patients reported concern about becoming homeless in the next 2 months and 9.1% had been evicted in the past year. 42.0% of patients reported difficulty meeting essential expenses and 35.9% were worried about running out of food. In conclusion, we found high rates of homelessness and other social needs in ED patients. Addressing patients"™ SDOH will become increasingly important under new healthcare payment models.

Background: Certain vulnerable patient groups including the homeless and those with Medicaid insurance are disproportionately represented among ED patients, yet little is known about ED patients' social determinants of health (SDOH). Objectives: This study seeks to quantify the presence of certain SDOH in ED patients. Methods: Using questions from previously validated or widelyused questionnaires, we conducted a cross-sectional survey of a random sample of patients presenting to an urban academic ED. Patients were excluded if they were physically or mentally unfit to participate, were intoxicated, were under police custody, or had already completed the study. Surveys were administered by trained research assistants (RAs) from June-August 2014 seven days a week from 8 am-11 pm and during eight 12 am-8 am shifts. RAs used a random number generator and patient whiteboard displays to select patients to approach. Survey responses were entered by RAs directly into a secure iPad survey platform. Multiple imputation was used for missing data. Results: 1,463 patients were assessed for eligibility, 592 were ineligible, and 246 of those eligible refused to participate, yielding 625 total participants. There were no statistically significant differences in gender or age between those who chose to participate and those who refused. 58.1% of participants were male, 39.8% were Hispanic, 25.9% were black, and 27.2% were white. The most common insurance status was uninsured (28.1%), followed by Medicaid (26.7%). 13.8% of patients were currently living in a homeless shelter or on the streets and 30.5% had been homeless at some point in their lives. In addition, 25.4% of patients reported concern about becoming homeless in the next 2 months and 9.1% had been evicted from their home in the past year. 42.0% of patients reported difficulty meeting essential expenses, 35.9% were worried about running out of food, and 27.7% had not seen a doctor or taken medications (24.5%) because of money concerns. Conclusion: Our survey found high rates of homelessness and other SDOH in ED patients and demonstrates the importance of further research on ED patients' SDOH. Addressing patients' SDOH will become increasingly important under new health care payment models that demand greater accountability for population health

Medical control of prehospital emergency services, triage in the emergency department, and the dual duties within the Emergency Medical Treatment and Active Labor Act challenge emergency medicine physicians with both statutory obligations and liabilities. Each independently may seem to present a definable boundary of liability for the practitioner. Under the Emergency Medical Treatment and Active Labor Act, the sequential duties of the medical screening examination and subsequent stabilization or transfer are confounded by the potential for tremendous sanction for a mechanistic violation. Nevertheless, the true obligation is to provide appropriate care to all who present to the emergency department and not simply weigh the totality of risk to the emergency medicine physician