Faculty Bibliography

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.

BACKGROUND: Enhanced Recovery after Surgery (ERAS) pathways have been shown to reduce length of stay, but there have been limited evaluations of novel electronic health record (EHR)-based pathways. Compliance with ERAS in real-world settings has been problematic. OBJECTIVE: This article evaluates a novel ERAS electronic pathway (E-Pathway) activity integrated with the EHR for patients undergoing elective colorectal surgery. METHODS: We performed a retrospective cohort study of surgical patients age ≥ 18 years hospitalized 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 other elective procedures. 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 and 30-day readmissions. RESULTS: = 0.231) decrease in monthly costs of 0.57% (95% CI 1.51 to - 0.37%) postintervention. For the 30-day readmission rates, there were no statistically significant changes in either cohort. CONCLUSION/CONCLUSIONS: Our study is the first to report on the reduced costs after implementation of a novel sophisticated E-Pathway for ERAS. E-Pathways can be a powerful vehicle to support ERAS adoption.

Individuals living with complex diabetes experience limited access to endocrine care due to a nationwide shortage of endocrinologists. Project ECHO (Extension for Community Healthcare Outcomes) is an innovative, scalable model of health care that extends specialty care to medically underserved areas through ongoing telementorship of community primary care providers. We evaluated the effects of an endocrine-focused ECHO program (Endo ECHO) on patients with type 1 and complex type 2 diabetes, and report here on changes in patient-reported measures of health care access and quality from baseline to one year aft er program enrollment. Patients were eligible for Endo ECHO if they were 18 years or older with complex diabetes. Aft er participating in Endo ECHO, access to health care and diabetes-related quality of care improved dramatically. Our results suggest that Endo ECHO may be a suitable intervention for extending best practices in diabetes care to medically underserved patients.

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:Evidence-based therapy for heart failure remains underutilized at hospital discharge, particularly for patients with heart failure who are hospitalized for another cause. We developed clinical decision support (CDS) to recommend an angiotensin converting enzyme (ACE) inhibitor during hospitalization to promote its continuation at discharge. The CDS was designed to be implemented in both interruptive and non-interruptive versions. OBJECTIVES/OBJECTIVE:To compare the effectiveness and implementation of interruptive and non-interruptive versions of a CDS to improve care for heart failure. METHODS:Hospitalizations of patients with reduced ejection fraction were pseudo-randomized to deliver interruptive or non-interruptive CDS alerts to providers based on even or odd medical record number. We compared discharge utilization of an ACE inhibitor or angiotensin receptor blocker (ARB) for these two implementation approaches. We also assessed adoption and implementation fidelity of the CDS. RESULTS:percentile) of 14 (5,32) alerts were triggered per hospitalization. CONCLUSIONS:A CDS implemented as an interruptive alert was associated with improved quality of care for heart failure. Whether the potential benefits of CDS in improving cardiovascular care were worth the high burden of interruptive alerts deserves further consideration. CLINICALTRIALS. GOV IDENTIFIER/UNASSIGNED:NCT02858674.

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.

Background: Clinical decision support (CDS) systems can be valuable resources in chronic disease management, but provider utilization of these tools and their integration into workflow remains suboptimal. We used a user-centered design approach to build a CDS recommending evidence-based therapy for heart failure in an inpatient setting. We implemented two versions of the CDS: an interruptive (pop-up) alert and a non-interruptive alert displayed in a provider checklist activity. In a prior study, we found that the interruptive alert was more effective than the non-interruptive alert but suffered from a high dismissal rate. The purpose of this study was to understand provider's perceptions of factors impacting CDS utilization following its implementation.
Method(s): We performed a qualitative study following implementation of two versions of a CDS at an academic medical center. We recruited providers who had either version of the CDS triggered in the prior 24 hours and obtained feedback through semi-structured interviews. Interviews were recorded, transcribed, and double-coded. We performed a constant comparative analysis of the transcripts and developed a coding scheme informed by the Five Rights of CDS combined with Proctor's outcomes for implementation research framework. We recruited participants until thematic saturation was achieved.
Result(s): Fourteen providers participated in interviews. In general, providers found the CDS triggered for appropriate patients, provided the right information to determine appropriateness of recommendations, and had good usability. At least four providers believed they were not the right person to receive the alert, reporting that they primarily participated in cross-coverage, worked in a setting where these medications were typically contraindicated, or were already fully compliant with evidence-based medications. Providers complained that the interruptive alert led to workflow disruption and that frequently they would "just need to click through all of this." Nonetheless, many providers still preferred the interruptive version of the alert because they were either: 1) unaware of the non-interruptive alert in the checklist; 2) "don't use the provider checklist" where the non-interruptive alert resided; or 3) were unaware of the provider checklist.
Conclusion(s): We found that CDS was generally found to be acceptable, although the interruptive version of the alert was limited by disruptions in workflow. The interruptive alert was ultimately more successful as providers were unaware of the existence of the non-interruptive alert. Furthermore, they infrequently used the provider checklist, a native EHR feature for non-interruptive alerts and messages. Our findings suggest that incorporating user-centered design features can lead to success of an interruptive alert. Furthermore, future efforts to implement non-interruptive alerts must incorporate approaches to increase awareness of the alert and encourage changes in workflow to monitor alert lists

Background: Older adults with diabetes continue to be overtreated despite current guidelines recommending less aggressive target A1c levels based on life expectancy. The suboptimal management of this vulnerable population could be due to physicians having conflicting beliefs regarding this guideline or simply lacking awareness, and changing these behaviors is challenging. Clinical decision support (CDS) within the electronic health record (EHR) has the potential to address this issue, but effectiveness is undermined by alert fatigue and poor workflow integration. Incorporating behavioral economics into CDS tools is an innovative approach to improve adherence to these guidelines while reducing physician burden, and offers the promise of improving care in this population.
Method(s): We applied a systematic, user-centered approach to incorporate behavioral economic " nudges" into a CDS module and performed user testing in six pilot primary care practices in a large academic medical center. To build the nudges, we conducted: (1) semi-structured interviews with key informants (n=8); (2) a two-hour 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 the module components. Clinicians were observed using the module in practice; detailed field notes were collected and summarized by module idea and usability theme for rapid iteration and refinement. Frequency of firing and user action taken were assessed in the first month of implementation via EHR reporting to confirm that module components and reporting were working as expected, and to assess utilization.
Result(s): Insights from key stakeholder and clinician group interviews identified the refill protocol, inbasket lab result, and medication preference list as candidate EHR CDS targets for the module. A new EHR navigator section notification and peer comparison message, derived from the design workshop, were also prototyped and produced. User feedback from site visits confirmed compatibility with clinical workflows, and contributed to refinement of design and content. The initial prototypes were first piloted at two sites, refined, and then activated at an additional four additional sites. Preliminary Results for the six clinics indicate that over approximately 31 weeks: 1) the navigator alert fired 1047 times for 53 unique clinicians, and 2) the refill protocol alert fired 421 times for 53 unique clinicians. Reports for the other " nudges" are in development.
Conclusion(s): Integrating behavioral economic nudges into the EHR is a promising approach to enhancing guideline awareness and adherence for older adults with diabetes. This novel pilot will demonstrate the initial feasibility and preliminary efficacy of this strategy and determine if a full-scale effectiveness trial is warranted

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.