The 21st Century Cures Act and Emergency Medicine - Part 1: Digitally Sharing Notes andÂ Results
Among the provisions of the 21st Century Cures Act is the mandate for digital sharing of clinician notes and test results through the patient portal of the clinician's electronic health record system. Although there is considerable evidence of the benefit to clinic patients from open notes and minimal apparent additional burden to primary care clinicians, emergency department (ED) note sharing has not been studied. With easier access to notes and results, ED patients may have an enhanced understanding of their visit, findings, and clinician's medical decisionmaking, which may improve adherence to recommendations. Patients may also seek clarifications and request edits to their notes. EDs can develop workflows to address patient concerns without placing new undue burden on clinicians, helping to realize the benefits of sharing notes and test results digitally.
From smartphone to EHR: a case report on integrating patient-generated health data
Patient-generated health data (PGHD), collected from mobile apps and devices, represents an opportunity for remote patient monitoring and timely interventions to prevent acute exacerbations of chronic illness-if data are seen and shared by care teams. This case report describes the technical aspects of integrating data from a popular smartphone platform to a commonly used EHR vendor and explores the challenges and potential of this approach for disease management. Consented subjects using the Asthma Health app (built on Apple's ResearchKit platform) were able to share data on inhaler usage and peak expiratory flow rate (PEFR) with a local pulmonologist who ordered this data on Epic's EHR. For users who had installed and activated Epic's patient portal (MyChart) on their iPhone and enabled sharing of health data between apps via HealthKit, the pulmonologist could review PGHD and, if necessary, make recommendations. Four patients agreed to share data with their pulmonologist, though only two patients submitted more than one data point across the 4.5-month trial period. One of these patients submitted 101 PEFR readings across 65 days; another submitted 24 PEFR and inhaler usage readings across 66 days. PEFR for both patients fell within predefined physiologic parameters, except once where a low threshold notification was sent to the pulmonologist, who responded with a telephone discussion and new e-prescription to address symptoms. This research describes the technical considerations and implementation challenges of using commonly available frameworks for sharing PGHD, for the purpose of remote monitoring to support timely care interventions.
mHealth in emergency medicine [special report]
With the proliferation of smartphones over the past several years, apps now play a prominent role in many social and work contexts, including medicine. This is enough of a phenomenon to have inspired the abbreviation â€œmHealth,â€ short for mobile health. The number of app-driven clinical calculators, checklists, and risk scores in common use in the emergency department (ED) has significantly increased and shows no sign of slowing. Thanks to this digital development and innovation, clinical decision support is now just a finger-tap away.
Patient portal access for caregivers of adult and geriatric patients: reframing the ethics of digital patient communication
Patient portals are poised to transform health communication by empowering patients with rapid access to their own health data. The 21st Century Cures Act is a US federal law that, among other provisions, prevents health entities from engaging in practices that disrupt the exchange of electronic health information-a measure that may increase the usage of patient health portals. Caregiver access to patient portals, however, may lead to breaches in patient privacy and confidentiality if not managed properly through proxy accounts. We present an ethical framework that guides policy and clinical workflow development for healthcare institutions to support the best use of patient portals. Caregivers are vital members of the care team and should be supported through novel forms of health information technology (IT). Patients, however, may not want all information to be shared with their proxies so healthcare institutions must support the development and use of separate proxy accounts as opposed to using the patient's own account as well provide controls for limiting the scope of information displayed in the proxy accounts. Lastly, as socioeconomic barriers to adoption of health IT persist, healthcare providers must work to ensure multiple streams of patient communication, to prevent further propagating health inequities.
Early Rooming Triage: Accuracy and Demographic Factors Associated with Clinical Acuity
INTRODUCTION/BACKGROUND:Early rooming triage increases patient throughput and satisfaction by rapidly assigning patients to a definitive care area, without using vital signs or detailed chart review. Despite these operational benefits, the clinical accuracy of early rooming triage is not well known. We sought to measure the accuracy of early rooming triage and uncover additional patient characteristics that can assist triage. METHODS:We conducted a single-center, retrospective population study of walk-in emergency department (ED) patients presenting to the ED via an early rooming triage system, examining triage accuracy and demographic factor correlation with higher acuity ED outcomes. RESULTS:Among all patients included from the three-year study period (N = 238,457), early rooming triage was highly sensitive (0.89) and less specific (0.61) for predicting which patients would have a severe outcome in the ED. Patients triaged to the lowest acuity area of the ED experienced severe outcomes in 4.39% of cases, while patients triaged to the highest acuity area of the ED experienced severe outcomes in 65.9% of cases. An age of greater than 43 years (odds ratio [OR] 3.48, 95% confidence interval: 3.40, 3.57) or patient's home address farther from the ED ([OR] 2.23 to 3.08) were highly correlated with severe outcomes. Multivariable models incorporating triage team judgment were robust for predicting severe outcomes at triage, with an area under the receiver operating characteristic of 0.82. CONCLUSION/CONCLUSIONS:Early rooming workflows are appropriately sensitive for ED triage. Consideration of demographic factors, automated or otherwise, can augment ED processes to provide optimal triage.
Differences in antibiotic prescribing rates for telemedicine encounters for acute respiratory infections
INTRODUCTION/BACKGROUND:Health systems are increasingly implementing direct-to-consumer telemedicine for unscheduled acute care, however quality of care may be variable. Acute respiratory infection antibiotic prescribing rates in telemedicine visits performed by emergency physicians affiliated with medical centers has not been compared to care by unaffiliated, vendor-supplied physicians (a heterogeneous group). We hypothesized that, in virtual visits for acute respiratory infection, affiliated physicians would prescribe antibiotics at a lower rate than unaffiliated physicians. METHODS:We performed a retrospective analysis of on-demand telemedicine visits available to health system employees and dependents at a large urban academic health system from March 2018 to July 2019. We performed multivariable logistic regression to determine the effect of physician affiliation on antibiotic prescribing patterns for acute respiratory infection, adjusting for patient age, visit weekday, and overnight visits. RESULTS:â€‰<â€‰0.01) of being prescribed antibiotics, an average marginal effect of 15% (95%CI 2-29%). DISCUSSION/CONCLUSIONS:In this study of virtual visits for unscheduled acute care in a single health system, vendor-supplied physicians were predicted to prescribe an antibiotic in 15% more acute respiratory infection visits compared to system-employed emergency physicians (35% vs 19%). Physician affiliation and familiarity with a health system, in addition to other factors, may be important in guideline adherence and antibiotic stewardship in direct-to-consumer telemedicine encounters.
The 21st Century Cures Act and Emergency Medicine - Part 2: Facilitating Interoperability
Changes in alcohol-related hospital visits during COVID-19 in New York City
BACKGROUND AND AIMS/OBJECTIVE:Increased alcohol consumption has been proposed as a potential consequence of the coronavirus disease 2019 (COVID-19) pandemic. There has been little scrutiny of alcohol use behaviors resulting in hospital visits, which is essential to guide pandemic public policy. We aimed to determine whether COVID-19 peak restrictions were associated with increased hospital visits for alcohol use or withdrawal. Secondary objectives were to describe differences based on age, sex and race, and to examine alcohol-related complication incidence. DESIGN/METHODS:Multi-center, retrospective, pre-post study. SETTING/METHODS:New York City health system with five participating hospitals. PARTICIPANTS/METHODS:Adult emergency department encounters for alcohol use, alcoholic gastritis or pancreatitis or hepatitis, alcohol withdrawal syndrome, withdrawal seizure or delirium tremens. MEASUREMENTS/METHODS:Age, sex, race, site and encounter diagnosis. Encounters were compared between 2019 and 2020 for 1Â March to 31Â May. FINDINGS/RESULTS:There were 2790 alcohol-related visits during the 2019 study period and 1793 in 2020, with a decrease in total hospital visits. Of 4583 alcohol-related visits, median age was 47Â years, with 22.3% females. In 2020 there was an increase in percentage of visits for alcohol withdrawal [adjusted odds ratio (aOR)Â =Â 1.34, 95% confidence interval (CI)Â =Â 1.07-1.67] and withdrawal with complications (aORÂ =Â 1.40, 95% CIÂ =Â 1.14-1.72), and a decline in percentage of hospital visits for alcohol use (aORÂ =Â 0.70, 95% CIÂ =Â 0.59-0.85) and use with complications (aORÂ =Â 0.71, 95% CIÂ =Â 0.58-0.88). It is unknown whether use visit changes mirror declines in other chief complaints. The age groups 18-29 and 60-69Â years were associated with increased visits for use and decreased visits for withdrawal, as were non-white race groups. Sex was not associated with alcohol-related visit changes despite male predominance. CONCLUSIONS:In New York City during the initial COVID-19 peak (1 March to 31 May 2020), hospital visits for alcohol withdrawal increased while those for alcohol use decreased.
System Level Informatics to Improve Triage Practices for Sickle Cell Disease Vaso-Occlusive Crisis: A Cluster Randomized Controlled Trial
BACKGROUND:National Heart Lung and Blood Institute guidelines for the treatment of vaso-occlusive crisis among people with sickle cell disease in the emergency department recommend assigning an emergency severity index of 2 at triage. However, patients with sickle cell disease often do not receive guideline-concordant care at triage. To address this gap, a decision support tool was developed, in the form of a text banner on the triage page in the electronic health record system, visible to triage nurses. METHODS:A prospective quality improvement initiative was designed where the emergency severity index clinical decision support tool was deployed to a stratified random sample of emergency department triage nurses to receive the banner (nÂ =Â 24) or not to receive the banner (nÂ =Â 27), reminding them to assign the patient to emergency severity index category 2. The acceptability of the emergency severity index clinical decision support tool was evaluated with the Ottawa Acceptability of Decision Rules Instrument. Descriptive and bivariate (chi-square test) statistics were used to characterize the study's primary outcome, proportion of visits assigned an emergency severity index of 2 or higher. A generalized linear mixed model with clustering at the level of the triage nurse was performed to test the association between the banner intervention and triage practices. RESULTS:Â =Â 8.79,Â P â‰¤ .003). Accounting for clustering by nurse, the odds ratio for proper triage emergency severity index assignment was 3.22 (95% confidence interval 1.17-8.85; P â‰¤ .02) for the intervention versus control. Surveyed triage nurses reported the emergency severity index clinical decision support tool to be moderately acceptable (nurses' mean Ottawa Acceptability of Decision Rules Instrument scores ranged from 4.13 to 4.90 on the 6-point scale; nÂ =Â 11). There were no differences in ED experience outcomes including time to first analgesic or length of stay between the control and intervention groups. CONCLUSION/CONCLUSIONS:Substantial improvements in triage guideline concordance were achieved and sustained without direct nursing education.
SARS-CoV-2 Infection and Associated Rates of Diabetic Ketoacidosis in a New York City Emergency Department
INTRODUCTION/BACKGROUND:In early March 2020, coronavirus 2019 (COVID-19) spread rapidly in New York City. Shortly thereafter, in response to the shelter-in-place orders and concern for infection, emergency department (ED) volumes decreased. While a connection between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hyperglycemia/insulin deficiency is well described, its direct relation to diabetic ketoacidosis (DKA) is not. In this study we describe trends in ED volume and admitted patient diagnoses of DKA among five of our health system's EDs, as they relate to peak SARS-CoV-2 activity in New York City. METHODS:For the five EDs in our hospital system, deidentified visit data extracted for routine quality review was made available for analysis. We looked at total visits and select visit diagnoses related to DKA, across the months of March, April and May 2019, and compared those counts to the same period in 2020. RESULTS:A total of 93,218 visits were recorded across our five EDs from March 1-May 31, 2019. During that period there were 106 diagnoses of DKA made in the EDs (0.114% of visits). Across the same period in 2020 there were 59,009 visits, and 214 diagnoses of DKA (0.363% of visits) CONCLUSION: Despite a decrease in ED volume of 26.9% across our system during this time period, net cases of DKA diagnoses rose drastically by 70.1% compared to the prior year.