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Implementing the physical activity vital sign in an academic preventive cardiology clinic

McCarthy, Margaret M; Fletcher, Jason; Heffron, Sean; Szerencsy, Adam; Mann, Devin; Vorderstrasse, Allison
The aims were to implement physical activity (PA) screening as part of the electronic kiosk check-in process in an adult preventive cardiology clinic and assess factors related to patients' self-reported PA. The 3-question physical activity vital sign (PAVS) was embedded in the Epic electronic medical record and included how many days, minutes and intensity (light, moderate, vigorous) of PA patients conducted on average. This is a data analysis of PAVS data over a 60-day period. We conducted multivariable logistic regression to identify factors associated with not meeting current PA recommendations. Over 60 days, a total of 1322 patients checked into the clinic using the kiosk and 72% (n = 951) completed the PAVS at the kiosk. The majority of those patients were male (58%) and White (71%) with a mean age of 64 ± 15 years. Of the 951 patients completing the PAVS, 10% reported no PA, 55% reported some PA, and 35% reported achieving at least 150 min moderate or 75 min vigorous PA/week. In the logistic model, females (AOR = 1.4, 95%CI: 1.002-1.8, p = .049) vs. males, being Black (AOR = 2.0, 95%CI: 1.04-3.7, p = .038) or 'Other' race (AOR = 1.5, 95%CI: 1.02-2.3, p = .035) vs. White, unknown or other types of relationships (AOR = 0.0.26, 95%CI: 0.10-0.68, p = .006) vs. being married/partnered, and those who were retired (AOR = 1.9, 95% CI: 1.4-2.8, p < .001) or unemployed (AOR = 2.2, 95%CI: 1.3-3.7, p = .002) vs. full-time workers were associated with not achieving recommended levels of PA. The PAVS is a feasible electronic tool for quickly assessing PA and may prompt providers to counsel on this CVD risk factor.
PMID: 34150483
ISSN: 2211-3355
CID: 4936852

Applying A/B Testing to Clinical Decision Support: Rapid Randomized Controlled Trials

Austrian, Jonathan; Mendoza, Felicia; Szerencsy, Adam; Fenelon, Lucille; Horwitz, Leora I; Jones, Simon; Kuznetsova, Masha; Mann, Devin M
BACKGROUND:Clinical decision support (CDS) is a valuable feature of electronic health records (EHRs) designed to improve quality and safety. However, due to the complexities of system design and inconsistent results, CDS tools may inadvertently increase alert fatigue and contribute to physician burnout. A/B testing, or rapid-cycle randomized tests, is a useful method that can be applied to the EHR in order to rapidly understand and iteratively improve design choices embedded within CDS tools. OBJECTIVE:This paper describes how rapid randomized controlled trials (RCTs) embedded within EHRs can be used to quickly ascertain the superiority of potential CDS design changes to improve their usability, reduce alert fatigue, and promote quality of care. METHODS:A multistep process combining tools from user-centered design, A/B testing, and implementation science was used to understand, ideate, prototype, test, analyze, and improve each candidate CDS. CDS engagement metrics (alert views, acceptance rates) were used to evaluate which CDS version is superior. RESULTS:To demonstrate the impact of the process, 2 experiments are highlighted. First, after multiple rounds of usability testing, a revised CDS influenza alert was tested against usual care CDS in a rapid (~6 weeks) RCT. The new alert text resulted in minimal impact on reducing firings per patients per day, but this failure triggered another round of review that identified key technical improvements (ie, removal of dismissal button and firings in procedural areas) that led to a dramatic decrease in firings per patient per day (23.1 to 7.3). In the second experiment, the process was used to test 3 versions (financial, quality, regulatory) of text supporting tobacco cessation alerts as well as 3 supporting images. Based on 3 rounds of RCTs, there was no significant difference in acceptance rates based on the framing of the messages or addition of images. CONCLUSIONS:These experiments support the potential for this new process to rapidly develop, deploy, and rigorously evaluate CDS within an EHR. We also identified important considerations in applying these methods. This approach may be an important tool for improving the impact of and experience with CDS. TRIAL REGISTRATION/BACKGROUND:Flu alert trial: NCT03415425; Tobacco alert trial: NCT03714191;
PMID: 33835035
ISSN: 1438-8871
CID: 4840962

Giving Your Electronic Health Record a Checkup After COVID-19: A Practical Framework for Reviewing Clinical Decision Support in Light of the Telemedicine Expansion

Feldman, Jonah; Szerencsy, Adam; Mann, Devin; Austrian, Jonathan; Kothari, Ulka; Heo, Hye; Barzideh, Sam; Hickey, Maureen; Snapp, Catherine; Aminian, Rod; Jones, Lauren; Testa, Paul
BACKGROUND:The transformation of health care during COVID-19, with the rapid expansion of telemedicine visits, presents new challenges to chronic care and preventive health providers. Clinical decision support (CDS) is critically important to chronic care providers, and CDS malfunction is common during times of change. It is essential to regularly reassess an organization's ambulatory CDS program to maintain care quality. This is especially true after an immense change, like the COVID-19 telemedicine expansion. OBJECTIVE:Our objective is to reassess the ambulatory CDS program at a large academic medical center in light of telemedicine's expansion in response to the COVID-19 pandemic. METHODS:Our clinical informatics team devised a practical framework for an intrapandemic ambulatory CDS assessment focused on the impact of the telemedicine expansion. This assessment began with a quantitative analysis comparing CDS alert performance in the context of in-person and telemedicine visits. Board-certified physician informaticists then completed a formal workflow review of alerts with inferior performance in telemedicine visits. Informaticists then reported on themes and optimization opportunities through the existing CDS governance structure. RESULTS:Our assessment revealed that 10 of our top 40 alerts by volume were not firing as expected in telemedicine visits. In 3 of the top 5 alerts, providers were significantly less likely to take action in telemedicine when compared to office visits. Cumulatively, alerts in telemedicine encounters had an action taken rate of 5.3% (3257/64,938) compared to 8.3% (19,427/233,636) for office visits. Observations from a clinical informaticist workflow review included the following: (1) Telemedicine visits have different workflows than office visits. Some alerts developed for the office were not appearing at the optimal time in the telemedicine workflow. (2) Missing clinical data is a common reason for the decreased alert firing seen in telemedicine visits. (3) Remote patient monitoring and patient-reported clinical data entered through the portal could replace data collection usually completed in the office by a medical assistant or registered nurse. CONCLUSIONS:In a large academic medical center at the pandemic epicenter, an intrapandemic ambulatory CDS assessment revealed clinically significant CDS malfunctions that highlight the importance of reassessing ambulatory CDS performance after the telemedicine expansion.
PMID: 33400683
ISSN: 2291-9694
CID: 4767802

Patient Experience With Notification of Radiology Results: A Comparison of Direct Communication and Patient Portal Use

Garry, Kira; Blecker, Saul; Saag, Harry; Szerencsy, Adam; Jones, Simon A; Testa, Paul; Kang, Stella
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.
PMID: 32289281
ISSN: 1558-349x
CID: 4401322

Implementing the Physical Activity Vital Sign in an Academic Preventive Cardiology Clinic [Meeting Abstract]

McCarthy, Margaret M.; Heffron, Sean; Fletcher, Jason; Szerencsy, Adam; Mann, Devin; Vorderstrasse, Allison
ISSN: 0009-7322
CID: 4688862

User-Centered Development of a Behavioral Economics Inspired Electronic Health Record Clinical Decision Support Module

Chokshi, Sara Kuppin; Troxel, Andrea; Belli, Hayley; Schwartz, Jessica; Blecker, Saul; Blaum, Caroline; Szerencsy, Adam; Testa, Paul; Mann, Devin
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.
PMID: 31438106
ISSN: 1879-8365
CID: 4046992


Chokshi, Sara; Troxel, Andrea B.; Belli, Hayley; Schwartz, Jessica; Blecker, Saul; Blaum, Caroline; Szerencsy, Adam; Testa, Paul; Mann, Devin
ISSN: 0883-6612
CID: 4181082

[S.l.] : 11th Annual Conference on the Science of Dissemination and Implementation in Health, 2018

Design thinking for implementation science: A case study employing user-centered digital design methodology to create usable decision support

Chokshi, Sara; Belli, Hayley; Troxel, Andrea; Schwartz, Jessica; Blecker, Saul; Blaum, Caroline; Szerencsy, Adam; Testa, Paul; Mann, Devin
CID: 4256142

Promoting judicious antibiotic use: Results of an outpatient-based randomized EMR-generated intervention study [Meeting Abstract]

Stachel, A; Szerencsy, A; Pulgarin, C; Fucito, N; Pham, V
Background. According to the CDC, up to 50% of antibiotic (abx) prescriptions are not needed or inappropriate-often used too long or too broadly. Repercussions include multidrug resistance, adverse reactions, and increased incidence and mortality from Clostridium difficile. A JAMA study demonstrated that IDSA guidelines can influence abx prescribing patterns positively for genitourinary infections. In this electronic age, interventions include providing direct access to guidelines through a Best Practice Alert (BPA) embedded within electronic medical records (EMR). This assists clinicians when recommending abx. The study's goal was to improve compliance with guidelines when treating uncomplicated UTIs at outpatient sites by using targeted education and Clinical Decision Support (CDS). Methods. Outpatient sites were randomized with matching into two groups: BPA intervention group (IG) (71 sites; 4,555 visits) or control group (CG) (56 sites; 2,078 visits). The BPA listed the appropriate abx regimens according to guidelines. A second modification presented all providers with a list of abx options including dosage and frequency. The effects of two CDS interventions were assessed for one year. Results. Results indicate the IG improved in BPA abx compliance over the CG. Figure 1 shows compliance with BPA recommended antibiotics among the IG increased from 17% to 23% during Q1 2014-Q2 2017 compared with a 0% increase in the CG (P <.0001). However, overall IDSA recommended compliance did not significantly increase: IG -2% vs CG 1% (P = .26). UTI patients of providers who saw the BPA alert were 1.9 times (CI: 1.7, 2.3) times more likely to receive recommended abx compared with the CG. Conclusion. This randomized control study provides promising data that the use of CDS, specifically BPAs embedded within EMRs, can be used effectively to assist and encourage compliance with guidelines. Next steps include: continuing to educate providers on best practices, consider including more abx options in BPA to reduce errors in prescribing and improve overall compliance, and implementing similar CDS interventions for upper respiratory infections and other infections. (Figure Presented)
ISSN: 2328-8957
CID: 3931572

Use of an electronic patient portal among disadvantaged populations

Ancker, Jessica S; Barron, Yolanda; Rockoff, Maxine L; Hauser, Diane; Pichardo, Michelle; Szerencsy, Adam; Calman, Neil
BACKGROUND: Electronic patient portals give patients access to information from their electronic health record and the ability to message their providers. These tools are becoming more widely used and are expected to promote patient engagement with health care. OBJECTIVE: To quantify portal usage and explore potential differences in adoption and use according to patients' socioeconomic and clinical characteristics in a network of federally qualified health centers serving New York City and neighboring counties. DESIGN: Retrospective analysis of data from portal and electronic health records. PARTICIPANTS: 74,368 adult patients seen between April 2008 and April 2010. MAIN MEASURES: Odds of receiving an access code to the portal, activating the account, and using the portal more than once KEY RESULTS: Over the 2 years of the study, 16% of patients (n = 11,903) received an access code. Of these, 60% (n = 7138) activated the account, and 49% (n = 5791) used the account two or more times. Patients with chronic conditions were more likely to receive an access code and to become repeat users. In addition, the odds of receiving an access code were significantly higher for whites, women, younger patients, English speakers, and the insured. The odds of repeat portal use, among those with activated accounts, increased with white race, English language, and private insurance or Medicaid compared to no insurance. Racial disparities were small but persisted in models that controlled for language, insurance, and health status. CONCLUSIONS: We found good early rates of adoption and use of an electronic patient portal during the first 2 years of its deployment among a predominantly low-income population, especially among patients with chronic diseases. Disparities in access to and usage of the portal were evident but were smaller than those reported recently in other populations. Continued efforts will be needed to ensure that portals are usable for and used by disadvantaged groups so that all patients benefit equally from these technologies.
PMID: 21647748
ISSN: 0884-8734
CID: 161593